U.S. Department of Health and Human Services

Inventory of Affordable Housing Plus Services Initiatives for Low and Modest-Income Seniors

Mary F. Harahan, Alisha Sanders, M.P.Aff., and Robyn Stone, Dr.P.H.

Institute for the Future of Aging Services, American Association of Homes and Services for the Aging

August 2006

PDF Version

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This report was prepared under contract #HHS-100-03-0009 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and the Lewin Group. Additional funding was provided by the U.S. Department of Housing and Urban Development. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the ASPE Project Officer, Gavin Kennedy, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. His e-mail address is: Gavin.Kennedy@hhs.gov.

The opinions and views expressed in this report are those of the authors. They do not necessarily reflect the views of the U.S. Department of Health and Human Services, the U.S. Department of Housing and Urban Development, the contractor or any other funding organization.

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TABLE OF CONTENTS

I. INTRODUCTION AND PURPOSE

II. METHODS

III. SCOPE AND PURPOSES OF THE AHPS INVENTORY

IV. AHPS INVENTORY

Privately Financed Housing Plus Services Strategies

Publicly Subsidized Housing Plus Services Strategies

NOTES

I. INTRODUCTION AND PURPOSE

The aging of the baby boomers is a significant economic and social issue. By 2030, older adults are expected to make up 20 percent of the population, doubling from 35 to 70 million people. The relationship between older age, chronic illness and disability, and higher use of long-term care services is well established. In response to the rising demand for long-term care, consumer advocates, policy makers, and service providers have encouraged the development of new models of organizing and delivering health-related and supportive services that are attractive and affordable to older adults, particularly those who are poor or of modest means.

Assisted living facilities (ALFs) are a residential model of care that has received considerable attention as a potentially less expensive and more appealing alternative to nursing homes. The Assisted Living Quality Coalition has defined assisted living as a congregate residential setting that provides or coordinates personal services, 24-hour supervision and assistance (scheduled and unscheduled), activities, and health-related services and is designed to minimize the need to move; to accommodate individual residents' changing needs and preferences; to maximize residents' dignity, autonomy, privacy, independence, and safety; and to encourage family and community involvement.¹ While the number of ALFs across the country has rapidly expanded over the last decade, they have remained largely cost prohibitive for older people with limited incomes. Many states have secured waivers allowing Medicaid to cover ALF costs; however, assisted living remains primarily private pay. In 2002, Medicaid helped pay for approximately 11 percent of the total number of assisted living residents in 41 states.²

A less well-publicized residential care model providing lower-income seniors with access to health-related and supportive services is emerging in publicly subsidized housing communities. This service delivery model, referred to in this report as “affordable housing plus services” (AHPS), is intended to integrate independent, unlicensed, and primarily subsidized multi-unit housing environments for older adults with services and supports. The goal is to enable older residents who are frail and/or disabled to remain in their housing community even as their health declines and disability increases.

The U.S. Departments of Health and Human Services (HHS) and Housing and Urban Development (HUD) and the A.M. McGregor Home in Cleveland, OH, funded the Institute for the Future of Aging Services (IFAS), the policy and applied research arm of the American Association of Homes and Services for the Aging (AAHSA), to examine the potential of AHPS strategies to meet some of the long-term care needs of low and modest-income seniors. IFAS defines AHPS as having three elements:

• Independent, unlicensed, primarily subsidized, multi-unit housing where large numbers of low and modest-income older adults live in close proximity.
• Health-related and supportive services, funded separately from the housing, and available to at least some older residents (e.g., personal care, housekeeping, meals, transportation, health and wellness services, etc.).
• A purposeful linkage mechanism connecting residents to needed health-related and supportive services so that they are able to “age in place” in the face of declining health and increasing disability.

Three reports have been produced in conjunction with the AHPS study:

1. A Synthesis of Findings from the Study of Affordable Housing Plus Services for Low and Modest-Income Older Adults (summarizes study findings). [http://aspe.hhs.gov/daltcp/reports/2006/ahpssyn.htm]

2. Inventory of Affordable Housing Plus Services Initiatives for Low and Modest-Income Seniors (describes the AHPS strategies and programs identified by IFAS during the course of the study). [http://aspe.hhs.gov/daltcp/reports/2006/ahpsinv.htm]

3. Lessons from the Workshops on Affordable Housing Plus Services Strategies for Low and Modest-Income Seniors (reports on the findings and lessons learned from the proceedings of four invitational workshops held across the country to analyze the merits of AHPS strategies and the barriers to their more widespread diffusion). [http://aspe.hhs.gov/daltcp/reports/2006/ahpsless.htm]

Each of the three reports may be found on:

• the IFAS website (http://www.futureofaging.org);
• the ASPE website (http://aspe.hhs.gov/daltcp/reports.shtml);
• the HUD website (http://www.huduser.org).

This report presents the findings from the AHPS workshops.

II. METHODS

The inventory described in this report was developed through a combination of methods, including:

1. A review of the research and evaluation literature.
2. Two informal workgroup meetings, held with AAHSA members and staff and other experts.
3. Telephone and in-person discussions with AAHSA members, other housing providers, and aging and housing experts to identify exemplary AHPS programs.
4. Four invitational workshops attended by housing and aging services stakeholders.

