Heumann, Leonard F., Ph.D., Karen Winter-Nelson, and James R. Anderson, Ph.D. The 1999 National Survey of Section 202 Elderly Housing. Public Policy Institute, AARP, Washington, DC (2002).
The Elderly Housing Program, commonly known by its section number, Section 202, is a federal program focused on constructing subsidized rental housing for older adults. In 1999, over 3,500 Section 202 facilities housed more than 300,000 older people. The 1999 National Survey of Section 202 housing is the third national survey of Section 202 sponsors and facility managers; previous surveys were conducted in 1983 and 1988. The survey continues to document changes in characteristics of the project, residents, consumer demand, offered services, management, and capital needs.
The 1999 National Survey of Section 202 housing for older people involved a random sample of a third of existing projects and two different survey instruments, one for managers and another for sponsors. A total of 509 managers, (47 percent response rate), and 480 sponsors (44 percent response rate) participated in the survey. Because of the survey's focus on the effect of legislative and regulatory changes, analytic results compare project, resident, staffing, services, and financial characteristics over time. Facilities are categorized into five phases according to when they were built, these phases include: Moderate-Income Phase (1959-1974), Low-Income Phase (1974-1984), Cost-Containment or Very Low-Income Phase (1985-88), Transition Phase (1989-1994), and the Project Rental Assistance Contract (PRAC) Phase (1993-present).
The following is a summary of findings on staffing and management, service availability and usage in Section 202 elderly housing. Since authorization of professional service coordinators in 1990, more than a third of facilities (37.4 percent) in 1999 had professional service coordinators on staff. Another 43.8 percent of residents had access to community-based service coordination. Managers with service coordinators on staff report that service coordinators have increased the range of services (90.5 percent), increased the quality of services (78.3 percent), and allowed residents to stay independent longer (81.1 percent). There was a 17 percent increase in total staff hours per unit between 1988 and 1999, averaging 2.1 hours a week, while services hours increased 57 percent to an average of 1.1 hours per week. In the past decade, the number of part-time managers, working less than 30 hours per week has increased from 22 to 27 percent. This trend is concentrated mostly in small facilities.
Facilities that are more likely to provide supportive services to elderly residents tend to be older with large numbers of units, more residents over the age of 80, a higher percentage of frail residents, residents that pay for services, and large communal spaces for group services and activities. Section 202 projects reporting lower levels of full or partial congregate support (i.e., meals and housekeeping) were more likely to be developed between 1985 and the present. Higher levels of congregate support were reported from older projects developed between 1959 and 1985. Some projects (10.9 percent) extended services to nonresidents from the surrounding community.
Sources of funding differed by type of service. Resident funds were the primary source of income for group meals for 81.3 percent of moderate-income facilities and 57.9 percent in the other four phases. Medicaid was the most common source of income for personal care services in all phases, except for the moderate-income phase. For other services such as transportation or visiting nurse services resident funds were used by 63.8 percent of moderate-income facilities, and 42.8 percent of facilities in the other phases.
Services such as group dining, social work and counseling, and social and recreational activities were most likely to be provided by on-site staff. Personal care, housekeeping, care management, medication management, and religious services were most likely provided by external agencies or contractors, while transportation and money management are services most likely provided by family and friends. Support from family and friends remained unchanged across all Section 202 phases, suggesting that program changes or use of outside agencies had little effect on the use informal support networks.
Legislative and regulatory changes have improved the Section 202 program since 1988. For example, legislative changes in the early 1990s allowed facilities to hire service coordinators. Service coordinators have increased the range and quality of services as well as allowed residents to stay in their individual units longer. Residents in Section 202 housing are older and more likely to be frail than in previous surveys. In 1983 the average resident age was 72, compared with an average age of 75 in 1999. As residents continue to age in place, facilities are setting up congregate services or converting to assisted living to accommodate residents' needs. But, facilities built in the past decade are much smaller, on average, than those in previous years with fewer staff and services. It may be less economically efficient for these facilities to serve a smaller number of residents.
There are two important issues to examine in future research. The first is the need to address resident satisfaction and perceptions about the quality of federally subsidized housing and care. The second is to address quality of care issues in facilities providing support services, where currently there is no data about the adequacy or appropriateness of support services in elderly subsidized housing. It is also recommended that HUD improve its databases for the inventory of projects serving older people and people with disabilities, besides establishing a regular process for updating information in this survey.
Cox, Beth Madvin. "Linking Housing and Services for Low-Income Elderly: Lessons from 1994 Best Practice Award Winners." Journal of Housing for the Elderly 15, no. 1-2 (2001): 97-110.
This study identified the characteristics of HUD's Best Practice Award winners for subsidized multiunit housing facilities that offered supportive services program to older residents. Supportive housing was designed to provide services at a new site or pre-existing facility to an aging population, where the services increase as the population ages. Facility management typically developed supportive programs by providing direct services or securing community resources. Charitable organizations also provided supportive services to federally subsidized housing facilities.
The author used data from 117 applications for the HUD 1994 Best Practice Award competition, and compared the 23 winners with the other 94. The purpose of this competition was to recognize and award HUD subsidized multiunit housing facilities.
The best practice sites had more access to supportive, clinical, and ancillary services, and astutely utilized community resources. The winners of the 1994 HUD Best Practice award provided linkages to a greater number of supportive services (p<0.0.1), and were more likely to provide on-site nursing services (p<0.01), mental health services (p<0.05), and security services (p<0.05). Winners used outside providers more often in the provision of service coordination (p<0.05), congregate meals (p<0.05), and mental health services (p<0.05).
These characteristics would be imperative in the continued development of comprehensive aging-in-place programs for older adults with low incomes. Winners were also more likely than non-winners to be located adjacent to community centers.
Ficke, Robert C., and Susan G. Berkowitz. Report to Congress: Evaluation of the Hope for Elderly Independence Demonstration Program and the New Congregate Housing Services Program. Washington, DC: U.S. Department of Housing and Urban Development, Office of Policy Development and Research, 2000.
This report presents the evaluation results from two Department of Housing and Urban Development (HUD) programs, the HOPE for Elderly Independence Demonstration program (HOPE IV) and the Congregate Housing Services Program (CHSP). Both programs combine housing assistance with case management and a range of supportive services for the frail, low-income elderly population. The purpose of evaluating these programs is to provide information and support in legislation, programs, and policies that address the housing and service needs of elderly individuals in federally assisted housing.
