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


HUD Congregate Housing Services Program (CHSP)

Program model: HUD’s CHSP, originally funded as a demonstration program in 1979, was among the first federal initiatives to provide a comprehensive housing and supportive services package within a subsidized housing environment (HUD, 2012). HUD administers the program in coordination with the Rural Housing Service of the U.S. Department of Agriculture. Congress has continued to appropriate funds to extend existing programs to continue services for participants, but has not funded new programs since 1995. Today, 51 public housing agencies and private assisted housing owners administer 63 grants. CHSP is a project-based, rather than tenant-based program.

A “new CHSP” was authorized in 1990 (Griffith et al., 1996). The new program requires providing service responsive to resident needs and the active participation of the resident in decisions about services.

Services include service coordination, at least one hot congregate meal per day, personal assistance, housekeeping, transportation, preventive health/wellness programs, and personal emergency response systems (HUD, 2012). A service coordinator, typically a social service staff person, is responsible for assuring that participants are linked to services. Sites had considerable flexibility in the services they provide, how they offer or “package” services, and the fees they charge for services other than meals.

Eligible grantees included states, local government units, public housing authorities (PHAs), Indian housing agencies, tribally designated housing entities, and projects funded under Section 202, Section 8, Section 221(d)(3), Section 236, and Section 515 of the Rural Housing Service.

Eligible participants include frail elderly (age 62 and older) and people with disabilities residing in federal subsidized housing who are unable to perform at least three ADLs. Sites used different criteria for selecting among eligible residents.

Under the new CHSP, funding is through a cost sharing arrangement, with HUD funding up to 40% of the cost of supportive services, grantees paying at least 50% of the cost, and participants paying fees amounting to at least 10% of program costs, or up to 20% of the participant’s adjusted income.

Very few CHSP participants (5.1% of elderly and 13.1% of non-elderly) participants had experienced a move in the past period of less than 6 months. Thus, CHSP participants had typically “aged in place” and not had to move to receive supportive services. In contrast, about a third of the early HOPE IV participants had moved in order to participate, many of them because they lived in housing that could not meet HUD’s Housing Quality Standards (HQS).

Impacts for residents: A 1996 evaluation of HUD’s CHSP found that both grantees and residents reported that services helped residents continue living as independently as possible in their own homes (Griffith et al. 1996). Two-thirds or more said it would be difficult to continue living as they are without assistance in toileting, getting in or out of the chair or bed, getting in or out of the shower or tub, bathing, shopping for personal needs, getting dressed, meal preparation, personal grooming, money management, home-delivered meals, eating, and housework.

Over half left the program during the two-year evaluation period. The majority of those moved to a more restrictive environment or died. These numbers were similar to attrition rates found in earlier research on frail elderly residents.

Data showed the majority of CHSP participants said program staff provided them with information on services and helped arrange for and get services for them. CHSP program staff were the most frequently mentioned source of these kinds of assistance in the resident survey. These findings indicated that CHSP was helping most participating residents learn about and gain access to needed supportive services.

The areas where the smallest percentage of residents said the program met their needs were toileting (70%) and transferring (77%), areas where assistance is needed frequently or needs to be available quickly on an as-needed basis.

Service coordinators provided a variety of types of assistance to residents and were important in helping residents navigate the often confusing array of available care and overcoming reluctance to seek or accept assistance.

The 1996 CHSP evaluation found high levels of satisfaction among participating residents (Griffith et al., 1996).

Responses for non-elderly participants were similar to those for elderly participants.

Grantees mentioned a variety of benefits of the program for residents. These included meeting service needs and housing needs; providing service coordination; enabling them to live in their homes with independence, security, and dignity; and helping reduce isolation and increase sociability. The services most frequently mentioned by service coordinators when asked what services elderly residents need or want most were housekeeping, meals, and transportation.

Impacts for programs: CHSP grantees reported that services available through the program, particularly the availability of a services coordinator, contributed to higher occupancy rates, lower turnover, and better maintenance of units.

In addition, 10 of the 21 grantees said it affected the degree of coordination among social and housing agencies in the community. Also, the majority of grantees and service coordinators said it improved the ability to assess residents and expanded capabilities to develop care plans, provide services, and arrange and monitor services. In most cases where no change was reported, a typical comment was that they already had that capability.

Challenges and strategies: In the CHSP evaluation, 11 of the 21 grantees interviewed said that raising the 50% match was one of the most significant challenges they faced in applying for new CHSP funding (Griffith et al., 1996). However, most grantees were confident that the matching funds they obtained would be reliably available for the program period. Despite difficulties some sites experienced in the start-up period, most were providing services by the end of the first year of operation. Reasons for implementation delays included time required to raise the match and get partnerships firmly in place, hiring the service coordinator, and recruiting and enrolling residents.

Ten service coordinators mentioned that residents’ inability to afford services was a barrier, and ten said that the program not having enough funds was a barrier (Griffith et al., 1996). The issue of resident fees and the costs of services to residents were an important concern for CHSP. When asked about resident fees, 61.5% of service coordinators said that other service providers in the area provided free or very low cost services that residents used instead of CHSP. Half said that fees had discouraged participation by at least some residents who need the services. About a third (34.6%) said that fees had been a burden on at least some participants.

