The "Value Added" of Linking Publicly Assisted Housing for Low-Income Older Adults with Enhanced Services: A Literature Syntheses and Environmental Scan. Appendix B: Findings From Similar Programs in Other Settings


Aging in Place (AIP) Program

Program model: As part of the AIP program, a partnership between the University of Missouri Sinclair School of Nursing (MU SSON) and the Missouri Department of Health and Senior Services, the University of Missouri-Columbia (MU) developed the TigerPlace project to help seniors “age in place” in an independent senior living community near the campus that was specifically designed to accommodate aging in place (Rantz et al., 2005; Rantz et al., 2008a). CMS funded a pilot and evaluation of the program. Some of the primary objectives for residents were helping older adults stay healthy and active longer, avoiding hospitalization, and relocation to a nursing home (Rantz et al., 2005).

The community consists of 33 apartments for seniors. The building plan team included nurses, physicians, physical therapists, occupational therapists, environmental design specialists, and older adult consumers. The program was designed to help seniors stay active, health, and avoid nursing home placement. TigerPlace is built to nursing home standards; however, it includes additional amenities like private garages and very nice common spaces. Additionally, pets are welcome at TigerPlace.

The organization Senior Care was formed to provide home care agency services (Marek et al., 2005). They became a Missouri Care Options (MCO) provider. The AIP program clients were assigned a nurse care coordinator. This coordinator provided intensive post-acute Medicare home health care; they also followed clients through the MCO program to ensure that their needs were met after they stabilized. The coordinators also identified barriers to care and helped to coordinate services to meet the needs of the frail older adults. They worked closely with primary care physicians and other health care providers to develop a plan of care, in partnership with the client. Staff performongoing resident needs assessments and health promotion activities.

Sinclair Home Care provides health care and promotions services to TigerPlace residents (Rantz et al., 2008a). MU SSON developed this home care agency to support aging in place, using $2 million in CMS funds.

TigerPlace is being used by students and researchers as a good location for technology research (Rantz et al., 2008a). This includes ways to monitor and access potential mobility and cognition problems in older adult residents. Their team is developing an integrated sensor network.

In 2011, Rantz et al. provided the results of a 4-year evaluation (described in more detail below) of the program at TigerPlace and another Missouri AIP program. They reported that the income levels of the research sample in both settings were considerably higher than publicly assisted senior housing residents.

Cost impacts: Rantz et al. (2011) conducted a 4-year evaluation of the AIP program in two long-term care settings in Missouri (one was TigerPlace, another was a continuing care retirement community [CCRC]). These settings had RN care coordination. They were compared to national data for traditional long-term care costs.

Results showed that the combined care and housing costs for residents who received enhanced AIP services and who qualified for nursing home care never approached or exceeded nursing home care costs at the two locations in the study. The costs of the AIP program in both settings were substantially below nursing home costs and in the CCRC setting were several thousand dollars per year less than the national assisted living cost.

Impacts for residents: In a 2005 study of TigerPlace, researchers matched 78 AIP clients with 78 nursing home residents on admission period, ADLs, cognitive status, and age (Marek et al., 2005). Minimum Data Set data were collected over two years, every six months. Results indicated that AIP participants’ clinical outcomes were better for cognition at 6, 12, and 18 months; depression at 6 and 12 months; ADLs at 6, 12, and 24 months; and incontinence at 24 months. These were the statistically significant outcomes. In these four outcomes (cognition, depression, ADL, and incontinence), the AIP group stabilized or improved their outcome scores; the nursing home group’s scores deteriorated.

In the 2011 evaluation results, measures of mental health (Mini-Mental State Examination, Geriatric Depression Scale, SF-12 MH) and physical health (SF-12 PH, ADL, and Fall Risk) indicated that the AIP model for long-term care was effective for restoring health and fostering independence (Rantz et al., 2011).

Finally, residents of the AIP program at both locations gave the program/facilities high marks for satisfaction (Rantz et al., 2011).

Challenges and strategies: Early in the project, the research team conducted focus groups with residents to assess their attitudes toward technology (Rantz et al., 2008a). They found that residents would benefit from technologies that monitor activity level and sleep patterns, preventing/detecting falls, and caregiver alerts in emergencies. Residents did not want burdensome or obtrusive technology systems.

The challenge in developing this technology was that researchers were no longer working in lab settings; rather, they were in home settings and needed to be cognizant of aesthetics (Rantz et al., 2008a).

A primary lesson learned was fostering collaborative relationships between the partners involved in this effort (Rantz et al., 2008b). In this case, that included public, state, and private partners.

Sinclair Home Care, the home care agency, utilized an electronic information system, and this helped nursesbetter coordinate care (Rantz et al., 2008b).