Section 802(1) of the National Affordable Housing Act of 1990 mandated an evaluation of HOPE IV and the new CHSP. The objectives of the two evaluations were to provide a comprehensive description of each program, assess the effectiveness of the two programs in providing supportive services to frail elderly with the goal of maintaining their independence, and compare HOPE IV with the new CHSP. Although both programs provide similar services with the same goal, one major difference is that HOPE IV is tenant-based and CHSP is project-based. The HOPE IV program combines Section 8 rental vouchers with case management support services to enhance elderly residents' quality of life and prevent unnecessary institutionalization. These services are provided either in the tenants home or in other community locations. To be eligible for HOPE IV the person must have been at least 62 years of age, have income not exceeding 50 percent of the median for their area or be willing to move to a private rental unit that meets HUD's Section 8 standards, not participating in Section 8 or other housing assistance programs, and need assistance with personal care or home management activities.
The CHSP program provides a combination of housing and supportive services to low-income frail elderly or nonelderly with disabilities to encourage maximum resident independence, improve management's ability to assess service needs, and ensure delivery of needed services. Services are delivered in the resident's apartment or in the development's common areas (i.e., dining room, activity center). For eligibility to both HOPE IV and CHSP programs, HUD required that participants need assistance in three or more HUD defined ADLs: eating, bathing, dressing, grooming, and home management activities (e.g., housework, shopping, laundry).
Another difference between the two programs is in recruitment and participation. Participants for the HOPE IV program were recruited by grantees, but could not have been receiving HUD housing assistance before applying to the program. CHSP participants came from HUD-assisted congregate housing sites, many of them having lived in these communities for several years. One key feature of both programs was the establishment of a service coordinator position responsible for designing and implementing a system of case management and supportive services to their frail elderly residents.
HUD awarded grants to 16 agencies or grantees for HOPE IV housing projects ranging from 25 to 150 residents during a five-year demonstration period. Grantees represented state-level agencies, county jurisdictions, and municipalities across the nation including states in the West (California, Colorado, Washington), Southwest (Arizona, Oklahoma, and Texas), Midwest (Iowa, Ohio), South (Kentucky), and East and Northeast (Maine, Massachusetts, New Hampshire, New Jersey, and Pennsylvania). Thirteen of the 16 grantees reported serving suburban, rural or small town communities.
Another 39 grants were awarded to fund CHSP projects in 45 developments with the number of participating residents in each development ranging from less than 10 to 100. These projects existed in various types of federally subsidized housing including Section 202, Public Housing Authorities (PHAs), Rural Housing Service, Section 236 and Section 8. Most of the CHSP developments were located in urban or metropolitan areas, only four were in nonmetropolitan areas. CHSP projects were concentrated geographically in the Midwest (12 developments) and Northeast (11 developments). West and Midwestern developments were located mainly in large metropolitan areas, while Northeastern developments were in moderately sized metropolitan areas, and Southern developments were mostly moderate-sized metropolitan areas to nonmetropolitan areas.
The service coordinator and professional assessment committee (PAC) were key parts of the HOPE IV and CHSP programs. The service coordinator's responsibilities included recruiting and formal case management, educating resident and staff, building a network of providers and service agencies, and linking participants to those providers and services. The PAC worked in conjunction with the service coordinator to determine eligibility, help develop the case plan for services, and monitor participants' condition.
Services provided to participants under HOPE IV and CHSP included: meals, housekeeping, grooming, dressing, maintaining personal hygiene, transportation, nonmedical supervision, wellness programs, preventive health screening, personal emergency response systems, and other supportive services approved by HUD. Grantees either provided services directly or through contract agencies or providers. HUD paid 40 percent of the program costs, the grantees paid an added 50 percent, and participants paid for the remaining 10 percent with a cap up to 20 percent of their income.
The report discusses program design, implementation, and operation. Subsequent chapters compare and contrast the demographic profile and functional health status of participants in each program. There is a discussion of the informal and formal assistance, social support, and service utilization of program participants and comparison of the effect of the two programs on measures of well-being and exit patterns (e.g., nursing home placement, mortality). Finally, the authors present conclusions, policy implications, and recommendations for how HUD and Congress might address the needs of the frail elderly in federally subsidized housing through housing and supportive services.
Program Implementation. Because of differences between CHSP and HOPE IV models, recruitment of HOPE IV participants took considerably longer than CHSP. Almost all HOPE IV grantees reported difficulty in recruiting and placing eligible applicants in subsidized rental housing, with 40 percent of applicants having to relocate to a qualifying apartment to receive the programs services. Public housing authorities had to make considerable changes to their Section 8 application and placement policies and procedures to accommodate the frail elderly in applying and finding subsidized housing as well as balance the implementation activities with supportive service requirements for participants. Because of the implementation requirements in the HOPE IV program, the role of the service coordinator developed differently from the CHSP program. Throughout the five-year demonstration period, HOPE IV service coordinators continued to work on efforts to recruit and retain participants, while CHSP service coordinators were able to focus on more case management activities. In follow-up surveys HOPE IV and CHSP participants reported they were satisfied with their service coordinators' help in providing information and linkages to services. HOPE IV participants stressed their role in finding housing and rental assistance, while CHSP participants focused on the personal and interactive relationship with the service coordinator.
Participant Characteristics. Most of the participants in the HOPE IV and CHSP programs were widowed, white females, living alone. Over half were 75 years of age or older, while the median age of CHSP participants was higher than HOPE IV (82 years versus 74 years). Half the HOPE IV participants changed residence within one year of enrollment, compared with 12 percent of CHSP residents, partly caused by the design differences of each program. All HOPE IV participants were new to HUD housing assistance, while CHSP participants were already living in HUD assisted congregate housing. In terms of ADL limitations, HOPE IV and CHSP participants were considerably frailer than the elderly population as a whole but less frail than people who receive, or are eligible, for institutional care. HOPE IV and CHSP participants report having many chronic health conditions. The most frequently reported chronic conditions were heart conditions, diabetes, arteriosclerosis, and stroke. A greater percentage of HOPE IV participants indicated they sought medical care because of falls during the past year compared with CHSP (22 percent HOPE IV, 12 percent CHSP), however a similar proportion (9 percent HOPE IV, 7 percent CHSP) reported they were hospitalized for more than one day due to a fall during that period. More than a third of participants in both programs reported that they had stayed overnight in a hospital over the past year, twice the rate of the elderly as a whole. But, a majority reported they had not been confined to a bed or chair during the month before the baseline interview.
