The Jewish Community Federation of Cleveland began its Community Options program in 1995 using a grant from the federal Department of Housing and Urban Development (HUD). When the AoA grant money became available in 2001, Community Options officials proposed to use the money to determine whether its NORC services program was replicable in other sites in Ohio. Program staff successfully marketed the model and provided AoA grant money and technical assistance to four new sites--Canton, Cincinnati, Columbus, and a new site in Cleveland. These sites will be referred to as subgrantees--the term that Community Options staff use.
This site visit summary describes the original Community Options program in Cleveland as well as developments in three of the subgrantee sites--Canton, Cincinnati, and Columbus--that participated in this study. The following information comes from discussions with two staff people from Community Options and five staff from the three subgrantees. The subgrantees were in the early stages of developing their programs in the summer of 2003.
Description of the NORC and Its Residents
The Original Program
Community Options. The original Community Options program operates in five private apartment buildings where resident incomes range from lower- to upper-middle class. The buildings within which Community Options operates are located east of the Cuyahoga River in Cleveland. Although the Jewish Community Federation of Cleveland received the AoA grant and most Jews in Cleveland live in the east, the buildings that Community Options serves are not predominantly Jewish and Community Options programs are open to anyone who resides in the buildings they serve.
There are two distinct groups of older residents in these buildings. The longer-term residents are typically widows who sold their homes upon retirement and moved to the apartments with their husbands, who have since died. More recent residents are people who chose to hold on to their homes as long as possible, and have relocated to apartments during their eighth decade rather than their sixth. These apartments are attractive to residents because they are within walking distance of synagogues, shopping, and bus lines.
Community Options first began operations in two buildings managed by separate landlords. A year later, both landlords requested that the program be expanded to another building for a total of four buildings. The program added a fifth building in 2002. In two of the buildings, initially 70 to 75 percent of the residents were age 60 and over. Over the past eight years, as younger families have moved into the apartment buildings, this percentage has dropped to about 50 percent. In another building, there is a rising proportion of older African Americans. Few immigrants live in any of the five buildings, and in only one are the residents predominantly Jewish.
The five buildings in the program are each six- to seven-story high rises, located on a major thoroughfare. Although all have elevators, they also have steps leading to the entrances so that wheelchair accessibility is an issue. In contrast, the subgrantee sites operate in various types of buildings and neighborhoods.
The Subgrantee Sites
Canton. The Canton Program--Community Connections--serves three apartment buildings in an urban, primarily residential, area. The three buildings are not on the same campus but are less than a block apart. One landlord owns all of the buildings, each of which has about 100 residents, about half of whom are age 65 and older and aging in place. Two of the buildings have old physical plants with concomitant accessibility problems akin to those in the buildings that Community Options serves. The third building is newer, with few older people and, unlike the older buildings, has no common areas. The Area Agency on Aging in Canton, which is receiving the AoA funds from Community Options, chose these three buildings because they were close to one another and staff knew that the buildings had substantial numbers of older people.
Cincinnati. Jewish Family Services operates its NORC services program in two locations in a suburban area of Cincinnati. The first is a combination of town homes and "mini-rises" consisting of four three-story buildings where 80 to 90 percent of residents are age 60 and over. Because of steps and curbs, accessibility is an issue. Together, the four buildings contain 144 private rental units. The second location is a more traditional high rise with 100 units where 90 to 95 percent of residents are over age 60. Both locations have common areas. The residents are predominantly white middle to upper-middle class with few minorities. The agency targeted these locations because they have clients in the buildings, but NORC program services are not limited to Jewish residents.
Columbus. Wexner-Heritage Village, a Jewish, nonprofit provider of health, housing, social, and spiritual services, including a CCRC, an SNF, community services, as well as housing for older people and people with developmental disabilities, sponsors the Connections program. The program operates in four sites representing a range of populations and building types. One building is a mid-rise, private rental apartment with upper-income residents, most of whom are age 65 and older. The building's entry presents no barriers to access but the bathrooms are small. The second location is a combination of town homes and apartments on a large campus owned by the same landlord that owns the first building. Access is good but there are no common areas. The third has two buildings with garden-style apartments that are private rental units. The fourth is a public housing complex that covers 50 acres and has a diverse population. The complex has been plagued with frequent management turnover and episodes of violence.
