Participating in the TTOUR program has been both affirming and transformative for me as a hospice social worker and as someone deeply engaged in the Assisted Living Waiver (ALW) and Enhanced Care Management (ECM) pathways. What I appreciated most was how the program framed clinical encounters with older adults through the lens of the 4M’s What Matters, Medication, Mentation, and Mobility. These concepts were not only presented as theoretical models but also as practical tools that I could immediately see reflected in my daily work with older adults and their families.
The emphasis on “what matters” reminded me of the countless times I have walked with families through difficult decisions after a crisis such as a fall, hospitalization, or caregiver burnout. In those moments, it can be easy for the system to focus strictly on medical stabilization, yet the TTOUR program reinforced the importance of pausing to elevate the patient’s own goals. Whether it is remaining close to a spouse, maintaining independence, or preserving dignity in the last stages of life, centering these priorities creates
care plans that truly honor the individual.
Mobility was another area that resonated with my experience. At Calstro CCA, we have designed and implemented models to transition patients from high-cost skilled nursing facilities into assisted living communities under the ALW. These transitions do more than reduce healthcare spending; they restore freedom, community, and quality of life. I recall working with families in San Bernardino who were told their loved one would not qualify for assisted living because of Medi-Cal share-of-cost rules. By educating them on options like the Board and Care personal care needs allowance, we made what seemed impossible achievable. That type of advocacy reflects the best of age-friendly, person-centered care.
The TTOUR experience also reminded me of the essential role of interprofessional collaboration. Nurses, physicians, case managers, social workers, and community health workers each bring unique expertise, but challenges often arise when communication is fragmented. The program reaffirmed that safe, quality care cannot be achieved in silos. Our pilot project with Molina showed that when diverse professionals collaborate with shared goals, the results are fewer emergency visits, more stable members, and most importantly, older adults able to age in place with dignity.
What made the program especially meaningful was the positive feedback I received from classmates about my contributions during discussions. Several peers shared that my real-world stories and experiences helped bridge theory with practice. That encouragement has inspired me to consider participating in future TTOUR classes as a guest instructor. I would be honored to share insights on long-term care transitions, interprofessional teamwork, and advocacy strategies to support older adults.
Overall, the TTOUR program validated my mission: to advocate for older adults, dismantle barriers that keep them institutionalized unnecessarily, and foster dignity through community-based solutions. It deepened my commitment to person-centered care and expanded my vision for how I can contribute to the next generation of learners in this field.
Tyrel Rosell, MSW
Calstro CCA Regional Director
