Supportive Services Programs in Naturally Occurring Retirement Communities. Program Services and Outcomes

The programs at the five sites show the various ways services programs can get started. In Baltimore and Cleveland, the programs grew naturally out of earlier community programs. Baltimore's program evolved from efforts to stabilize the neighborhood in the face of continuing out-migration; in Cleveland, the program staff is using AoA grant funds to replicate the existing program in four new communities in Ohio. In Philadelphia, residents learned about the services that social workers could provide and asked for one to work in their building. In contrast, in Pittsburgh, agencies sought to identify residents who needed the services they could provide. In St. Louis, program organizers are conducting research on which neighborhoods might need what services. At the time of our visit, the services program was still under development, so most of the discussion in this section will focus on the other four sites.

Most agencies began their services programs by implementing their own ideas about the programs residents would appreciate and use, generally based on their knowledge of the particular community or of similar communities, sometimes with input or feedback from residents. In the four grantee sites that have implemented programs, social workers or activity coordinators are the focal point for work with residents. These workers are generally based in the buildings and are responsible for contacting residents, organizing activities, assessing residents' needs, and referring residents to other professionals for additional services. The program staff use volunteers in these activities to varying degrees. In Philadelphia, for example, volunteers, both from within the community and from outside, are screened and matched with residents who need assistance. In Cleveland, resident volunteers help run the social activities.

These different development and implementation strategies rely on different mechanisms and have elicited different levels of resident input into program design. Nonetheless, the services offered are similar across the programs and vary more by the age of the residents and their levels of frailty than across sites. Transportation, reduction of physical barriers, opportunities to socialize, and opportunities to learn are common themes. In Cleveland and Baltimore, staff members report that activity preferences vary by building and over time within buildings. The younger members of the NORC population prefer activities such as trips outside the community and exercise programs such as yoga. The older residents prefer more sedentary activities that involve being entertained over those that require active participation. The staff have found that residents prefer a mix of activities, with interests that rotate among bingo games, current events discussions, and health lectures.

Despite the similarities in the service mix across the sites, there are some site-specific services and different approaches to service provision. In Baltimore, Cleveland, and Philadelphia, nurses deliver preventive health services such as blood pressure checks and presentations on health-related topics. In Philadelphia, the program arranges for chaplain services. In Cleveland, the program focuses on providing residents opportunities to socialize through activities organized by resource coordinators; the coordinators also provide service information and referral on request. In Pittsburgh, inter-agency care teams develop care plans for residents. Pittsburgh's program has the narrowest range of direct service provision, but the strongest emphasis on comprehensive individual resident assessment. When Pittsburgh staff found that program participants were not taking full advantage of the recommendations for services and activities, they realized that they sometimes needed to go beyond simply providing information and referral for services and actually help older people link up with the recommended services.

The grantees provide some services directly, but they address several categories of services only through referrals. If a person appears to need home health care or mental health services, program staff will refer the resident to a mental health professional or an appropriate agency. Some agencies affiliated with NORC programs offer these services, but residents must pay additional fees for them. Similarly, even within the services they provide, programs may limit the scope of their involvement. For example, meals are viewed as a social activity and not as part of a nutrition initiative. In some cases, residents themselves limit the types of services they are willing to accept from the program. For example, one program resource coordinator mentioned residents usually prefer to request assistance in relocating to an assisted living facility or nursing home from a family member.

All the grantees have had difficulty addressing the problem of resident mobility. Physical barriers within buildings have been eased in many cases but the solutions to broader barriers to mobility, such as environmental barriers between buildings and lack of suitable transportation options, do not appear easy to solve. Available paratransit at the sites can require long waits and advance reservations, which residents do not like. Although public transportation is available in all the grantee sites, it is not always accessible or efficient for residents with physical limitations. Baltimore's SFN program has created several services to address resident's transportation needs, including a shuttle bus that serves 16 buildings, subsidized vouchers for local taxi cab rides to medical appointments, and a weekly van service to shopping areas. The staff is also exploring the use of a sedan service, with drivers who can assist people into and out of the van, allowing residents with disabilities to get to medical appointments.

