The "Value Added" of Linking Publicly Assisted Housing for Low-Income Older Adults with Enhanced Services: A Literature Syntheses and Environmental Scan. Appendix C: Findings From Workshops and Summits


Aging in Place: Coordinating Housing and Health Care Provision for America’s Growing Elderly Population

Interview overview: Lawler (2001) conducted 60 interviews with senior service providers across the United States and reviewed the lessons learned that emerged from the interviews.

Challenges and strategies: The concerns these health and housing professionals expressed included: (1) Aging in Place in a Rural versus Urban Context--in both areas, providers worked with limited resources. Rural providers felt their communities were better at helping seniors age in place; however, when they are in need of institutional support, the facilities may not be able to accommodate. A lack of housing was a concern for urban providers; however, they were concerned about the inadequate number of support services for older adults; (2) Understanding the Market for Assisted-Living Facilities--community groups should be turned to to understand the market for supportive living facilities; (3) The physical deterioration of a house can cause mental health deterioration--directors of home repair programs mentioned that providing this service helped the older adult feel more in control; (4) Partnerships to deliver services--Lawler (2001) quoted a provider in saying “We are good at housing, we are not good at delivering services.” Community-based housing providers felt comfortable in meeting housing needs of local seniors, but not service needs; therefore, they partnered with other service providers to fill these caps; and (5) Partnerships can occur in a variety of places--interviewees pointed out that community-based organizations that collaborated successfully with local health providers ended up working on multiple ventures together in the future.

Regional Workshops on Affordable Housing Plus Services Strategies for Low and Modest-Income Seniors, 2006

Workshop overview: In 2005, AAHSA (now LeadingAge) convened four invitational workshops across the country, which brought together 230 stakeholders from 14 states to discuss the development of affordable housing plus services strategies (Harahan, Sanders, & Stone, 2006b).

Program models: The workgroups resulted in three reports, including an “Inventory of Affordable Housing Plus Services Strategies” document, which identified several affordable housing plus services program models, summarized below (Institute for the Future of Aging Services [IFAS]/AAHSA, 2006).

  • Privately financed housing plus services strategies.

    • These strategies include Housing Cooperatives, where individuals own shares in a corporation that owns or controls the land and buildings that provide the housing. Services in these locations can be informal or formal, which would involve the joint purchase of services and/or a coordinated and managed services program. Some examples include the Penn South Cooperative and PSPS and the 7500 York Cooperative in Edina, Minnesota.

    • Another strategy includes Shared Housing, where two or more unrelated individuals live together in a private single-family home or in a property with commons paces. Another option is Accessory Housing, where a separate private living unit is adjacent to a main home. Some examples include HomeShare Vermont and the Pat Crowley House in Chicago.

    • Mobile Home Parks and Manufactured Home Communities are another example of privately financed housing plus services strategies. In this model, the housing unit is owned by the individual, but the lots are leased. When there is a high concentration of seniors in these mobile communities, finding ways to bring services to older adults is a strategy to assist with aging in place. Some examples include Millennium Housing and Leisureville Mobile Home Park in California.

    • Single Room Occupancy (SRO) Hotels are a final strategy among privately financed housing with services. This is a residential building that rents small private rooms on a weekly or monthly basis to lower-income individuals. There are typically common/shared spaces in SROs. Some examples include Project Hotel Alert in Los Angeles and the Capri Hotel and Sara Frances Hometrel/Transitional Housing for Displaced Seniors program in San Diego.

  • Publicly subsidized housing plus services strategies.

    • Co-Location and Volunteerism is a strategy where housing providers/managers may work with community groups to encourage the co-location of supportive services in proximity to the housing property. This can include a Title III meals site, a senior center, or health and wellness programs. Some examples include the Golden West Senior Residence in Boulder, Colorado or Koinonia Apartments in Lenoir, North Carolina.

    • Service Coordination is a strategy that includes a property manager/housing sponsor employing a staff person to help residents identify service needs, link them to those services in the community, advocate for their receipt of services and educate residents. Examples of these services include the National Church Residences in Columbus and Schwenkfeld Manor in Lansdale, Pennsylvania.

    • Integrated Care Coordination and Enriched Services involves offering older residents a formal assessment of function, health status, and service needs. Those who are found to be frail and/or disabled and who have unmet needs are offered a formal services plan, which is coordinated and monitored by property staff in collaboration with services agencies and providers in the community.

