RUSH Generations Evidence-Based Program Infrastructure

To learn more about RUSH Generations and read our newsletters and annual reports, go to
www.rush.edu/rush-generations

The Programs We Offer

RUSH Generations offers a suite of evidence-based group programs that are vetted, extensively studied
for effectiveness, and endorsed by the National Council on Aging. We offer these group workshops at
RUSH, throughout the Community, as well as some virtually and telephonically. We offer all our group
models in both English and Spanish.

Our team offers a suite of evidence-based programs encompassing chronic condition management, pain
management, emotional wellness, cancer survivorship, balance, and falls prevention.

All programs are co-facilitated by individuals with lived experience who have gone through extensive
training. All leaders are monitored to ensure program fidelity and are supervised by LSWs and LCSWs to
handle challenging group dynamics and to ensure the appropriate escalation of social needs.

Workshop leaders come together annually for a retreat, which reinforces fidelity and helps leaders meet
each other and improve their facilitation skills. There is also an annual in-service that includes
requirements and other trainings. Our workshop leaders are also able to participate in additional
professional development training such as Mental Health First Aid, harm reduction and narcan
administration, health at any size and body positivity, adaptations for low vision and blind participants,
and adapting programs for individuals with severe and persistent mental illness.

Figure 1: CDSME and Falls Prevention Programs

CDSME Programs Falls Prevention Programs
• Chronic Disease Self-Management Program • A Matter of Balance: Managing Concerns
“Take Charge of Your Health” about Falls
Tomando Control de su Salud Un Asunto de Equilibrio: Controlando el
• Diabetes Self-Management Program “Take Temor al Caerse
Charge of Your Diabetes” • Fit & Strong!
Manejo Personal de la Diabetes ¡En Forma y Fuerte!
• Chronic Pain Self-Management Program • Tai Chi for Arthritis and Fall Prevention
“Learning to Live Well with Chronic Pain” Tai Chi para Artritis y Prevención de Caídas
Vivir una mejor vida al pesar del dolor • Bingocize!
crónico.
• Cancer: Thriving and Surviving
Cáncer: Sobreviviendo y Triunfando
• Walk With Ease
Camine con Gusto
• Wellness Recovery Action Plan (WRAP) and
WRAP for Healthy Aging
Plan de Recuperación del Bienestar
To Best Serve our Community, We Must Enhance our Program Delivery
Figure 2: Life Expectancy Gap in Chicago
As explained in the next section, our service area is Neighborhoods
comprised predominantly of low-income older adults of color.
The diverse and vibrant neighborhoods we serve show the
strength and resilience of communities of color in the face of
historic disinvestment. The West Side is home to predominantly
Black neighborhoods with strong church and communities, as
well as home to the highest concentration of undocumented
immigrant individuals within the State of Illinois (Rush, 2022;
Stanley and Lange-Maia, 2020), aided by motivated networks of
promotoras de salud.
Because of the barriers created by decades of structural
racism, health outcomes in the West Side have led to a
measurable gap in life expectancy. As noted in Figure 2, in
Chicago’s downtown Loop, a baby born today has a life
expectancy of 80 years. In East Garfield Park, a few miles away
from Rush, a baby born has a life expectancy of just 66 years. This gap is largely attributed to the burden
of chronic health conditions.
The evidence-based group programs we offer provide an opportunity for residents to build
community, raise awareness, and build skills to help them navigate the health care and social service
delivery systems they have been systematically excluded from. Our programs build off the strengths of
the community, training CHWs, CBO staff, and other leaders from the community with lived experience
that are from and reflect the neighborhoods we serve.
To ensure that the programs we offer reach those who need it most—those who suffer the
greatest burden of falls and chronic conditions—we have enhanced our evidence-based program
delivery through the leadership and alignment with social work and social care. We do this through
addressing the social determinants of health (SDoH), motivational interviewing-based recruitment, and
continued relationship building.

Addressing Social Determinants of Health

While the workshops we offer are incredibly effective in improving health literacy and health confidence,
decreasing social isolation, and increasing patient activation, individuals who live with complex health
and social needs may not be able to prioritize attendance in these groups. The individuals in our service
area live complicated lives, consistently facing barriers to their health, wellness, and overall wellbeing.
We cannot expect an individual who is struggling to pay their rent, affording their medications, or putting
food on the table to take the time out of their day to participate in a 2-hour workshop. And when, in the
face of these many barriers, if participants are able to show up, it shows the immense dedication they
have to improving their health.
For this reason, during our recruitment and throughout facilitation of groups, we are identifying,
escalating, and addressing social needs. As referred patients or current participants express SDoH
needs such as food, housing, utilities, insurance access, medication access, transportation,
employment, or safety, we have protocols in place to help them. With individuals’ consent, we escalate
their issues to social care management services, provided by social workers, community health workers
(CHWs), and/or nurses, including those on our team. Through addressing these social needs, we are
eliminating barriers to participation in the programs and building trust and rapport with the community.
Figure 3: West Side Neighborhoods by Hardship Index Our Service Area – Intentionally Reaching
those Most Heavily Burdened by Chronic
Conditions and Falls