Finding residents who met the frailty requirements for eligibility was a challenge for some grantees (Griffith et al., 1996). Twenty of the 26 service coordinators interviewed said they had undertaken publicity and outreach activities to identify people who might benefit and encourage them to participate. More than two-thirds of participants said they first learned about CHSP from staff of CHSP or the building, suggesting the importance of publicity and outreach by staff of the program, building, or housing authority. Some residents (16%) learned about the program from staff of the local AAA or another local community service agency.

Some CHSP grantees reported that developing acceptance of the new program among residents was a challenge, and residents had many reasons for being resistance (Griffith et al., 1996). For example, service coordinators said some already had services, some did not fit in with congregate style or wanted to manage on their own, and some were concerned they might get evicted if they indicated needs. The report suggested this underscores the importance of active outreach.

Grantees suggestions of ways to improve CHSP included:

  • Reduce the number of ADLs required for eligibility;
  • Reduce fees, or allow communities to make choices on how to handle fees;
  • Reduce the size of match required;
  • Simplify application and reporting requirements and have HUD staff available who can answer questions;
  • Facilitate communication and learning among CHSP sites.

HUD Hope for Elderly Independence (HOPE IV) Demonstration

Program model: HUD’s HOPE IV was a tenant-based program, administered by PHAs, for persons who were not previously receiving HUD assistance (Ficke & Berkowitz, 1999). The purpose of the program was to help low-income, frail older persons maintain the highest quality of life in the community, preferably their own homes. HOPE IV was not extended after the demonstration.

In addition to providing Section 8 housing, HOPE IV provided case management through service coordinators and non-medical services (e.g., transportation, personal care, and homemaker services to residents with certain limitations in their ability to carry out routine activities).

A key feature of HOPE IV was the establishment of a service coordinator position within the PHA responsible for designing and implementing an integrated system of case management, personal care, and home management services for frail elderly Section 8 tenants. Of particular importance was the coordination of traditional Section 8 staff activities with the new case management and service components of HOPE IV. The Service Coordinator was also responsible for forging relationships with aging agencies and organizations in the community. Supporting the Service Coordinator was a Professional Assessment Committee (PAC) responsible for screening applicants for frailty and documenting need for services. Only one grantee directly delivered supportive services to HOPE IV participants. The others contracted out service delivery, and several also contracted for service coordination.

Participants could remain in their home as long as it was in the PHA area and met HUD’s Section 8 quality standards; otherwise they had to move into a HUD approved rental property (Ficke & Berkowitz, 1999). Over 40% of participants moved either to meet Section 8 HQS or the rental housing requirement.

Similar to CHSP, HOPE IV funding was through a cost sharing arrangement, with HUD paying 40% of supportive services costs, grantees paying 50%, and participants, except those with very low incomes, paying 10%. A requirement of the grant was that grantees collaborate with local AAAs or other agencies in developing their applications, and these agencies were the primary source of matching funds, either as in-kind services or dollars donated for services.

In 1993, HUD awarded HOPE IV grants to 16 agencies for demonstration projects for a five-year period. The grants included a supportive services component and a rental assistance component.

Impacts for residents: Ficke & Berkowitz’s 1999 evaluation of HOPE IV compared outcomes for older residents who received services through the demonstration with a group of older residents who did not receive demonstration services. Demonstration participants received a significantly higher level of services than the comparison group, and this disparity in access to care remained over time. For example, at follow-up, nearly one-third (32%) of comparison group members reported receiving no services despite high levels of frailty, compared with 7% of participants.

In addition, receipt of services was significantly correlated with improved functioning across multiple domains. For example, service participants scored significantly higher in four major mental health dimensions (anxiety, depression, loss of behavioral/emotional control, and psychological well-being), social functioning (quantity and quality of social activities), vitality (energy level and fatigue), and other measures of social well-being.

The evaluation also found that the receipt of services in the demonstration group correlated with higher social functioning and well-being and better mental health (Ficke & Berkowitz, 1999). Property managers in the public housing site reported reductions in resident conflicts related to mental illness, police calls to apartments, emergency room (ER) visits, and better social interaction.

PAC members reported that the program benefited residents through increased availability of services (mentioned by 10 of 16 PAC members) and increased ability to live independently in their own homes (mentioned by eight).

Eighty-five percent of participants at baseline, and 91% at follow-up, reported they were very satisfied with HOPE IV, and most of the remainder said they were somewhat satisfied.

However, the program did not appear to reduce rates of nursing home placement or mortality or increase tenure in Section 8 housing (Ficke & Berkowitz, 1999). The researchers noted that this finding is consistent with the assumptions in the research design and the results of prior studies showing that similar programs address quality of life and care and increasing access to services, rather than changing outcomes such as death, institutionalization, or otherwise having to leave one’s home due to frailty.