    • Integrated Health Care and Supportive Services involves a purposeful collaboration between low-income housing properties, neighborhood health care providers, and aging services providers. This collaboration can assist low-income senior residents in independent housing in accessing health and long-term care services. The availability of adult day care and/or adult day health care in a co-located space or a nearby property helps make this strategy successful. Examples include presentation Senior Housing in San Francisco and Over 60 Heath Center/Centers for Elders Independence/Mable Howard Apartments in Oakland, California.

    • Linking NORCs to formal service programs is a strategy for affordable housing plus services. The development of service delivery programs helps respond to the needs of aging tenants. Some examples of this include Vladeck Cares/N-SSP in New York.

    • State Supportive Services Programs Linked to Publicly Subsidized Housing is another strategy to promote affordable housing with services. Often, the goal of state supportive housing programs is to reduce Medicaid nursing home costs through helping older adults remain in independent housing for longer. This requires the state housing agency, the state’s aging and health agencies and the housing properties to collaborate. A state agency selects providers to deliver a range of services to participating housing properties, which can include case management, Medicaid HCBS waivers, home care, and medication management. Examples of this include the Connecticut Congregate Housing for the Elderly.

    • Assisted Living as a Services Program is another strategy. Assisted living can be licensed as a service, and not a physical entity, in some states. These services, typically provided by a home health agency, can be provided by the property or contracted out. These services include 24-hour available personal care, medication management, meal preparation, housekeeping and laundry and transportation. Connecticut is a state that uses this strategy.

    • A Campus Network Strategy links independent housing for older adults with a licensed assisted living facility. The housing property and the assisted living facility typically provide services separately. An example of this is Cathedral Square Senior Living in Burlington, Vermont.

    • Affordable Housing/Health Systems Partnership are a final strategy listed in this inventory. A health system and an affordable housing sponsor establish a formal partnership to expand the supply of affordable housing with services. This partnership could also link health services to existing affordable housing. The health systems can bring primary care and health-related services to older residents. Services provided include health screenings, care management, wellness programs, and geriatric assessments to name a few. Examples of these programs are the Sixty Plus Program in Atlanta.

Challenges and strategies: The workshop report listed four pre-requisites of a successful strategy: (1) the commitment of housing providers to a broader role; (2) partnerships between the housing provider and the surrounding community; (3) persistence and creativity; and (4) the need for a catalyst.

The obstacles included licensing and regulation, liability, fair housing laws, difficulty bridging housing and aging services, finding funding for resources, a limited understanding of some housing providers to meet service needs of residents, opposition of residents, affordability and nursing home influence (Harahan, Sanders, & Stone, 2006b).

National Summit on Affordable Senior Housing and Services, May 2010

Workshop overview: This summit was hosted by AAHSA in partnership with Enterprise Community Partners, Inc., with support from Evercare United Healthcare Group, the McGregor Foundation, and JP Morgan Chase. This summit brought together policy makers from government, housing and long-term care providers, and other key stakeholders. The goals were to share ideas, successful strategies, and planned policy initiatives to develop affordable senior housing with services; to identify barriers to the development of this model, and to identify next steps.

Program models: A discussion from this summit was on the essential components of a successful housing with services strategy. Participants determined that this model would need to be resident-centered, allow resident’s choice in services received, include assessments for resident status and needs, include service coordination/care management, include a viable and accessible design for the physical structure, and have access to quality services for residents.

The drivers participants identified to actually facilitate the development of this program model included the need for a catalyst or champion, effective partnerships, sustainable funding mechanisms, flexible models, and adequate workforce.

The desired outcomes of this model include the following: Lowering transfer to higher levels of care; lowering ER visits and hospital stays, better chronic disease management and better transition out of the hospital to the property; improved medication management; improving physical functioning; improving mental health; reducing and preventing falls; enhancing resident physical activity; reducing lifestyle barriers through health/wellness activities and better nutrition; reducing isolation; improving a sense of security, and enabling residents to live in their apartments for as long as they choose (AAHSA, 2010).

Challenges and strategies: The participants raised questions and concerns related to developing this model, which included the concern over the availability of health services, retrofitting older buildings, single funding streams, and technology in a housing with services model.

Barriers identified include regulations, funding, liability, culture and capacity, fragmentation of local services, a silo mentality, eligibility requirements (like Medicaid waivers), the need for data on resident characteristics, and limited knowledge on affordable housing settings (AAHSA, 2010).

