Design of a Demonstration of Coordinated Housing, Health and Long-Term Care Services and Supports for Low-Income Older Adults. I. Overview


In 2011, as the baby boomers begin to reach age of 65, their preference to remain as independent for as long as possible and to “age in their communities” underpins the conceptual framework for housing with services for older adults presented here. Consistent with the U.S. Department of Health and Human Services’ (HHS’) Vision and Strategic Framework on Multiple Chronic Conditions1 policymakers, housing and services providers, elderly consumers and their families increasingly embrace person-centered, holistic and cost-effective approaches to addressing the needs of vulnerable low and modest-income older adults. The person-centered philosophy places the elderly individual (and family where available) squarely in the center of the local health and long-term care delivery system and recognizes that the quality of the larger physical and social environment within which an individual lives (including shelter) significantly influence one’s health and quality of life.

Building on over two decades of efforts to increase access to home and community-based services (HCBS), the Patient Protection and Affordable Care Act (ACA) further expands primarily Medicaid-funded options, providing unique opportunities for exploring how housing with services models may be efficient ways of serving large numbers of lower-income older adults. The Money Follows the Person demonstration that seeks to transition nursing home residents to the community has identified the lack of service-enriched affordable housing as one of the demonstration’s major barriers (O’Malley-Watts, 2011). The U.S. Department of Housing and Urban Development (HUD) also recognizes the important role of services in helping its elderly housing residents to remain safely in their apartments. HUD’s recent policies emphasize aligning new Section 202 developments with health care reform efforts at the state and federal levels to better support elderly as they age in place in the community.

Acknowledging the lack of service coordination and integration for Medicare and Medicaid beneficiaries--particularly those with multiple chronic conditions and functional problems--the ACA established several new offices within the Centers for Medicare and Medicaid Services (CMS) to develop and oversee a range of payment and service reform demonstrations and programs (Accountable Care Organizations [ACOs]/Shared Saving Program, Medicaid Health Home) that test new approaches to reducing fragmentation and excessive costs. These new options offer unique opportunities to explore the role of affordable housing with services in achieving the goals and objectives of these initiatives. The American Recovery and Reinvestment Act provides additional sources of support for the delivery of evidence-based prevention services to low-income elderly residents of publicly subsidized housing and those living in close proximity to these properties (Stone, 2011).

In sum, the conceptual framework offered here that will guide the design of affordable housing with services for older adults demonstration options recognizes the increasing adoption of a person-centered philosophy of service delivery and the desire of most individuals and their families to “age in place”. The models that ultimately emerge from this project should build on these trends and the federal and state policy initiatives currently underway to reform health care and housing for low-income older adults.

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