A relationship was found between having a case manager and the number of services received for both participants and comparison group members, suggesting that the combination of case management and services is an effective approach to addressing the needs of a frail, elderly tenant population.

Impacts on Section 8 programs: Another program impact was that nearly all grantees reported that the Section 8 program in their PHA changed as a result of their involvement in HOPE IV. Half of the 16 grantees characterized these changes as “dramatic,” “major,” or “revolutionary.” Grantees said that prior to HOPE IV,the Section 8 programs in their sites had discounted the frail elderly as a service population. To meet the new demands of the program, grantees made formal and informal changes in their organization and organization. For example, one PHA reduced by 50% the caseload its Section 8 staff carried when involving frail elderly tenants. Another provided formal training for Section 8 staff on the status and needs of the frail elderly using the resources of a local university.

Challenges and strategies: Many grantees took over a year to get the programs started. The largest problems were finding qualified participants, adequate housing, and linking housing and services. However, PHAs were able to overcome initial implementation problems and successfully serve persons at risk of institutionalization.

Grantees were only able to fill a few HOPE IV units through existing Section 8 waiting lists and usual recruitment methods. When they relied on referrals from the AAAs and other community agencies, combined with extensive outreach efforts, in most cases, this strategy worked. Recruitment suffered at several sites where the PHA/AAA partnership failed to develop. In many places, recruitment sped up considerably after information about the program reached the network of aging service providers and spread through word-of-mouth to the older population at large.

Just under half of responding participants first found out about HOPE IV from their local AAA or the housing authority. Only about 5% first heard about the program from impersonal sources, such as ads, radio announcements, or brochures. This supports the idea that word-of-mouth is key to the recruitment process.

Another challenge was participant attrition from the program, which increased staff time spent on outreach, recruitment, and assessment. To minimize time spent recruiting participants who never enrolled or quickly dropped out, one grantee pre-screened applicants for willingness to accept supportive services. However, some attrition was probably inevitable given the intense physical, emotional, and financial needs of this population. The relatively high turnover required that HOPE IV Service Coordinators continue their intensive recruitment and placement activities, while at the same time providing ongoing case management to current participants.

A general lesson from the 16 grantee PHAs was that they must adapt their programs to fit the needs and circumstances f the low-income, frail older persons in their communities. This includes knowledge of aspects of this population such as housing conditions, economic circumstances, family support, and lifestyle. The authors stated:

“Any basic program model, however sound, must be shaped to fit the particular environment. Intimate working knowledge of community conditions as they affect the frail, low-income elderly is more useful than abstract projections or generic demographic data. This detailed knowledge permits a realistic assessment of what will be required to establish a viable program for the target population in a given community, including many of the likely obstacles to be overcome.”

For example, in establishing a program in a largely Mexican-American community, PHA staff had to make a number of program adaptions beyond translating materials into Spanish. Other issues included appreciating inter-generational dynamics of these families and overcoming cross-cultural differences in assumptions underlying receipt of services. The authors recommended, in most communities, knowledge of local housing conditions--including the quality and availability of appropriate housing, the proportion of renters versus owners, and current and future rental market conditions--is vital to the ability to design a viable housing program for this constituency. The report quoted a grantee who stated, “Really know your frail elderly population, not just the state level data.” Another grantee noted that in making projections, the application team had not taken into account how many low-income elderly in their community own their own homes and would be reluctant to move into rental housing to meet the requirements of the program.

When asked about improvements they would recommend, six PAC members suggested expanding the program to cover additional persons or continuing it beyond the five-year period, while three said that the ADL definition should be changed to allow more elderly persons with documented needs into the program. Two respondents suggested eliminated participant fees. Three said that improvements in administrative areas would be helpful, including assistance in addressing the matching funds requirement and having computers to handle the records and reports.

The 16 grantees offered several recommendations for improving the HOPE IV program based on their experiences:

  • HUD should supply technical assistance.

  • HUD should change the participant fee structure--five grantees suggested that the 10% participant fee be either charged on a sliding scale or eliminated altogether.

  • HUD should allow qualified existing Section 8 tenants to participate.

  • HUD should fund additional unexpected costs--these included funds to pay for service coordinators’ time spent recruiting, marketing, and helping participants locate and move into housing.

  • Find better ways of accommodating nursing home short stays and other chronic flare-ups--three grantees specifically cited difficulties with Section 8 rules that did not permit tenants to be out of their units for more than 60 days. Participants admitted to nursing homes rarely returned home within the 60-day limit.

  • Two grantees recommended restricting the PAC’s responsibilities and reducing the number of PAC meetings.

  • Two grantees said that requiring impairment in three ADLs was too many.

The report suggested policy implications of the evaluation, including:

  • The role of the HOPE IV service coordinator was essential to the successful design and implementation of the evaluation. HUD could expand the existing SCP.

  • HUD could encourage the provision of supportive services for frail elderly Section 8 tenants through linkages with other federal, state, and community-based aging programs.