NORC Building Management and Communication with Residents
Community Options has generally had enthusiastic support from the buildings' management, who have supplied the names and addresses of older residents. The building owners have contributed funding to the on-site program costs because their residents value Community Options programs and thus may be more likely to remain in the buildings and tell others about the value of living in them. In addition, Community Options helps management by providing certain support services to residents.
Program staff's early experience with management at the subgrantee sites runs the gamut from tepid to supportive. Staff report that at some locations landlords view the NORC service programs as a "value added" that helps keep tenants happy and encourages others to move in. At other sites, landlords cite privacy and liability concerns in refusing to give information about their residents to program staff. Landlords at the subgrantee sites have not yet been approached for financial contributions because program staff want to demonstrate the value of their programs to landlords before asking for support.
NORC Service Organizations
Community Options, the original NORC services program, is an independent program sponsored by the Jewish Community Federation of Cleveland. The program began in 1995 under a $2 million dollar special purpose grant from HUD. In 1995 or 1996, The Federation convened a committee made up of volunteers of all ages to oversee the program; most of the members still do. A consultant, Susan Lanspery, then at Brandeis University, helped the committee determine the program design. The proposed design was based on a community organizing, consumer-directed model, largely because The Federation typically uses a community organizing approach in its work. The three subgrantees for which we have information, although they are largely adopting the Community Options model, have not yet formed advisory or oversight committees, although they are considering doing so.
Evolution of the NORC Service Program
The goal of the Community Options program is to allow people to stay in their homes by providing them with access to social activities and by helping them access community services, such as transportation and home help, through information and referral. The program's staff use the community organizing model, which involves empowering people by talking with them about their needs and issues without any preconceived ideas. Then, with the assistance of community residents, the program organizes the desired services. The program is never static because residents' needs and desires change over time as the community changes. The residents feel a sense of ownership of the program because it is based on their expressed needs. As program staff began using this model, they observed that many older adults in Greater Cleveland felt marginalized. The program was designed, in part, to help counter these feelings by involving residents in program design.
The Federation decided to develop Community Options in apartment buildings that housed a large number of older people. Staff visited likely buildings during the day to observe whether large numbers of older people lived there. Of the 12 possible sites they identified, two had owners who were open to the program. They began operations in these two buildings--Huntington Green and Sherri Park--in August 1997, after building managers agreed to try the program for a year.
Although the owners were enthusiastic, their building managers were concerned that the buildings might be viewed over time as senior housing, thus decreasing their attractiveness to other age groups. These fears were not realized; since Community Options began offering services in 1997, the ratio of older to younger people has remained relatively stable in the buildings they serve.
Currently, the program operates in five buildings; it employs four resource coordinators, one of whom is responsible for activities in two buildings. The coordinators are in the buildings about 20 hours a week, organizing and running activities as well as communicating with residents. In addition to the director, Community Options has an administrative assistant and an assistant director in the main office. The assistant director works full-time managing the program and the office staff who spend 12 to 14 hours a week keeping provider referral lists accurate.
With the availability of new funding under the AoA grant in 2001, Community Options addressed the possibility of replicating its successful program in other sites. It is in the planning stages of expanding its own program into the western part of Cleveland. In looking for the subgrantee sites, program staff canvassed likely nonprofit organizations in several areas of Ohio to determine if any were interested in using the AoA grant funds to replicate Community Options in their locales. The sponsoring organization at the new sites needed to be a large nonprofit and had to be willing to match one-third of the money it obtained from the grant. Community Options found that few organizations wanted to receive a large amount of money that had to be spent in one year and had matching requirements. Thus, Community Options staff undertook a major education effort as it recruited the subgrantee sites.
Eventually, the Community Options staff identified four organizations that met the requirements and were interested in the program. The Canton and Western Reserve AAA saw the NORC services program as a natural outgrowth of its mission to serve older people and help them remain independent in their homes and communities. The Cincinnati Jewish Family Services had already been doing case management for older clients and saw this opportunity as a logical next step in service provision. The executive director at Wexner-Heritage Village in Columbus had previously worked in Pittsburgh and was familiar with NORC service program there and had a great deal of interest in helping people age in place.
