We are asking a direct question…

What curriculum, program, toolkit, or structured process are community health workers, social workers, case managers, transitions of care teams, and palliative care professionals currently using to help people age in place with dignity, clarity, and measurable progress?

Our impression is that many healthcare systems hire caring professionals for these roles and, in practice, give them a difficult message:

“You are here to help people. Now go figure it out.”

That may sound blunt, but many professionals know the feeling. They are expected to screen for social needs, address barriers, support patients and residents, communicate across care teams, document accurately, understand coding, reduce avoidable utilization, support family caregivers, and help people set meaningful goals.

Then they are handed a maze of forms, referral lists, software platforms, screening tools, and online resources.

We want to learn what already exists, what people are using, what feels helpful, and what still feels missing.

The question we are asking

At JeremyHolloway.com and through Tellegacy, we are exploring the creation of a practical curriculum and program that could become a strong tool for professionals who help people age in place.

We are especially interested in hearing from people connected to:

Community health workers
Social workers
Case managers
Transitions of care teams
Palliative care teams
Care coordinators
Aging services professionals
Professional caregivers
Healthcare students preparing for these roles
Organizations supporting older adults at home

Here is the core question:

What structured curriculum or program are these professionals using right now to guide screening, goal setting, social determinants of health support, What Matters conversations, documentation, and follow through?

If the answer is “we use several things, but nothing feels ‘for sure’,” that is important to hear.

If the answer is “there is a good tool, but it is hard to find,” that is important to hear.

If the answer is “our team had to build our own process,” that is important to hear.

The real issue: caregivers and care professionals are overwhelmed

A great deal of information exists online. That sounds helpful until a professional actually needs to use it.

The challenge is that many resources are scattered, unclear, overly academic, locked behind organizations, tied to specific grants, limited to one health condition, or written for systems rather than the person sitting across from the patient, client, resident, or family caregiver.

Professional caregivers already carry a heavy load. Personal caregivers carry one as well. Asking them to research every possible tool, compare every screening model, understand every referral process, interpret every social needs framework, and then translate it into a practical conversation can become exhausting.

That is the maze.

The professionals doing this work are often asked to help people move through complex systems while they themselves are moving through a complex system.

This is why we are asking the public, professionals, organizations, and caregivers to help us learn what is actually being used.

Why this matters for people aging in place

Aging in place is often described as a goal. For many older adults and families, it is deeply personal. It means staying connected to home, memory, independence, routines, community, and dignity.

Yet aging in place requires more than a desire to remain home.

It may require transportation, safe housing, medication support, food access, family communication, care coordination, fall prevention, trust, social connection, and a clear understanding of what matters most to the person.

The CDC describes community health workers as trusted frontline public health workers who connect people to health and social services by addressing barriers related to the social determinants of health.

That bridge role is powerful. It also requires training, structure, and tools that make the work easier to carry out consistently.

We are interested in a curriculum that helps professionals move from screening to progress

Screening is important. A screening tool can reveal needs related to food, housing, transportation, social connection, safety, finances, caregiving, or access to healthcare.

Yet screening alone is rarely enough.

A person can complete a screening and still leave without a realistic plan. A professional can identify a need and still lack a clear next step. A team can document a social need and still miss the larger story of what the person is hoping to improve.

That is why we are exploring a curriculum that would help professionals move through a practical sequence:

Ask meaningful questions
Use screening tools with confidence
Connect social needs to the person’s goals
Introduce basic coding awareness
Document needs clearly
Support progress across social determinants of health
Use What Matters as the guiding anchor
Help the client, patient, resident, or caregiver see real strides over time

CMS notes that social determinants of health information can be collected before, during, or after a healthcare encounter through structured health risk assessments and screening tools. CMS also explains that SDOH related Z codes, generally within ICD 10 CM categories Z55 to Z65, can document factors such as housing, food insecurity, and transportation.

That matters because documentation can help teams see patterns, improve coordination, and show where support is needed. But coding awareness should serve the person, rather than reduce the person to a code.