Social Support and Service Utilization. HOPE IV and CHSP participants differed in their social support and interaction. HOPE IV respondents reported contact with family members in-person or on the phone at one or another extreme, either frequently (several times a week or more) or infrequently (less than once a month). More than a quarter (25 percent) of HOPE IV participants reported seeing their child more than three-times a week and 12 percent reported they saw their child every day, while 47 percent reported they saw a child less than once a month. The distribution of family contact with CHSP participants was much more even across categories. Participants in both programs reported similar levels of loneliness (20 percent HOPE IV, 21 percent CHSP). Not surprisingly, a greater proportion of CHSP participants compared with HOPE IV participants were receiving formal services before entering their program. However, the core services received by participants were similar across programs with almost four-fifths of participants in both groups reporting they received housekeeping services, slightly less than a half indicated they received transportation services, and about a third received personal care. Participants reported they were satisfied with both the program and the amount and types of services received.
Outcomes. A separate comparison group of frail elderly receiving Section 8 rental assistance but not enrolled in HOPE IV was part of the evaluation to determine what the level of services might be without the program. Both participant and comparison groups were interviewed at two points in time, during a baseline and follow-up survey two years apart. The evaluation found that HOPE IV participants received considerably more services than the comparison group, a disparity that continued to increase over time. At follow-up 32 percent of the comparison group reported receiving no services compared with 7 percent of the HOPE IV participants. HOPE IV service recipients scored higher on mental health measures (anxiety, depression, loss of behavioral/emotional control, and psychosocial well-being), social functioning, vitality, and other measures of social well-being. However, there was no statistical difference in the rate of nursing home placement, mortality, or exiting Section 8 housing between the HOPE IV participants and comparison group. Similarly there is no independent effect of receiving one specific individual CHSP service on continued participation in the CHSP program. Twenty-four months after the baseline study, half the residents were still in their respective programs. Nine percent had left the program but remained in their subsidized housing either because they were not eligible, were dissatisfied, or obtained services from some other source. More CHSP participants had moved into a nursing home compared with HOPE IV participants (25 versus 9 percent), possibly because of their higher median age. Another 14 percent of participants in both programs had died.
The HOPE IV and CHSP service coordinators played a key role by providing case management services to participants, educating PHA staff and building managers, and linking community agencies with each other and the low-income elderly population in federally assisted housing. Linking federal, state, and community-based programs on aging was a key factor in the programs success. According to service coordinators, information sharing among grantees on the stages of initial development across programs would have provided them with the ability to build on existing conceptual designs and avoided duplication of models. Shared information on client assessment instruments and procedures for selecting participants would have also been useful. The evaluation showed a high level of frailty and unmet need for services among current HUD housing residents, patterns that are likely to exist in other communities. Long waiting lists for congregate housing and limited availability of Section 8 rental vouchers leaves barriers to expansion of HUD's housing assistance programs for the frail elderly. Although the evaluation demonstrated high satisfaction among participants, turnover was also high between the two-year baseline and follow-up period suggesting that increasing levels of frailty even with supportive services may preclude elderly residents from participation. Finally, the HOPE IV and CHSP program models are complementary and respond to different population needs, with the tenant-based approach responding to those frail elderly living in scattered-site housing that meet HUD housing quality standards and the project based-approach to those living in subsidized congregate housing. The authors also note that the HOPE IV and CHSP models are similar to and correspond with the Medicaid waiver and assisted living programs professionals are using in the development of alternative long-term care policies.
The following are recommendations for action from the lessons learned from the evaluations of HOPE IV and CHSP. These recommendations include, in the absence of funding, expanding the congregate service coordinator's role to support tenant-based HUD programs. This would create some central organization for the recruitment, placement, and arrangement of supportive services to frail elderly tenants. To facilitate this expanded role for the service coordinator, HUD could encourage formal links with other federal, state, and community-based programs that provide these services. Also, Congress and HUD can encourage the dissemination and utilization of the evaluation results and information about the specific design, implementation, and operation of these programs through HUD's Office of Policy Development and Research, national conferences, and publication of journal articles. Congress and HUD should also provide incentives for pubic housing authorities to set aside vouchers for the frail elderly or offer additional vouchers to meet demand for Section 8 and congregate housing. This effort might encourage public housing authorities to set up supportive services or offer additional money to service coordinators as incentives to congregate housing sponsors who include supportive services. It is recommended that HUD continue monitoring HOPE IV and CHSP grantees after the program ends to determine how successful grantees were in continuing the program using alternative resources. Further promotion of the adoption of the HOPE IV and CHSP models by Congress and HUD would help toward the increasing demand for housing assistance and supportive services programs. Finally, HUD policies must ensure that a range of housing assistance options, both tenant-based and project-based, exists for the frail elderly.
Schafer, Robert. Housing America's Seniors. Cambridge, MA: Joint Center for Housing Studies of Harvard University, 2000.
This study examined the housing choices of the elderly population and the public policy challenges innate to housing for the elderly.
This study analyzed a recent survey conducted by AARP in Understanding Senior Housing, (1996) as well as the 1993 AHEAD survey, the 1995 American Housing Survey, the 1997 American Housing Survey, and the 1997 Current Population Survey
About 80 percent of older people prefer to remain in their own homes, and this percentage increases with age, with almost all people age 85 and over preferring to remain in their homes. However, 39 percent of American changed residences after they reach the age of 60, with most moves being local. Typically, about one percent of the elderly moved across a state boundary, and even these moves were within the same metropolitan region.
In 1993, three-fourths of the nation's population age 70 and over lived in conventional housing, whereas 5 percent of this group live in supported housing (i.e., where "seniors receive assistance from outside the home from a nonfamily member or an organization"). Seniors who chose supported housing normally had difficulties with activities of daily living, but continued to have good cognitive ability. Younger, married seniors preferred conventional housing, particularly those with children in the home or nearby. Three percent of those age 70 and older in 1993 lived in the most expensive living arrangement--assisted communities (i.e., "age-restricted communities that provide some assistance"; this category includes assisted living communities and continuing care retirement communities). The housing choices were influenced by age, need for assistance, and availability of children. Assisted communities without income limitations resulted in out-of-pocket costs for the average resident of $1,461 monthly. Then the order was shared housing ($442), conventional housing ($351), and supported housing ($328). These figures do not include the cost of purchased support services.