III. SCOPE AND PURPOSES OF THE AHPS INVENTORY

In conducting the AHPS study, IFAS identified numerous examples of AHPS programs that have been implemented across the country, largely at the initiative of individual housing providers and community aging agencies. Information describing these programs was collected through web-based research and discussions with publicly subsidized housing sponsors, property managers and other housing staff, researchers, and AAHSA staff. It was then organized into an inventory that is presented below. The purpose of the inventory is to stimulate thinking among housing providers, community agencies, and policy makers about the range of AHPS strategies that are now being employed and to provide “real world” examples where interested readers could obtain additional information. Hopefully, the inventory also will help inform public and private funders of the potential value of demonstrating and evaluating the role AHPS strategies might play in addressing some of the long-term care needs of lower-income elders.

The inventory could have been categorized in many different ways. Staff decided to first organize the material based on the source of financing for the housing arrangement. Subcategories were then selected to illustrate some of the variation among AHPS strategies with respect to how services are organized, coordinated, and delivered within affordable housing communities; the scope and comprehensiveness of services available to residents, staffing arrangements; community partners; etc. The subcategories are not mutually exclusive; in practice, housing providers may employ multiple strategies to link residents to services. Each AHPS strategy is illustrated with examples of on-going programs. These examples should not be viewed by readers as best practice models--this will require further codification through careful case study and evaluation.

IV. AHPS INVENTORY

The inventory is divided into two broad categories of affordable housing:

1. Privately Financed Housing. This category refers to multi-unit owner and rental housing that is privately funded and receives no public subsidies, but is still affordable to low and moderate-income older adults. It also may include neighborhoods of single-family homes with large concentrations of senior households.

2. Publicly Subsidized Housing. This category refers to multi-unit rental housing that is subsidized by government entities at the federal, state, and/or local levels. Subsidy sources may include public housing, Section 202, Section 236, Low Income Housing Tax Credits (LIHTC), tax-exempt bonds, or other such programs. It may be owned and operated by a public entity, such as a housing authority, or a private entity, such as a nonprofit organization

Privately Financed Housing Plus Services Strategies

Housing Cooperatives

In a housing cooperative, individuals own shares in a corporation that owns or controls the land and buildings that provide the housing. Share ownership entitles the individual to occupy a unit within the cooperative and confers other rights and responsibilities. Cooperatives stress resident participation in management and programming decisions. Housing cooperatives come in many shapes and sizes, including townhouses, garden apartments, mid and high-rise apartments, single-family homes, student housing, senior housing, and mobile home parks. Cooperatives wishing to remain affordable typically limit the maximum price at which shares can be sold, as is done in limited-equity cooperatives, and restrict the re-sale of cooperative shares to designated low-income groups.

Services can be both informal, involving mutual support among residents, or formal. They may involve joint purchasing of multiple supportive services and/or a coordinated and managed services program, staffed by community agencies or personnel employed by the cooperative. In some cooperatives, most notably those in New York City, an organized program of supportive services has developed as residents have grown older, involving partnerships between residents, community agencies, and the housing manager. These services are delivered by onsite and offsite staff in response to resident-identified needs. In some programs, services are quite comprehensive and can include assessment and care planning, personal care, counseling, benefits and entitlement assistance, advocacy, financial management, home-care, crisis intervention, and Meals-on-Wheels. Funding for services is separate from the housing. Services may be paid for out-of-pocket or by government subsidies, charitable contributions, the proceeds from property refinancing and/or special government and philanthropic programs targeting aging residents of the cooperative.

Examples:

Penn South Cooperative & Penn South Program for Seniors, New York, NY Built in 1961, Penn South is a limited-equity cooperative with 2,820 units and 6,200 residents. Twenty years after its inception, many of Penn South’s residents began reaching retirement age. The co-op board established a special committee, the Penn South Program for Seniors (PSPS), to set up programs to support aging residents. PSPS partnered with three agencies to provide services and a foundation to develop the program. Within a few years, PSPS was formalized into a separate nonprofit, Penn South Social Services, Inc. PSPS offers case management; group recreation; educational, cultural and artistic programs; home-care coordination and nonacute nursing care; social day care for those with dementia; health education and preventive services; money management; and advocacy. The program is staffed by social workers, nurses, and home-care coordinators. Penn South also has been selected as a training site for geropsychiatric fellows and receives free psychiatric consultations. In addition, two medical centers have opened geriatric practices onsite, and the Visiting Nurse Service of New York is contributing a half-time nurse to perform nonreimbursable services.

7500 York Cooperative, Edina, MN Developed in 1978, 7500 York was the first senior housing cooperative in the United States. It is a limited-equity cooperative with 330 units. As residents began to age, many hired private aides to assist with housekeeping, shopping, and personal care needs. Approximately 12 years ago, the co-op decided to give space on the property to a home health care agency. The office is managed by a nurse who oversees the home health aides who work in the building. Residents arrange for their services directly with the agency. Giving the agency an onsite office allows it to offer services in 15-minute intervals rather than the customary two-hour blocks. This allows residents to better target the service to their needs and is more economical for both the resident and the agency. The onsite office is feasible for the home health agency because of the co-op’s large size. The agency also may serve seniors in surrounding apartment buildings out of this office.