The RUSH University Medical Center

service area includes 12 West Side neighborhood
and 5 suburban townships. The West Side
neighborhoods span over 11 zip codes (Figure 3).
West Side residents are predominantly Black
(51.6%) and Latinx (30.9%), and, due to
structural racism and continued disinvestment,
severely lacks resources for health and aging
(Thompson, 2021; Rush, 2022).
According to hospitalization and
emergency department (ED) admission data
analyzed by the Rush Center for Excellence in
Aging (CEA) from the Illinois Department of
Public Health (IDPH), 2,625 adults 55 and older
were admitted to the ED or hospitalized because
of a fall in 2020 and 2021. These admissions and hospitalizations account for more than 9% of the total
hospitalizations in Chicago, significantly disproportionate to the percentage of seniors who occupy the
West Side vs. the rest of the city (Stanley, 2022).
The older adults of the West Side also account for a disproportionate percentage of older adults
living in high hardship areas in the City of Chicago (Laflamme et al., 2019). As explained in the CEA
report, older adults from these high hardship
West Side neighborhoods are more likely to Figure 4: Hospitalizations and ED Admissions for Falls in the
experience a fall, and more likely to be West Side by Neighborhood (2020 & 2021)
admitted to a hospital following a fall. Figure Humbodlt Park and N. Austin (60651) 188 55
4 shows the incidences of ED admissions and Logan Square & Humboldt Park (60647) 188 35
hospitalizations for falls across each
neighborhood. In addition to the ED and Austin (60644) 278 58
hospitalization data, Rush and the Center for Belmont Cragin (60639) 223 46
Community Health Equity completed a study Archer Heights & Brighton Park (60632) 195 33
in 2021 (Lange-Maia et al., 2021) that
researched the physical function of Black
E & W Garfield Park (60624) 143 50
midlife older adults through church-based N &S Lawndale (60623) 276 60
screenings. This study found an overwhelming West Town (60622) 110 30
25% of the 423 participants ages 40 to 59 had Near West Side & E. Garfield Park (60612)
205 54
physical limitations placing them at increased
fall risk due to health conditions.
Pilsen (60608) 258 59
In addition to the disproportionate Near West Side (60607) 69 12
prevalence of falls experienced by the West
Total Hosp Total ED
Side, these neighborhoods also have higher
rates of chronic condition burden, as demonstrated by instances of emergency department admissions
and hospitalizations. In 2021, the Illinois Department of Healthcare and Family Services (HFS) published
an in-depth Community Needs Report analyzing epidemiologic data from the West Side of Chicago
(Austin, Belmont-Cragin, West Garfield Park, East Garfield Park, North Lawndale, Little Village, Pilsen,
Humboldt Park, West Town, and the Near West Side). Analysis of the uninsured and Medicaid-insured
patients of the six FQHCs serving the West Side of Chicago showed that up to 36% of their patients had
poorly controlled A1c scores or had no test that year-a major disparity compared to 14.6% nationally
(CDC, 2020). And the rate of diabetes-related hospitalizations for the West Side was 496 per 100,000
residents, more than triple the national rate of 158, and was 2.5 times higher than the national average
(673 per 100,000) for Medicaid recipients 65 and older (Thompson, 2021).
In addition to 25.2% of the population living under the poverty line, a report from the Chicago
Department of Public Health names chronic disease as the primary driver of lower life expectancy
among Black Chicagoans (Thompson, 2021, CDPH, 2021). These West Side zip codes also are in the top
sextile for both frequency rate and average hospital readmission score for mood disorders (bipolar and
depression), chronic lower respiratory diseases (COPD and asthma), hypertensive diseases, diabetes
mellitus, and liver disease. Data from this Community Needs Report (see Figure 5), shows the lack of
outpatient care that individuals with mental health issues, substance use disorders, and ambulatory
Figure 5: Outpatient Care among Patients Hospitalized
care sensitive conditions (i.e., diabetes mellitus,
(3 months prior and 3 months after hospitalization) hypertension, lower respiratory issues) receive
Prior After both before and after their admissions to the
Ambulatory Care 21.1% 36.6% hospital for those issues. While this data shows
Sensitive Conditions some increased engagement in outpatient care,
Mental Health Disorders 9.8% 14.5% most Medicaid enrollees still do not access
Substance Use 25.1% 42.5.% outpatient care even after hospitalization (Basu et
Disorders al, 2021).

