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The Scopewell Podcast features candid conversations with leaders transforming how organizations think, operate, and grow. Hosted by James Leuthe, CEO of Scopewell Solutions, the podcast explores leadership, AI, digital transformation, and the operational realities of turning ideas into measurable impact. Each season goes deep into a different industry and the challenges of driving meaningful change inside complex organizations.
speaker-0 (00:03)
Hello and welcome to the Scope Well Podcast. My name is James Leuthe. Today we're going to talk about reimagining aging care on Chicago's South Side and building a repeatable model. Joining me for today's discussion is Estrelitta Harmon, Executive Director of the Center for Better Aging, CBA.
Estrelitta, thank you so much for joining me today. Thank you. Perfect. Well, to get us started, can you please share a bit about yourself and your work in healthcare?
speaker-1 (00:23)
for having me.
Yes, so my background is actually public health. I've spent a majority of my professional career working in government, actually leading large-scale initiatives such as Get Covered Illinois and the state's ⁓ grant program initiative for the Department of Public Health. but I wonderfully made a transition into consulting ⁓ later on in my professional career and really got exposure to a wide range of pro of professions and projects and
Wonderful things happening across the nation. ⁓ and my current initiative, ⁓ my organization that I run, the Center for Better Aging, came to me as an opportunity that really aligned with the work that I was doing at that time and resonates because it's supporting a community where I live, work, and play.
speaker-0 (01:16)
Thank you so much for that background. So let's go deeper into the community that you referenced, the Southside of Chicago. So the life expectancy gap between some north side and south side of Chicago communities can be as wide as 30 years. Can you break that down for the listeners? Why does that gap exist and what does it actually demand from a care model?
speaker-1 (01:38)
Yes. So, you know, there's the saying that your zip code ⁓ is more important or more critical to your health outcomes than your genetic code. ⁓ in Chicago, that is very relevant where we do see a difference in life expectancy ⁓ just because of the zip code where someone lives. And so in the south side, that could just be two miles away from another community. you know, on the north side, we do see dozen years.
two dozen years in difference in life expectancy. And that isn't because of their health. Mostly it is because all of the other things. So it's it's we're not seeing that life expectancy gap because of a doctor or someone's engagement with their doctor. ⁓ it is less about the things that they are doing themselves and more about the conditions in which they find themselves, honestly. ⁓ and so that matters because typically we address the life expectancy gap through healthcare.
We're trying to understand how can we better get them connected to primary care? How can we ⁓ address maybe their comorbidities or they they have diabetes or hypertension? And that is really just a band-aid because healthcare really only informs about 20, maybe 30% of our health outcomes, where the remainder is really the social determinants of health, all the other things that impact our daily living. So if we're only addressing health care alone, we cannot move the life expectancy gap.
we can't reduce the life expectancy gap in a way that's meaningful and certainly won't see the individual health benefits on the scale that we need to to really improve health outcomes over time. So it has to be the whole person that you look at, it has to be the whole communities. You have to look at the conditions in which they find themselves to really be able to address the life expectancy gap. And especially in Chicago, understand how that varies from neighborhood to neighborhood and community to community.
speaker-0 (03:32)
Can you say a bit more about what you mean about whole person care and then also foundationally what it means to age in place?
speaker-1 (03:41)
Yeah, so whole person care recognizes that you need to support the whole individual. And so while health is one component of us, ⁓ we also have mental health, right? We also have the daily living activities. So food, right? Do we have a place to live? Are we safe? Do we have access to transportation? ⁓ it recognizes that there's more to our well-being than just our health. ⁓ and so
Treating an individual's health is wonderful and has benefits, but that won't actually address all the other things, all the other impacts of our well-being that exist outside of that. And so aging in place is ⁓ really closely aligned with whole person care because it is the concept of allowing and really supporting a model where people can age safely and independently in their homes and in their communities. It means that they're connected to their communities.
⁓ and that they don't have to transition to an institution, like a nursing home in their later stage of life. ⁓ it is incredibly important in a city like Chicago, where one in six individuals are already over 60 plus. So where you have a higher concentration of older adults, you need to support a model like Aging in Place so people can stay in their homes, stay in their communities, and stay connected. The system cannot even absorb all the people who are over 60 plus ⁓ if they needed to transition to.
an institute an institution like a nursing.
speaker-0 (05:09)
You point out ⁓ such a critical you you make a lot of great points there. So with that with that as a foundation, how would you describe what CBA is building to address these challenges?
speaker-1 (05:22)
Yes, so ⁓ I'm gonna try to describe it quickly, easily, anyway that's to in a way that everyone can understand. ⁓ you know, the system is not designed to actually ⁓ operate together, right? We have healthcare, we have organizations that provide transportation or food. The Center for Better Aging exists to fill that gap and to connect them in a way that's seamless. And so I like to design, I like to describe what we're designing as an ecosystem.
