LifeSTEPS House Plus Services – RN Coaching Program
A Proven Model for Helping Seniors Thrive in Place 

LifeSTEPS’ House Plus Services RN Coaching Program brings compassionate, community-based nursing directly to affordable senior housing communities. By placing highly trained Registered Nurses alongside LifeSTEPS’ social workers and property partners, we provide the personalized medical guidance, health education, and care coordination older adults need to remain safe, stable, and thriving at home. 

Our approach is simple yet transformational: consistent nurse engagement, coordinated support, and early intervention—all right where residents live. 

As Executive Director Beth Southorn explains: 

“Our biggest goal is finding ways for our seniors to age in place, where they’re not having to be hospitalized over and over again, and they get the quality care they need when they come back from the hospital. And so for that reason we developed our nursing program.”

Strengthening Communities Through RN Coaching 

While the program is grounded in the work of licensed Registered Nurses, LifeSTEPS also partners with emerging nursing professionals. While we do occasionally receive Registered Nurses who are pursuing their bachelor’s degrees, this typically occurs only once a year. For the rest of the year, we primarily work with nursing students in their final year completing their Community Health course. These students work under the supervision of a licensed RN instructor and collaborate closely with LifeSTEPS social workers and property partners—allowing them to contribute meani

ngfully while gaining real-world experience in community-based care. 

What RN Coaching Looks Like in Our Communities 

RN Case Managers serve as trusted, on-site partners for residents—offering health assessments, medication support, chronic disease education, and guidance through the complexities of the healthcare system. A typical day includes:  

•  One-on-one coaching for residents managing chronic diseases
• Medication reviews and safety education 

• Group health classes on diabetes, hypertension, fall prevention, and more 

• Coordinated follow-ups based on referrals from social workers, property managers, and maintenance staff 

• Advocacy and navigation support following hospitalizations or medical appointments 

• Helping residents understand treatment plans and practice ongoing self-care 

As RN Staci Moore describes: 

“Typically, I’ll see individual residents on a case-by-case basis, as well as have some sort of group activity, whether it’s a healthcare class, or a social that’s around chronic disease management such as diabetes or hypertension.” 

By working as a unified team, RN, social worker, and property staff identify potential medical issues early—often preventing crises before they occur. 

Beth affirms the impact of this model: 

“Having a community-based nurse, onsite, with the social worker, is really why this is a program that’s working. It saves dollars and it saves dignity.” 

Why RN Coaching Matters 

Many residents face barriers—limited income, low health literacy, mobility challenges, and complicated medication regimens—that make navigating healthcare overwhelming. RN Coaching addresses these issues with: 

• Clear explanations of diagnoses, medications, and treatment plans 

• Assistance understanding Medicare/insurance barriers 

• Support coordinating care after hospital discharge 

• Early detection of changes in health status 

• Links to community resources, food programs, transportation, and more.

  As Staci notes: “I find a lot of satisfaction in coming to work and being able to do the job, because without someone helping them out, a lot of these folks would just fall through the cracks.” 

Measurable Impact 

The RN Coaching Program isn’t just compassionate—it’s effective. Pilot data from 5,893 total outcomes demonstrates real improvements in health stability, safety, and quality of life: 

• Chronic Disease Management & Healthy Aging: 3,352

• Care Coordination: 1,369

• Care Plan Creation: 562

• Medication Management: 234

• Social Determinants Support: 251

• Fall Prevention & Home Modifications: 125

A Collaborative Model That Works 

This innovative program was built through partnership, persistence, and a commitment to redefining senior housing support. 

Beth shares this vision: 

“We are very, very proud of this program. I feel elated that we’re at the point where we have enough to talk about that we can move the needle closer and closer to resident healthcare. We have created a database with advanced measurements that is a lens for Geoff and me to have the numbers to show the success. We want to show nationally what works. We’ve learned some important things and we don’t care who does them, as long as they get done!” 

Thriving in Place—Together 

LifeSTEPS’ RN Coaching Program continues to expand because it works. Residents trust the nurse, engage more deeply in their health, and gain confidence to maintain independence. Property owners see improved stability and reduced turnover. Families gain peace of mind knowing their loved ones are supported. Most importantly, seniors receive dignified, community-centered care—right at home.