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


The public health model would incorporate a full range of primary, acute, chronic care and long-term care services and support. Services organization and delivery could be based in and managed by a single free standing housing property or the corporate owner/sponsor of multiple housing properties within a region or within a nearby community agency such as a federally qualified health center, area agency on aging (AAA), physician practice designated as a medical home, health plan or a local public health department. The housing property and property service coordinator would be an instrumental part of the partnership. The housing provider would provide space, contribute to or manage the screening and assessment of potential participants, help to negotiate agreements with community providers, facilitate onsite visits for other partners and assist in monitoring services delivery and quality.

The public health model would be anchored in communities with high concentrations of low-income seniors and subsidized senior housing properties with a sufficient volume of elderly residents to have some possibility of showing cost-effectiveness for Medicare and Medicaid programs, the service delivery system and for the payers. The model targets all low-income older adults in participating properties and the surrounding community with the goal of improving the health and quality of life of all. Participants could include:

  • Healthier older adults who might benefit from preventative and wellness services such as health education, blood pressure and glucose monitoring, exercise classes, etc.

  • More at risk individuals who are growing older and more frail and are therefore more subject to illness and injury.

  • Special populations who have multiple chronic conditions, severe behavioral health issues and/or significant disabilities and are at high risk for repeat ER or hospital visits, falls, etc.

  • While recognizing the entire elderly resident population as the target, models within the public health approach could run the gamut from modest interventions addressing the prevention, psycho-social and chronic care needs of select individuals within the properties and adjacent community to fully integrated programs that address the entire range of medical and social needs of the resident and adjacent community population.

Examples of existing programs3 that illustrate this model include:

  • Lapham Park, Milwaukee, WI--Lapham Park is a senior-designated public housing property that provides a continuum of onsite services through a group of community partners to address residents’ preventative, acute, and long-term health care needs. St. Mary’s Family Practice Clinic offers physician care to all residents. Community Care Organization, which operates a Program for All Inclusive Care for the Elderly (PACE) program, provides acute, primary, specialty and long-term care for nursing home eligible residents enrolled in its capitated program. The Milwaukee County Department on Aging provides a congregate meal site. Multiple other community partners provide additional wellness programming. S.E.T. Ministry provides case management services.

  • Seniors Aging Safely at Home (SASH), Burlington, VT--SASH is a care management model that helps coordinate health and long-term care services for residents in affordable senior housing properties and individuals in the surrounding communities. The core of the model is a full-time SASH coordinator employed by the housing property, who coordinates a team of community service providers including a home health agency nurse assigned to the site, an AAA case manager, a community mental health provider, representatives of other HCBS providers (such as PACE). A “health aging plan” is developed with all residents who choose to participate and the SASH coordinator assists in coordinating with the community partners to facilitate the plan.

  • Mable Howard Apartments, Oakland, CA--A community health center and PACE program adult day health center, co-located with a low-income senior housing community, provides the opportunity for residents to age in place. Residents get benefit of a full range of services from less intensive, flexible services from the health center to full medical and long-term care benefits in a managed care plan. The health center is a federally funded Qualified Community Health Center. It provides preventative care, primary care and case management, including mental health services, podiatry, dental care, health education and screening, physical therapy, and links to home health services. The PACE program provides nursing home eligible residents access to comprehensive medical, social and long-term care services under a capitatedsystem of reimbursement in an onsite adult day health center. PACE staff provide care in the residents own apartment as needed.

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