Because there's all these pieces that already exist. We are not redefining the model of how people are accessing or the the services that they're actually accessing. We're just making that seamless. We're making the system that already exists work better together. And so this is really a model that connects all the pieces that actually impact the whole person, right? Food safety, access to housing and fresh food and produce, and access to healthcare.
into a single place and we are that convener. We're the place that one person can come or a family can come and know that they will get connected to all the resources to help them support ⁓ their aging journey.
speaker-0 (06:28)
All that complexity and disconnection, there bound to be some friction points where people ⁓ are falling through the system. What does that actually look like for a real person in this in the Southside and how like you actually support them on the day to day?
speaker-1 (06:43)
Yes. So I can actually walk through what that looks like right now in the safety net where our clinic is physically located. ⁓ We are in Englewood. ⁓ When you look at the studies that talk about life expectancy gap, it was the example of the lower life expectancy in Chicago at 62.3 years. And so we know that there's already limited resources. There's already, ⁓ you know, a a gap that needed to be filled in terms of navigating those individuals to care.
And so the the status quo experience is that an individual may actually go to a hospital, typically you know, for urgent care or immediate care through an emergency room. ⁓ if they're if they're feeling the need to go for a prescription refill, right? Or if something actually physically happened to them. They may go to that ER, they may actually see a doctor, they may be admitted, they may even be prescribed some medication, ⁓ and then they leave. Now.
In the same scenario, maybe they actually are keeping track of their well-being and they go to their primary care physician. Maybe they have one and actually do engage. They go a single time, they see the provider. ⁓ they may get some feedback in terms of things that they can do to improve their health, and then they are sent home. Now, the reality is we have to actually understand what happens once somebody leaves. What happens when they get home? Do they have the support that they need to actually meet the the
the diabetic ⁓ food program that they were prescribed by their provider? Do they have the resources to get that prescription refilled once they run out? ⁓ do they even have a home that's accessible? Maybe they left the emergency department in ⁓ in a wheelchair. Are they able to actually return into their home? the system isn't actually designed currently to support them beyond what the services that's being provided. Now that's just in the typical health healthcare setting. ⁓
But all the other things that are, you know, needed to actually be healthy and whole, the individual is then responsible for figuring out themselves for the most part. They would then have to figure out calling their their provider, their payer to get transportation to or from an appointment. They would have to call, you know, the food deposit port food depository to get ⁓ meals on wheels. they would actually have to maybe connect to a social worker to get some other support, maybe like a job assistance.
But that isn't something that the hospital or a single entity can do all of those things for them. And so this model really takes all of that segmented, siloed engagement that people are really tired of, honestly, and makes it more seamless. And so in the Center for Better Aging model, if an individual goes to the emergency department, if they agree that they'd like to become a Center for Better Aging member, ⁓ when they are discharged, they will get a phone call. They'll get
A reminder not only about their appointment, their follow-up appointment, which will be scheduled before they leave, but they will also have the option to have someone come to their home and check on them. And we call those welcome home visits. because it is not enough to just send somebody on their way. We need to know that you are actually doing well to prevent you from going back into the emergency room. And so we provide that welcome home visit. Now, if they're in the clinic and they don't show up to their appointment, a big problem, right? ⁓ with no shows.
We actually can send someone out to that home to to go find them or to that community to go find them to check on them. It's more than a well-being check. It's actually ensuring that they have what they need to make it to their appointments. And even beyond that, we focus on education and prevention. So we do a lot of ⁓ community-facing events. We go find the people where they are. So if you are at church, we're bringing resources to you so that you don't have to depend on going to the EDE or to your doctor to ask a question.
you can actually find resources right there in the community. And so we're that's just a a sliver of the things that we're doing. ⁓ but it really is intended to wrap services around the individual as opposed to them having to go out and find them themselves.
speaker-0 (10:48)
Ashley, describing a great deal of effort and coordination. You're going out into the community rather than waiting for people to come to you. What strategies or approaches have you found work best to get people engaged? And how are those efforts connecting to the broader goal of keeping older adults healthier longer?
speaker-1 (11:09)
It's easy to have the concept, right, of a whole person care model or ⁓ a transformative, you know, new way of caring for aging adults. but it is one is a whole different thing to come into a community and build the trust ⁓ and to actually deliver on what you promise. And so our approach has been primarily boots on the ground, people going into the community and finding older adults in trusted places where they already are.