Others:

Co-op City Senior Services Program, Bronx, NY Chatham Park South Cooperative, Chicago, IL Parkway Cooperative in Burnsville, Burnsville, MN

Shared and Accessory Housing

Shared housing refers to an arrangement in which two or more unrelated individuals live together in a private single-family home or in close proximity to one another and share some common space. It is an alternative for those who cannot afford to live alone and/or need some supportive services. In some cases, formal match-up programs help homeowners find others to share their home with them. The homeowner may offer free or reduced rent to the tenant in return for providing supportive services such as meal preparation, laundry, and assistance with personal care tasks. This approach may be attractive to “over-housed” seniors who have vacant space and need extra income to purchase services or maintain their home. Accessory housing refers to a separate private living unit adjacent to a main home. The unit may already exist on the property or a small portable manufactured home or mobile home may be placed next to a single-family home. In some instances, family members may use accessory units to move an aging relative closer to them to facilitate informal caregiving.

Examples:

HomeShare Vermont, Burlington, VT HomeShare Vermont links elders and persons with disabilities with individuals seeking affordable housing and/or caregiving opportunities. HomeShare provides a comprehensive screening and matching service. In a typical home-sharing situation, a student or person working outside the home is matched with a home provider and works 12-15 hours a week doing household chores such as cooking or shopping in exchange for free rent. In other situations, the person may provide less service and make a small contribution to household expenses, or he or she may provide no services and pay rent in the range of $250-$300 per month. In live-in caregiving situations, a person assists a frail elder or person with disability with nonmedical personal care such as bathing, dressing or walking. Caregivers also provide companionship and assist with homemaking services such as shopping, cooking, and household chores. In return, the caregiver receives a weekly salary and room and board. HomeShare also matches frail elders or persons with disabilities with paid nonmedical caregivers who do not live-in and instead provide services on an hourly basis.

Ruggles House, Burlington, VT Operated by Cathedral Square Corporation, Ruggles House is a shared housing community consisting of 14 units with kitchenettes and private baths and shared common spaces. Units are available at a range of rental rates, with some units designated for Housing Choice (Section 8) vouchers. Ruggles House offers a service coordinator, three meals daily and homemaker services, all of which are provided directly by Cathedral Square staff and purchased by residents on a sliding-scale basis. Personal care services also can be arranged through the Visiting Nurses Association and are either paid for through a state-funded program or out-of-pocket.

The Pat Crowley House, Chicago, IL The Pat Crowley House, a three-story, six-flat building, was founded in 1983 by Housing Opportunities & Maintenance for the Elderly. The house accommodates 12 seniors who need assistance with daily living tasks, four students, and one young family in an intergenerational living situation. Common areas include living rooms, dining rooms, kitchens, and bathrooms. A full-time coordinator and her family live in one of the third-floor apartments, while four students share another apartment. The young people assist the elderly and cook on the weekends in exchange for room, board, and the opportunity to live in a family-like environment away from home. Residents pay a monthly rental fee according to their financial means. The house is subsidized with private donations, grants from foundations, and gifts from corporations.

Others:

ECHO Program, NW New Jersey Community Action Program, Phillipsburg, NJ HomeShare, University Of Michigan Hospital System, Ann Arbor, MI Home Sharing Program, New York Foundation for Senior Citizens, New York, NY See http://www.nationalsharedhousing.org/directory.html for a listing of shared housing programs in each state.

Mobile Home Parks and Manufactured Home Communities

Mobile home parks and manufactured housing communities often provide home ownership opportunities for lower-income seniors. Generally, lots are leased and the housing unit is owned. Upkeep and maintenance are usually included in the lot fee. The community may be age restricted or age integrated, and residents may live there full or part-time. Many mobile home parks are disappearing as land values increase. In several areas, efforts are being made to convert the parks to cooperatives, giving control to residents and groups interested in maintaining their affordability. Mobile home parks with high concentrations of seniors are most prevalent in Florida, California, and Alaska.

Formal efforts to link park residents with services are difficult to identify. Communities usually have some shared amenities such as social and recreational activities. Because mobile home parks and manufactured housing involve multiple single-family housing units within close proximity, they have the potential to attract services providers who wish to capitalize on the park’s group purchasing capability.

Examples:

Millennium Housing, Newport Beach, CA Millennium Housing operates several senior mobile home parks throughout California. Through a monthly magazine, Millennium distributes a variety of information on community programs assisting seniors such as Meals-on-Wheels and utility assistance programs. The group also arranges for community organizations to make presentations on the properties, such as the local HICAP organization, and brings flu shot clinics to the properties. In three parks in San Marcos, CA, Millennium has partnered with Project CARE, a community volunteer program that provides local homebound elderly with outreach services, including municipal workers alerts, computerized calls with emergency response, and home repairs.

