Supportive Services Programs in Naturally Occurring Retirement Communities. SUMMARY OF THE SITE VISIT TO SENIOR FRIENDLY NEIGHBORHOODS

Baltimore, Maryland
June 5, 2003

The following information was derived from discussions with six staff from The Associated Jewish Community Federation of Baltimore (hereafter The Associated) and four organizations that operate under the umbrella of The Associated. They are Comprehensive Housing Assistance, Inc. (CHAI), Jewish Family Services (JFS), the Jewish Community Center (JCC), and the Myerberg Senior Center (MSC). These organizations run the Northwest Baltimore NORC services program called Senior Friendly Neighborhoods (SFN) that grew out of the earlier Senior Friendly Apartments (SFA) program. The Agency on Aging (AoA) grant enabled the organizations to subsume SFA into SFN by serving new apartment buildings and planning to expand into adjacent neighborhoods of row houses and single-family homes. Two members of the SFN resident advisory council to the NORC service program also participated in the discussion.

Description of the NORC and Its Residents

SFN serves the community of Upper Park Heights, located in Northwest Baltimore. The community is largely Jewish, but about 25 percent of its residents are black and a small minority are Hispanic. A subset of the older Jewish residents are Russian immigrants who came in the late 1980s. Most of the community's older residents have aged in place, living in the same homes or apartments for 30 years or more. Services are provided to residents regardless of religion affiliation or ethnicity, and SFN staff could not supply data on the percentages or total numbers of people in each demographic category.

In the late 1980s, Jewish community leaders decided to try to stabilize the community because they feared that the "Northwest flight" of people leaving Baltimore, which has been underway for about 50 years, would eventually change the community's profile. Under this stabilization initiative, The Associated and its affiliated agencies helped families buy homes and helped older people remain in their homes. In addition, they provided a range of programs such as volunteer days and sponsored community associations for Jewish people in the neighborhood.

Upper Park Heights is home to a number of agencies that are part of The Associated--the Jewish Community Center, the Myerberg Senior Center, and Baltimore Hebrew University. There are numerous synagogues, two large churches, and a public library. The community has grocery stores, shopping areas, and two activity hubs--the senior center, which operates with Baltimore City and private funding, and the JCC. The community has public bus transportation, and a senior shuttle, which holds up to 20 passengers, is accessible to people with disabilities. The shuttle has 36 stops and runs a continuous loop, five days a week.

Upper Park Heights is bordered by several major thoroughfares and has market-rate apartments, subsidized apartments, Section 8 apartment buildings, garden style apartments, row houses, and single-family homes. Each apartment building has a different character. The buildings with predominantly American-born residents have older physical plants, and the residents are frailer than those in the buildings with a high proportion of Russian immigrant residents. The latter group is younger in age, with fewer disabilities. Some of the smaller buildings do not have community spaces for programs and meetings, and the older buildings have accessibility problems such as stairs and curbs in front of building entrances.

The typical row house or semidetached home in the community is at least 30 years old, with street parking, stairs leading to the entrances, and steep interior stairs that do not have double banisters. Many homes do not have air conditioning and their exterior paint and lawns are in poor condition. The homes typically have only one bathroom, located on the second floor and lacking such aids as grab bars. Laundry facilities are located in the basement, which generally has stairs without railings. The layout of the homes presents problems related to accessibility, cleanliness, and risk of falls, and similar problems. For over 10 years, CHAI has provided home assessments and modifications to help people with low incomes remain in their homes.

SFN currently provides services in 13 buildings in Upper Park Heights and plans to expand services to the neighborhoods with row houses and single-family homes. Eight buildings originally received services under SFA; the remaining five buildings were added with the creation of SFN. Two of the 13 buildings were built using Section 8 funds from the federal Department of Housing and Urban Development (HUD). The buildings that SFN serves range in size from 45 to 190 apartments. The latest building to become part of SFN was the Milbrook building in 2002. The Milbrook building has 705 garden apartments, 450 of which have a resident who is age 62 or older. Most of these residents are Russian immigrants.