  • The HOPE IV demonstrations and evaluation constitute a valuable information resource, and HUD can encourage dissemination and utilization of the results through existing clearinghouse and communication mechanisms.

  • To address unmet needs among Section 8 tenants, HUD could promote adoption of the HOPE IV models for existing tenants as well as new Section 8 applicants.

  • HUD policies should ensure that frail elderly have a range of housing assistance options and the opportunity to choose from among them, rather than favoring congregate versus scattered-site programs.

HUD Service Coordinator Program (SCP)

Program model: Generally, services coordinators determine needs of residents, provide information and referral at resident request, link them to services, and monitor services delivery. Some are very proactive, seeking out residents who may need assistance, formally assessing needs and developing a care plan. Many experts believe they are the core of a publicly assisted housing with services model (see Levine & Robinson Johns, 2008; Golant et al., 2010).

Impacts for residents: Levine and Johns (2008) examined results from a survey of property managers of HUD’s SCP in eligible multifamily developments. Based on the ratio of hours to the number of residents, each resident received 30 minutes of service coordination per week.

Impacts on residents: The study found a high level of satisfaction with the SCP and a strong perception among property managers that service coordination improves residents’ quality of life. For those properties with service coordinators, the perceived benefits included: better quality of life, having advocacy, facilitating a sense of security and social cohesions, resident engagement, and reinforcing independent living. Property managers felt that the value added of service coordinators was having a knowledgeable, well-connected individual working at the property.

Survey results indicated that the average length of occupancy was 6 months longer among residents of properties with HUD-funded service coordination than for residents of similar developments without service coordination (Levine & Johns, 2008).

HUD Resident Opportunities and Self-Sufficiency (ROSS) Resident Service Delivery Models (RSDM)

Program model: HUD’s ROSS grant program links public housing residents with appropriate services. ROSS differs from the SCP in that it is designed specifically for public housing residents. The ROSS program has five funding categories, including the RSDM-EPD. Three not-for-profits received ROSS RSDM-EPD grants.

The ROSS RSDM-EPD used a similar set of strategies as the SCP and CHSP, but without reliance on an assisted living setting. ROSS RSDM-EPD provides a service coordinator and grocery delivery, whereas the SCP provides a service coordinator and CHSP provides a service coordinator, meals, and assisted living.

Impacts for residents: A 2009 study of the effects of HUD’s ROSS RSDM-EPD model compared residents living in housing properties in Seattle where ROSS services were available with residents living in properties without ROSS services (Siu, 2009). The study found a statistically significant difference between the two groups with respect to social interaction, receiving treatment for chronic conditions, and fewer evictions. A large percentage of study participants were under age 62.

However, residents living in buildings with services still showed a high prevalence of chronic conditions, experienced barriers to obtaining healthy foods, and had an inadequate daily intake of fruits and vegetables. Overall, residents in communities where ROSS RSDM grant funded services were available still faced significant health problems, but less so than those in communities where the same supportive services were not available.

Supportive Services Program in Senior Housing (SSPSH)

As noted by Pynoos and colleagues (2005), in the 1980s, the Robert Wood Johnson Foundation created a SSPSH demonstration project that encouraged state Housing Finance Agencies to use their excess reserves for implementing services coordination and new services (Feder, Scanlon, & Howard, 1992). While services were based on residents’ willingness to pay for them, an evaluation of the program indicated that the service coordinators successfully leveraged new resources. This suggests that the program helped increase access to services.

Senior Living Enhancement Program (SLEP)

Program model: SLEP was a collaboration between the Allegheny County Housing Authority (ACHA), the Allegheny County AAA, and the Pittsburgh Foundation (Castle, 2008). SLEP was a 24-month demonstration project, with seniors located at 12 ACHA sites. Nursing/health promotion and social service coordination were offered at these sites, along with social and recreational opportunities.

Participants had to be age 60+ to meet the AAA model of older adults who receive their services. This excluded about 10% of the sample.

Impacts on residents: The study compared users of the SLEP to non-users at baseline and two years later. The ten outcomes (or 10-keys to healthy aging) examined in the initiative to improve health of seniors were: (1) Be Active; (2) Regulate Diabetes Blood Glucose <110; (3) Stop Smoking; (4) Maintain Social Contact; (5) Participate in Cancer Screening; (6) Get Regular Immunizations; (7) Lower LDLC to <130; (8) Combat Depression; (9) Prevent Bone Loss and Muscle Weakness; and (10) Control Systolic Blood Pressure <140 (Castle, 2008). Over the 24 month study period, seniors included in the study showed improvements in a majority of the 10-keys. Significant influence was shown in four of the keys (Be Active, Participate in Cancer Screening; Get Regular Immunization, and Combat Depression). However, the authors noted that health information was available for 91% of the sample at baseline, but decreased to about 50% after two years, potentially creating a bias in the findings (Castle, 2008).

Challenges and strategies: Castle (2008) discussed barriers to service-enriched housing, primarily focusing on the bigger picture and not the SLEP.

