The following information was derived from discussions with 16 people on May 5, 2003--ten employees of the Jewish Family and Children's Services (JFCS), two JFCS contractors, and three residents and one building manager at a NORC building located in the Center City section of Philadelphia.
Description of the NORC
The NORC encompasses four cooperative apartment buildings (co-ops) and one condominium in the Center City section of Philadelphia. Four were constructed using federal Department of Housing and Urban Development funds--2101 Walnut Street, Penn Center House, Kennedy House, and Rittenhouse Plaza. The fifth building is The Philadelphian, built with private financing.
The buildings are all high-rises with apartments ranging in size from studios to two-bedroom units. The apartments are not considered accessible housing for people with disabilities. Although the buildings have elevators, which help foster accessibility, public areas of the buildings visited have features that pose difficulties for some older residents. For example, residents have slipped and fallen due to problems with the automatic doors; building management responded by adjusting the doors to close more slowly. Of the five buildings, three have few, if any, chairs in the lobby, and one has expressly forbidden people to sit in the lobby to avoid having the building "seem like a nursing home."
The building managers annually inspect residents' apartments to find and eliminate safety hazards and to ensure that equipment is functioning properly. Every year these inspections uncover some unsafe situations. The building management works with residents to eliminate the problems and brings in social workers from Jewish Family and Children's Services, if needed, to help facilitate the process. Problems that remain unsolved can lead to eviction. Starting eviction proceedings is seen as a last resort for both compassionate and legal reasons. First, people may deny that they need help, even if they need substantial assistance with daily activities, or they may be reluctant to leave their homes. Second, although people can be evicted if they are deemed incompetent, legal protections against being declared incompetent can be very difficult to overcome.
Some financial issues related to the NORC buildings have proved burdensome or divisive for the residents and might cause some to leave their apartments. A person moving into the building we visited would have to pay about $65,000 in 2003 for a one-bedroom apartment plus a nonrefundable "buy-in fee" that ranges from $17,000 to $25,000. In addition, the monthly "carrying charge," which ranges from $350 to $750, is becoming difficult for some residents to meet. Property taxes are increasing as well, with some residents facing a doubling of their tax burden following the city's reassessment of most of Center City Philadelphia properties in 2002. Some residents would like the ability to sell their apartments on the open market and, thus, turn the co-op into a condominium, an issue that has become divisive. At present, the co-op's by-laws prohibit such sales, a restriction that can only be lifted by a vote of two-thirds of the residents.
According to JFCS staff, at least 75 percent of residents in the five apartment buildings are age 65 or older, and those who have lived in the buildings the longest came in the 1970s. The typical resident is white and, while the population includes a substantial number of Jewish residents, the resident population is diverse, including blacks, Protestants, and Catholics. Residents tend to be well educated; they are retired teachers, social workers, and others who are committed to the concept of co-op living. Residents come from all economic strata, although most have incomes at or below 200 percent of the federal poverty level. The few younger residents have an average annual household income of about $75,000. Precise demographic data about NORC residents are not available.
Most residents have aged in place, but some in-migration has occurred for several reasons. Retirees have sold homes in the suburbs and moved to these Center City buildings because costs are relatively low compared to other city residences. The neighborhood is attractive; people can walk to their health care providers, use public transit, and take advantage of educational and cultural opportunities close to their homes. Temple University and the University of Pennsylvania are located nearby, as are museums and restaurants. People have also moved to the five buildings because of what they have heard about the availability of social services. Three of the five buildings have waiting lists. For example, the building we visited has 800 people on its waiting list, some of whom have been on it for 17 years.
NORC Building Management and Communication with Residents
Four of the five buildings have elected co-op boards, and each has at least a part-time building manager. The co-op we visited has two floor captains for each floor, elected annually or biannually. One of the buildings is a condominium governed by a condominium association.
The co-op board in the building we visited hears from its residents formally and informally. Residents are comfortable voicing their opinions to board members both during and outside of board meetings. Formal feedback comes from residents when they leave the building and fill out the requisite questionnaire, or when the family of a deceased resident does so. Residents also have monthly House Council meetings to discuss issues of concern to residents. Part of each meeting is open to all residents, while the rest of the meeting is limited to discussion among the floor representatives. Upon request, the board appoints one or more of its members to attend House Council meetings.