NORC Building Management and Communication with Residents

All of the new SFN buildings are either market-rate or HUD-subsidized buildings. Building management companies operate these buildings, with at least a part-time building manager on site in each building. Two of the apartment buildings have resident councils, floor captains, and phone trees, all of which were in place before the SFN program started. SFN has hired residents in two buildings as on-site coordinators; their jobs involve seeking input from residents, informing residents about activities, and coordinating these activities. SFN is hiring residents to determine if this is a cost-effective model for organizing and delivering programs.

NORC Service Organizations

The four organizations that run SFN have different roles. CHAI's mission is to stabilize the communities for Jewish residents and their neighbors in Northwest Baltimore, primarily through housing and neighborhood services. CHAI received the AoA grant and coordinates SFN and its outreach to residents and businesses in the NORC. CHAI has a Board of Directors and a Senior Citizens Committee. CHAI sought the participation of JFS, JCC, and the Myerberg Senior Center as it began developing SFN.

Jewish Family Services (JFS) offers a wide variety of social services to Jewish people of all ages. JFS supervises the SFN caseworkers, nurse, and volunteers. The Jewish Community Center and the Myerberg Senior Center serve as activity hubs for SFN. The senior center receives funding from the Baltimore City Commission on Aging and Retirement Education, the Jewish Community Federation of Baltimore, and the Center's own fundraising activities. Since these agencies are part of The Associated, their working relationships have evolved without formal screenings, competitions, or contractual relationships.

CHAI developed SFN with limited formal input from older people, but has since established a SFN Advisory Council, which began operations in February 2003, to facilitate resident involvement and empowerment. CHAI staff asked residents who were involved in SFN programs to volunteer to serve on the Council to provide advice about SFN's operations. Staff are now turning over the chair function to the Council members and the precise function of the council is under development. Every NORC building has a quarterly SFN forum where residents can ask questions as well as share concerns and ideas.

Evolution of the NORC Service Program

CHAI staff found out about the concept of NORC service programs through their work with older people (age 62 and older) in the community. They sought and received a small grant ($20,000) from the local Morris Goldman Foundation in 1996 to begin providing services in apartment buildings as part of their efforts to stabilize the community and enable older people to age in place. The new program, Senior Friendly Apartments, paid for two JFS case workers to work in the apartment buildings and provide information and referrals, brief assessments, and, where needed, case management. SFA also made arrangements with the local Sinai Hospital to provide some health education programming.

In 1998, JFS decided to assign caseworkers to specific buildings so that residents would get to know them and so the workers' travel time would decrease. JFS also asked for and received donated community space from the buildings in which the caseworkers operated. CHAI used the NORC AoA grant to create SFN in 2002 by incorporating the original eight SFA buildings and an additional five buildings chosen based on staff's experience in the community and pre-established relationships with building owners and managers.

When CHAI received the AoA grant, it held open community meetings in the eight SFA buildings to explain how the grant would affect SFA and to talk about plans for SFN. Some older residents expressed concern about changes to their existing services and were initially confused about them. For the additional five buildings, CHAI initiated contacts with residents and housing management in the targeted buildings to explain the program and assess their interest in participating.

CHAI's outreach to the row houses and single-family homes in the neighborhood surrounding the apartment buildings is based on the concept of "warm houses"; individual residents would open their homes to community programs and activities, which would become community spaces like those in the apartment buildings. The "warm house" concept has been challenging to implement, but SFN plans to continue organizing in this community.

