A service coordinator was an essential component of several of the programs.
The literature revealed many challenges to implementing housing with services programs. The good news is that the studies also described many promising strategies that programs have developed to overcome the challenges.
Funding--Funding was mentioned as a top challenge in several of the studies. Funding sources mentioned in the literature included partnerships/matches, participant fees, federal demonstration grants, and existing funding streams such as Medicare and Medicaid.
Importance of service coordinator--A service coordinator was an essential component of several of the programs. For example, the CHSP evaluation noted that the service coordinators provided a variety of types of assistance to help residents navigate the often confusing array of services and overcome resident reluctance to accept or seek assistance.
Importance of a health educator--The WellElder program included a health educator in addition to a service coordinator. Property managers suggested that health educators spend more time at the properties (Sanders & Stone, 2011).
Need for a catalyst or champion--In the May 2010 Summit on Affordable Housing and Services, one of the drivers needed to develop this program model mentioned by participants was the need for a catalyst or champion to lead the effort.
Finding people who might benefit from the program--This was a challenge for some programs. In the PATCH model, building staff or indigenous workers served as case finders. They were trained to look out for evidence of psychological illness in residents and refer those residents to the nurses (Rabins et al., 2000). This is consistent with our notes from the TAG meeting of experts in May 2011. Many participants advocated for training property employees, like maintenance and janitors, to be able to identify these issues.
Recruiting and enrolling participants and overcoming resident concerns, especially in rural areas with a lower population density (Bolda et al., 2000), was another challenge. Some studies reported that resistance among some providers and residents made recruitment difficult. The CHSP and HOPE IV evaluations noted the importance of outreach by staff of the program, building, or housing authority, especially word-of-mouth outreach. The Colorado models study suggested the importance of providing lots of education and information consistently to get people involved and to address concerns.
Forming partnerships--Many studies discussed the importance of forming partnerships with various entities, including with Area Agencies on Aging (AAAs) and other aging organizations, with hospital discharge planners, and with nursing schools, universities, or colleges. In HOPE IV, for example, the service coordinator was responsible for forging relationships with local aging organizations. The WellElder program illustrated the benefit of forming relationships with hospital discharge planners (Sanders & Stone, 2011). Several of the programs involved partnerships with universities or nursing schools. Rantz et al. (2008b) noted 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 University of Missouri-Columbia and TigerPlace.
Need for technical assistance and training--Another frequently mentioned issue was that housing and service providers could benefit from increased technical assistance and training. A suggestion for programs consisting of multiple sites was that program staff may find that they can learn from experiences across sites. In the HUD CHSP evaluation (Griffith, Greene, Steward, & Wood, 1996), grantees suggested that the facilitation of communication and learning among CHSP sites would be beneficial. Many of the partnerships identified between housing and service providers have not been formalized to include cross-training. In the Summit on Aging in Public Housing (2011), participants suggested that housing and service providers increase their skills and knowledge to better interact with each other and with residents. In the National Summit on Affordable Senior Housing and Services in May 2010, summit participants also suggested the development of common language/definitions to communicate goals to policymakers, regulators, and funders (American Association of Homes and Services for the Aging [AAHSA], 2010). Development of this common language and definitions would not only require collaboration, but also cross-training between housing and service providers to develop these partnerships. Additionally, in Ficke and Berkowitzs (1999) HOPE IV Evaluation, grantees suggested that HUD should supply technical assistance. In the 2011 Summit, a finding was that housing authorities and service providers need to increase their skills and knowledge to better interact with each other and with residents. This suggests that cross-training may be beneficial.
Involving residents and adapting the program to participants needs--Several studies noted the importance of knowing and adapting the program to the needs of participants and older adults in the local community. The HOPE IV evaluation noted the importance of adapting programs based on knowledge of the specific needs of the local community. The need for data to respond to residents changing needs was mentioned as an issue in the study of three Colorado models (Washko, Sanders, Harahan, Stone, & Cox, 2007). Bolda et al. (2000) suggested involving area residents early in project planning. Cultural and ethnic differences was discussed as an area of consideration in the WellElder evaluation (Sanders & Stone, 2011). Ficke and Berkowitz (1999) also mentioned the need for overcoming cross-cultural differences in assumptions underlying the receipt of services. Participation of residents in service planning was a goal of the new CHSP. In the March 2011 Summit, residents noted that their inside perspective can be valuable to assisting properties in identifying resident needs (Enterprise Community Partners, Inc. & LeadingAge, 2011). Knowledge of resident needs was mentioned by housing providers as an issue at the Summit.
Including family caregivers--Washko et al.s 2007 study of three Colorado models found a high amount of family involvement with residents. The authors 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. A 2010 study by Sanders, Stone, Meador, and Parker described the development and testing of a training program for family caregivers of residents living in affordable senior housing. The authors suggested that the development and dissemination of a successful caregiver training program could significantly improve the ability of senior housing properties to help their elderly tenants remain in their own homes. An unexpected benefit of the program was the support family caregivers gave each other when they began meeting with other caregivers whose family member lived in the same HUD-assisted property (Levine, Kennedy, & Rosenoff, 2010).
Use of health information technology--Health information technology was an important component in some programs. In the Just for Us program, for example, clinicians carried laptops when they visited residents, and electronic records were available to all clinicians (Yaggy et al., 2006). Computer software was developed to facilitate coordination of care with the hospital. In the TigerPlace program, a noted advantage of the model was that home care agency staff used an electronic information system that helped nurses better coordinate care (Rantz et al., 2008b).
Connection between housing properties and AT/home modifications (HM)--An area that could be further explored in housing with services research is the connection between housing properties and AT/HM. The draft final report from the Lewin Groups recent research for ASPE on AT/HM found that a growing number of studies have found evidence to support the effectiveness of AT/HM in helping older adults remain independent in the home and/or slow functional decline (Demiris et al., 2003; Gitlin et al., 2006; Liu & Lapane, 2009; Mann et al., 1999; Szanton et al., 2011; Wilson et al., 2009). In Mann et al.s study (1999), for example, AT/HM services were shown to decrease Medicaid costs and delay institutionalization.
Recruiting and retaining workers--In the May 2010 Summit, participants identified an adequate workforce as one of the needed drivers to facilitate development of an affordable housing with services program. The Annapolis Work Where You Live model is a promising strategy for recruiting and retaining direct service workers. A strategy used in some rural areas is to share staff across facilities (Bolda et al., 2000).