Rantz et al. (2008b) also note that one of the advantages of TigerPlace was having a school of nursing undertake the project. Nursing students and other students can benefit from the relationship between MU and TigerPlace.

The authors suggest revisiting the idea of applying the AIP model to public congregate housing (Rantz et al., 2008). They suggest that a low-income of TigerPlace could be achieved if health care is supplemented by Medicaid In-Home Services Program funds. Additionally funding would be needed for RN coordination--in Missouri (and other states), Medicaid funding does not cover this service.

Rantz et al. (2011) recommended changing long-term care regulations in order to make AIP programs possible nationwide. The authors argued that residents should be allowed to remain in independent housing with services or assisted living facilities as their health deteriorates, not be forced to relocate when this occurs.

NORC Supportive Service Program (N-SSP)

Program model: Lawler (2001) provided a case study on Penn South NORC, a community in the Chelsea area of Manhattan and a more detailed full report. The case study site is the community is where the term “Naturally Occurring Retirement Community” was coined, after a co-op board investigated possible strategies for bringing services to senior residents. They set up the Penn South Program for Seniors (PSPS) which selected agencies to provide programs and services to the NORC. As of 2001, 14 NORCs were operating in New York under the N-SSP legislation. Between fiscal years 2002 and 2005, AOA provided grant funding that financed 41 N-SSP projects in 25 states (Colello, 2007).

The PSPS provides many services that help older adults age in place, including care coordination of services, home care coordination and non-acute nursing care, health education and preventative services to name a few.

Cost Impacts: The New York N-SSPs forestalled a reported 460 hospital stays and 317 nursing home placements, saving the state $11 million over 3 years.

Challenges and strategies: Hallmarks of NORC services programs are: the active engagement of tenants in governance of the program and identifying service needs (in some case tenants also pay a membership fee that entitles them to a group of services); a partnership between property managers, tenants and community agencies to bring services to the properties; and the energized involvement of volunteers in decision making and programming (Enguidanos, Pynoos, Diepenbrock & Alexman, 2010).

Engquist, Johnson, and Johnson (2010) reviewed the potential of NORCs with a Program for All Inclusive Care for the Elderly (PACE)-like model. They reviewed N-SSPs, which assist residents with health and social services that may delay or prevent institutionalization, promoting “aging in place.” Some of the distinct characteristics of these N-SSPs, which include the following: the provision of a range of health care/social services to match the needs of seniors; making these services available to all seniors in that community, without consideration of health or income; offering these services on the housing site and in the senior’s home; having neighborhood associations, housing corporations and health/social service providers collaborate to ensure program success. The services provided by N-SSPs include case management/assistance and social work services, health care management which includes assessments, disease prevention and health promotion, and chronic condition management assistance. Additionally, N-SSPs provide educational and recreational activities and volunteer opportunities. The authors discuss the potential for NORCs to accomplish goals including the promotion of consumer-directed care and delaying or averting ER visits and nursing facility admissions.

In a NORC PACE-like Model, as outlined by the authors, all the services provided by N-SSP and by PACE would be provided; however, this program would be flexible enough to meet the needs/preferences of participants. The facility within the NORC site would be rent-free/bricks and mortar and would be used for delivering primary and acute care, adult day care and other PACE activities. In this model, eligibility criteria would be 55+ and residing in (or near) the complex/service area. The article provides additional details on funding and governance in this model.

A proposed delivery model to support successful aging in place is to establish an integrated set of supportive services for NORC residents. Ormond et al. (2004) report on this potential through reviewing existing literature, discussions with national NORC experts, and conducting five NORC case studies with NORC sites and associated service programs from five AOA demonstration sites. The researchers found that AOA grantees felt that NORC sites presented problems for older residents in terms of accessibility. At all of the sites, service agencies had difficulty with building manager and resident acceptance because their services were started by the agency and not by the NORC residents. Additionally, they found that the AOA grantees provided services including transportation, reduction of physical barriers, and learning/socializing opportunities. Services like home health care or mental health were more often addressed through referrals.

The researchers examined ways that SSPs can help older adults living in senior communities age in place. They found that many of the sites were able to address short-term goals through the programs; however, they needed to work toward long-term outcomes. They suggest that supportive services need to evolve along with the needs of the community, and two-way communication between residents and program staff can foster that. Another suggestion is to measure outcomes. Ormond et al. (2004) also stress that supportive services program cannot address every issue in a NORC; rather, public institutions may have to address programs such as paving sidewalks. They suggest that SSPs educate the community about these needs. A final discussion point is that of expanding supportive services programs to less densely settled communities. Some of the sites that attempted to serve residents in single-family houses experienced difficulty. The researchers suggest that programs in urban areas or suburban communities adjacent to urban areas could ease implementation problems.

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