Services Available to NORC Residents

SFN services are targeted to people age 62 and over who live in the Upper Park Heights and the new Milbrook building. SFN services include case management, information and referral services, preventive health screening, recreational activities, and transportation, all designed to keep people independent in the community for as long as possible. Apartment residents must become members of SFN to receive services; membership requires a short application and a $15 annual membership fee. SFN currently has 149 members. "Case aides," who are JFS-contracted employees, assess a member's physical and psychosocial needs in the member's apartment or another private location, provide information and referral to needed services, and help residents obtain such services as Meals on Wheels, home care, and others. SFN does not provide hands-on assistance with daily activities; however, staff refer residents to agencies that can provide these services. Case aides will also follow up with members who have received a referral, if the resident has further need of assistance. NORC residents can tap into additional services from JFS, including counseling, advocacy, home care services, outpatient mental health care, geriatric services, volunteer services, and limited financial assistance.

In addition to case aides, JFS contracts with one nurse and resident activity coordinators in each SFN apartment building. The nurse conducts preventive health screening activities such as blood pressure checks. She can also assess a resident's health care needs and, based on her findings, refer individuals to appropriate health care providers. Due to funding limitations and liability concerns, the nurse cannot provide most health care services. The activity coordinators in each building help find out what services residents want, publicize activities, and help organize them.

Residents would rather attend group activities, which might include a health care component, than seek out services individually. The types of activities that are popular include "Eating Together," which is a meals program funded by the Baltimore Commission on Aging, discussions of current events, and book clubs. Residents want to be entertained, but at minimal cost. Also, the types of programs that appeal to the younger-old Russian immigrants involve activities such as yoga. Residents who are in the oldest age groups would rather go to events where they can sit and observe.

JFS coordinates a broad range of volunteer activities under SFN in which residents may either offer or receive help. For example, some residents volunteer in schools, while others request friendly visitors. Some volunteers drive people to appointments or do minor home repairs. Other groups of residents have become involved in group programs such as a writing program where they become pen pals with 3rd grade students. JFS recruits and screens volunteers and coordinates their efforts.

In 1998, CHAI surveyed neighborhood residents about their transportation needs and designed several services to help meet the identified needs. After receipt of the federal grant, SFN began operating a shuttle bus that serves about 16 buildings, not all of which are part of SFN. Residents must make reservations a day in advance of their trips. SFN also sells residents subsidized vouchers for local taxi-cab rides to be used for medical appointments up to twice a week. Residents pay only one-third of the usual cost of a taxi. In July 2003, SFN will explore providing an accessible sedan service to enable residents with disabilities to go to their medical appointments; drivers would be able to help people into the van and to and from their medical appointments. Also in July, SFN will provide a van to shopping areas every Monday. SFN staff suggested that a vehicle purchase might be a more economical option than the numerous hired vehicles but the AoA grant rules prevent purchase of automobiles in demonstration projects.

NORC Service Program's Communication Methods

The primary methods that CHAI and its partners use to communicate with SFN members include flyers, telephone calls, monthly newsletters in two languages, posters, word of mouth, and mass mailings. Staff were not sure which communication methods work best.

Case aides, who are assigned to particular buildings, send out flyers or put up posters to introduce themselves and to advertise their drop-in hours. Some case aides go door to door to introduce themselves. Case aides also try to speak with building management about tenants who seem to be having problems remaining independent.

SFN also has an outreach worker whose job is to work with building managers and to identify people who need services. The outreach worker began working in November 2002. Staff believed that they should dedicate one staff person to marketing activities to develop a strong publicity plan and improve their effectiveness.

NORC Service Program Challenges

SFN has faced the related challenges of engaging the interest of both NORC residents and building managers in its programs. Turnout for programs varies by building, with low cost or free activities drawing the most attendees. According to SFN staff, almost anyone will come out for a party, so parties tend to be some of the most well attended activities. Reaching isolated residents is a challenge; staff must rely on other residents to seek isolated residents out. How well this works is not known.

One group that has resisted the SFN program is condominium associations. Over the last six years, four different buildings have turned SFN down, primarily because the associations do not want to be viewed as nursing homes or to receive what some view as charity. Some older people do not want to "spend time with old people." When apartment building managers were resistant at the beginning of the program, staff turned to building owners whom they knew through their work in the larger community. Some of these owners encouraged building management to try out the program.