Leisureville Mobile Home Park, Woodland, CA Leisureville Mobile Home Park is a 20-acre, 150-unit senior park that was converted to cooperative ownership in 1995. The park was purchased from the owner by the resident association in an effort to preserve affordability. The limited-equity cooperative structure allows occupants to own their own units, while the resident association owns the park. A recreational committee organizes social events. Residents participate in a “community car” program, which transports park residents and other seniors in the community to medical appointments and places like the grocery store.

Others:

River Ranch Mobile Home Park, Victorville, CA

Single Room Occupancy Hotels

A single room occupancy hotel (SRO) is a residential building, often in a downtown area, that rents small private rooms to low-income individuals on a weekly or monthly basis. SROs usually have some common or shared spaces such as bathrooms, living rooms, and kitchens. Although urban renewal has eliminated many SROs, some cities are trying to increase housing options for homeless persons, which includes many seniors, by acquiring and rehabilitating run-down hotels and converting them into SROs with supportive services. Services can include meals, health and nutrition education, assessment and case management, and transportation. Services funding typically comes from municipal sources. Some senior centers may target older residents of SROs.

Examples:

Project Hotel Alert, Los Angeles, CA Project Hotel Alert (PHA) is operated by the Single Room Occupancy Housing Corporation with funding from the city of Los Angeles Department of Aging. PHA provides a range of services to seniors living in SROs in downtown Los Angeles, including case management services, information and referral, monitoring and follow-up, advocacy for public benefits, completion of forms and housing assistance. It also provides transportation, two congregate meal sites and home-delivered meals, enrichment field trips, social events, shopping trips, art workshops, medical screenings, informational workshops and more. One of the SROs served by PHA is the Ellis Hotel, which opened in 1989 to serve the “at-risk” elderly. The Ellis has 56 units with handicap-accessible bathrooms on each floor.

Capri Hotel and Sara Frances Hometel/Transitional Housing for Displaced Seniors Program, San Diego, CA The Transitional Housing for Displaced Seniors Program temporarily houses homeless seniors in downtown SROs. The program is operated by Senior Community Centers with funding from the city of San Diego’s redevelopment arm. The program pays rent for up 35 rooms in the Capri Hotel and the Sara Frances Hometel for up to six months. It also pays for up to five rooms at St. Paul’s Villa, an ALF, for seniors who are too frail to live independently. Participants receive meals at Senior Community Centers’ congregate meal sites and receive support from social service case managers and a nurse to address entitlement issues, health concerns, and any other needs that would inhibit their ability to transition to a healthier living situation.

Others:

1000 Montgomery, San Francisco, CA Dr. William L. Gee House, San Francisco, CA

Publicly Subsidized Housing Plus Services Strategies

Co-Location and Volunteerism

Housing providers lacking sufficient resources to invest in resident services may choose a lower-cost alternative involving the co-location of supportive services in proximity to the housing property and/or organizing volunteer services. Commonly co-located services may include a meal site under Title III of the Older Americans Act (OAA), a senior center, or health and wellness programs. Volunteers may assist residents with transportation, housekeeping, or shopping or may organize education and entertainment activities.

Examples:

Koinonia Apartments, Lenoir, NC Koinonia Apartments is an 84-unit Section 202 property sponsored by the First Presbyterian Church of Lenoir. The administrator functions as a property manager, service coordinator, and case manager. Koinonia Apartments has identified multiple community agencies that can provide services onsite at little or no cost to residents. The property serves as the site for an OAA Title III nutrition program, which serves a noon meal five days per week to residents and community members. Green Thumb, which operates a federally-funded training program for older workers, supplies housekeepers in training at no charge to provide light housework such as laundry, making beds, and sweeping. The property administrator also has a list of individuals in the community who provide reasonably priced housekeeping services. Personal care is available from the Caldwell County Home Health Agency and from the local Community Action Program. Both agencies provide a limited amount of personal care at no charge to residents. The property also provides a variety of activities for its residents, including exercise, blood pressure checks, craft activities, entertainment, and transportation.

Others:

Preiss-Steele Place, Durham, NC Mabuhay Court and Northside Community Center, San Jose, CA Edgewood Village Apartments, Elletsville, IN Sarah’s Circle, Washington, DC

Service Coordination

The property manager or housing sponsor employs a full or part-time staff person to help residents identify services needs, link them to community services providers, advocate on their behalf, and provide educational programs. The service coordinator is available to all residents of the property and typically responds to resident-identified needs. The housing property does not offer supportive services through it own staff or negotiate formal contracts with community providers for such services. Properties with service coordinators also often have common activity space for all residents, recreational opportunities, a group dining room, emergency response system, and 24-hour security. Service coordination is most likely to be found in Section 202 properties. It is also a component of some public housing and LIHTC properties.

According to a national study of resident service coordinators, the most prevalent services to which residents are linked are housekeeping, home health, and personal care. Services are typically paid for through a combination of out-of-pocket payments, Medicaid personal care and waiver funding, OAA funds, and private and municipal sources. Funding for the service coordinator position is usually supported through a HUD grant or the property’s operating budget. State and philanthropic funds also may be used.