Why What Matters needs to lead the work

The 5Ms of geriatrics offer a helpful frame for working with older adults. They are commonly described as:

What Matters
Medication
Mentation
Mobility
Multicomplexity

The American Geriatrics Society’s Health in Aging resource explains that the Geriatrics 5Ms focus on key areas important to care as people age, with care guided by what matters to each person.

Each M matters.

Medication asks whether prescriptions, supplements, side effects, costs, and daily routines are supporting health or adding burden.

Mentation looks at mood, memory, cognition, depression, anxiety, confusion, and the emotional realities that can shape daily life.

Mobility considers movement, falls, strength, transportation, safety, independence, and the ability to participate in meaningful activities.

Multicomplexity recognizes that older adults often live with layered medical, social, emotional, financial, family, and environmental realities.

What Matters is the most important because it gives direction to the other areas.

A person’s medication plan should connect to what matters. Their mobility goals should connect to what matters. Their care transitions should connect to what matters. Their screening process should connect to what matters. Their support plan should connect to what matters.

The Institute for Healthcare Improvement describes Age Friendly Health Systems as care that follows evidence based practices, causes no harm, and aligns with What Matters to the older adult and their family caregivers.

That is the heart of this work.

When What Matters is missing, the care plan can become busy without becoming meaningful.

Our impression: many systems hire the role, then leave the roadmap unclear

Many healthcare systems understand the value of hiring community health workers, social workers, care coordinators, and case managers. That is progress.

The concern is what happens after the hire.

A professional may enter the role with passion and training, yet still feel unsure about how to connect all the pieces:

Which screening tool should I use?
How do I ask these questions in a human way?
How do I move from screening to goals?
How do I document social needs?
How do I avoid overwhelming the person?
How do I help someone see progress when the barriers are large?
How do I work with family caregivers?
How do I align the plan with What Matters?
How do I support the person aging in place without making the work feel like a pile of disconnected forms?

These are practical questions. They deserve practical answers.

The National Academies has called for a stronger workforce and better systems to integrate social care into healthcare delivery, including clearer roles for social workers, community health workers, gerontologists, and other social care workers.

That recommendation points to a larger reality: the workforce is essential, but the workforce needs structure.

What we are hoping to learn from readers

We are asking readers to contact us immediately if they know of existing tools, curricula, programs, frameworks, or workflows that already address this need well.

We would especially value feedback on these questions:

What curriculum or program is your organization currently using?

What tool has been most helpful for CHWs, social workers, case managers, transitions of care staff, or palliative care teams?

What feels missing from current training?

What is too complicated, too scattered, or too hard to apply in real life?

What do professionals need before they begin screening for social determinants of health?

What do they need after screening, when it is time to set goals and support follow through?

What would make this work easier for people helping older adults age in place?

What do family caregivers and personal caregivers need that current systems overlook?

What would help a professional caregiver feel more confident, organized, and supported?

This is the kind of feedback that can shape something useful.

What we hope to build

Our goal is to explore a practical curriculum that helps professionals and caregivers move through the work with more confidence and less confusion.

The curriculum could support professionals as they help people:

Identify social needs
Understand the meaning of those needs
Connect needs to What Matters
Set realistic goals
Track visible strides over time
Communicate with care teams
Understand basic SDOH coding concepts
Support aging in place with dignity
Make the process feel human rather than mechanical

This kind of tool should be practical enough for daily use, grounded enough for healthcare settings, and warm enough to honor the person being served.

This is an invitation

We are approaching this with curiosity.

There may already be strong tools available. There may be excellent curricula that deserve more visibility. There may be organizations doing this work beautifully in quiet corners of healthcare, aging services, home care, palliative care, or transitions of care.

We want to know about them.

We also want to know what professionals feel is missing.

Because if people who provide care are overwhelmed by the maze of resources, then the people receiving care may feel the confusion too.

The goal is clarity. The goal is dignity. The goal is a practical roadmap that helps the helper and strengthens the experience of the person aging in place.

Contact us

If you know of an existing curriculum, toolkit, program, screening workflow, documentation guide, or training model that could help shape this work, please contact us right away.

You can email:

social@tellegacy.com

You can also connect with me directly through my LinkedIn page: https://www.linkedin.com/in/jeremy-holloway-phd/