Services Available to NORC Residents
Community Options and its subgrantee sites focus on organizing socialization opportunities for building residents and on making referrals to community providers when residents need additional services to help them remain independent at home. The program usually refers residents to up to three different agencies for any given service, while trying not to show a preference. The agencies come from a provider database that the program maintains, which has information on services and prices. The types of referrals that residents request most include transportation, homemaker services, and beauticians.
The types of activities that residents want vary by building. For example, some buildings' residents like playing Bingo while others prefer book reviews. The range of activities currently includes senior exercise classes, current events discussions, luncheons, and monthly blood pressure checks. The activities vary over time in response to residents' expressed preferences. Transportation is a large and ongoing problem for residents because many older people cannot drive and public transportation in Cleveland is not well developed.
Most health-related activities are preventive in nature and include such things as speakers on pharmaceutical issues, a podiatric clinic, and safety lectures. Building management and tenants will not allow medical staff, such as a nurse, on site because they want to avoid having the building appear to be a nursing facility. Most activities take place in the apartment buildings' party rooms. Those living in the buildings with the party rooms tend to participate more frequently than those who live further away.
Attendance at activities varies. For lunches, one of the most popular activities, Community Options sites typically have between 30 to 50 residents in attendance. Most activities require a reservation because resource coordinators need to know how much food or other supplies will be needed. Different people attend different events; for example, those who come to luncheons are not always the ones who go to other events. The variety of events offered by the program attracts residents of different incomes and ages.
Community Options also has a role for volunteers. Residents volunteer their services at activities, particularly for entertainment purposes. Resident volunteers distribute newsletters, set up events, take money, and make phone calls, among other activities. Residents either offer to serve as volunteers or, in some cases, the resource coordinator asks the more active participants to serve as volunteers.
The three subgrantee sites were beginning to implement their programs in the Summer of 2003. Like Community Options, their programs focus on socialization activities and information and referral. Two of the new sites are considering whether to help residents link up to service providers by contacting the provider on behalf of the resident and helping to ensure that residents obtain services they say they need. The final decision on this matter will be made as the subgrantee sites gain experience with their residents' needs.
NORC Service Program's Communication Methods
Community Options has several methods of communicating with residents of the buildings they serve. Staff held resident focus groups and surveyed the older residents of their first two buildings to determine what they wanted. In 2003, an intern conducted a new resident survey in these buildings to determine how resident interests had changed. The results are still being analyzed.
Resource coordinators also engage in outreach when they begin a program in a building and as new, older residents move in. When the program opens at a new site, management sends a letter to the residents introducing the program and gives a list of older people to the resource coordinators who then knock on all doors to introduce the program and find out what residents want. Based on the results of the outreach, the coordinator develops a profile of the building and its residents' preferences, which then goes to residents for their feedback. Coordinators also track attendance at activities to determine whether to continue a particular activity in a building.
Resource coordinators hold office hours in each of Community Options' buildings, Tuesday through Thursday. The office is located in the activities room in two buildings and is located near the mailboxes in the other three. The coordinator produces a quarterly newsletter and puts flyers in elevators, laundry rooms, mailrooms, and on bulletin boards. In addition, the coordinator and volunteers place personal phone calls to residents they have not seen in a while.
One resource coordinator we spoke with believes that communication with residents could be better because management does not always notify the coordinator when new older people move into the building. As a result, the outreach to new residents may be delayed.
The new sites also rely on door-to-door outreach to communicate with residents. In addition, two of the subgrantee sites have surveyed residents to determine their needs and preferences regarding activities. Preliminary results of these activities indicate that residents' value outside trips, socialization, and transportation. This last service appears to be a big unmet need among older people at all locations.