Examples:

National Church Residences, Columbus, OH National Church Residences (NCR) has 154 service coordinators working in 194 of its Section 202 and LIHTC properties. The primary role of NCR service coordinators is to provide residents with information and linkages to needed resources and services. Service coordinators do not provide direct service. Service coordinators conduct an intake evaluation of those residents requesting their assistance, assessing the residents’ behaviors, functional abilities, and needs based on information from residents and their own observation. Service coordinators draw up case management plans that identify residents’ needs and give them information and referrals to community agencies that can help meet their needs. The plan also spells out the goals of the referrals, and the service coordinators monitor the plans and follows-up with residents to ensure they are getting their needs met. NCR also has instituted a quality assurance program that tracks each service coordinator’s performance and, through monthly feedback, ensures they are in compliance with all regulations and standards and are providing residents with the highest level of service.

Schwenkfeld Manor, Lansdale, PA Schwenkfeld Manor operates 225 units across three Section 202 senior properties and residents are supported by two service coordinators. Schwenkfeld has chosen to fill the service coordinator positions with registered nurses (RNs). While not functioning as a nurse or conducting diagnostic assessments, the RN service coordinators are able to assess residents through their skilled observations. For example, they look for facial expressions, skin color, tone of voice, posture, wringing of hands, etc. Based on their observations and interactions with residents, the RN service coordinators can help alert residents to possible early medical problems, help residents understand and coordinate their medical needs, and liaison with medical professionals. In addition to informal interaction, the RN service coordinator conducts an annual health and wellness assessment with the resident’s permission. Based on this assessment, the RN service coordinator can help link the resident with any services or supports he or she may need.

Others:

Catholic Charities, Baltimore, MD Volunteers of America, Alexandria, VA Retirement Housing Foundation, Long Beach, CA Wesley Senior Ministries, Memphis, TN Lutheran Home Society, Toledo, OH

Enriched Services and Service Coordination

In contrast to the service coordination approach described above, this strategy combines service coordination, including a formal assessment of resident’s health and functional status, on-going case management of residents who are particularly frail and/or disabled, and more formalized arrangements for assuring access to needed services. Some services may be the result of formal contracts between the housing property and community services agencies. In other cases, the housing provider may also be the service provider.

The amount and intensity of services available to residents is varied. Services may include 24-hour staffing, a personal response system, personal care, medication management, and housekeeping. Services may be bundled into packages depending on level of need or offered a la carte. Staffing for the case management function may be paid for through the Medicaid home and community-based services waiver program, the property’s operating budget or possibly proceeds from the refinancing of a Section 202 loan. Services may be paid for out-of-pocket, through the Medicaid home and community-based services waiver program and/or the personal care program, OAA funding, state or municipal programs, or philanthropic funds. Some older programs continue to be paid for in part by the HUD Congregate Housing Services Program.

Examples:

Peter Sanborn Place, Reading, MA Peter Sanborn Place gives priority to seniors needing a high level of care, a population it was able to target after getting HUD to agree to such priorities in its tenant selection plan. This housing community refinanced its old Section 202 loan (one of the first to do so in the country), freeing up significant resources to be invested in building repairs, renovations, and resident services. To ensure the availability of personal care to frail residents, as well as the surrounding community, Peter Sanborn Place also created a sister agency, Sanborn Home Care. Sanborn Home Care provides case management and service coordination; personal care, including assistance with showering, grooming, toileting, meal preparation, feeding, mobility, and medication monitoring; homemaker services such as housekeeping, shopping, and laundry; transportation to medical appointments; companion and respite care; and assistance with local errands and other tasks. Peter Sanborn Place also contracts with the Visiting Nurse Association for nursing care and rehabilitation therapy. Services are paid for through a variety of methods including self-pay, state programs, Medicaid, and Medicare.

Osceola County Council on Aging, Kissimmee, FL The Osceola County Council on Aging has developed a consolidated AHPS strategy that provides residents access to a comprehensive range of health and supportive services. The Council is both the conduit for OAA funds and the owner and manager of four affordable senior housing properties funded through a combination of the Section 202 program, LIHTC program, rural development loans, and loans from the state. This dual role enables it to establish relationships with a host of aging organizations, health providers, and community and volunteer groups. Through these partnerships, the Council is able to offer older and disabled residents living in its four subsidized housing properties everything from case management, transportation, meals, discounted commodities, homemaking, home repair, and chore services to health and wellness services and personal care.

Others:

Congregate Housing Services Program, Housing Authority of Portland, Portland, OR Potiker Family Senior Residence, San Diego, CA

NORC Service Programs (housing properties may be either publicly subsidized or privately financed)

Naturally occurring retirement communities (NORCs) are geographic areas--a neighborhood or a building--originally populated by individuals of all ages, which have evolved over time to contain a high proportion of older adults. The residents of some NORCs, in collaboration with community services providers and property managers, have developed service programs to respond to the health-related and/or supportive services needs of aging tenants. NORC service delivery programs may be found in both publicly subsidized and private housing. Although NORC service programs are most commonly found in New York City, they are increasingly emerging in other parts of the country, largely in response to federal demonstration funding.