Collaboration is needed between housing agencies and service agencies--HUD and other housing sponsors need to take more responsibility over serving the frail elderly.

The other barriers include financing and regulation/licensing procedures in housing and services that are not coordinated with each other.

SLEP was able to overcome these problems, partly because funding came from the Pittsburg Foundation. Also, the 12 sites received community buy-in due to an academic affiliation.

Castle (2008) stated that SLEP was successful because it meets the effective strategies outlined by Pynoos et al. (2005) for expanding service-enriched housing. These include: (1) increased service coordination; (2) retrofitting and modifying existing housing arrangements: and (3) using Medicaid waivers to help make housing with services more affordable.

Three Colorado Models of Connecting Affordable Senior Housing and Services

Program models: A qualitative study described, compared, and assessed the potential of three publicly subsidized senior housing properties in Colorado that evolved different services strategies to support residents as they aged and their needs changed (Washko et al., 2007). One property organized itself as a direct service provider, the second developed a rich array of community partnerships, and the third left it to residents and family members to organize their services.

Each of the properties was an affordable independent rental property designed for seniors aged 62 and above. Each was originally built with federal or state subsidies that restricted resident eligibility to low-income seniors. In addition to construction subsidies, the properties also received project-based rental subsidies. All three properties have since refinanced their initial loans and not all remain under the same income restrictions, but all three remain committed to serving low and modest-income seniors.

The research team compared the housing communities’ different strategies in four areas:

  • Philosophy about resident services;
  • Services available and service organization, delivery, and financing;
  • Types of services actually received by residents;
  • The role of families in providing support.

Impacts for residents: The study was a process evaluation based on a collective case study approach, which collected data through a resident survey, participant observation, focus groups, structured interviews, and property records review. The study found that focus group participant residents in the two properties with purposefully organized services programs were more confident they could maintain themselves in an independent living setting.

The study also found residents did not use many of the available services, although more residents used services when they were available on site.

Challenges and strategies: When asked to identify possible barriers to residents’ ability to age in place, housing staff at one site mentioned funding as a primary barrier. In all three properties, staff cited resistance from residents and sometimes their families as a barrier to supporting residents to age in place. Staff suggested that this may be partially because of residents’ perception that if they need services, they are losing their independence. Several staff mentioned that a lot of education and information needs to be provided on a consistent basis to get people involved in activities or to use services and address concerns.

The study found a high amount of family involvement with residents and suggested that housing providers consider including informal caregivers as they evolve resident services strategies, including involving families in care consultation meetings and development of service plans.

The research team found wide variation in the data available to housing management and staff that would allow them to systematically respond to changing needs of residents and their families over time or to tell how well the property is meeting resident needs.

This study supported previous research that housing providers were cobbling together services from a variety of public and private funding sources. The report recommended that policymakers review their regulatory and administrative policies to assess how well current programs help facilitate the development of a seamless system for providers and residents.

Also, the report recommended more systematic evaluation of the impact of affordable housing plus services models on residents, housing providers, and public and private costs. The report recommended further research to examine how services can be linked with affordable housing in the most efficient and cost-effective manner to help low-income elderly in urban, suburban, and rural communities remain as independent as possible.

Creating Affordable Rural Housing with Services

Program model: A paper by Bolda et al. (2000) reviewed housing with services in rural areas of Maine, New Hampshire, Vermont, and Massachusetts. Some of the models were subsidized assisted living. Others included state housing authority funds (Maine), HUD CHSP (New Hampshire), and the “Home in Housing” Project sponsored by the Vermont Department of Aging and Disability. Their review of these models sheds lights on rural challenges in providing affordable housing with services to older adults and people with disabilities.

Challenges and strategies: Bolda et al. (2000) identified many challenges related to affordable housing with services in rural areas. The rural-specific challenges include the demographics of rural areas, which include lower population density and more lower-income consumers. This supports the use of small facilities, which then limits opportunities for taking advantage of economies of scale for construction and service delivery. The researchers also noted that housing in rural areas may have difficulty finding qualified staff to hire. Some of these small facilities sub-contracted for services or they shared staff across facilities. Some facilities also employed live-in managers who helped provide a sense of security for tenants.

Rural areas also faced financing strategies (Bolda et al., 2000). Some facilities had to renovate older buildings, which opened the doors to historical preservation funds. However, these funds come with restrictions like construction methods or materials. Rural housing providers also need access to financing expertise, which is typically provided by the state’s housing finance agency.

Some rural housing providers also needed to ensure local/community support (Bolda et al., 2000). One strategy for ensuring this is to involve area residents in the early planning of the project.

Many rural areas did not have as much trouble funding and providing housing, as they did services (Bolda et al., 2000). Funding sources for services were more limited. Many states relied on their Medicaid waiver programs; however, that excludes certain residents who are not medically eligible or requires those that are to spend down their assets to meet eligibility guidelines. Regular Medicaid is not as restrictive for medical eligibility--again, this requires residents have very low-incomes/assets to quality, though. In some states, Bolda and colleagues found a “disconnect” between the state’s housing development agency and its human services agency, not allowing for an easy coordination of services with housing.

