« The Dual Agenda: July 9, 2015 Issue

Eldercare Voices

Affordable Senior Housing and Services: A Coordinated Approach to Serving Vulnerable Older Adults

Robyn I. Stone, Ph.D.

An estimated two million older adults currently live in publicly subsidized housing properties located in urban, suburban and rural communities nationwide. Findings from a recent federally-funded study of affordable senior housing properties in 12 jurisdictions across the country, conducted by researchers at the LeadingAge Center for Applied Research (CFAR) and the Lewin Group, indicate that elderly residents of low-income housing properties have more chronic conditions, take more medications, are more functionally disabled and have higher emergency department (ED) and hospital visits than their peers living in the community. Approximately 70 percent of these elderly residents are dually eligible Medicare and Medicaid beneficiaries, underscoring their high-risk status and suggesting that publicly subsidized housing may serve as a locus for better management and coordination of services for vulnerable older adults.

Multiple efforts are underway at the federal and state levels, and in the private sector, to reform our health and long-term care delivery systems to better address the country’s care needs, particularly among vulnerable populations. These efforts focus on lowering Medicare and Medicaid expenditures by providing timely preventive care; improving care coordination and service integration; reducing over-utilization; and providing overall population health management at the community level.

The current reform climate, focused on transformation of our health care system, provides a unique opportunity for senior housing/health care organization partnerships to achieve common goals. Since residents of affordable senior housing communities are an ideal demographic for implementing population-based health reforms, they present especially conducive opportunities for the forging of such partnerships.

Benefits of a Housing and Health Partnership

Affordable senior housing communities offer several benefits that can make them valuable partners to healthcare providers and payers, including:

Operating Efficiencies of Serving a Geographically Concentrated Population

This concentration of older, vulnerable individuals in a common location offers several advantages to health care providers, including the potential for:

• Streamlined access to the individuals they currently serve or are looking to serve.
• More cost-effective service delivery and health education through reaching multiple individuals in one place at a common time, whether in one-on-one interactions or group programming.
• Greater follow-through and compliance by individuals. Providing services and programs onsite creates easier access for residents. Trusted property staff can also offer reminders and encouragement. Friends and neighbors can help reinforce healthy behaviors and provide ongoing peer support.
• Enhanced understanding of the social factors that may have a bearing on an individual’s health status. Health care providers can gain that understanding from visiting a resident in his or her apartment or obtaining information from the housing staff.
• Improved patient engagement and activation through ongoing monitoring of residents’ activities and behaviors and resident-to-resident reinforcement.
• Better management of “super-utlilizers” who may be living in the same building or complex. Partnerships with affordable senior housing facilities provide a unique opportunity to minimize ED and hospital visits and to ensure smooth and long-lasting transitions from hospitals and skilled nursing facilities.

Physical and Personnel Infrastructure

Affordable senior housing properties offer an infrastructure that can be valuable to health care providers. This may include office and/or community space that can be used for one-on-one meetings or group activities like health education sessions or fitness classes. There may also be opportunities for co-locating a health clinic or other medical office space at the housing property.

Another important aspect of the housing property’s infrastructure is its staff. Many housing properties employ a service coordinator to help residents identify and access needed services and supports. Service coordinators play a vital role in helping to keep residents healthy and independent by developing trusting relationships with them, learning their preferences, needs and capacities and possibly noticing and addressing issues before they become a crisis. They can encourage residents to participate in social and health education activities and help them overcome barriers that may be preventing them from following through on medical appointments and needed self-care management. Service coordinators in culturally diverse properties are often familiar with the practices and preferences of the ethnic and cultural groups living in their communities and may also be bilingual or have ready access to translators, enhancing the potential for patient activation and engagement in self-care management. Other housing property staff – including property managers and maintenance personnel – also build relationships, and can help support residents’ well-being.

Over the past decade, CFAR, in collaboration with a number of senior housing providers and with support from the U.S. Department of Health and Human Services, HUD and several private foundations, has explored the development and efficacy of new service models that formally link affordable senior housing with medical and social services in the community. The CFAR team, together with RTI researchers, is evaluating the most comprehensive senior housing/services partnership to date – the Seniors Aging Safely at Home (SASH) program in Vermont. The model is based around an onsite fulltime service coordinator/part-time wellness nurse per 100 residents (funded through Medicare) living in affordable senior housing; currently over 100 publicly subsidized housing properties are participating in the program statewide. SASH teams are integrated into Vermont’s health care reform effort and specifically, the community health teams that are imbedded in the state’s regional primary care medical homes. SASH staff work with the primary care practices and other community resources (area agencies on aging, home health agencies, mental health clinics, hospitals) to provide care coordination, health monitoring and individual and group health education. Preliminary results from the first year of the evaluation indicate that growth in annual total Medicare expenditures was lower by an estimated $1,756-$2,197 per beneficiary among beneficiaries enrolled in SASH panels than beneficiaries in two comparison groups.

These promising results have begun to attract attention at the federal, state and local levels. The pioneering Camden Coalition of Healthcare Providers in New Jersey, founded by Dr. Jeffrey Brenner to coordinate and deliver care to highly vulnerable “hot spotters,” was certified by the state of New Jersey to form a Medicaid Accountable Care Organization (ACO) on July 1. The Camden Coalition is partnering with FairShare Housing, one of LeadingAge’s members. In Oregon, four low-income senior housing developers representing 11 housing properties have created a not-for-profit LLC that includes Care Oregon, a large accountable care organization in Portland, the local area agency on aging, a local mental health provider and other community services partners; the state has contributed resources through its state innovation grant. Ohio is exploring the potential of linking senior housing and services for its dual eligible population through its managed care partners.

The implementation of this model is not without its challenges, including the need for enough volume of high risk individuals to attract health care partners, regulatory and administrative barriers that may impede integration of housing and services and the lack of communication between housing and health care in most communities. CFAR recently released an online toolkit to help housing organizations interested in partnering with local health care entities. Such collaborations could become part of the solution for states and the federal government as they strive to reach the triple aims of health care for an aging population – improved quality of care, enhanced health and reduced costs.

Robyn I. Stone, Ph.D., is the Executive Director of the LeadingAge Center for Applied Research and Senior Vice President of Research at LeadingAge. Dr. Stone came to LeadingAge from the International Longevity Center-USA in New York, NY, where she was Executive Director and Chief Operating Officer. Previously, she worked for the Federal Agency for Health Care Policy and Research (now known as the Agency for Health care Research and Quality). Dr. Stone also served the White House as deputy assistant secretary for disability, aging and long-term care policy and as acting assistant secretary for aging in the U.S. Department of Health and Human Services under the Clinton administration. She holds a doctorate in public health from the University of California, Berkeley.