Seniors frequently need environmental modifications to accommodate their disabilities, but only 20 percent of conventional housing have bathroom grab bars; only five to eight percent of such housing has call devices, railings, and ramps.
The differences in the definitions of assisted communities and supported housing are not distinct. The 1993 data probably does not reflect the major shift to assisted living facilities and other group housing that has occurred during the last decade.
Sheehan, Nancy W. "Resident Services Coordinator Program: Bringing Service Coordination to Federally Assisted Senior Housing." Journal of Housing for the Elderly 13, no. 1-2 (1999): 35-49.
The author reviewed the role of service coordinators in six state-assisted housing developments for the elderly by analyzing a two-year federally funded, on-site program in Connecticut called the Resident Services Coordinator Program.
The evaluation included: key informant interviews with property managers, resident services coordinators (RSCs), and management company representatives; case studies of elderly residents at risk of entering a nursing facility; RSCs' weekly activity logs; and, pre-test and post-test interviews with elderly residents in the six demonstration sites and random samples of residents living in two other senior housing sites, which were included for comparison purposes. Post-test interviews were conducted eight months after the program began at each site.
The typical resident was white, female, and living alone. About half of those residents in the demonstration sites characterized their health status as fair or poor, compared with less than 40 percent in the comparison sites. Levels of disability also differed among the six sites.
The RSCs expressed concerns about being able to maintain the confidentiality of communications with residents with respect to the on-site property managers who wanted to know about residents' needs and circumstances. Working relationships between RSCs and property managers could be somewhat problematic; part of the issue was that RSCs believed that they needed on-going supervision from someone who had the training necessary for supervision.
Property managers believed that the RSCs improved the quality of life for residents, reduced residents' risk of entering nursing homes, and resulted in savings due to lower apartment turnover, and vacancy rates as well as better upkeep of the apartments. RSCs also freed property managers from trying to meet the support needs of elderly residents.
Frail older people in the demonstration sites reported significant improvement in perceived health status in comparison to their peers as well as functioning related to activities of daily living and instrumental activities of daily living between the pre-test and post-test interviews. There were no changes among frail elderly people in the comparison sites.
The majority of residents said that the RSCs had benefited them through providing emotional support, help with problems, and information and referral. As a result, participation in social activities and housing satisfaction had increased significantly for residents, regardless of their level of disability.
The authors state that key informants might have been reluctant to criticize a program that benefited them and responses might have changed if interviews had been conducted later in the life of the programs. Since the authors could not match residents from the demonstration and comparison sites, the conclusions that can be drawn from comparing these results are limited. Finally, one third of residents who received help from the RSCs did not participate in the pre-test interviews.
Park, Jungwee, and Jean Burritt Robertson. "Mental Health Needs and Supportive Services for Elderly and Disabled Residents." Journal of Housing for the Elderly 13, no. 1-2 (1999): 79-91.
This study examined the effects of the provision of supportive services on the mental health and quality of life of older adults, including those with mental disabilities, living in 12 housing developments for older people and people with disabilities.
The authors interviewed 205 residents of 12 housing projects in Rhode Island, who were interviewed at baseline and six months after they began receiving chore, homemaker, and personal care services. Of these residents, 44 reported that they had or were "known to have" mental health conditions. The majority of services that residents received fell into the chore and homemaker categories.
During both interviews residents completed an assessment designed to measure their cognitive and affective functioning as well as their psychosocial well-being. The assessment was drawn from items in several recognized assessment tools, such as the Mini Mental Health Status Exam.
At baseline, there were significant differences related to cognitive and affective functioning, but not psychosocial well-being, between the full sample and the 44 residents with reported mental health conditions. Six months after support services began, there were no significant differences in any of the three areas of functioning between the entire sample and the subset of 44. The authors conclude that the provision of supportive services to residents with mental illness led to increases in their cognitive, affective and psycho-social scores, and that such services may be more important for those with mental illness than for those without.
The authors speculate that reminders to take medications may have contributed to improvements in the functioning of the 44 with reported mental health conditions. The authors also contend that the program was less expensive than personal care programs in congregate housing settings.
The subset of 44 people may well have had mental health conditions but the authors did not supply information on diagnosis or the level of cognitive impairment. And, the cost savings estimates are not methodologically sound.
Howe, Judith L. "Linkage House: A Case Study Highlighting the Challenges and Opportunities in Linking Housing and Programs for Older Adults." Care Management Journals 1, no. 2 (1999): 138-45.
The Mount Sinai Medical Center, New York City and three community-based organizations sponsored supportive services programs in the Linkage House, a 70-unit building with low-income residents, using a capital grant under HUD 202 program. The Linkage House program fostered an environment of communal living and the formation of support networks, while enabling a resident to maintain his/her privacy. The model for the Linkage House program was dynamic, thus enabling it to adapt to the changing needs of its residents. In 1991, the Department of Geriatrics and Adult Development at Mount Sinai Medical Center commissioned New York Community Trust to do a feasibility study of the program. By 1992, Mount Sinai began to include leaders from the East Harlem community in development of the Linkage House program. According to the author, it was difficult to achieve successful aging in place, primarily because there was separate housing and health & social service funding streams. However, health programs, including health education and on-site medical care, were critical to the Linkage House success.
The continuum of care covers a broad range from services for healthy adults to those with chronic or acute health conditions that need more assistance. The Linkage House model included a full-time, bilingual social worker with graduate level education to provide care and service coordination for the residents. Furthermore, the residents must be at least 62 years of age and meet federal income guidelines. For example, a single person household cannot have more than $17,100 in annual income from all sources, and a two-person household cannot have more than $19,600. Furthermore, potential residents must be either homeless, have poor housing, have difficulty paying the rent, or documentation of elder abuse.
According to the authors, there was difficulty in securing funding for the program at the Linkage House because the HUD Section 202 program provided support only for construction costs, operation, and rent subsidies.
Other elements of the program included building design. The building was designed to create space for examination and consultation rooms for the health programs. Additional space was created for furnished common areas and meetings places for tenants. Five one-bedroom apartments were grouped around each common area to promote socialization.
According to the author, securing funding and the hiring of an on-site social services coordinator were critical to the program's success.
Lanspery, Susan. Service Coordination in Senior Housing: Roles, Problems, and Strategies: A Guide for Aging Network and Other Professionals. Los Angeles, CA: National Resource and Policy Center on Housing and Long Term Care, University of Southern California, Andrus Gerontology Center, 1997.