Bolda et al. (2000) suggested that state policies and programs need to directly address the unique challenges faced in rural communities to provide affordable housing with services. They stressed that as states continue to work on this kind of service delivery, they need to ensure that rural residents’ needs are considered.


Program model: The WellElder program is located in four low-income senior housing properties in the San Francisco Bay area operated by Northern California Presbyterian Homes and Services and Bethany Center (Sanders & Stone, 2011). One of the properties was developed through Section 202 funds, and the other three were developed through Section 236. The model pairs a nurse health educator with a service coordinator already operating in the housing property. The goal is for the health educator to enhance the service coordinator’s capacity by applying her skills in assessing health-related needs, knowledge of health-related services and resources, and an ability to communicate with the medical community. Each property has a resident service coordinator and nurse health educator, who provide one-on-one assistance to residents.

The health educator also monitors vital signs, provides health education, medical coordination, assessments, discharge coordination, and supportive counseling. The service coordinator provides assessments, benefits assistance, bill reconciliation, supportive counseling, outreach, follow-up/monitoring, discharge planning, medical coordination, legal form assistance, grief and loss support, and emergency health information sheets.

No eligibility criteria or fees are required to participate in WellElder for residents living in the property.

Assistance is primarily provided through one-on-one contacts. No appointments are required and residents may drop by the service coordinator or health educator office anytime during their working hours.

While residents primarily initiate contact, program staff also reach out to residents who are facing health problems if they have not seen them in a while. Other property staff, such as security guards or maintenance workers, also alertprogram staff if they observe a resident who appears to need some additional help. Contact with residents usually occurs in the service coordinator’s or health educator’s office, but may also take place over the phone or in a resident’s apartment. Program staff also visit residents in the hospital or nursing facility. In most cases, the service coordinator and health educator meet separately with residents.

The WellElder team conducts/organizes group education sessions by outside entities, which include a “Wellness for You” program. Topics are identified by staff and by residents and may run the gamut from yoga classes to sexuality at older ages, cancer and diet, dental health, and managing osteoporosis. Health educators produce a biannual newsletter, which addresses topics like arthritis, and balance.

Impacts on residents: Feedback from staff and residents suggest that the program helped increase access and quality of services for residents, helped them feel safer and more secure, and helped them stay in their apartments longer. The WellElder staff believed residents the program benefited residents in many ways (Sanders & Stone, 2011). These included:

  • Access and maintain benefits and services;
  • Improve self-care abilities;
  • Facilitate communication with health care providers;
  • Enhance sense of empowerment;
  • Support transitions home from the hospital or nursing home;
  • Increased sense of security.

In a resident survey, many residents across the four properties reported that the program helped them find out about resources and services (66.7%) (Sanders & Stone, 2011).Participants reported a higher use of transportation, personal care, homemaker, exercise, and case management services than non-participants. Also, 62.5% reported they were helped through getting services and assistance quicker than they could on their own. They also felt safer knowing that someone was available to answer their questions (66.2%). Almost two-thirds (65%) stated that they would be able to stay in their apartment longer because of the assistance they received from the nurse and service coordinator. In focus groups, participants supported these statements. When asked why they did not use the health educator more often, some stated that they felt they got the information they needed from their doctor or that she was not available that often.

Benefits to the property and community: WellElder staff also believed that the program benefited other groups beyond the residents, including family members, property managers, discharge planners, paramedics, and in-home supportive services aides (Sanders & Stone, 2011). Property managers felt that the program benefited the property because it minimized the time staff spent dealing with resident issues. It also reduced resident turnover and potential property damage/resident disruption of the community. The property managers believed that the health educator should spend more time at each location.

Challenges and strategies: One challenge WellElder staff faced was in attempting resident follow-up during a hospital visit (Sanders & Stone, 2011). They did not always know where residents were taken to because there are multiple hospitals in the area and different insurance providers. Some discharge planners were unwilling to discuss the resident’s situation with WellElder staff. To address this, staff formed relationships with some hospital discharge planners.

Another challenge was serving residents with mental health issues, including dementia.

Cultural and ethnic differences: The WellElder staff believed Russian and Chinese residents were well-connected to community services and resources. The San Francisco property health educator believed Russian residents were on top of managing their own health and support needs and did not access her for assistance frequently. The same health educator felt that Chinese residents did utilize her more frequently, coming to her for blood pressure monitoring. Multiple WellElder staff at different locations felt Chinese residents were proactive in getting health needs met. On health educator felt that, because the service coordinator was Chinese-speaking, residents utilized her services (the health educator) because the coordinator could help to interpret. In a property with a Russian-speaking service coordinator, Russian residents did not utilize her services as often, but were frequently engaged with the service coordinator. Some of the staff interviewed perceived White and African-American residents to be less knowledgeable about resource options. At times they were also reluctant to accept services. Staff felt they needed to do more outreach to White and African-American residents to encourage participation in services.