NORC Service Organization
The founding organizations that merged to form Jewish Family & Children Services of Greater Philadelphia (JFCS) began offering services in Philadelphia as early as 1855. Although its name and mission have evolved since then, JFCS has always focused on serving as a social safety net for people of all ages and creeds. The agency currently has 300 employees in 10 offices, offering a variety of social services for all ages. The organization's total budget for 2003 is $16 million. During fiscal year 2002, JFCS served about 40,000 unduplicated clients. (The term client includes the person being served directly and his or her family.)
Since 1953, JFCS has provided elderly services that focus on keeping people in the community in the least restrictive setting possible. JFCS has several departments involved in serving the older population.
- Core Services for Older Persons provides subsidized services, such as assessment, care management, support services and counseling, in residents' homes or in the program's offices. The program serves community-dwelling, homebound older people throughout Philadelphia and its adjoining counties.
- The City Line Aging Support Program (CLASP) provides outreach and service coordination to frail, isolated elderly in the City-Line/Wynnefield Heights area, which has a high density of very poor people age 65 and over.
- Senior Horizons is a private-pay geriatric care-management program. This unsubsidized program helps generate income to support the subsidized programs.
- Boarding Home Outreach Project serves residents in 18 boarding homes that house deinstitutionalized people with mental health conditions. The program employs a nurse who provides health education, advocacy, and organizes wellness groups, as well as a chaplain who performs nonsectarian services on the Sabbath and holidays. All age groups are served.
- Critical Needs provides emergency financial assistance for people of all ages in economic need.
Evolution of the NORC Service Program
JFCS's work with the five Center City apartment buildings began in the early 1990s when the retired Dean of Temple University's undergraduate School of Social Work approached a JFCS employee to ask for help with a conference. The employee helped arrange for speakers at a conference on Medicare and Medicaid for residents of the four co-ops. About 1,000 people attended the free event in 1992.
Following the success of the conference, its organizer approached the agency employee about the need for a social worker at one of the buildings to help residents find and secure the services they needed to remain at home. Despite strong resistance by a vocal minority of residents in this building who did not want the building to resemble a nursing facility, JFCS created the original Services to Apartment Residents (STAR) program in 1993. Under this program, a social worker visited each building to help residents arrange for services with JFCS and other community providers and to place people who could not live on their own into group residential settings such as nursing homes and assisted living facilities.
Other service programs have been tried in the buildings. For example, in 1994, a board member at the one of the buildings arranged for a local hospital to have a nurse visit periodically. The hospital participated in the hope that making a nurse available would increase its admissions. When it became clear that admissions were not affected and the board member supporting the nurse's activities went off the board, the hospital dropped out of the program.
In 2002, JFCS obtained the AoA grant to expand the STAR program, starting in August 2002. Under the expanded program, which was renamed STAR NORC, the social workers spend one half-day a week in each of the five buildings. The primary benefit of the expansion has been the evolution of the program from a reactive one, where workers only dealt with people who needed a service, to a more proactive one, under which a nurse, group educator, and chaplain provide group services. Grant funding also permitted an increase in the number of social workers from one to three; this increase enabled the workers to reach out to residents who previously did not seek services.
Services Available to NORC Residents
The goal of the STAR NORC program is to keep older people living independently in the community in the least restrictive environment for as long as possible. The program targets people who are isolated or who might have problems remaining at home. JFCS has not created any formal eligibility criteria for services.
The JFCS social workers are the key actors in the STAR NORC program. A social worker spends four to six hours a week in each building coordinating services for residents, formally interviewing residents who have requested or been identified as needing services, and seeing residents by appointment or drop-in. When not on site, the social workers arrange for services for the residents, speak with families, work with the manager and board of the building, and recruit for the various group events provided by STAR NORC staff. These staff--the geriatric nurse practitioner, the chaplain, and the community educator--tell the social worker about residents they believe may need help. All of the professionals make initial contacts with residents through the programs that they conduct in the five buildings. In addition, when the social worker finds that a resident has a particular need, he or she will arrange for the appropriate professional to help the resident. Building management will also alert the social worker when they know of a resident who may need assistance.