And that may be, like I said, a church, a senior building. ⁓ in in the city of Chicago, we have what we call senior satellite centers that are run by the city of Chicago. ⁓ it may be a grocery store. ⁓ or we go door to door and hang up door hangers. one, because we're a new organization, was really important for people to understand who we are and that we were here for them. But two, to see us coming back. So this was not a, hey, we're here.
And you may hear from us one time, we're gonna make sure that you know we're here. We're gonna make sure that you and your family know that we're here and that you know what to expect when you come to the Center for Better Aging. And that is dignified care, that is people who are excited to help you and support you on your aging journey. That is access to all of the services that you need to stay healthy and whole. and so mostly we have focused on going and finding the individuals where they are and then earning their trust.
for to bring them to where we are. ⁓ because that isn't just something that we take for granted. We don't expect them to just want to to switch ⁓ maybe their decades-long experience with their providers or the way that they've been managing their care. ⁓ we're really just earning their trust so that they can believe in the work that we're doing here and also know that we're there to support them.
speaker-0 (12:52)
And to do this work, you work with a lot of collaborative partners and working organizations. They're all moving at different speeds with different cultures, different capacities. What has that experience been like? And how what have you found has been most helpful to lead through through that complexity?
speaker-1 (13:13)
Well, you know, it's interesting because you know, the the concept of collective impact and collaborative work ⁓ is not novel. I think we all know the importance of it. It is how we can move more ⁓ robust initiatives forward. ⁓ the reality is that it it is ⁓ a very large ship that you're steering when you have more people on that ship. one of the benefits though, I will say is that you know, we've been able to really
be aligned on the mission. I think with a large collaborative, so we have five, in addition to sit Center for Better Aging, five other contractual partners, but we work with 40 plus organizations to actually move this initiative forward. ⁓ but the consistent thread line is that we are all committed to the vision. We're all committed to the mission. We all believe in the transformative model that the Center for Better Aging is able to provide. Now, what that actually looks like day to day is that you do have to navigate.
the different complexities, ⁓ the different maturities of all the organizations that are in that collaborative. And so we work with organizations that are over 130 years old and as recent as, you know, two years old, and everyone in between. And so that means that their ability to adopt a new workflow or to integrate with your data platform are all going to vary as well. And what really allows that to move forward is structured.
You've you've got to actually have some commitment to ⁓ an organized structure in which that you know you can actually have them plug into. ⁓ but then you also have to be flexible and understand that the organization that is a hundred plus years old is going to move more like a cruise ship and the startup is gonna move more like you know a jet ski. And ⁓ how do you manage the people in those processes? ⁓ all of the ways that they're plugging into your model.
And then continue to move everything forward in a cohesive way. And so it is a daily activity of really making sure that you're bringing people along. So it's more than just selling them on the vision, but bringing them along in the journey so that they also understand how to manage that change within their own organization.
speaker-0 (15:25)
Building something this complex, it takes time to show results. How do you think about sustainability and making sure this work has long life?
speaker-1 (15:36)
It's something that I think about all day, every day, because it is so needed. This model, I I know that it is so needed, and the people who we've supported believe it as well. They've seen how their individual lives or their family members' lives have been transformed by having access to a model that truly identifies all of their needs through a whole person care ⁓ model. And so one of the things that you have to do is really understand, ⁓
know how this sits in terms of the revenue structures that support it. ⁓ we are primarily grant funded right now. And so when you're grant funded, you have to show ⁓ outcomes early and often. And so ⁓ right now our environment is really around measuring how do we demonstrate that? How do we demonstrate value early and often in a grant environment? And that is through really looking at more of those like leading metrics, right? Like
How we measuring engagement? How are we measured accessibility? ⁓ how are we measuring, you know, things like did they go to the clinic? Did they actually go to the community events? And so that's allowing us to actually see are are we reaching the people? Are we engaging the people? And are they sticking? Are they coming back? ⁓ and and what in what and in what ways are they coming back to seek support? and so that because of the structure of our funding, we've really had to do that early and often type of thing. And even while we're still trying to
work towards actual health outcomes, we're able to demonstrate progress, right? We're able to see that people are accessing care. They are ⁓ utilizing the ED less. they are actually going to the community events and engaging in huge numbers. we had more than 18,000 touch points last year. ⁓ this is as an organization that's only two and a half years old. ⁓ so that's really what we've leaned on is really ⁓ leading towards the trajectory of being able to
to talk about those life expectancy gap decreases and to talk about the health outcomes ⁓ later down the road. But right now we're showing ⁓ our progress in the way that we can. And all that speaks to sustainability because the new funders that we pursue will want to know what we've done and how we've impacted the communities and that we're being thoughtful and how we do that in a collaborative way.