This guide reviewed the role of service coordinators in state-assisted housing developments for older people, the challenges they faced, and alternatives they could use to address these challenges. Many housing developments have added service coordination to manage daily activities in housing developments to improve the quality of life and minimize early institutionalization.
The methods were not described in the guide.
The guide asserts that the five most common functions service coordinators perform are: advocacy with community agencies for services, mediating disputes among residents, advocacy with housing management for supportive services, assisting resident organizations, and assisting residents with financial management. The challenges they faced were lack of funding, unresponsive agencies, "turf" issues, varying syntax, minimal monitoring, and fragmentation with the supportive services delivery system.
Two major factors influenced success, namely the level of involvement of residents in meaningful ways and the nature of the collaboration among the entities involved in the housing development. According to the author, the service coordinators could develop new services, establish an interagency group, promote volunteer programs, and possibly work with agencies to find new sources of funding to combat the challenges they face.
Since this is a practice guide, there is no emphasis on research methods. However, the lack of information on methods makes it difficult to judge the guide's conclusions.
Schulman, Abbott. "Service Coordination: Program Development and Initial Findings." Journal of Long-Term Home Health Care 15, no. 2 (1996): 5-12.
The study's purpose is to describe the development and one-year evaluation of a service coordination program designed to help older people and people with disabilities experience an improved quality of life and to minimize institutionalization.
Service coordinators served residents of 20 Section 202/8 housing projects in 12 states and Puerto Rico. The 20 Service Coordinator programs were implemented during the first 10 months of 1993. The service coordinator had four major functions: (1) to identify the needs of residents, (2) to arrange for supportive services to cover residents' needs, (3) to monitor the quality of those services, and (4) to reassess the residents' needs. Assessment of residents' needs has varied by program. The needs driven assessments used the medical model, where the service coordinator made an evaluation prior to determining what services were needed, where the resident had little input. The consumer driven model did not have an assessment, and the service coordinator marketed the services available, and then allowed the residents to choose what services they want to purchase.
The author selected 25 randomly chosen residents who had used service coordination from each of the 20 properties, totaling 500 individuals. The residents were then asked to complete a survey of 12 true-false statements about their perspectives on the Service Coordinator program in their projects. The service coordinator distributed the survey and asked residents to complete it at their leisure. About 458 people responded, 120 of whom were men and 338 were women, but not all respondents answered all questions.
Due to the cost of the services offered by the service coordinator, and fear of possible rent increases or evictions from their apartment, many residents were afraid of approaching the service coordinator. About 75 percent of male and 72 percent of female respondents believed that the service coordinator involved their families in their care. While over 98 percent of both male and female respondents saw the service coordinator as being available when needed, 15 percent and 11 percent, respectively, thought the service coordinator was too busy to see them when they desired. About 90 percent of the respondents had used the service coordinator to help them avoid loneliness. Over 93 percent in both populations believed that they benefited from the service coordinator's support.
The author believed this survey showed the importance of a service coordinator's role and made some assertions regarding such things as delayed institutionalization that were not supported by the research conducted.
KRA Corporation, and Office of Policy Development and Research, U.S. Department of Housing and Urban Development. Evaluation of the Service Coordinator Program. Washington, DC: U.S. Department of Housing and Urban Development, Office of Policy Development and Research, 1996.
The Housing and Community Development Act Amendments of 1992 authorized HUD to administer the Service Coordinator Program (SCP). The program is designed to meet the needs of people with disabilities living in HUD-assisted housing by directly funding service coordinators who are to coordinate provision of supportive services for this group. Service coordinators (SCs) determine the needs of eligible residents, identify available community services, link residents with needed services, monitor and evaluate services used, and carry out other functions as needed; coordinators are prohibited from direct service provision. Projects eligible for SCP are Section 202, Section 8, Section 221(d), and Section 236 projects; Section 811 projects are not eligible. The goals of the study were to describe the Service Coordinator Program and the residents served, assess resident satisfaction with programs, as well as to identify implementation problems and recommendations for improvement in the programs.
The reported data came from two sources: (1) information from application forms from 645 programs that received HUD funding. These data were only used to describe programs and residents; and (2) site visits to 18 SCP projects during 1995. Site visits involved interviews with service coordinators and HUD project managers, as well as resident focus groups. The 18 sites were selected to represent the variation in characteristics of HUD projects, service coordinator type, and geographic location of programs sites. However, the sample cannot be considered nationally representative.
Of the 645 projects that received funding, about one-third had 100 or more units, one-third had 50-99 units, and one-third had fewer than 50 units. The projects were located in all but three states. In 99 percent of the projects, at least one-quarter of residents had disabilities. Similarly, in 17 of the 18 case study sites, 25 percent or more of residents had disabilities. The majority of residents at all sites were elderly, at least two-thirds of all but one site's residents were female, 11 projects were majority white and two projects majority black. Thirteen projects had part-time service coordinators, 11 coordinators worked at more than one SCP, and three projects contracted with other agencies for coordinators. Most coordinators had bachelor degrees and relevant prior work experience. All but one coordinator had received some type of training.
Service coordinators in the 18 sites worked with autonomy but coordinated with project directors when planning activities. More than half the coordinators had contacts with 90 percent or more of the project residents and case loads ranged from 7 to 112 residents, which represented between 10 and 96 percent of residents. Coordinators' outreach to residents consisted of print materials and presentations at resident meetings. Coordinators in the 18 sites arranged for services to come into the project; transportation and housekeeping were the most frequently provided services. Other services included health screenings, exercise programs, and budget assistance. Service coordinators sometimes provided services themselves despite the HUD prohibition against doing so; services included transport to medical appointments and housekeeping chores. Half of coordinators said that more transportation was needed at their sites; other needed services included housekeeping, financial counseling, errand services, and eye and dental services.
Residents in the 18 sites reported that SCP linked them to services and that the coordinator was someone to confide in about their problems and made them aware of how to access available services. The 18 sites did not report serious obstacles to program implementation, but seven sites reported inadequate office space primarily due to lack of privacy, and one site required residents to climb stairs to access the office.
