Design of a Demonstration of Coordinated Housing, Health and Long-Term Care Services and Supports for Low-Income Older Adults. Appendix A: Examples of Relevant Existing Practices


In order to ground the fundamental demonstration design and research considerations outlined in Chapter IX, this Appendix provides examples of relevant existing practices or other operational aspects related to the basic elements of the intervention, and how they might work to produce desired outcomes. Examples in each area were drawn from the literature and current experience.

Demonstration Design/ Research Considerations Relevant Existing Practices
Type of Evaluation -- Degree of standardization
  • Channeling demonstration used randomized controlled design had a uniform service package, both basic and complex models, an assessment and case management approach defined by the government so there was consistency across sites.
  • Cash and Counseling demonstration used randomized controlled design and standard intervention frameworks, but relied upon existing practices for assessment, service packages and service coordination.
  • Medicare Care Coordination demonstration used randomized controlled design, but allowed each demonstration site to implement its own service coordination model.
  • Better Jobs Better Care demonstration targeted changes in policy and practice that focused on recruitment and retention of direct care workers. The applied research and evaluation program focused on workplace and public policy that addressed recruitment and retention of direct care workers.
Selection of Demonstration Sites
  • Identifying candidate communities and subsidized housing--Census data could be used to identify urban areas with higher than average concentrations of older adults. HUD and State Housing Agency administrative data could then be employed to identify within these census tracts communities where there are clusters of HUD subsidized senior housing and LIHTC properties located in close proximity to one another. By combining data from HUD administrative files with data available in the CMS Chronic Condition Warehouse, which includes Medicare and Medicaid enrollment and claims, and assessment data based on Outcome and Assessment Information Set for Medicare home health recipients, the characteristics of housing residents and residents of the surrounding community can be analyzed and compared. Other tools for assessing the health status of older adults could include the use of public health surveillance strategies, public health records and other tools.
  • Determining necessary volume--Volume of individuals in the demonstration will be a consideration from two aspects: (1) power requirements necessary to detect a particular impact; and (2) implications for a business model in the real world.
  • Existing management information systems--Most housing properties do not use electronic assessments, although a few may have electronic care management systems, but these are often not standardized. Community-based organizations have varying degrees of electronic assessment and participant tracking, which are often based on the state’s Medicaid HCBS waiver system requirements. Increasingly, health care providers have adopted electronic health records and some communities are standardizing protocols for the exchange of health information across providers, some even including community-based organizations.
Identification of Target Population
  • Soliciting referrals from community providers of individuals who meet the risk criteria.
  • Predictive modeling techniques could be developed based on data from public health records and or Medicare/Medicaid claims to identify high risk residents.
  • Residents of the housing property could be asked to complete a short assessment of their health status and services needs.
Assessment of Participant Service Needs
  • Candidate tools for assessing participant needs include: the CARE Tool under development for CMS, state assessment tools for Medicaid HCBS, the Minimum Data Set Resident Assessment Instrument. Alternatively, the housing property could develop its own assessment tool and processes.
Potential Delivery and Financing Models
  • Models that integrate health and long-term care services to varying degrees (e.g., PACE program, Evercare, Arizona’s’ Medicaid Managed Care Program, Minnesota’s Senior Health Options, Massachusetts’s SHO program).
  • ACA models which attempt to link integrated care delivery with payment incentives that encourage providers to collaborate with one another to improve patient care and reduce costs--“Medicaid Health Homes,” ACOs, and the Independence at Home Demonstration.
  • Standardized integrated care models (e.g., Guided Care developed by researchers at Johns Hopkins (Dr. Chad Boult), the GRACE model developed by Dr. Steve Counsel, the Care Transitions Program led by Dr. Eric Coleman, and the Transitional Care Model developed by Dr. Mary Naylor).
  • Necessary core services--Core services might include a needs assessment, case management (at least for high risk participants); access to primary care and chronic care management (possibly onsite), transportation for medical appointments, housekeeping and social services, personal care, medication management, behavioral health services, and health and wellness services. Such services would be offered to residents on a voluntary basis and delivered in increments that meet need and maximize efficiency. Access to assistance on a 24/7 basis for emergencies may also be crucial to maintaining resident safety and reducing the revolving door between the ER and a resident’s apartment (e.g., PACE or health plan help line). Whether that could be delivered by an offsite agency or must be present in-house is a question for the design team. Some integrated care models also rely on enhancing patient self-care and “health coaches”--non-professional staff who can work with individual participants on health issues.