NORC services programs are made available to residents without regard to income or functional status. Services can be very comprehensive and include assessment and case management, health and wellness services, personal care, and housekeeping. NORC services programs can be paid for out-of-pocket, through government programs such as Medicaid and OAA, through philanthropic and charitable contributions, and through the in-kind efforts of volunteers. New York has a unique supportive services program for NORC residents in designated public housing and housing cooperatives.

Examples:

Vladeck Cares/NORC Supportive Service Program, New York, NY Vladeck Cares/NORC Supportive Service Program serves the seniors living in Vladeck House, a public housing project on Manhattan’s Lower East Side comprising 27 buildings that house 3,000 residents (860 seniors). The program is a partnership between Henry Street Settlement, the Visiting Nurse Service of New York, and the New York City Housing Authority. The program offers comprehensive and preventative social services and health care, medical and nursing services, supervised case management, mental health counseling and therapy, cultural programs, educational programs, social activities, nutritional counseling, home visits, and escorts. It is funded by the New York City and New York State Departments for the Aging and private and philanthropic foundations.

Others:

Pelham Parkway NORC Program, Bronx, NY Senior Friendly Neighborhoods, Baltimore, MD Community Options Program, Cleveland, OH STAR NORC Program, Philadelphia, PA

State Supportive Housing Partnerships

State supportive housing programs are intended to improve coordination and expand the range of services available to senior residents of publicly subsidized housing properties. Often, the goal is to reduce Medicaid nursing home costs by maintaining older adults in independent housing for a longer period, thus delaying unnecessary institutionalization.

The approach requires collaboration between the state housing agency, the state’s aging and health agencies, and the housing properties. Care coordination may be provided by the property, a designated state agency, or both. A state agency selects one or more licensed services providers to deliver a range of personal care and supportive services to participating housing properties. Services can include case management, Medicaid home and community-based waiver services, 24-hour available personal care, home-care, medication management, housekeeping, meals, and social programming. The amount of services available depends on the funding source and resident eligibility.

Examples:

Connecticut Congregate Housing for the Elderly Program Connecticut’s Congregate Housing for the Elderly Program is a state-subsidized congregate housing program for low-income elders who have temporary or periodic difficulties with one or more essential activities of daily living. Funded by the Department of Economic and Community Development, the program provides grants or loans to construct or rehab congregate rental housing units. Residents pay a minimum rent and a congregate service charge, which is based on their adjusted income. The program subsidizes residents who cannot afford to pay the full cost of services. Services include housekeeping, emergency call systems in each room, 24-hour security, community meals, and social and recreational activities. Congregate facilities are not licensed, and staff may not dispense medication or provide nursing services. (For example, see The Marvin, Norwalk, CT.)

Massachusetts Supportive Senior Housing Initiative Program The Executive Office of Elder Affairs and the Department of Housing and Community Development developed the Supportive Housing Initiative to create an “assisted living like” environment in public housing for the elderly and persons with disabilities. It currently operates in 22 locations. Like traditional assisted living, services are offered on an as-needed basis, 24-hours per day. Residents pay 30 percent of their income in rent. Residents who are eligible for the Massachusetts Home Care Program receive all or some of the services at no additional cost (depending on income, there may be a monthly co-payment). Residents who do not qualify for state-funded home-care services based on their frailty level and income are able to purchase privately the entire package of supportive services or some of the services based on their need. Supportive housing benefits include service coordination, case management, 24-hour personal care/onsite or on-call person, homemaker services and laundry, medication reminders, social activities, and at least one meal per day. Supportive services are provided by an Elder Affairs approved personal care agency. Each site has a designated agency. (For examples, see the Cambridge or Salem Housing Authority.)

Others:

New York Enriched Housing Program New Jersey Congregate Housing Services Program Maryland Congregate Housing Services Program Vermont Housing and Supportive Services Program

Assisted Living as a Service Program

In some states, assisted living is licensed as a service rather than as a facility. The properties in which the assisted living services are provided are not licensed ALFs and generally are bound only by local building codes. In some instances, the properties may be required to register with the state (to keep track of the facilities rather than to regulate them). States may require the properties to provide residents with a disclosure statement about what and how services will be provided; however, residents maintain a landlord/tenant relationship with the property. Typically, the assisted living services are provided by a home health agency subject to its own licensure and regulation requirements.

Assisted living services customarily include 24-hour available personal care, medication management, meal preparation, housekeeping, laundry, and transportation. Services are generally funded under a state-subsidized program and/or a Medicaid home and community-based services waiver program. The state determines eligibility for services.

Examples:

Connecticut Connecticut licenses “assisted living services agencies” (ALSAs) to provide some nursing or medical care and personal care aides to residents of “managed residential care” (MRCs) communities. While MRCs are not licensed caregiving facilities, they must provide a core set of services to residents, including three meals a day, housekeeping and laundry service, transportation, maintenance services, 24-hour security, emergency call systems in each living unit, washers and dryers, common use space large enough to accommodate 50 percent of the tenant population, and social and recreational programs. Each MRC must also employ an onsite service coordinator to ensure services are available to residents, help tenants meet their needs, establish collaborative relations with other service agencies and community resources, establish a tenant council, serve as a liaison with the ALSA’s quality assurance committee, and ensure that a tenant information system is in place. The MRC may either contract with a separate ALSA or become licensed as an ALSA itself. At the discretion of the Connecticut Department of Public Health, some housing communities supported through the state subsidized congregate housing program also may offer onsite ALSA services without meeting the core services requirements governing MRCs.

