NORC-Health Care Linkages | Archived


Five NORC-Health Care Linkage projects received implementation support:

Samuel Field Bay Terrace YM & YWHA
Henry Street Settlement
Lincoln Square Neighborhood Center
Montefiore Medical Center
Spring Creek Community Corporation

Read more about these grants/projects.


The United Hospital Fund, in collaboration with the New York Community Trust, established the NORC-Health Care Linkage Project in 2003 to develop and strengthen effective linkages between NORC-Supportive Service Programs (NORC-SSPs) and key health care providers serving their communities. The $400,000 project builds on lessons from the Fund's Aging in Place Initiative.


For the past three years, through a combination of coordinated grant making, program development, technical assistance, and training, the Fund's Aging in Place Initiative (AIPI) has guided the development of the city's 27 NORC-Supportive Service Programs in housing developments in which 46,000 seniors have aged in place.

Staffed by teams of nurses and social workers, these programs are partnerships between a housing organization, health and human service providers, government, and other funders to organize and locate a range of services on-site where seniors live to engage them before a crisis, promote healthy aging, and respond to the changing needs of the communities' older residents as they age in place.

While there has been considerable progress in the last decades in the development of community-based service systems for seniors, effective linkages with the health care system (hospitals, community physicians, and free-standing health centers) remain hard to achieve and are more the exception than the rule. In the course of the Fund's work with the city's NORC programs, the lack of effective linkages with health care providers emerged as a significant problem for programs trying to provide coordinated and integrated care for seniors with constantly changing health needs. Where linkages do exist they are at best erratic, tending to occur episodically around individual seniors rather than systematically, bringing the full extent of resources each system has to offer to address both individual and community-wide health issues.

Few NORC programs know when a senior in their community is hospitalized (unless they were involved in the admission), and yet they possess important client information and resources that can assist in the discharge planning process.

Similarly, few physicians practicing in private offices or free-standing health centers know about the NORC programs servicing their patients. Those that may be aware of them do not necessarily know how to work with the NORC programs' nurses and social workers so that the care and management of their patients can be complemented and reinforced in the community.

Project Strategy

To address this problem, in June 2003 the Fund, in collaboration with New York Community Trust, established the NORC-Health Care Linkage Project. Given the more mature capacity of a number of the NORC-SSPs, and a heightened awareness by health care providers of the need for better information-sharing, management, and problem solving, it was a favorable time to test new models and strategies.

The three-year project includes three phases: planning, implementation, evaluation. It combines strategic grantmaking with technical assistance, analytic work, and evaluation to support and test new linkage methods.

In November 2003, the Fund and the New York Community Trust awarded $30,000 grants to six projects to support planning, developing, and pilot testing new linkage methods. Three of the projects sought to link the NORC program to hospitals; two to form linkages to area community physicians; and one to a primary health care clinic.

In October 2004, the Fund and the New York Community Trust awarded an additional $150,000 in grants to five projects for full-scale implementation.



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