Integration into health care system

RUSH Generations ensures that our evidence-based programs are integrated both into the community
and into the health care system. As part of the larger RUSH University System for Health, with numerous
departments, as well as specialty and primary care clinics, RUSH Generations has worked to enhance
and perfect the ways evidence-based programs are complementary to health care, care management,
and prevention.
• Referral orders integrated into the Epic Electronic Medical Record (EMR) system. Our team
built a referral order so that providers can refer directly from a patient’s chart and verbiage is
populated into the patient’s post-visit handouts and documentation. We provide verbiage to
providers to refer their patients, as well as reach out to the various clinics and departments at
RUSH to socialize the referral.
• Documentation in EMR. As part of our integration into the EMR, our team documents all outreach
to referrals and other patients identified in the community. This way, the entire care team can see
the support we are providing. This infrastructure of documenting our outreach and assessment
has helped build the capacity to bill HBAI codes in the future.
• Motivational interviewing for Recruitment and Retention. RUSH Generations staff receive
formal training in motivational interviewing so that we can apply those skills and concepts to our
recruitment. As part of our outreach and assessment with referred patients and participants
identified in the community, we are assessing current stages of change and adapting our
approach based off that assessment. Through this ongoing relationship building, we are
connecting patients to services and groups that are the best fit for them. Our team authored a
guide on this process here. Through utilization of motivational interviewing, as well as our ongoing
assessment and relationship building, we can serve those who need the services the most,
ensure folks don’t fall through the cracks, and ensure our services are patient-centered and
reinforce self-determination.
• Escalation and social care management of complex health and social needs. As health and
social needs are identified in recruitment or in workshops, we are escalating those participants to
our CHW, social work, nursing, or pharmacy services available through our social care
management departments, which includes SWaCH Community Practice Social Work. We
recognize that falls and chronic conditions, as well as how we prevent and manage these iss ues,
do not occur in isolation and can impact an individual’s ability to engage in, participate in, or
complete a group. If a patient is worried about having enough food to make it through the end of
the week or paying their rent, our workshops are not their priority. (See the figure below of
Maslow’s Hierarchy of Needs). This gives us an opportunity to identify and address those needs,
which helps establish rapport and eliminate barriers to participation, as well as gives us the
opportunity to praise and recognize participants who do come, in spite of their complex health
and social needs. We document our
social needs escalations in the EMR and
track the number of escalations that
occur over time. Our group leaders
receive training in how to identify and
escalate these social needs within our
protocol, as well as how to have
challenging conversations with
participants about the escalation
process and seeking help. We believe by
assessing for and escalating these
 issues, we are providing more holistic care, as well as ensuring that our programs are reaching
those most at need.
• Sustainability through Health Behavior Assessment and Intervention Services (HBAI) As our
team of social workers is already reaching out to patients referred by their providers and
assessing health goals, level of motivation, and health challenges, this places us in an
advantageous position to be able to bill Medicare for HBAI services. As social workers are already
assessing these needs and are actively documenting in the patient record, we have great
headway in building the capacity to be able to bill for these services, as well as the patients’
participation in evidence-based program. This will lead to continued sustainability for the
programs.
• Sustainability through Integration into RUSH’s Community Health Improvement Plan. As a
requirement of the Affordable Care Act, all nonprofit hospitals must complete a community
health needs assessment (CHNA) and develop and implement a plan to address the disparities
and needs found in that assessment through a community health improvement plan (CHIP).
Rush’s CHNA specifically identifies the burden of chronic health conditions and access to health
care as predominant drivers of health inequity in our service area; therefore, we were able to
integrate the implementation of community-based evidence-based group programs into Rush’s
CHIP.
• Continuing to investigate more options for sustainability. Through the Center for Health and
Social Care Integration (CHaSCI), RUSH Generations is consistently advocating and submitting
comments for expansions to the CMS Physician Fee Schedule and other venues to expand
funding and reimbursement for the evidence-based group work provided by CHWs and social
workers.

