The Saratoga Senior Center has a program called Senior Life Transitions that uses a Social Palliative Care model to work with seniors in Saratoga County providing support and needed services.
Seniors are 60 yrs + and have at least one chronic medical condition. Income or assets are not considered. The program was developed by and is run by Phil DiSorbo, MS, BCPA. He and co-author Dr. Bill Vacca, MD, FACC, wrote an article for CAPC titled Increasing Palliative Care Accessibility through Grassroots Community Collaborations and Teamwork. It's definitely worth a read.
This article, Increasing Palliative Care Accessibility through Grassroots Community Collaborations and Teamwork, discusses a grassroots model at a senior center in New York.