“Someone to Talk to” - An Intervention Supporting Serious Illness Conversations in Medicaid-Funded Assisted Living

TL;DR

This study introduces a community health worker-led program to help low-income older adults in assisted living discuss serious illness and advance care planning.

Contribution

The novel contribution is a scalable, strengths-based intervention using community health workers to facilitate advance care planning in Medicaid-funded assisted living programs.

Findings

Residents engaged in advance care planning discussions through structured sessions with community health workers.

ACP preferences were effectively communicated to care teams, addressing critical care gaps.

A sustainable model for integrating ACP into assisted living programs was developed and tested.

Abstract

Medicaid-funded assisted living programs (ALPs) provide essential support for under-resourced older adults who wish to age in place. However, these facilities lack structured support for serious illness management and advance care planning (ACP). As a result, residents experience significant health-related risks, including social isolation, unaddressed medical needs, avoidable hospitalizations, and premature nursing home placement. In this presentation we will present the findings from “Someone to Talk To,” a community health worker (CHW)-led intervention designed to facilitate serious illness conversations and introduce ACP among ALP residents. Through a five-year partnership with three NYC-based Medicaid-supported ALPs, qualitative research involving 75 low-income older adults and focus groups with staff and administrators major care gaps were identified. A resident-led Community Advisory Board (CAB) informed program development, emphasizing a strengths-based approach that prioritizes autonomy, trust-building, and meaningful engagement. “Someone to Talk To” pairs residents with CHWs under nurse supervision for three structured one-hour sessions addressing medical and social needs. The intervention incorporates the PREPARE for Your Care program, an evidence-based ACP tool designed for low-health-literacy populations. Key outcomes include: 1. Resident engagement in ACP discussions 2. Communication of ACP preferences with care teams 3. Development of a scalable, sustainable model for ACP integration in ALPs This pilot study assesses feasibility and “lessons learned”, laying the foundation for a broader implementation strategy to improve ACP engagement among low-income, high-risk older adults in ALPs.