Appendix.

Selected Evaluation Questions and Thematic Findings.

1. What are the necessary program components for program to be successful?

• Common goal/win–win situation

• Shared language*

• Consistent point person at the residence

• Knowledge of care transitions/follow-through

• Consistent team* of RN, MSW, and MD

• Consistent and frequent communication*

• MD understanding role as the “go to person,” not a figure head

• Knowledgeable and available SW

• Professionals with knowledge of aging issues

• Knowledge of community networks

• Trust*

• Knowledge of how human services systems work

• Physicians doing convenient house calls in a uniform way that is reimbursable

• Engagement of leadership and members of both organizations

• Concentrated area of consumers

2. What are the barriers to program delivery?

• Language barriers/cultural backgrounds among residents and staff

• Language barriers/culture between health care and housing provider staff

• Resistance from primary care physicians (PCP)

• It takes time to build trust*

• Lack of financial resources

3. What factors external to the program influence program delivery?

• Perception of home visits as not efficient*

• Level of trust* and transparency among providers

• Uneducated population of seniors who do not use primary care as prevention

4. Have there been any unanticipated consequences of the program (good or bad)?

• Discover underlying health conditions before they get more serious

• Broadened awareness of how social issues impact health*

• Awareness of importance of community-based providers

• Housing plays a huge role in health care for seniors

• Awareness of care fragmentation and confusion in senior population

^*additional process components