Other residents who wanted to maintain their independence were also difficult to serve. Program staff reported that they could have helped those residents avert a crisis, but the resident did not let them.

The study suggested several recommendations for improvement, including:

  • Expanding the health educator’s hours.

  • Clarifying the health educator’s role.

  • Assuming a more proactive role in assisting the residents.

  • Formalizing transition assistance.

  • Clarifying program ownership and authority (clarity was lacking around who the owners of the WellElder program were and who had authority to give the program direction).

  • Eliminating the concept of program membership (residents who participated in focus groups did not actually know or were familiar with what the “WellElder Program” was and did not know they were members. The rationale for “membership” was unclear--no eligibility requirements to join the program. Stone and Sanders (2011) suggested that the program might be better received if it was just a service to all residents and not a “membership” program.

Work Where You Live: A Case Study of the Annapolis Housing Authority

Program model: In 2010, the Lewin Group, through the Centers for Medicare and Medicaid Services (CMS) National Direct Service Workforce Resource Center, conducted a case study of the Housing Authority of the City of Annapolis (HACA), Maryland (Lewin Group, 2009). While serving as the Housing Authority’s Director of Senior and Disabled Services, from 1996 to 2002, Renee Kneppar designed and implemented an innovative model of recruiting workers to provide HACA overcame challenges in recruiting personal care assistants to provide needed services to tenants and others living in the local community. The Work Where You Live Program was implemented at the Glenwood High-rise property, a 154 unit, mixed-population building. Eligible residents were age 62 and over or younger adults with disabilities and their families.

Challenge and strategy: Recruiting and retaining workers to provide services is a challenge across long-term services and supports settings. Findings workers to provide services in congregate housing can be particularly challenging, due to the stigma associated with public housing. Hiring a worker can be made more affordable by arranging for the same worker to assist a number of people in the same community. Ms. Kneppar used the Work Where You Live concept to recruit and retain direct service staff into the Congregate Housing Program. She pursued hiring employees who lived in the development and in other nearby subsidized housing.

Several actions taking by Ms. Kneppar and other factors made it convenient and cost-effective to find and keep employees using this model: (1) recruiting staff by advertising on the bulletin board, using the HACA newsletter, and mostly by word-of-mouth; (2) communicating that working would result in a substantive increase in disposable income; the income would not go primarily to increased rent; (3) counseling employees on applying to the Housing Authority for self-sufficiency incentives, such as the Earned Income Disallowance, which would delay rent increases; (4) the approach of employees working where they live made getting to work very easy for employees; Ms. Kneppar promoted the fact that transportation to work and to training was not an obstacle; (5) flexible work hours were available and promoted; (6) Ms. Kneppar assisted employees with accessing a variety of benefit programs for which they qualified, including Maryland Pharmacy Assistance, Medicaid, local health clinics, and emergency funds available through public and private agencies; (7) providing supportive supervision--Ms. Kneppar recommended that supervisors show appreciation for staff and demonstrate a willingness to perform the same tasks that all employees are expected to perform.

Results: A total of approximately 8-10 personal care attendants (PCAs) were hired during Ms. Kneppar’s tenure from 1996 to 2002. The PCAs lived throughout the Annapolis Housing Authority complexes. The workers included healthy older people or people with mild disabilities who lived in Glenwood or across the street at College Creek.

At first, the PCAs were employed by the Housing Authority and had benefits. Later, they were shifted to being employed via yearly contracts, with paid time off but no health benefits. Frequently, the workers voluntarily checked in on the individuals they served during their off hours. They worked an average of 10-28 hours a week. Most of the PCAs stayed, and turnover was minimal.

Medication management was a challenge. In Maryland, unlicensed staff could remind participants to self-administer their medications, but could not manage their medications in any way. Often nurse case managers from the AAA or family members provided this assistance.

Another challenge was matching workers with individuals receiving services. Generally, the PCAs worked with the same people. When a person preferred to have a different PCA, adjustments were made as needed.

Overall, this approach benefitted people with disabilities by helping them remain in a community setting. It also benefited Public Housing and Voucher Programs by encouraging employment and increasing self-sufficiency by making it more convenient and cost-effective for potential employees to become employed and diminishing obstacles to employment.

Considerations for expanding this approach to other settings: Ms. Kneppar advised that this approach is much more likely to work in Housing Authorities that have a service coordinator who is knowledgeable about residents’ needs and partners with the community, rather than a building manager only. Also, she suggested exploring opportunities to coordinate with state Congregate Housing and/or Moving to Work programs.

Suggested outreach strategies to consider included: (1) HUD could potentially send letters to PHA Executive Directors encouraging the promotion of the initiative and cooperation with direct service organizations; (2) State Medicaid agencies may choose to partner with local government and private health care agencies to work in conjunction with housing authorities; (3) direct service organizations might contact PHA Directors to establish a PHA coordinator or other social service employee to promote the program internally; and (4) a Housing Agency could contact direct service organizations to partner to share the information pertaining to the initiative via agency newsletters, posters, or speaking at resident meetings.