Minnesota Most assisted living services in Minnesota are provided in facilities registered with the Department of Health as “housing with services establishments.” These properties provide sleeping accommodations to one or more adults, at least 80 percent of whom are 55 years of age or older. For a fee, they offer or provide one or more regularly scheduled health-related services or two or more regularly scheduled supportive services. Health-related services include professional nursing services, home health aide tasks, home-care aide tasks, and the central storage of medication for residents. Supportive services include help with personal laundry, handling or assisting with personal funds or arranging for medical services, health-related services, social services or transportation to medical or social service appointments. If the housing with services establishment provides the services directly, it must have the appropriate home-care provider license from the Department of Health. If the facility contracts or arranges for these services, the entity providing the services must have the appropriate license.

Others:

New Jersey Michigan Indiana

Campus Network Strategy

This approach has some of the attributes of a continuing care retirement community (CCRC). It links independent housing for older adults with an ALF, providing residents a broader choice of settings as they age and their functioning changes. No entrance fee is charged and separate payments are required for different levels of care and different amounts of services. One goal of this approach is to maintain affordability of supportive services for individuals in independent housing who may not be eligible for Medicaid-reimbursed assisted living by apportioning some costs for management, professional and program staff between the independent housing property and the ALF.

In general, the independent living property and ALF separately provide services, which may include meals, transportation, and social activities. Each unit maintains separate social work staff. Case management may be shared. All ALF residents are assessed and receive a plan of care from the ALF case manager. Residents of the independent living property may be assessed as needed by ALF case managers and plans of care developed as appropriate. Other services that may be shared across settings include medication management, 24-hour staffing, and after-hours care. Assisted living services for low-income persons are funded through the Medicaid program. Residents not eligible for Medicaid pay for some services out-of-pocket. Whether the ALF is able to provide services to residents in the independent property may depend on state licensing requirements and whether the ALF is also licensed to provide home-care services.

Example:

Eaton Senior Programs, Lakewood, CO Eaton Senior Programs (ESP) operates Eaton Terrace Residences (ETR), a 162-unit independent senior property financed through tax-exempt bonds with project-based Section 8 rental assistance, and Eaton Terrace II (ET II), an adjoining ALF. ESP is able to leverage resources across both residential properties. ET II has both an assisted living license and a home and community-based services license, which allows staff to provide personal care and homemaker services anywhere in the community, including at ETR. ETR residents may purchase personal care, housekeeping, and medication monitoring services at whatever level they may need. Residents pay out-of-pocket, unless they are participating in a Medicaid program that covers the costs. ESP also has created a “care consultation team” to support resident needs, which includes social workers, activities coordinators, pastoral counselors, resident assistants, and other staff. Although each property has staff that focuses specifically on its residents, each is able to leverage expertise and resources across the team. For example, ESP contracts with an RN for 16 hours a month to serve both ETR and ET II residents, and the RN participates in ESP weekly care team meetings that address residents of both properties.

Cathedral Square Senior Living, Burlington, VT Cathedral Square Senior Living (CSSL) is a Section 202 senior housing property co-located with an assisted living program. If CSSL residents need help with basic activities of daily living such as bathing, dressing, and toileting, Cathedral Square can license their apartment as an assisting living unit and bring services to them, rather than making them move to the nursing wing. Should they no longer require help with basic living activities, the apartment reverts to independent living. The assisted living arm of CSSL is not able to provide services to residents in the independent arm because it is not licensed as a home health agency. Independent living residents at CSSL, however, may receive support through the state’s Housing and Supportive Services program, which funds service coordination and case management, in addition to wellness activities and homemaker services. These services, as well as the assisted living services, are provided directly by CSSL staff.

Integrated Housing, Health Care, and Supportive Services

This goal of this approach is to provide poor and near poor seniors access to an integrated package of affordable housing, health care, and home and community-based services comparable to what is available to more affluent residents of CCRCs. A key resource for making this strategy work is access to adult day care and/or adult day health care in co-located space or in close proximity to the housing property. The availability of adult day services is likely to make it easier for residents with cognitive difficulties in need of supervision to maintain independent living.

Funding sources may include the Federally Qualified Health Center Program (for community health centers), PACE (adult day health care), Medicaid home and community-based services, and OAA resources (adult day health/adult day care and in-home and other supportive services).