speaker-0 (17:50)
They'll wanna know what you're done what you've done and what you're doing. And one of the things that you're doing that is ⁓ really exciting, I think, is the home modification program. Can you talk about that?
speaker-1 (18:03)
We actually conduct what we call health risk assessments. And the top three social needs that we identify are transportation, housing, and food. Consistently, those are the top priorities when people say that they need support. We provide transportation. We were able to, you know, check that one off. ⁓ and we are ⁓ looking now and we also provide some food security.
But we're looking now to move into a way to really address aging in place through home modifications and repairs. So while we aren't yet providing housing for those who may be transient or have unstable housing, we are looking to really support people in being able to stay in their homes. And so what that looks like early on is that we're going to develop a three-tiered program. The first is just giving people things that they need. And we do that currently through our durable medical equipment program called DME and me.
Where people, if they need a walker, they need a blood pressure cuff, we give it to them, but those are medical devices. So now we're going to transition it to the home so that people can be safe in their home. If they need a non-slip floor mat, they need a grab bar, they need light bulbs. We're gonna get those things delivered to them so that they can feel safer in their home. The second tier is actually ⁓ actually connected to our workforce pillar in terms of utilizing apprentices to do a little bit more ⁓ hands-on things within people's homes. And so that may be installing.
window clings when it gets to the winter when the you know you want to reduce the draft in the home. we're gonna be preparing now for a hot summer. So installing air conditioners, things that require some manual labor, but not a skilled worker. ⁓ but we know those things are incredibly important for aging adults who are also more isolated in Chicago. And we have one in three who live alone in Chicago. So what does it mean to live by yourself, but then need to install an air conditioner? ⁓ if you don't have that support,
then you are looking to maybe you have to go to a cooling center during the during the summer. And so we're really helping to keep people connected to those resources and allow them to choose what can help them be safe at home. And then the third tier is actually utilizing skilled and and trained workforce in collaboration with an organization called Home here in Chicago, H-O-M-E. We'll actually be doing home modifications and repairs for homeowners. And that could be replying ⁓ restoring a a broken floorboard.
Or it could be installing a ramp, but things that actually allow them again to modify their home, to support aging in place, to reduce falls, and to keep them safe at home.
speaker-0 (20:36)
Looking ahead more broadly, if this overall model works the way that you envisioned, what does that mean for age and care beyond the Southside?
speaker-1 (20:44)
Well, I am so excited. One, that I know it will work. And two, that there are more communities like the ones that we serve. We serve a 22 Zip Code area in the south side of Chicago. That is actually a very wide range of health disparities, food access, needs. so we're already demonstrating through our model, even in diverse communities, ⁓ that
Coordinated care matters and that access to those resources matters. And we know that this model can be replicated. We are connected to a safety net hospital in Chicago, but there are lots of safety nets. There's lots of fairly qualified health centers. There's lots of community health facilities that also can't go beyond their four walls. And so we are that solution. We're the ability to go beyond the four walls of the hospital or the health institution into the communities.
That need the resources brought to them in a way that's really thoughtful and intentional. And so I'm excited that ⁓ we're essentially piloting the fact that this can work, that collaboratives working together through, you know, shared data, through agreements to really move towards ⁓ a single mission can do it, that it's possible and ⁓ that it's something that can be scaled and replicated. So yeah, we're gonna use the outcome data to to demonstrate that other
other communities, other states even can benefit from the Center for Better Aging's type of model.
speaker-0 (22:11)
Well, I think that's a great note to end on. Estrelitta, one thank you for your time and insights today. We appreciate you joining us on the Scope World Podcast.
speaker-1 (22:19)
Thank you
so much, James.