The staff who conduct group meetings and see individual residents work under contract with JFCS. A geriatric nurse practitioner spends four hours each week in each of the five buildings visiting residents or holding "drop-in" hours for residents; this time also includes a monthly program on a health topic, such as "questions to ask your doctor." The nurse practitioner also provides preventive health services such as blood pressure screenings and advice about medications. The nurse sees individual clients in their apartments to discuss their health problems, take medical histories, assess residents' physical and mental functioning, and review medications. After obtaining the resident's permission, the nurse may contact his or her primary care physician about any problems in communication. The nurse currently works with 43 people, all of whom were referred by a social worker. A community educator facilitates group socialization opportunities once a month in each building; most of the participants are women in their late 80s or early 90s who cannot get out of the building without great difficulty. A geriatric psychiatrist is on call through JFCS to provide services to residents, if needed. All of the group activities are delivered in the apartment buildings, and the individual services are delivered in residents' apartments or the social workers' office in the building. Residents do not pay for their STAR NORC services because the program does not want to discourage participation. In the future, the program will explore some method of co-payment such as a membership fee for those wanting to attend group meetings.
In addition to the services provided directly by the program staff, the social workers offer information and referrals for services provided by outside agencies, including JFCS. JFCS services include in-home assessments and care plans, case management, home care, shopping, individual or family therapy, guidance on alternative living arrangements, support groups, outreach to Jewish Holocaust survivors, respite care, meals, and transportation. When residents receive homecare or chore services, they pay between 25 and 30 percent of the cost of the services; other services are offered at market rates. JFCS also provides spiritual counseling through its chaplain, who is an intern at the agency. Although the intern is training to be a rabbi, the counseling is nondenominational and he refers people to practitioners of other faiths upon request. The chaplain offers one program a month in each building.
Transportation is one of the most frequently requested services. The local transportation system for seniors is viewed as extremely unreliable, and residents avoid using it rather than risk being stranded somewhere for long periods of time. Residents generally have to rely on the subway, taxis, and buses. The STAR NORC program has begun to develop paratransit (i.e., public transit for people with disabilities) and other pooling options to address the transportation problem. In addition, STAR NORC issues transportation vouchers for taxis, and volunteers sometimes provide transportation. In spite of these initiatives, transportation remains a problem that STAR NORC staff feel has been only partially addressed.
JFCS makes extensive use of volunteers to help provide some of its services to NORC residents. All volunteers undergo a criminal background check and receive a training manual. The social worker fills out a volunteer request form based on discussions with residents about their need for services and tries to match a volunteer with the resident. The volunteer who agrees to provide services sends in a confirmation form and files monthly reports that describe the services rendered to the resident.
JFCS had about 40,000 unduplicated clients for all of its services in fiscal year 2002;1 this count includes clients of all ages and residents of the five STAR NORC buildings as well as those in JFCS's other services areas. During the same period, the original STAR program had 102 clients and provided information and referral services to 224 clients. In the first 10 months of the expanded program (August 2002 through May 2003), STAR NORC had 325 clients and 506 instances of information and referral services.
JFCS supplied the following demographic data on their STAR NORC clients from September 1, 2002 through April 28, 2003: 17 percent were age 90 or older, 49 percent were age 81 to 90, and 24 percent were age 71 to 80. Sixteen percent of clients were divorced, 12 percent were married, 17 percent had never married, and the remainder were widowed.
Program participation varies across activities. The chaplain had a total of 116 people attend the eight programs he conducted in two buildings over eight months. Maximum attendance at a program was 15. Several programs have brought in six to eight participants and one had no attendees.2 In a four-month period, the nurse held 13 group meetings attended by a total of 104 people. In addition, she averages 43 individual visits per month. Group meetings address such topics as Heart Health, Questions to Ask Your Doctor, Memory and Aging, Recipes for Healthy Living, Blood Pressure Screening, and Test Your Stress Level. A group specialist has been holding psychoeducational discussion groups for six months in all buildings on a biweekly basis. Attendance averages 11 people per session.