Examples:

The Over 60 Collaboration, LifeLong Medical Care, Oakland, CA This project blends health care, personal care, supportive services, and affordable senior housing through a collaboration between Resources for Community Development (a housing developer), LifeLong Medical Care (operates the Over 60 Health Center, a federally qualified health center), and the Center for Elders Independence (a PACE program). Through co-location of the Over 60 Health Center in Mabel Howard Apartments, a Section 202 property, healthy and moderately disabled residents may receive primary medical care and other health services including case management, mental health services, podiatry, dental care, adult day health care, health education and screening, physical therapy, and links to home health services. The partnership with PACE allows nursing home eligible residents access to comprehensive medical and social services in an adult day health center, which is also located onsite. The program is intended to provide low-income seniors in subsidized housing an assisted living level of service without special funding.

Presentation Senior Housing, San Francisco, CA Presentation Senior Housing is collaboration between Mercy Housing California and North & South Market Adult Day Health that integrates affordable housing with onsite adult day health services. The Section 202 building includes 93 units, 60 of which are targeted to very low-income frail elders. Approximately half of the residents participate in the day health program, which provides a variety of services such as nursing care; social work services; physical, occupational and speech therapy; podiatry services; mental health support; case management; transportation; and a daily meal. Those not enrolled in the adult day health program receive support and services from a service coordinator, as well as a variety of community organizations. Almost three-quarters of residents receive services from the In-Home Supportive Services program, a Medicaid-funded program that provides homemaker and personal care services. Operating as a separate day health program and independent living apartments allows the project to avoid state licensing as an ALF while providing roughly the same level of services to residents.

Others:

Angelus Plaza, Los Angeles, CA Caroline Street Apartments, New Bedford, MA Homestead Apartments, Homestead, PA Eskaton Natomas Manor, Sacramento, CA Joseph J. Hill Ralston/Mercy-Douglass House, Philadelphia, PA On Lok House, San Francisco, CA Gamelin House, Seattle, WA

Affordable Housing/Health Partnerships

In this model, formal partnerships are established between a heath system or health providers and affordable housing sponsors. The health system may be instrumental in seeding the development of low-income housing, as well as bringing primary care and health-related services to elderly residents. Incentives for such partnerships are varied and may include honoring the mission of faith-based nonprofits, tax benefits, creating new uses for defunct community hospitals, and encouraging referrals of elderly residents in return for services.

Services may include health screening, care management, wellness programs, geriatric assessment, primary medical care, immunizations, and exercise programs. Funding may be the result of discounted services by providers in exchange for referrals, as well as Medicaid, hospital and health system resources, community development organizations, or corporate and individual donors.

Examples:

Golden West Senior Residence, Boulder, CO Golden West is a 255-unit former Section 202 property now refinanced with tax-exempt bonds. Golden West has partnered with Medically Based Fitness (MBF) to operate an onsite wellness center. Golden West provides the space and equipment and MBF staffs the center, which is open five days per week, with a physical therapist and exercise physiologist. Residents pay a monthly membership fee, which for many is subsidized by fundraising through the Golden West Foundation. The Center also puts on educational activities, which are available free to all residents. Golden West also partners with several other programs or individuals in the community who come to the property on a regular basis to provide services. Through these relationships, they are able to bring in foot care, massage, reflexology, hearing aid maintenance, wheelchair and walker maintenance, banking services, and many activities. These services are generally provided free or at a minimal cost to the residents.

Sixty Plus Program, Piedmont Hospital, Atlanta, GA The goal of Piedmont Hospital’s Sixty Plus program is to help seniors maintain and maximize their independence. The program partners with four affordable senior housing properties in the Atlanta area. The program sends a nurse to each property one day a week. Residents can schedule individual appointments, and the nurse also conducts post-discharge, follow-up visits with residents who have had a recent stay in Piedmont hospital. Physicians who work with Piedmont hospital also can ask the nurse to check in on any of their patients they think might need attention. The nurse can help residents coordinate any follow-up appointments or other health-related resources they might need. In addition to one-on-one appointments, the nurse conducts health fairs and other educational opportunities in the properties. The program is paid for by the hospital.

WellElder Program, Northern California Presbyterian Homes and Services, San Francisco, CA Northern California Presbyterian Homes and Services created the WellElder program to address concerns that too many residents in their HUD-subsidized properties were moving to board and care or nursing homes because of health care needs. The WellElder program provides an onsite health educator (RN or licensed vocational nurse) to work directly with residents to provide one-on-one consultations and health assessments; advocacy on the resident’s behalf with doctors, insurance providers, pharmacies, and other health services; referrals to medical services; medication reminders; health-related classes and group programs; and information about medical costs and insurance resources. The health educator also teams with a service coordinator to help residents obtain the services they need to remain in their housing community. Two of the four sites housing the WellElder program have been able to work the health educator into their operating budgets. At the other two, the positions are funded through grants.

Others:

Mercy Village, Joplin, MO

NOTES

1. C. Hawes, M. Rose, and C. Phillips, A National Study of Assisted Living for the Frail Elderly: Results of a National Survey of Facilities, Prepared for the Office of Disability, Aging, and Long-Term Care Policy, Office of the Assistant Secretary for Planning and Evaluation, HHS, 1999. [http://aspe.hhs.gov/daltcp/reports/facres.htm]

2. Bernadette Wright, An Overview of Assisted Living: 2004, In Brief FS62R (Washington, DC: AARP Public Policy Institute, 2004), 2.