Integration into the Community

• Offering workshops in community sites. While we do offer some programs at Rush,
telephonically, and virtually on Zoom, the majority of our programs are hosted at community sites
throughout the West Side. As we work with those who express interest in our programs and those
who are referred, we work on finding a workshop that is the best fit for them, both in terms of goals
and geography. For workshops based at community sites, we also address barriers to
participation through our social work and CHW care management services.
• Gathering referrals from trusted community partners. We created a secure referral form so
that partners can refer their patients to our programs (https://bit.ly/RushGenReferral). Our team
then follows-up and begins the assessment, recruitment, and retention process with each
referral. We work hard to establish referral source relationships with community organizations
such as nonprofit organizations, health clinics, faith-based institutions, community health
workers, and community organizers.
• Building Trust with CBOs. Through showing CBOs that RUSH Generations is not going anywhere,
we build long-lasting trust in the community and our partnerships then grow from word of mouth.
The West Side is a tight-knit collaborative community. When a workshop wraps up at a
community site, we always offer other programming we can continue to bring out to them to
benefit their communities. As appropriate, we also connect them to other services and programs
at RUSH, and invite all of our CBO partners to escalate social needs identified amongst their
community members to our team of CHWs and social workers—even if they do not have a
workshop happening. We can also offer Mental Health First Aid, community talks, and can
participate in health fairs.
• Training and building the capacity of community sites and leaders. We offer multiple free
trainings every year in falls prevention and CDSME programming, and we work to recruit members
from the community, including staff and volunteers from the organizations we partner with, to
 become leaders. For sites that train leaders, we support their workshops logistically and with
materials. We provide all of the required materials for the workshops, as well as assist the agency
staff with their promotion, recruitment, retention, and overall coordination of the workshops.

Integrating Participants into a Continuum of Care and Services

• Consistent programming. We offer more than 40 evidence-based programs annually, so it’s
never long until the next workshop. As participants graduate or drop from the workshops we offer,
we continue to follow-up with them to offer other groups and opportunities, as well as to assess
for barriers and other goals. Some participants continue to take multiple workshops throughout
the West Side and at RUSH, becoming a more active and engaged patient and member of their
community. Cross-participation of participants between our exercise and wellness classes, our
CDSME, Falls Prevention, and other programs is high.
• Newsletters and communication. All participants have the option to opt-in to receiving our
monthly e-newsletter and quarterly mailing. For those who decline continued outreach and
assessment can still return to programming as they see fit, and the door is always left open for
them to come back.

Engaging and Empowering Leaders

• Training Community Health Workers (CHWs), Older Adults with Lived Experience, and
People from Community-Based Organizations (CBOs). We are always actively seeking these
individuals to become trained in our evidence-based group models for both CDSME and Falls
Prevention. This involves consistent outreach, integration into the community and community
meetings, as well as proactive outreach to CBOs and community networks. Working with CBOs,
we attempt to align with their goals, scope of practice, as well as the needs of their specific
communities. We create and implement an MOU with each site that we train, which includes how
we support them financially and logistically.
• Providing ongoing enhancement and skill building training, opportunities for connection, and
recognition for leaders to keep them enthusiastic and involved. RUSH offers a quarterly
newsletter for all EBW leaders that includes pictures, updates, upcoming workshops in need of
leaders, and upcoming trainings. This newsletter also includes a thoughtful article about how to
enhance or improve your workshop facilitation—these articles have included topics of mental
health, substance misuse, gender identity and the importance of pronouns, program adaptations
for participants with low vision or blindness, and food insecurity. We also organize ongoing
trainings for workshop leaders to support them and enhance their skills, including fidelity retreats,
in-service trainings. The trainings focus on issues relevant to the communities we serve, including
previous trainings on Narcan administration and harm reduction and navigating conversations in
workshops of religion and identity.
Our Team
The RUSH Generations team is led by a diverse team of competent, motivated, and compassionate
individuals. Our team genuinely cares for older adults and the communities we serve.

Program Leadership

Grisel Rodríguez-Morales, MSW, LCSW Grisel_Rodriguez-Morales@rush.edu

Senior Manager of Health Promotion,
Program Director of RUSH Generations
she/her/ella

Padraic Stanley, MSW, LCSW Padraic_Stanley@rush.edu

Program Manager of Community
Integration
he/him/él

Lashone Brown, MBA Lashone_Brown@rush.edu

Operations Specialist and Volunteer
Coordinator
she/her

Chronic Disease Self-Management Education Programs

Chronic Disease, Diabetes, and Chronic Pain Self-Management, Cancer: Thriving and Surviving, Walk
With Ease, and WRAP
Theo Lakshmanan, MSW, LSW Theo_Lakshamanan@rush.edu
CDSME Program Coordinator
they/them/elle

Yessenia Cervantes-Vázquez Yessenia_Cervantes@rush.edu

Lead Community Health Worker
she/her/ella
Falls Prevention Programs
Matter of Balance, Tai Chi for Arthritis and Fall Prevention, Fit & Strong, and Bingocize
Mary Granados, MSW, LSW Mary_C_Granados@rush.edu
Falls Prevention Program Coordinator
she/her/ella

Natalia Mojica Natalia_Mojica@rush.edu

Community Health Worker
she/her/ella

Tyler Alexander Tyler_A_Alexander@rush.edu

Community Health Worker
she/her