Sites recommended improvements to the SCP program including: ensuring that the SCP office is accessible and that SCs do not share office space with project staff so that SC conversations with residents can be confidential. Additionally, the SC office should be located where residents tend to congregate such as mailboxes, the dining room, lounges, or community rooms. SCs also believed that they should be able to provide some services themselves where services are not readily available, including transportation in rural areas and social activities planning, and that HUD could fund these activities through the SCP. SCs would welcome HUD identification of training opportunities in rural areas and HUD development of materials such as assessment and service tracking and monitoring forms. SCs also made recommendations for changes to the annual reporting form.
The 18 case study sites cannot be considered representative of the 645 sites in existence at the time of the study.
Nachison, Jerold S. "The Housing Programs of the Department of Housing and Urban Development: Description and Issues." In Housing and the Aging Population: Options for the New Century, edited by W. Edward Folts (83-104). New York, NY: Garland, 1994.
The Congregate Housing Services Program (CHSP) provides grants to various public housing programs to enable them to purchase supportive services for their residents who are aging in place. The federal Department of Housing and Urban Development (HUD) provides up to 40 percent of funding for services, the users of services pay 10 percent of the cost of services, and funding must be raised from other third parties to cover 50 percent of the cost of services. Funding is available in Section 8 and Section 236 HUD housing projects for the older population, Farmers Home Administration projects; states, Indian tribes and local governments also can seek this funding. Projects must accept food stamps as full or partial payment for meals, and a service coordinator must provide case management and service coordination to program participants.
National Eldercare Institute on Housing and Supportive Services, and U.S. Administration on Aging. Linking Housing and Services: Six Case Studies. Los Angeles, CA: National Eldercare Institute on Housing and Supportive Services, Andrus Gerontology Center, University of Southern California, 1994.
After consultation with key informants, the authors chose six study sites that represent a range of approaches to linking housing with services. This paper provides descriptive information about six program sites, focusing on how they "operationalize" the housing and supportive services linkage and address challenges unique to each services program. It then offers advice for replication of similar program types.
The Housing Authority of St. Paul, Ravoux and Valley Hi-Rises, in St. Paul, Minnesota, is a HUD CHSP and the first national program linking housing and services. The program's staff credit its success to several key skills the CHSP Supervisor demonstrates, such as flexibility, creativity, knowledge of community services, and good organizational skills. Other factors that have contributed to the program's long-term success are community education and involvement and resident support. The program faces several challenges including long-term funding viability and a changing resident population that includes a frailer elderly population, a growing younger disabled population, and a more culturally diverse resident profile.
The Southern California Presbyterian Homes, Los Angeles, California, is a Section 202 federal housing site with a "circuit rider" approach to community service coordination. The program staff links frail residents with available community services. The only program cost is staff salaries, which are currently funded by HUD. The paper identifies limitations to this model as service gaps or lack of service providers, which can restrict resident's choices, and the lack of ability to monitor the quality of care provided.
The State of Maryland, Office on Aging, Multi-Family Senior Assisted Housing (SAH) Program operates in several public and private senior facilities. The SAH program provides a package of services that allows frail elderly residents to remain in their own homes, potentially avoiding any Medicaid costs that would incur due to premature institutionalization. Payment for services is on a sliding scale. The SAH program has faced several challenges, including residents' resistance to having to pay for services, the meals component of the service package is somewhat inflexible, maintaining high enrollment across the state has been difficult, and limited funding has been a problem. Additionally, there is still an independent living "mind set" that is difficult to overcome with housing managers and some of the more independent residents.
The Silsbee Tower's Supportive Services Program in Senior Housing in Lynn, Massachusetts, is a large national program linking housing with supportive services that began as a national demonstration funded by the Robert Woods Johnson Foundation (RWJF). The program is now privately funded, although it takes pubic support when available, and is currently being replicated through the national No Place Like Home program, also funded by RWJF. According to the authors, the program has been successful because of its close connection to the Area Agency on Aging (AAA), ongoing communication with residents through surveys and meetings, and the service coordinator's ability to balance different stakeholder agendas, including the building manager, residents, and AAA.
The Area Agency on Aging Senior Home Care Services, Inc. in Gloucester, Massachusetts, allows the agency to take advantage of economies of scale in offering alternatives to nursing home placement by providing supportive services to residents of senior housing. The program's success has been attributed to good communication and willingness to collaborate, good planning and management, and willingness to learn from other programs that link housing and services. Obstacles include lack of funding and flexibility, "turf issues" that may lead to service duplication, and an emphasis on process rather than outcomes.
One key component of the On Lok program in San Francisco, California, is the On Lok House, a HUD Section 202 building, which has demonstrated that very frail elderly can live in their own apartments with health and supportive services provided by a capitated managed care program based on an adult day care model. While the program does not provide skilled nursing care, the program has found it difficult to distinguish itself from a nursing home. Staff also face the challenge of determining when a resident is too frail to live independently at On Lok House.
Nenno, Mary K. "Public Housing: A Pioneer in Housing Low-Income Older Adults." In Housing and the Aging Population: Options for the New Century, edited by W. Edward Folts (61-81). New York, NY: Garland, 1994.
This article provides a brief history of public housing programs and policies for low-income elderly in the United States. Starting with the development of programs initiated in the 1930s that spurred the Housing Act of 1956, which first recognized the elderly as a distinct population needing public housing assistance. Then, the Housing and Urban Development Act of 1970 authorized the use of about 10 percent of all public housing development for the elderly, displaced, and handicapped. The next major development occurred in 1978: the Congregate Housing Services Program, which was a demonstration program for 33 public housing agencies and 30 HUD Section 202 nonprofit housing sponsors. Subsequently, the National Affordable Housing Act of 1990 restructured the Congregate Housing Services Program and expanded its coverage. As the elderly public housing program continued to mature, a medley of structure types evolved.
By 1989, over 1.4 million households headed by an elderly person lived in federally subsidized housing. A subset of 517,000 resided in public housing, which comprised 38 percent of national public housing occupancy. By the late 1970s and early 1980s, the proportion of public housing occupied by elderly households leveled off at about 45 percent.
Congress directed HUD to carry out a CHSP evaluation, which was designed as a four-year evaluation involving three types of evaluation: process, performance, and impact. The CHSP evaluation denoted missed success and was devoid of positive outcome during the first 14 months.
