Introduction: The dramatic increase in life expectancy and number of older adults living in the community with limited functional ability has contributed to a significant rise in the need for rehabilitation and reablement services among older adults. Many countries are investing resources to develop effective policies, strategies and models to meet the growing needs of older adults, in varying states of functional decline, for services that support physical, social and cognitive functional ability. One strategy focuses on the synchronization of different service systems and providers on a regional basis. This leads to improved quality of treatment; greater access to and utilization of services; optimizing functional ability potential; and prevents decline. In Israel, several factors lead to low utilization of rehabilitation services within the community. These include a complex and splintered bureaucratic process, lack of collaboration between service providers, and low client awareness and motivation. Therefore, JDC Israel Eshel and the Ministry of Health piloted the Regional Approach to Geriatric Community Rehabilitation program.

Goals: Increase the utilization of existing rehabilitation and reablement services within a given geographic area by strengthening collaboration and efficient planning, through a GIS database of services and needs, among all regional rehabilitation resources.

Methods: Construct a regional system through a three-part process: 1. Develop a self-assessment tool and GIS database of available services that interface to provide personalized action plans; 2. Establish a multi-sector regional partnership comprised of health, social service and community organizations to promote consistent use of all services; 3. Promote a geriatric rehabilitation approach among professionals in the region.

In the first phase of the project, relevant organizations were identified and recruited; common challenges were identified; an integrative work plan was drawn up; a GIS database of needs and services was built; and a functional self-assessment tool and professional training modules were developed.

Summary and conclusions: From the first phase results we conclude that (1) a platform for cross-sector meeting and planning is an effective way to harness the commitment of professionals and services for older adults with functional decline living in the community and (2) community-dwelling older adults are interested in assessing and addressing their functional abilities but do not have the resources.

This program has the potential to improve patient experiences, improve population health (functional ability) and reduce treatment costs for services.