Design of a Demonstration of Coordinated Housing, Health and Long-Term Care Services and Supports for Low-Income Older Adults. B. Examples of a Risk Based Model within Subsidized Housing


The risk-based model also requires communities with high volume of low-income older adults in affordable housing properties. In this case however, community selection would take into account other criteria as well such as higher than average clusters of very old (85+) and/or chronically ill older adults. The model could target services to one or more of the following types of high risk seniors which are not mutually exclusive:

  • Dual eligible who are high users of Medicaid and Medicare services.

  • Individuals with three or more chronic illnesses.

  • Those at risk of nursing home entry for an extended stay because of cognitive and or physical impairments (e.g., multiple ADLs).

  • Individuals with significant behavioral health issues.

  • The top 5% or 10% of Medicare spenders.

Services organization and delivery is more likely to be managed by an entity outside the housing property4 such as a health plan, primary care practice, community mental health center, medical home or ACO for three primary reasons:

  1. A lack of capacity of most housing providers to manage the high level of care required.

  2. Service organization and delivery and most property owners or managers are leery of the regulatory requirements of being licensed as a health care provider.

  3. Properties often do not have enough volume to support the business model--they need an outside entity that has a larger population (Stone, 2011).

Examples of current strategies5 illustrating this model include:

  • The Marvin, Norwalk, CT--The Marvin operates Connecticut’s Congregate Housing for the Elderly Program, which is a state subsidized program for low-income elders who have temporary or periodic difficulties with one or more essential ADLs. Residents pay a minimum rent and a congregate service charge, which is based on their adjusted income. The state provides a subsidy for residents who cannot afford to pay the full cost of the service program. Services include housekeeping, emergency call systems in each room, 24-hour security, community, meals social and recreational activities, wellness/prevention programs and emergency transportation. The Marvin also participates in the state’s assisted living services program. Under this program, the Marvin provides an onsite nurse (hours depending on needs and number of participants; on-call nurse (24 hours/day); personal services including hands-on assistance with daily activities including, but not limited to: dressing, grooming, bathing, using the toilet, transferring, walking, and eating; and additional core servicesmay be provided including housekeeping, personal laundry and meal preparation. Assisted living services are provided through the Connecticut Home Care Program for Elders program and paid for through either a Medicaid waiver or a state-funded component (for persons whose income exceeds the Medicaid waiver limits).

  • Just for Us, Durham, NC--Just for Us is collaboration between the Duke University Medical Center Division of Community Health, the Lincoln Community Health Center (Durham’s federally qualified community health center), the Durham County Department of Social Services, the Durham County Health Department, the Council on Senior Citizens, and the City of Durham Housing Authority. Collaborating agencies operate under a single administrative structure managed by Duke Community Health under contract with Lincoln Community Health Center. The program targets low-income seniors and disabled adults with multiple chronic conditions who are homebound and cannot access health and medical care on their own without great difficulty. Just for Us provides patients with annual physical examinations, consistent monitoring and treatment of chronic medical conditions, treatment of acute care needs that can be treated at home, lab tests and patient health education. Patients receive routine visits from the physician or physician assistant every 6-8 weeks, or more often when their medical condition warrants. Patients with specific needs may also be seen by a nutritionist (particularly diabetic patients) or occupational therapist. A social worker provides case management and helps patient apply for benefits, such as food stamps and Medicaid, and access supportive services, such as Meals on Wheels and home health aides (most of the housing properties served by the program do not have a service coordinator). The program can also help arrange mental health services.

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