According to the author, there are four areas that need considerable attention for public housing to remain a viable housing option. First, many of the public housing developments are over 30 years of age and need significant renovation. Second, many of the elderly developments have not designed or made accommodations for community space and other types of support services. Third, support services are only available on an ad-hoc basis. In the future, long-term and integrated resources must be made available. Finally, the author suggests that new housing policy must emerge to resolve issues of grouping the elderly with handicapped people. Ultimately, public housing will need to develop and hone an integrated system of support services, and provide adequate information about the various types of housing in all areas of the country.
King, Nancy Koury, Janet Hofmann, Ohio Department of Aging, and the U.S. Administration on Aging. Supportive Services in Federally Assisted Housing for the Elderly. Columbus, OH: Ohio Department of Aging, 1993.
This report discusses findings from several evaluation components of the Ohio Department of Aging's (ODA) Supportive Services in Federally Assisted Housing for the Elderly Project, a two-year grant program awarded by the U.S. Administration on Aging. The project's purpose was to develop a model to promote supportive services to the elderly in federally assisted housing by linking community-based services to public housing, thus allowing elderly residents greater access to support services. Specific program objectives include improving housing managers' ability to work with elderly tenants, linking housing providers with local assessment and delivery systems, developing programs that encourage volunteerism and integration of the facility into the local community, and managing current resource needs with available funding while advocating for future funding. Project activities were designed to address the development, implementation, and evaluation of the program's objectives. These activities included development of a working agreement between the ODA and other state agencies, a survey of Ohio's public housing managers, and a problem indicator resource tool for housing managers. Other activities included development and implementation of a training program and resource manual for housing managers, and improvement of a computer database program for Ohio's Area Agencies on Aging (AAAs) to use in maintaining directories of elderly housing facilities.
Public housing facilities in two pilot sites, Portsmouth, a rural area in southern Ohio, and Cleveland, an urban area in northeastern Ohio, were selected for program implementation. Both pilot sites developed and facilitated a coalition of organizations concerned with older adults in public housing. Coalition members collaborated to plan new services for the elderly tenants. The manager training and resource manual was revised. The housing manager-training program, a two day Train the Trainer course, was implemented in each of Ohio's 12 planning and service areas (PSAs).
Evaluations of the new programs for elderly residents at pilot sites were conducted. The pilot site evaluations contained two components: (1) results of each site's needs assessment survey, and (2) a qualitative evaluation of each site's activities. A sample of residents age 60 and older in the Miles Elmarge public housing facility in Cleveland were surveyed in-person to determine their characteristics and service preferences, 67 of the 139 residents living in Miles Elmarge were interviewed. In Portsmouth, Ohio, 95 older adults were interviewed in their apartments.
The following summarizes findings from a survey of housing managers in pilot site facilities, evaluations of the housing manager training program, resource manual and train the trainer program, and evaluations of the pilot site activities. According to findings from the housing managers' survey few housing facilities offered services other than housing, about a quarter (24 percent) had social or recreational activities, 10 percent offered congregate meals, 5 percent housekeeping, and 2 percent transportation. Managers perceived that medical and or physical health problems were the main functional or health difficulty, and transportation the major service requested by residents age 62 and older. Managers indicated they spend an average of 15.7 hours per week of staff time on personal, family, or health problems associated with residents. The majority of managers (88 percent) referred residents to social services agencies. However, more than half of managers (60 percent) report that residents' capabilities are assessed when problems arise.
Managers stated their biggest challenges were meeting the needs of residents aging in place, developing services for residents, and understanding mental health issues. This need for assistance was indicated by awareness of senior services such as homemaker services and meals on wheels, but lack of referrals to these services. Also there was limited awareness of Ohio's PASSPORT program, a statewide Medicaid waiver program for in-home community services for older adults, a potential benefit to managers and residents. Housing managers also expressed a desire for more information about dealing with the challenges of elderly residents.
Post-program evaluation results of the housing manager training program indicated that housing managers viewed both the training program and housing resource manual as useful, relevant, and effective. Housing managers improved their knowledge about aging related issues, and confidence in their ability to identify residents at risk, address problems, develop policies and procedures for action, and work with the appropriate service agencies in the aging services network. Overall, participants in the train the trainer program were satisfied with each components of the course.
Cleveland Pilot Site. The majority of residents were female (66 percent), African-American (98 percent), living alone (68 percent), and either active (10 percent) or interested (50 percent) in volunteering. Slightly more than a third (37 percent) reported health problems that limited their functional ability, and 60 percent rated their health as "fair." The majority of respondents (82 percent) indicated they could turn to relatives for help. Respondents were frequently unaware of many support services such as legal services, companionship visiting, personal care services, mental health counseling, exercise and adult education classes, and information and referral services. The most desirable services for respondents were transportation, homemaker, personal care, meals, and social clubs.
The program augmented many of the services Cleveland residents identified as desirable such as transportation, adult education, social activities, meals, information and referral, and nursing services. Other services such as homemaker and home health aide were identified but not strengthened other than increasing housing managers' awareness of resident service needs. The community coalition met monthly to address service access to the elderly in public housing and played an instrumental role in improving communication between the aging services network and housing community. The coalition has committed itself to continue efforts toward meeting the needs of elderly in pubic housing. At the request of housing managers, the Cleveland pilot site went beyond the ODA's housing manager training program and implemented a series of workshops on dealing with mental health issues. The coalition will continue to meet beyond the grant period, plan future training programs for housing managers, and retain many services such as educational opportunities, transportation, food distribution, and health promotion programs.
Portsmouth Pilot Site. Transportation, cleaning, shopping, and laundry were the activities respondents reported having most difficulty with. Transportation services (36 percent), house keeping (27 percent), the senior center (21 percent), and home delivered meals (18 percent) were other supportive services for which respondents indicated high usage. Although the survey did not ask residents about preferences for supportive services, respondents were asked about their interest in a variety of activities. Respondents most frequently requested music and wellness programs.
Besides the ODA's housing manager training program, a first aid and CPR class was conducted and the aging sensitivity training program became available to all Portsmouth Metropolitan Housing Authority (PMHA) employees. The coalition helped in overseeing the needs assessment, developing welcome baskets for new tenets, conducting a health fair, working with the senior center to improve transportation, assist the tenant council, and oversee resident programs. With added community resources and continued involvement from the coalition, welcome baskets, social activities, and first aid/CPR classes will continue along with blood pressure screening and blood sugar checks for residents and scheduled visits from a mobile mammography unit.