NORC Service Program Challenges
The challenges that the NORC service programs face have some common aspects but vary somewhat from site to site. Younger old people tend not to participate in programs because they are busy doing other things, such as volunteering in the community. In addition, some residents find it difficult to remember whether they have signed up for an activity that requires payment of a fee or pre-registration. Or, residents may remember their commitments but not feel up to fulfilling them on a given day. The resource coordinator has started to address these issues by having volunteers make telephone calls to remind residents and sending out electronic voice mail messages to senior residents regarding programs.
Community Options tried to set up a program in a suburban neighborhood on the east side of Cleveland, but had to withdraw because it could not get the funding to sustain that site. In addition, the suburban neighborhood presents obstacles to organizing, such as inclement weather and transportation that had not been encountered in the programs that were established in apartment buildings. Staff could not find a central activity center or office space that was easily accessible, and without a building manager who was familiar with building residents, they had to knock on every door in a neighborhood to locate the older residents. From this experience, one of the key lessons learned is to organize in partnership with a parish, synagogue, or other established institution in the target neighborhood.
In the subgrantee sites, staff found that transportation between separate buildings is difficult even when the buildings are in close proximity to one another. In addition, some building managers have unrealistic expectations about the program's ability to deal with tenant problems, such as cleaning the apartments of messy tenants. Some landlords are unwilling to release tenants' ages, citing confidentiality concerns, or the information they offer is inaccurate. One new site found that the management resisted door-to-door outreach in one location even though this task is part of the program's contract with building management. Staff have had to rely on other methods of communication, such as flyers and general word of mouth.
NORC Service Program Quality Assurance and Outcomes
Community Options has well-developed feedback mechanisms for quality assurance and measurement of outcomes that the new programs are adapting to their needs. The program has a master database that enables resident coordinators to call all residents for whom they have made referrals to determine if the resident was satisfied with the provider they chose. Resident satisfaction is then entered in the database. When Community Options staff note a pattern of dissatisfaction among consumers with regard to a certain provider, that provider will be removed from the computerized referral list.
The database also enables coordinators to track clients' interest and participation in activities. The database shows that about 86 percent of seniors in the five Community Options buildings have had contact with resident coordinators beyond door-to-door outreach or have participated in activities. Seventy-nine percent of residents have attended activities more than once over the past six years. The most frequently requested service referral is transportation, followed by housecleaning. The new sites are in various stages of planning to adopt the same approach to data collection that Community Options uses.
The AoA grant has allowed the Community Options program to participate in a research project that Dr. Eva Kahana at Case Western Reserve University is leading. The study will follow a group of 1,000 community-dwelling older people in Cleveland and compare their experiences to those of older people residing in buildings with Community Options and two of the new subgrantee sites. The outcomes that will be tested include nursing home and home health use. The report will be available in 2004.
NORC Service Program's Funding Sources
Community Options is unique in that it has substantial financial support from building management. When program staff approached the management at its first buildings, they asked for and received free office space and free use of the party room for each site. Using its $2 million HUD grant, the program initially paid for the telephone and resource coordinators' salaries. After the first year, the Community Options Oversight Committee proposed asking the building management to contribute financially. Because of positive feedback management had received from residents, they were willing to pay for on-site costs such as the coordinators' salary and benefits, office and party room space, and other programmatic costs such as paper and copying. Community Options covers its overhead costs at the main office through use of the HUD grant. Residents pay the costs of the activities, which range from 25 cents for coffee to $23 to $50 for transportation to various events.
Because the initial HUD grant was a spend down grant with no time limit, Community Options has not had to seek other funding. But now that the HUD grant is running out, the program is approaching foundations and like organizations. Initial reactions have been positive.
Like Community Options, the new sites initially asked for and received office and activity room space from landlords and plan to approach them in the second year for support with the costs associated with the resource coordinators and communications.
The form a grant takes can affect program implementation. Too much money to spend during a short time can cause implementation problems because organizations have insufficient time to plan.
The type of relationship the resource coordinator establishes with building residents enables trust to develop; having an accessible office on site facilitates this process. It is also important to avoid giving residents the perception that they are being assessed because they associate assessment with entry into an assisted living or nursing facility. Trusting relationships with resource coordinators often lead to requests for referrals for housekeeping, transportation, or other services that are more personal in nature.