Outreach into the neighborhoods composed of row houses and single-family homes has been particularly difficult. SFN has not been able to identify any appropriate "warm houses" to date. Homes in the NORC neighborhood are generally not accessible for people with disabilities; lack of transportation presents another obstacle. CHAI staff have tried to identify these houses through mass mailings in the neighborhood and by contacting neighborhood associations. Neither method has produced any volunteers willing to serve as "warm houses." Despite the difficulties, SFN plans to continue its search for appropriate sites.

NORC Service Program Quality Assurance and Outcomes

SFN has a number of quality monitoring methods. SFN staff collect information on the number of people attending each program and on the people using the case aide service. Members provide data on their age and service preferences, but no data are collected on ethnicity. Periodically, SFN volunteers call members to ask for feedback on activities or services. SFN also holds quarterly open forums to hear from residents about the program.

JFS social workers supervise the case aides through weekly meetings. In addition, all staff participate in team meetings to discuss their work and any relevant administrative matters. The aides can present resident problems or needs for services in the weekly peer group meetings. JFS also conducts a formal utilization review that involves review of clients' clinical records.

Beginning in June 2003, The University of Maryland Baltimore College (UMBC) Center for Health Policy will conduct a survey of a random sample of 100 SFN members and 80 nonmembers from the group of 507 NORC residents who have used SFN services. These users will be followed until June 2004. UMBC will also conduct a process evaluation of SFN's operations. The study results will be used to seek ongoing funding from local foundations and other sources.

NORC Service Program's Funding Sources

The program's funding comes from a combination of The Associated: Jewish Community Federation of Baltimore, local foundations, and Baltimore County funding. Funding for the first program, SFA, came primarily from The Associated; total funding was $187,309 for the first seven buildings, which was split between CHAI, JFS, and JCC five years ago when the program first started. Funding for services in Milbrook comes from a variety of sources: $25,000 from Baltimore County, $125,000 from the Weinberg Foundation, and free use of an apartment valued at $7,000. The AoA grant money is split between the original three agencies and the Myerberg Senior Center; funding is about $1 million over 14 months--$180,000 to the JCC, $200,000 to JFS, $100,000 to CHAI for staff, and the balance for the Senior Center. Baltimore County, The Associated, and the Weinberg Foundation provide the remaining matching money.

Funding is a significant challenge for the NORC because residents only bear a small share of the cost through their annual $15 fee. SFN is considering instituting user charges but has not yet imposed them. State and federal funding, apart from the AoA grant, are currently not available.

Recommendations

SFN staff and NORC residents made a number of recommendations regarding development of service programs. Before beginning, there should be a market assessment of who needs or wants what types of services in the target geographic area and an assessment of existing community resources--public and private sector. In particular, relationships with businesses can bring additional resources to the NORC service program.

Outreach is a critical component of the service program. A door-to-door marketing scheme is important because sometimes residents do not come out of their homes. Word-of-mouth referral also makes a big difference. The cooperation of building management is important so that when new residents move in they hear about available services.

Interviewees disagreed about the organizational foundation and structure of service programs. Some believe that a community development agency should take the lead in developing the program. Others believe that several agencies should collaborate to develop services. All staff acknowledged that having one central agency handle the administrative infrastructure helps keep intra-agency coordination informal and provides economies because the central agency in Baltimore--The Associated--carries required insurance, takes care of information technology services, employee benefits, capital repair, and central planning for the system.

SFN staff agreed that access to community space in buildings and neighborhoods was key to residents socializing together. Nine of the 13 apartment building owners provide such space, which promotes residents' participation in programs.

SFN staff agreed that careful consideration of the staffing for the case management function is critical. The original grant funded three master's level social workers. It has proved very difficult to recruit social workers at this level, despite much effort. SFN ended up hiring people with bachelor's degrees in social work. All staff need to be trained to actively help people, rather than just react to crises. Thus, all staff need training on appropriate assessment so that the NORC services program does not follow a traditional reactive model.

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