The Ohio Department of Aging's public housing manager survey was useful in understanding the needs of both public housing managers and tenants. Managers felt more knowledgeable and confident in dealing with issues involving their elderly tenants. AAAs were able to customize training programs to individual communities and provide networking opportunities for training participants and key stakeholders in the community. Involving the management of the local housing authority in planning and implementation of the training program was instrumental in gaining participation among housing managers.
Both pilot sites were able to successfully recruit a broad based group of local support services including social services, health service providers, housing groups, and community leaders. These coalitions were able to target attention on specific problems facing the elderly in federally assisted housing in their communities and find creative solutions. These community coalitions will continue to collaborate with residents of public housing and their communities to target needed services and programs to the elderly resident population.
For those considering development of similar or related projects, the authors recommend that AAAs develop a more complete understanding of the housing authority structure and role of housing manager. Future research and training should emphasize mental health issues, the role of the housing manager, and integration of the young person with mental health conditions into senior housing. Furthermore, the project should strengthen efforts to form broad-based community coalitions that include residents, community leaders, besides social service providers. There is also a need to address barriers in public housing's design and environment that may prevent elderly residents from living independently, and nonaging social problems that impact the elderly in public housing.
Lynn Greenleaf, Sheila Malynowski, and the New Hampshire Housing Finance Authority. Increasing Service Availability to Seniors in Housing: Final Report. Bedford, NH: New Hampshire Housing Finance Authority, 1993.
This report describes an Administration on Aging (AoA) grant project directed by the New Hampshire Housing Finance Authority (NHHFA). The project expanded the NHHFA's model of supportive services programs, originally developed for seniors living in privately owned, subsidized housing (Section 8 housing), to seniors living in public housing. The primary purpose of the program was to establish closer linkages between the network of state and local services for seniors and those older adults living in federally subsidized housing to prolong their ability to live independently in the community. Objectives of the study included allowing seniors to determine which services they wanted and providing increased service delivery to seniors in public housing for those identified services.
The NHHFA chose six public housing authorities in New Hampshire as pilot sites to develop supportive service programs. Each housing authority was responsible for designing and implementing supportive services programs to best meet the needs of their residents with the goal of financial self-sufficiency over the long-term. Services included transportation, meal preparation, light and heavy housework, and personal care. Service coordinators also helped residents apply for eligible entitlement benefits. Pilot sites implemented community-building programs that included social and recreational activities, and informational programs for elderly residents. The NHHFA provided technical assistance and oversight.
The NHHFA also developed and implemented a pilot statewide, telephone network between the housing and service provider network called Senior Care Connections (SCC). For an annual subscription fee, the service provided housing managers with a master's level social worker to help housing providers find and help residents access services.
Senior Care Connections, the pilot statewide, telephone network, faced several implementation challenges. Faced with lower participation than expected, focus group discussions were conducted with housing managers to determine the participation barriers and identify potential candidates for the program. Feedback from the focus groups identified management agents who are the best candidates for the program. These management agents are typically interested in supportive services, unable to hire a service coordinator, or have a service coordinator that requested social work support. Barriers to participation that were identified include a complex's financial constraints, a service coordinator with extensive experience or a background in support services, and managers who believed they could handle things on their own. Because of low demand, the program was cut by 50 percent for the second year of the grant and marketing efforts were enhanced. Face-to-face meetings with managers were determined to be the best marketing strategy during the program's second year.
Senior Care Connections enrolled 11 management companies representing 786 senior housing units in over 20 complexes. This represented about 25 percent of the potential market share. The program handled a total of sixty-one service requests and 46 follow-up contacts over the two-year grant program. The majority of requests involved assistance with mental health issues, followed by assistance with medical problems, and suspected abuse or self neglect. A follow-up program evaluation survey was developed and completed. The survey found that managers believed they were supported by the service, that the service relieved stress, enhanced their skills and abilities, and prevented resident situations from worsening.
The project helped 731 residents at the six pilot sites in getting services such as light and heavy household chores, shopping, transportation, meals, and personal care. The following table shows the number of residents who received assistance by service type.
||Number of Residents
|Light/heavy household chores
|Managing finances or filling out forms
|NOTE: Some residents received more than one service.
Interviews were conducted with 503 residents by NHHFA staff in four of the six public housing authorities chosen as pilot sites to determine residents' demographics and service needs. Laconia and Somersworth Housing Authorities opted to use preexisting information on support services programs rather than a survey to form the basis for designing their program expansion. Respondents to the resident market/needs assessment survey were overwhelmingly female (80 percent), single (85 percent), and living alone (84 percent). About half of respondents (47 percent) were 75 years of age and older. About half of respondents said they had lived in their complex six or more years, 10 percent had lived there more than 15 years, indicating the "aging in place" phenomenon. Most of the respondents had low incomes with 68 percent having gross annual incomes of $7,500 or less. Respondents rated their health favorably compared with others their age with 77 percent reporting excellent or good health. But, 27 percent reported putting off needed health care in the past year, with the most frequently reported reason being lack of financial resources followed by lack of transportation. It is important not to generalize from the resident market/needs assessment survey because the surveys were not from a random sample of resident.
The number of reported residents receiving services varied by complex, as did the number of reported residents in need of such services. The following table shows the ranking of services residents reported most needed compared with services reported most wanted. Except for shopping and transportation, what residents needed ranked closely with what they most wanted.
||Heavy household chores
||Heavy household chores
||Personal emergency response system
||Light household chores
||Personal emergency response system
||Light household chores
According to the authors, the supportive services pilot programs in senior public housing were successful, however, they do not state how the program's success was measured. Housing managers and residents benefited from the programs developed. The supportive services programs not only improved the quality of life for many seniors but allowed seniors to remain in their homes. All the supportive services programs developed under the AoA grant continued beyond the end of the grant, however, the funding came from a number of sources and future funding is uncertain. Education at the federal level is needed to ensure that supportive services programs in senior housing are valued and that funds are appropriated to HUD for inclusion of the program as part of a housing complex's regular operating expenses.
The Senior Care Connections telephone consultation service provided support to managers and service coordinators in need of social work services. Education of management agents about the benefits of a social worker led to increased participation in the SCC program during the second year of the grant. Although the SCC program had difficulty becoming financially self-sufficient, the program is continuing on past the end of the grant with slight increases in the enrollment fee and funding support by the parent organization, the Crotched Mountain Foundation. The service might be more successful in areas with larger markets of management agents for subsidized senior housing. Combining the SCC program with other services requiring social work staff might improve the program's financial situation.