NORC Service Program's Communication Methods
The STAR NORC program uses many communication methods with residents of the five buildings. Written materials include newsletters, flyers, brochures, and monthly advertising in building newsletters. Buildings have in-house television stations that announce STAR NORC activities. The program also maintains contact with the residents it serves via telephone and makes available telephone numbers where other residents can obtain general information about available services. The geriatric nurse practitioner's monthly health screening provides a means of communicating with residents individually.
Program staff have found that flexibility and persistence are important in communicating with residents. For example, the health educator placed flyers throughout the buildings and met informally with residents to announce program activities. She found that flyers are effective but not sufficient because not everybody responds to them. So, she made calls to key residents who helped spread the word to other residents prior to the scheduled program.
NORC Service Program Challenges
JFCS has faced sporadic resident resistance to STAR services. When JFCS originally presented the STAR program to the boards in the five buildings, they encountered resistance from some residents who did not want their buildings "turned into nursing homes" through the provision of services. Certain accommodations have been made to assuage these residents' concerns. For example, the nurse who conducts programs and visits residents wears street clothes. Residents also resist using mental health services; some program staff speculate that residents do not want the stigma attached to the use of such services. JFCS has even faced resistance from building management when it has offered to hold seminars, provide one-on-one counseling, or do group work when traumatic events, such as a suicide, occur in a building. Building managers turned down every free offer except for services offered after the 9/11 attacks. JFCS has dealt with this resistance by using health screenings and other programs in which professionals interact with residents to identify residents who may need services and to make discreet referrals to the geriatric psychiatrist, social workers, and other professionals.
There are some major problems in the physical environment of the five buildings. Some residents need home modifications such as grab bars in showers to be able to stay safely in their homes. Perhaps the biggest environmental issue is the lack of acceptable transportation options. For example, paratransit services are unpopular because they require making an appointment. Residents also feel that they waste a considerable amount of time because they have to travel long distances and must wait to be picked up when going home. Getting people to doctors' offices is one of the most challenging issues because people have to commit to appointment times and then may get delayed due to transportation problems. Staff have not yet identified an acceptable and affordable solution to this problem.
NORC Service Program Quality Assurance and Outcomes
The STAR NORC program has no formal outcome measures yet, but informal feedback from residents is available from resident interactions with various program staff. In addition, when the social worker closes a case, he or she gives the client a satisfaction form to fill out that provides an indication of both the outcome and quality of the interaction. Social workers may also interview clients or the clients' families.
According to the building manager we interviewed, some residents have been able to remain in their homes rather than going into an assisted living facility because of the availability of program services. STAR NORC also relieves the burden that the building manager would have, were he or she to broker services for residents. For example, when the manager notes that a resident has become reclusive, he or she can refer the problem to JFCS. Residents often benefit from contact by the program since, in some cases, the residents have not realized how much help they needed.
NORC Service Program's Funding Sources
The JFCS funding for the STAR NORC program comes from building fees that range from $5,000 to $7,500 a year per building; grants from foundations, such as The Pew Charitable Trusts, and The Connelly, Tuttleman, and Clayman Foundations; and from resident payments. The foundation grants for older people amounted to $2 million in 2003. Buildings pay $25,000 (about 13 percent) toward the STAR NORC budget. At present, state programs have no role in funding STAR NORC programs. However, in July 2003, STAR NORC staff met with the Pennsylvania Secretary of Aging who expressed great interest in this program and has offered to make available some state funds. Although JFCS is considering pursuing Medicaid funding, the potential may be limited because many residents with low incomes have financial resources that exceed Medicaid's eligibility standard.
Our discussants had two main recommendations. First, they noted that it is important that any NORC service program seek and receive buy-in from most residents before beginning services. Second, program organizers should make sure that events are properly marketed so that attendance is high. Specifically, the elderly population is not likely to attend events that present aging in any negative way.
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