A portrait emerges of a caregiver who may still be working or have children of their own. Especially if the care recipient is a family member, they may be feeling ill-prepared for the challenges that lie ahead. These include practical aspects like transportation and more complex matters such as disease progression or knowing how to keep someone safe at home.

Despite the intensity of caregiving—everything from shopping for groceries to managing medications to assisting the older adult with going to the bathroom—many of these helpers don’t identify as caregivers. Some adult children caring for an elderly parent may see it as a familial duty or simply an act of love. Uncomfortable with the label of caregiver, they might be thinking: This is my dad. I’m just taking care of my family.

In 2025 we brought an existing model, Caring for Caregivers, to western New York. The pilot is led by our longtime partner, the Healthcare Association of New York State (HANYS), and Rush University Medical Center in Chicago. Nicknamed C4C, the model enables health systems to develop a plan for a caregiver’s physical and emotional health and well-being while incorporating the care needs and preferences of the older adult they care for. Caregivers are screened for burnout and depression at the start of the program and linked with appropriate services and resources, such as transportation, respite, blood pressure monitoring, and mental health counseling. After receiving services, they are screened again to see if there’s been an improvement.

Supporting caregivers helps older adults remain at home rather than returning to the hospital or entering a nursing facility. The result is often better quality of life and reduced health care expenses.

C4C relies heavily on the 4Ms of the Age-Friendly Health Systems framework: medication, mobility, mentation, and what matters. All four areas create a holistic view of an older adult’s health and well-being. “At its core, it’s about making sure that we support older adults by adhering to best practices for managing medications, supporting safe mobility as much as possible, and recognizing changes in cognition—what we call mentation,” explains Christina Miller-Foster, Managing Senior Director in the Quality, Advocacy, Research, and Innovation Division at HANYS. “But most of all, it’s about honoring what matters and engaging older adults and their caregivers in honest conversations about their care.”

Just as the Age-Friendly framework prioritizes the needs of the older patient, C4C puts the caregiver at the center and asks: What are your goals for caregiving? What do you need to be successful?

The two western New York health facilities chosen for the C4C pilot are The Chautauqua Center and Erie County Medical Center. One serves rural communities, and the other serves an urban community. Both are certified Age-Friendly Health Systems providers that have achieved Level 2 status, Committed to Care Excellence. “We have a great network of age-friendly providers across the state, including The Chautauqua Center and ECMC” says Christina. “Both organizations really took the model and ran with it.”

When people become caregivers, self-care becomes paramount—something Amy Pease knows firsthand. “You have to make sure that you’re eating, you’re sleeping, and you’re taking care of yourself. How do you handle the family unit? How do you put your oxygen mask on first?”

Amy is the point person for the Caring for Caregivers pilot at The Chautauqua Center (TCC), a Federally Qualified Health Center with five sites in the Southern Tier. She knows that C4C involves understanding why a person has to come to the health clinic and having some idea of what’s going on in their life. This includes finding out whether or not there’s a caregiver in the equation.

TCC’s approach is to use the care team to recruit participants for the program. Members of the Chronic Care Management (CCM) team—made up of a Diabetes Self-Management Education and Support (DSMES) provider, registered dietitians, clinical pharmacists, and care coordinators—review the chronic care cases to anticipate which patients might have a caregiver or actually be a caregiver. From there, a CCM team member asks a few gentle questions, such as: Would you like to be part of a caregiver pilot project? Can we help you with any resources? Do you think you might benefit from some mental health support?

The TCC pilot is still in the early stages, and the team is focused on experimenting with different ways to engage caregivers. The search for participants has spurred fresh conversations among the care team about the age-friendly work they already do. Amy says the monthly peer learning sessions with the team from Rush have been invaluable. The numerous insights and suggestions will continue to help TCC troubleshoot ways not only to identify caregivers but also to encourage them to enter the C4C program.

The Chautauqua County Office for Aging Services (OFAS) rents space at TCC’s Dunkirk and Jamestown locations and regularly presents at all of TCC’s clinical team meetings. Amy explains that being in close proximity enables the TCC team to connect patients and their families with resources and services easily.

The Erie County Medical Center, more commonly referred to as ECMC, is a busy emergency and trauma center located on Buffalo’s East Side. Three members of ECMC’s Population Health Care team manage the C4C pilot at the hospital: Population Health Service Coordinator Vanessa McDonough, Clinical Care Coordinator Santosha Gompah, and Clinical Nurse Specialist Amanda Farrell. The three have even been dubbed The Solutioneers for their resourceful approach to implementing the pilot.

“We really do have to think creatively,” Amanda says. “How can we best support the patient? And one of the best ways is to loop in their caregiver through the age-friendly structure.”

Vanessa adds, “We want to move towards seeing the whole person, not just their medical concerns—but also making sure that the medical care decisions that are being made are fully understood by the caregiver.”

An algorithm is run on every person who is admitted under a medical service at ECMC. This algorithm predicts the risk of readmission so that high-risk patients are placed in the hospital’s Comprehensive Transition of Care (CTOC) program. If a member of the care team notices that the CTOC patient might have a caregiver, they can also make a referral to the C4C program.

So far, the team has identified 40 caregivers and enrolled 14 into the program. Vanessa and Santosha handle case management, receiving all the referrals and reaching out to each caregiver. They check in with a caregiver at least once a month and remind them of the available resources and services. One of the greatest needs, so far, is transportation. “You don’t always see that caregivers often have their own challenges, which can make it difficult for them to consistently transport patients or manage all the coordination,” Santosha explains. “I set one of our caregivers up with a mobile primary doctor to come to the home because that was easier than the recipient always going out of the house.” Another need is respite—even if that means a few hours of ‘me time’ while someone else is helping the care recipient.

Some caregivers welcome the C4C support because they feel overwhelmed. Others insist they’re okay and can handle things on their own. Vanessa and Santosha give out their contact information anyway, just in case anything changes. “It’s about how to find that balance between caring for your loved one, and maintaining your individuality and taking care of your own needs,”  Vanessa explains.

The ECMC team regularly reaches out to the Office for the Aging in both Erie and Niagara counties to connect families with available resources.

As the C4C model becomes more comfortable for everyone, there will likely be opportunities to connect caregivers with billable medical support, whether that’s mental health counseling, treatment for hypertension, or something else. This can help make C4C a sustainable program.

In the meantime, Christina points to other ways to measure success: fewer visits to the emergency department, fewer readmissions to the hospital, and improved patient satisfaction scores. “There’s a lot we can consider when trying to measure the value of the program and build toward sustainability, even without Medicare reimbursements,” she says.

By setting families up for success—from using the 4Ms for a holistic treatment plan to providing caregiver support—the C4C program is laying the groundwork for an integrated approach.

Amanda, Santosha, and Vanessa all agree that simply being able to help an overwhelmed caregiver slow down, open up, and let others provide support is a huge step. “Navigating the health care system is so complex that patients and their caregivers really need as many resources available to them as possible in order to stay healthy,” says Amanda.

Ultimately, Caring for Caregivers is about changing the narrative around caregiving and exploring difficult questions: How do we build trust with a patient and their caregiver? What do they need? How can our health facility help? How can we normalize self-care for caregivers? Both The Chautauqua Center and Erie County Medical Center are well on their way to finding some answers.