Recommendations: Participants also identified next steps to begin developing this housing with services model. Some of these steps were related to conducting research/investigation; including how housing with services models fit into health care reform and how these strategies can address dual eligible populations through health care reform and other initiatives. The summit suggests continuing to work collectively on developing a design demonstration and acquiring the funding needed to test the effectiveness of different housing with services models. A typology of these programs/strategies should be developed to help stakeholders understand how these models can be constructed. The summit also suggested the development of common language/definitions to communicate these goals to policymakers, regulators, and funders. Additionally, defining the core elements most likely to influence desired outcomes was a next step (AAHSA, 2010).

Summit on Aging in Public Housing, March 2011

The purpose of the summit was to examine opportunities and strategies for meeting health/ supportive needs of senior residents in public housing. Enterprise Community Partners, Inc. and LeadingAge (2011) identified three goals.

Workshop overview: This summit was hosted by Enterprise Community Partners, Inc. and LeadingAge. It was supported by the Atlantic Philanthropies. This summit included chosen representatives from PHAs, service providers, and public housing residents. The purpose of the summit was to examine opportunities and strategies for meeting health/supportive needs of senior residents in public housing. Enterprise Community Partners, Inc. and LeadingAge (2011) identified three goals:

  1. Explore effective strategies for how PHAs and service providers can work together to support the needs of aging residents to meet their health and supportive needs and remain safely in their home.

  2. Engage resident participation in developing and advocating for the types of service programs they would like to see in their housing community.

  3. Ignite interest and commitment from participants to continue to work together on next steps.

Program models: During a breakout group discussion, residents, service providers, and housing providers discussed the elements needed for a public housing with services model. The elements identified by residents were necessary supports, better individual needs assessments, compassion from housing staff, increased safety and senior-only buildings. Service providers indicated that there needed to be a system of services set up, a public health model that addresses all needs and not just high-risk targeting, sustainable funding, evidence-based strategies, a learning circle collaborative, and that the housing authority view themselves as a part of the service network. Finally, housing providers stated that they needed better information on resident needs, more flexibility/autonomy to ask residents questions about their situations, to move them where they can be better served, and to allow for sound business decisions. They highlighted the need for universal design and accessibility upgrades, sustainable funding for core services, full-funded service coordinators, and transportation (Enterprise Community Partners, Inc. & LeadingAge, 2011).

Challenges and strategies: Participants from the summit included PHAs, residents, and service provider partners from Atlanta, Brattleboro, Vermont, Denver, Chicago, Milwaukee, New York, and Oklahoma City. These participants shared their strategies for bringing health and supportive services to residents. They include resident assessments, the development of partnership networks, policy efforts including participation in a larger Medicare demonstration activity (Vermont), and resident engagement.

This summit also included resident perspectives--those involved were highly engaged and they raised the following points: residents have a desire to be engaged in their community; they are invested in it. They felt that they provide a support network to one another. Additionally, they want to feel greater compassion from housing staff. Residents also believe that their inside perspective can be valuable to assisting properties in identifying resident needs (Enterprise Community Partners, Inc. & LeadingAge, 2011).

When asked about challenges and needed policy/practice reforms, all three stakeholder groups identified these. Residents felt that reaching seniors not living in senior-only buildings was a challenge and that older adult and younger disabled population living together was a challenge. Service providers stated that there needed to be a policy directive or an incentive for the housing authorities to view themselves as a part of the service system and not as a product. Finally, housing providers highlighted a few challenges/reforms which included fair housing and knowing of resident needs, the challenge of resident suspicion when they are collecting information, finding funding for non-Medicaid and lower-risk populations and the complexity of eligibility.

Recommendations: All of the stakeholders also identified ways to measure success of these programs. Residents mentioned increased resident satisfaction, decreased crime, increased safety, reduction in turnover/evictions, and increased resident engagement. Service providers mentioned an improved quality of life, reduced hospital stays, and reduced ER visits. Housing providers stated that measures needed to be standard across entities and they needed to be simple to collect. The measures they suggest are reduced evictions, improved wellness, reduced hospital stays, increased quality of life, and a cost/benefit analysis.

The major findings from the event were the need to reach all elderly residents and to better understand the residents. The summit also highlighted the need for the housing authority to play an increasing/redefined role in providing services. Housing authorities and service providers need to increase their skills and knowledge to better interact with each other and with residents. Some residents expressed concern over the mix of older adult and younger disabled populations due to mental health issues among the younger population. The summit participants also found that housing authorities and their service partners need to be better aware of potential opportunities available for them to support their residents. Finally, most of the participants realized that this model of affordable housing with services is an inevitable path (Enterprise Community Partners, Inc. & LeadingAge, 2011).

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