Psychogeriatric Assessment and Treatment in City Housing (PATCH)

Program model: Rabins et al. (2000) studied a nurse-based mobile outreach program to mentally ill elderly individuals for six urban public housing sites in Baltimore, Maryland. This model educated building staff to be case finders, performed assessments in residents’ apartments, and provided care when needed. Researchers conducted a prospective randomized trial from 1993 to 1996 to assess the PATCH model’s effectiveness. Three buildings received the PATCH model, and three received usual care. The study examined if the program was more effective than usual care in decreasing depression levels, psychiatric symptoms, and undesirable outcomes like nursing home placement.

The PATCH model targets older adults living in urban public housing developments (Rabins et al., 2000). Building workers or “indigenous workers” served as case finders. They identified if a resident was at risk of psychiatric disorder and referred them to the psychiatric nurse, who evaluated and treated them in their homes. Case finders included managers, social workers, groundskeepers, and janitors to identify those at risk of a psychiatric disorder and potentially in need of treatment.

The services most often provided by the nurses included counseling the patient, patient education, being a liaison with their one site social worker, medication assistance, monitoring medication side effects, and referral for physical health problems (Rabins et al., 2000).

Impacts for residents: Rabins et al. (2000) found at 26 months’ follow-up, based on weighted data, the number of psychiatric cases in the intervention buildings had lowered significantly. Depressive symptoms also lowered significantly, and psychiatric symptoms and behavioral disorder symptoms lowered significantly in comparison to the sites receiving usual care.

No significant difference was seen between the groups in undesirable moves (e.g., nursing home placement, eviction, board, and care placement) (Rabins et al., 2000).

Challenges and strategies: The study did not list specific challenges; however, the authors highlighted the importance of the PATCH model approach: training individuals who were in daily contact with the older adult was very important to determining if they needed more assistance (Rabins et al., 2000).

The authors noted that Medicare policy reimburses home care, but only for those who are homebound (Rabins et al., 2000). This program demonstrates that persons with serious and persistent mental illness can benefit from this approach, supporting the need to extend the Medicare home care benefit to cover mental health care.

Just for Us

Program model: The Just for Us program provides primary care, care management, and mental health services delivered to medically fragile, low-income seniors and disabled adults subsidized housing residents in their apartments, using available public reimbursement (Yaggy et al., 2006). It was created through a collaboration between Duke University Medical Center; Lincoln Community Health Center; the City of Durham Department of Social Services, the local area mental health entity; and the Durham Housing Authority (Lyn & Johnson, 2011).

The program organizes multiple agencies under one administrative umbrella to participants living independently in clustered housing (Yaggy et al., 2006). In-home care services are provided by an interagency interdisciplinary team, through an innovative administrative structure that coordinates and leverages existing resources. The care team includes primary care providers, social workers, a geriatric psychiatrist and licensed clinical social worker, and a part-time doctor of pharmacy, led by a medical director. A part-time nutritionist, occupational therapist, and phlebotomist complete the team.

Because of Medicare reimbursement, only those with an “access impediment,” that is, inability to get to a primary care provider, are eligible (Yaggy et al., 2006).

Clinicians carry laptops when they visit residents, and electronic records are available to all clinicians (Yaggy et al., 2006). To facilitate coordination of care with the hospital emergency department, the program developed computer software to identify Just for Uspatients who arrive at the emergency department or are admitted to either of the two Durham hospitals. The system helps hospital staff discharge Just for Us patients home and ensure that they have needed services and food.

Impacts for residents: A 2005 study conducted by Yaggy et al. (2006) of the Just for Us program found the program improved resident health.

Cost impacts: Yaggy et al. (2006) found the program shifted Medicaid expenditures away from ambulances and hospital services to pharmacy, personal care, and outpatient visits. At two-year follow-up, the program was not breaking even, but it was moving toward that goal.

Challenges and strategies: The study identified two aspects of Just for Us that seemed important in explaining client and provider buy-in. First, the model was flexible--clients were not required to participate in an entire package of services, and they did not have to leave their homes. Second, the program enhances the existing capacity of service agencies.

Funding realities prevented the Just for Usconcept from being realized fully. For example, intensive case management services were available only to those receiving services through the Older Americans Act or a Medicaid waiver program. In the course of a year, only 100 of the 281 Just for Us enrollees qualified for this case management; those who did not received more limited case management.

A similar challenge was that the program emphasizes primary care and preventive care, neither of which is adequately financed. Both Medicaid and Medicare measure need for services using difficulties with ADLs, but deficiencies in IADLs are key reasons why frail elderly individuals are unable to remain independent. Just for Us addresses IADLs through the inclusion of a part-time nutritionist and occupational therapist. These services were grant funded, because neither Medicaid nor Medicare would reimburse them outside an acute episode or renal failure. This part of the program therefore was not self-sustaining.

The study noted that the financial viability of Just for Us depended on some core elements: an electronic information system for scheduling and medical charts, minimal support staff, use of less costly nurse practitioners or physician assistants, and clustered housing sites to save travel time.

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