Lanspery, Susan. Clustering Services at Senior Housing Sites: A Technical Assistance Guide for the Aging Network. Los Angeles, CA: National Resource and Policy Center on Housing and Long Term Care, University of Southern California, Andrus Gerontology Center, 1997.
Housing is a vital element in long-term care, however its priority is often minimized. Often senior housing residents only receive shelter assistance, but lack services. Finally, residents in assisted housing are often older, more isolated, less well off, and frailer than other seniors in other settings. Service clustering is a strategy to minimize costs by taking advantage of economies of scale; clustering involves consolidating the fragmented services of many clients. Many programs, such as HUD's Congregate Housing Services Program, the RWJ Supportive Services in Senior Housing, and No Place Like Home, have combined housing and services. The benefits of service clustering can include: more people receiving assistance, residents finding more support, housing sponsors having better staff and resident morale, managers focusing more on managing the property, and all parties benefiting from lower costs. Typical activities included congregate meals, care management and crisis management, planning and advocacy, and participating in inter-organizational groups or task forces.
Service coordinators in public housing primarily assist residents in finding needed services; coordinators also provide information and advocacy, and organize activities. Some see this coordination as unnecessarily duplicating aging network activities. Technically, the service coordinators should complement the aging network's coordination efforts. Some aging network staff assume that housing managers are ready to evict residents who need assistance, while network staff see themselves as advocates for older people. Some aging network staff believed that older people who live in senior housing have more support than older people who do not. To ensure long-term viability of service clustering the following factors are important: the extent to which the program promotes aging in place, how the program coordinates services, the development of new services, the extent of environmental modifications, and how much resident input would be used.
The factors that need to be examined in promoting aging in place are: supply and demand for services in the community, laws and regulations that restrict a program's ability to provide services, what services residents may use, characteristics of the physical setting of the housing, and the applicable financing streams for housing and services. Aging networks, as expected, had limited budgets.
The guide provides examples of service clustering. The New Jersey Congregate Housing Services Program provided supportive services to eligible frail, low-income residents of subsidized housing. In Massachusetts, the Managed Care in Housing and Group Adult Foster Care programs targeted low-income older people, primarily residents of multiunit housing, who were at high risk of losing their independence. The Massachusetts programs incorporated a clustering approach to service delivery and provided a range of services. The New York State Office for the Aging established the Resident Advisor Program, which helps assisted housing developments in hiring service coordinators.
Feldman, Penny H., Eric Latimer, and Harriet Davidson. "Medicaid-Funded Home Care for the Frail Elderly and Disabled: Evaluation the Cost Savings and Outcomes of a Service Delivery Reform." Health Services Research 31, no. 4 (1996): 489-505.
This article evaluates New York City's Cluster Care demonstration, a model where one home care agency serves a number of Medicaid beneficiaries with disabilities living in the same senior housing site. Cluster care was tested as an alternative to the City's one-on-one attendant care system (i.e., traditional care). The differences between cluster care and traditional care were: (1) under cluster care, a single agency provided services at one site, rather than multiple agencies delivering services in one site as in traditional care; (2) teams of workers served people whose apartments were close to one another under cluster care, rather than one aide serving one client at a time under traditional care; and (3) in cluster care, clients' service schedules were based on the tasks that clients needed accomplished compared with attendants delivering services in blocks of four, eight, or 12 hours under the traditional care system. The demonstration was designed to test cluster care's potential to reduce costs by reorganizing delivery of traditional agency home care services. The evaluation addressed cost issues as well as client well-being, which was measured by functional status, mortality, depression, and satisfaction with services.
The experimental group consisted of Medicaid beneficiaries who lived in seven senior housing sites with an on-site social worker or a senior center. Clients were not included in cluster care if their physical health condition made it unsafe for them to be alone, if they could not provide access to their apartments, or if they were psychotic. The control group was Medicaid clients receiving traditional care at four other senior housing sites. The study design involved comparing 229 clients at seven cluster care demonstration sites to 175 clients at four comparison sites. Medicaid clients in the experimental and control groups were interviewed in-person before and 16 months after the demonstration began. Home care agency and Medicaid records were used for the cost analysis and agency records were accessed to determine what happened to clients who were not available for follow-up at 16 months.
Measured variables included clients' average hours of home care used and the average cost of their home care per week in the 36 weeks preceding the intervention; post-intervention hours of care per week and home health costs per quarter; mortality; functional status using a scale of 10 ADLs and IADLs; a depression scale; a client satisfaction scale; severity of illness based on the number of classes of drugs that a client used, and the client need trajectory (the rate of change in the clients' use of hours of home care prior to the intervention).
On average, clients at cluster care sites used six fewer hours of care a week or 300 fewer hours a year than traditional clients. The reduction in hours was a result of reductions in hours of care for clients with higher functional needs at baseline. Clients in cluster care and traditional care sites with four or fewer limitations used about the same number of hours of care per week on average. Those with five to 10 limitations in cluster care sites used 7 fewer hours per week or 350 hours fewer per year than their counterparts in traditional care.
The lower hours of care in the cluster care sites resulted in cost savings. Controlling for differences in client characteristics, those in cluster care cost on average $720 less per quarter or $2900 less per year than clients in the traditional sites. Savings were achieved largely among those with 5 to 10 limitations in daily activities. The cluster care clients with this level of disability cost, on average, $4600 less per year than similar clients in traditional care. There were no significant differences in mortality, functioning, or depression between the experimental and control groups. However, when measuring functional differences, those with four or fewer limitations in cluster care sites had better functioning at follow-up than those at traditional sites and those with five to 10 limitations at baseline in cluster care fared worse than people with same level of disability in traditional sites. Client satisfaction at cluster care sites was lower than at traditional sites.
The authors do not say whether they attempted to match the experimental and control groups on demographic or functional characteristics. There were significant differences between the two groups that were controlled for in the multivariate regression analysis.
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