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Systems of Care 101: A Cross-Sector Orientation for Practitioners Working with Older Adults
August 19 @ 12:00 pm - 1:30 pm
Register for the webinar here.
Location: Zoom, hosted by UC Law SF (Will be recorded and available to registrants)
Description
Older adults navigate a complex web of systems — health and long-term care, housing, and social services — that are often designed, funded, and delivered in silos. Practitioners working in one part of this landscape often have limited visibility into the others, which can create gaps in referrals, care coordination, and advocacy.
This 90-minute online orientation is designed for practitioners who are already working in or adjacent to the aging field but have not had formal exposure to other systems of care. Whether you come from a health or long-term care setting, a housing or community development role, a legal or advocacy background, or community-based social services work, this session will give you a shared map of how the systems fit together, what each one covers, how it is funded, and where the seams and gaps are. No prior expertise across all systems is assumed.
The session will describe national frameworks applicable to practitioners in any state but have special focus on California programs. Resources available in any state will be provided.
Attendees will be encouraged to attend an in-person, full day convening on Wednesday, September 23rd at UC Law SF titled “Aging Well: Health, Housing, and Justice in California.” Free registration by September 1: https://www.uclawsf.edu/event/aging-well-health-housing-and-justice-in-california/
Learning Objectives
By the end of this session, participants will be able to:
- Describe the need for and role of long-term care supports and services among older adults. Explain the critical distinction between Medicare and Medicaid (Medi-Cal in California) with respect to long term care coverage and why it matters for older adults and their families.
- Describe the continuum of long-term care supports and services— from home and community-based services to skilled nursing facilities — and explain how it is accessed and financed.
- Identify the major housing options for older adults, including subsidized, supportive, and age-restricted housing, and explain the funding and eligibility landscape for each.
- Identify the structure and key services of the aging services network under the Older Americans Act.
- Share an example of how these systems intersect and create gaps in care for older adults.
- Apply a cross-system lens to their own practice by identifying at least one referral pathway or coordination opportunity outside their primary area of work.
Agenda
| Time | Segment | Description |
| 0:00 – 0:05 | Welcome & Housekeeping
Sarah Hooper, UCSF-UC Law SF |
Facilitator introduces the session and speakers, reviews Zoom logistics, and sets expectations. Brief poll: participants indicate which system they know best. |
| 0:05 – 0:15 | Setting the Stage: Why Systems Literacy Matters
Sarah Hooper, UCSF-UC Law SF |
Opening framing on why older adults frequently fall through the cracks between systems. Overview of the systems to be covered and how they relate to one another. Share medical-legal partnership story from hospital setting of foreseeable, avoidable conservatorship and how upstream gaps in health and LTSS, housing supports, and social-legal care led there.
|
| 0:15 – 0:35 | Section 1: Long-Term Care Supports & Services
Jarmin Yeh, UCSF |
Overview of the long-term care continuum: home health, personal care, adult day services, assisted living, memory care, and skilled nursing facilities. Explains how long-term care is funded — Medicare covers short-term skilled care only; Medicaid (Medi-Cal) is the primary payer for ongoing long-term care, but requires meeting income and asset eligibility thresholds. Covers basic terms and concepts in Medi-Cal, e.g. Medicaid spend-down and recovery, HCBS waivers. Name key integrated care models such as PACE.
|
| 0:35 – 0:55 | Section 2: Housing for Older Adults
Lauren Carden, Justice in Aging |
Overview of the housing landscape, covering the continuum from independent community living to housing with services. Covers key program types: HUD Section 202 Supportive Housing for the Elderly, Section 8 / Housing Choice Vouchers, Low-Income Housing Tax Credit (LIHTC) properties, Naturally Occurring Retirement Communities (NORCs), assisted living, and continuing care retirement communities (CCRCs). Explains eligibility at a very high level. Includes a brief Q&A via chat.
|
| 0:55 – 1:10 | Section 3: Social Services & the Aging Network
Kelly Dearman, Executive Director, Department of Disability & Aging Services |
Introduction to the Older Americans Act and the national aging services network. Covers Area Agencies on Aging, their role in local planning and service delivery, and the services they fund: nutrition, transportation, caregiver support, benefits counseling, and legal services. Name required vs optional services in OAA.
|
| 1:10 – 1:20 | Where the Systems Meet — and Where They Don’t
(Panelists to discuss and identify examples) |
Facilitated discussion on the intersections and gaps: What happens when an older adult is hospitalized, has need for more support than they are getting in the home, has some cognitive impairment, and is struggling financially? Who coordinates services when someone is housed but isolated? When does a housing problem become a legal problem? Choose one or two brief case vignettes to make the systems concrete and show how cross-system knowledge changes the response.
|
| 1:20 – 1:27 | Cross-System Referral & Coordination in Practice
Sarah Hooper, UCSF-UC Law |
Practical takeaways: 1) proactive, structured screening if possible, and if you screen you must intervene 2) vetted resources- don’t Google/AI search for elder resources and why. Lean on aging network first. How to find your local AAA, how to use Eldercare Locator, HUD’s resource locator, BenefitsCheckUp, LawHelp and ClarityPro and what to ask when making a cross-system referral. Systems map from Lauran Hardin’s group. If referring to private, paid resources what to consider to protect the elder against exploitation. 3) standardize documentation to improve intra and cross-team communication (when ethically permitted) Participants share one insight or referral gap from their own practice via chat. Call out medical-legal partnership as one pathway/model.
|
| 1:27 – 1:30 | Closing & Resources
Sarah Hooper, UCSF-UC Law |
Facilitator summarizes key themes. Participants are directed to a resource list (shared in chat and via follow-up email). Include DCA, CAPCT trainings. Evaluation link shared. Invite them to register for the Sept convening for deeper discussion with California systems leaders and practitioners. |
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