Residents' weaknesses or disabilities can create challenges for the conduct of program activities, particularly those that involve food service or transportation planned in advance. For example, staff reported that residents may sign up for activities and not remember having done so, or, if they do remember, they may feel ill or be otherwise unable to attend. Food may be wasted or transportation left unused.

The fact that resident preferences also change over time and by resident group presents a further challenge and reinforces the finding that ongoing feedback between residents and program staff is crucial. Grantees at several sites have set up mechanisms for internal feedback from residents. In Philadelphia, the co-op board solicits resident feedback and input on the program. The Baltimore program has hired senior residents to serve as on-site coordinators charged with seeking resident input and helping organize and publicize building events.

The grantee sites have very little information about program outcomes. While the overall goal of maintaining residents' ability to live independently is clear, gauging program impact is hampered by the lack of specified interim outcomes. St. Louis is attempting to address this problem in advance by incorporating the development of outcome measures into the program from the beginning. At some sites, staff members have tried to measure the outcomes of their programs by tracking resident participation in program activities and measuring resident satisfaction with the programs. Resident participation is one measure of program outcomes, since high participation probably indicates that the program is providing services that residents want or need. To meet the larger goal of helping residents stay independent, a services program should not only provide services that residents currently need but also publicize the availability of its services so residents will know where to turn when the need arises.

Running a NORC services program involves constant feedback from residents about what services they want and need, and trust is a key factor in getting residents to communicate their needs. Staff members note that residents are particularly sensitive to the notion that admitting their needs might be a prelude to being removed from their homes. Program staff report that it is easier to get people involved in social activities first and then build up residents' trust over time, suggesting that measuring sustained participation may be a good indicator of success. With increased trust, residents open up to staff about their more personal needs, such as a homemaker or home health services.

There is some evidence at the grantee sites that NORC residents, when faced with emergencies, may not have enough knowledge about community services to take advantage of them. Readily available information is particularly important for older people whose circumstances can change abruptly. As mentioned, staff in Pittsburgh found that the program participants who received referrals often did not follow up on them. They speculated that residents and their families might not make these arrangements unless faced with an emergency. Similarly, staff in St. Louis found that residents were unaware of many of the services available in their communities.

A potential measure of program outcomes is that residents view the program as a non-threatening source of services and information that they can turn to as their needs change. Unfortunately, it is unclear how to measure whether NORC services programs are evolving as a trusted information source. In the short run, participation rates may be a good proxy for progress toward this long-term goal.

It is difficult to gauge the effect of program activities on specific outcome measures. The programs at the study sites were in different stages of development when they received the AoA grant funding, so comparisons across sites are inappropriate. The grants were also not designed to support specific measurable goals, nor was funding directed toward research on the outcomes of program activities. Nonetheless, planned future research in some sites may illuminate how programs contribute to identified outcomes.

St. Louis has focused on getting primary data to establish a baseline and determine needs. Program organizers will then design a program to respond to those needs. Evaluation will be an ongoing part of the program. Staff expect commonalities across the St. Louis program sites and other NORCs, so their findings will be applicable to other NORCs. Because of the attention to both planning and outcomes, a follow-up visit to this site could yield useful information about mechanisms for measuring outcomes and the costs associated with this effort.

While evaluation and outcomes measurement are not components of the other sites we visited, outside researchers are conducting studies at two sites that may provide useful information on program outcomes. In Baltimore, the University of Maryland Baltimore College (UMBC) Center for Health Policy plans to follow service use of a random sample of SFN members and non-members over a year. This study will also include a process evaluation of SFN operations. In Cleveland, researchers at Case Western Reserve University will follow a group of 1,000 community-dwelling older people and compare their experiences to those of older people residing in buildings with Community Options. The study will look specifically at nursing home and home health use. Both studies are expected to be completed in 2004.

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