  • Lead agency--A variety of organizations, including the housing property itself, could manage and implement the demonstration. However, there may only be handful of housing sponsors and properties which are large enough or have sufficient capacity to act as the lead agency (e.g., Good Samaritan, Presbyterian Homes and Services, Mercy Housing). All participating housing properties would at a minimum need an onsite service coordinator dedicated to recruiting and assessing residents for participation, providing information and referral, acting as an intermediary to the provider network, assisting with services planning and arrangement, monitoring implementation and providing feedback for quality improvement purposes. Other candidates for lead agency might include the local Area Agency on Aging, a community health center, a Special Needs Health Plan, and a multidisciplinary physician group (medical house calls programs, medical homes) etc.
  • Formal and informal strategies for service delivery--Multiple and diverse strategies have been used in the past to staff a housing with services program and to link resident to needed services. Some housing properties have onsite staff including service coordinators who help residents identify needs and locate services, and nurses who operate a wellness clinic providing health education and preventative services. Other properties negotiate informal and formal agreements with local hospitals, community health centers or physician practices so that nurses, nurse practitioners and geriatricians come to the property at regularly scheduled times. Agreements have also been formalized between the property and academic health centers so that students can carry out clinical rotations and provides needed health services. Some properties co-locate services such as a PACE site, adult day care center, senior center or physician office to bring selected services to residents. Others recruit volunteers and other trained lay people from the property or the community to assist residents with managing their health issues. In some cases, housing properties are part of a larger campus that includes an assisted living facility and/or nursing home to provide more nighttime coverage or provide additional services such as personal care. A few properties own and operate licensed home health agencies that serve residents and the broader community, while some others partner with home health agencies to negotiate more affordable rates for homemaker and personal care services. (Harahan, Sanders & Stone, 2006b; Golant, Parsons & Boling, 2010). Achieving a comprehensive and integrated system of care for property residents is likely to require stronger, more formal relationships between health care providers and the housing property than has been previously implemented in housing with services programs.
Resource Development/ Financing Schemes
  • Program funding: (1) for program development, staffing, infrastructure and services not covered through Medicaid or Medicare because many residents are not eligible for Medicaid-funded HCBS and Medicare does not currently pay for comprehensive service coordination; (2) to augment a housing properties’ services coordinator with a full-time nurse or social worker; and (3) to design, implement and manage data systems to track performance.
  • Modifying existing policies and regulations: (1) Changing HUD rules to allow properties to identify a select number of services as a budget line item within their operating budget. Specific services could be required based on their demonstrated effectiveness to improve resident outcomes/lower cost. (2) Allowing properties under common ownership to pool residual receipts, reserves and excess cash flows (while assuring an adequate amount of reserves for all properties) and direct them to where they are most needed to strengthen resident services. (3) Making it easier to use residual receipts for resident services by clarifying HUD policy. (The Section 202 reform bill recently passed does clarify that unexpended funds from refinancing proceeds and residual receipts can be used for services). Although this may provide housing providers with more flexibility to pay for services, it is unlikely to generate enough revenue to support a services program. (Cohen, 2010). (4) Develop a new waiver that allows housing properties to combine housing and services resources as long as it is in the aggregate less costly than current practice.
  • Creating targeting incentives--Reward developers/sponsors for targeting older adults with services needs and insuring that needed services are available to them. For example, in cases where the developer agrees to admit a certain proportion of residents based on predictors of health risk and high health and long-term care costs, new Section 202 Housing for the Elderly awards and the allocation of LIHTC designated for seniors could include a bonus, part of which would go to the developer and part to fund services. This approach is similar to the new 811 Program under the Melville Act.
  • Giving preference in admissions--to high risk seniors identified by Medicaid HCBS providers, physicians groups, VA hospitals and clinics, and other community agencies in return for their willingness to guarantee an appropriate services package to the prospective resident.
  • Providing partnering incentives--to large housing sponsors with multiple properties to become stakeholders in the growing number of health care organization and delivery models such as medical homes, ACOs, and Medicare Special Needs Plans. Housing sponsors could be given a special bonus to be designated for gap filling services in return for their participation. Good Samaritan, Presbyterian Homes and Services and Mercy Housing likely have sufficient resident volume to be attractive to these health care delivery plans. Cathedral Square in Vermont is part of the shared savings activity in the Medicare Medical Home Demo.
Quality Improvement/ Performance Measurement and Accountability
  • The Health Indicators in Naturally Occurring Retirement Community (NORC) Programs initiative has developed promising quality improvement strategies and tools to help NORC providers identify and manage the care of NORC residents most at risk, focusing on heart disease, diabetes and increased risk of falls. Standards of Practice which reflect best practices and clinical guidelines in self-care, medical care and community supports have been developed which include detailed measures relating to each standard (Vladeck, et al., 2010). The COLLAGE effort (Kendall and Hebrew Senior Life program) is trying to collect standardized data across participating housing properties to use for benchmarking and accountability.

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