Affordable Senior Housing with Services

1. Affordable Senior Housing with Services Robyn I. Stone, DrPH Executive Director, Center for Applied Research Senior Vice President of Research, LeadingAge The SCAN Foundation Policy Roundtable Series – The Future of Affordable Housing with Services: How Can Residential Care Evolve to Serve Low-Income Seniors? October 4, 2012

2. Characteristics of Seniors in Publicly Assisted Housing • Roughly 2 million lower-income seniors live in independent, federally subsidized rental properties • Median income - $10,236 • They are growing older • Median age = 74 years old; about 30% are age 80+ • Median age moving in in 2006= 70; almost 20% were age 80+ • They are racially/ethnically diverse • Hispanic – 13% • White – 56% • Black – 19% • Other – 9% Data is for residents of Section 202 properties, 2006

3. Characteristics of Seniors in Publicly Assisted Housing • Chronic conditions and functional limitations more prevalent among advanced ages, lower incomes and minorities • Twice the prevalence of disability as their home owner counterparts • One-third have difficulty with routine activities • 12% have cognitive impairments • A 1999 survey estimated 30% of Section 202 residents transferred to a nursing home

4. Resident Profile of 4 San Francisco Properties • Median age – 78 years old • Gender – 37% male, 63% female • 60 % live alone • Race/Ethnicity • Hispanic – 9% • White – 34% (Russian immigrants) • Black – 3% • Asian – 58% • Native Hawaiian/Pacific Islander – .3% • American Indian/Alaska Native – 1% • Diversity • 14% born in the U.S. • 16% English first language • 71% health fair to poor; 29% good to excellent • 54% report 3+ chronic conditions • Functional limitations • No IADLs/ADL – 25% • Only IADLs – 21% • 1+ ADL – 55% • 35% fall in the past year • 32% ER visit in past year • 20% hospital stay in past year

5. Resident Profile of 5 Atlanta HA Properties • Median age – 67 years old (large younger disabled population) • Gender – 37% male, 63% female • 60 % live alone • Race/Ethnicity • Hispanic – 3% • White – 23% • Black – 61% • Asian – 10% • Native Hawaiian/Pacific Islander – 0% • American Indian/Alaska Native – 2% • 48% health fair to poor; 52% good to excellent • 60% report 3+ chronic conditions • Functional limitations • No IADLs/ADL – 55% • 1+ IADLs – 45% • 1+ ADL – 27% • 29% possible depression • 29% fall in the past year • 40% ER visit in past year • 27% hospital stay in past year

6. Policy Rationale • Residents are aging, seeing some degree of declining health and functional levels • Residents want to stay in their apartments • Fair housing laws allow them to stay, in most cases • Low-income residents have few affordable alternatives • Feds and states are looking for opportunities to enhance community-based options, improve health outcomes and lower health and long-term care expenditures • Possible opportunities to create some synergies

7. Value of Linkages with Affordable Housing Properties • Potential large concentration of duals and high cost/high risk individuals • Economies of scale offer potential service delivery efficiencies • Available infrastructure – service coordinator • Knowledge of residents – greater understanding of needs, abilities, resources • Trusting relationships with residents – draw out information and encourage action • Linkages and assistance accessing resources and services • 85% of doctors say unmet social needs lead to worse health outcomes • 4 out of 5 say they don’t have the capacity to address

8. Value of Linkages with Affordable Housing Properties • Regular eye on residents – potentially catch problems early, encourage follow-up • Onsite services enhance access – may encourage greater usage and follow-through

9. Why Affordable Housing Plus Services Links are Important to Policy Makers • Affordability of assisted living and nursing home care is big problem for seniors and for government • Promise of meeting some long-term care needs through existing housing linked to services instead of new facilities is appealing • Targeting affordable housing residents in communities with lots of services offers chance to provide additional services at low marginal cost • Multi-unit housing offers potential economies of scale/increased service delivery efficiency

10. Why Affordable Housing Plus Services Links are Important to Providers • Providers are experiencing an aging resident base • Without supports, this can lead to: • health and safety problems for disabled residents and other community members • serious management problems (poor housekeeping, dwellings in poor repair, etc.) • evictions and unnecessary tenant turnover • crisis/off-hour emergency calls • increased pressures on housingmanagers

11. Why Important to Providers (cont.) • With supports, aging in place is possible: • aging services providers can work with frail/ confused residents to eat regularly, pay bills, take care of their apartments, etc. • providers can organize willing family members, neighbors, friends to respond to unscheduled needs • health providers can deliver personal care, transportation to doctors, and access to primary care and preventativeservices

12. Why Affordable Housing Plus Services Links are Important to Residents • Most older residents in affordable housing want to remain where they are, even as health declines • They want to control their own lives and decisions, maintain neighbor and friendship networks, and avoid the trauma of relocation • They want services brought into their homes, just as older homeowners do • This paradigm has driven large investmentsin HCBS over past decade

13. Seniors Aging Safely at Home (SASH) • Connects health and long-term care systems to affordable housing settings • Core elements • Person-centered • Team-based care management • Housing-based staff – SASH coordinator, wellness nurse • Community-based providers – home health agencies, area agencies on aging, PACE, mental health providers, others • Information sharing • Connected to state’s health information exchange • Prevention and wellness through health aging planning • Comprehensive assessment • Individual and community plans

14. Seniors Aging Safely at Home (SASH) • Incorporated into state’s Blueprint for Health and Medicare Multi-Payer Demonstration • SASH teams serve as extenders of community health teams that support medical homes • Medicare pays for SASH coordinator and wellness nurse • Will roll out to 112 subsidized housing communities across state

15. Oregon • Proposed pilot in state’s duals demo • Up to 3 sites that will deliver services at subsidized housing properties through a consortium of community providers • Develop comprehensive service package based on a community needs assessment • May include service coordination, home and personal care, resident inclusion and involvement, recreation/community inclusion, money management, emergency fund, technology support, transportation • Partner and coordinate with Coordinated Care Organizations (CCOs) for primary care, wellness programs, behavioral supports and substance abuse treatment

16. Other Potential Activities • California • Request for Solutions seeking managed care providers for duals – applicants asked to describe how they would partner with housing providers • Massachusetts • Housing providers discussing partnerships with Senior Care Organizations (SCOs) – would link health care providers with coordination and supportive service abilities of housing providers

17. LeadingAge Center for Applied Research Resources • www.leadingage.org/research • Click on “Expanding Affordable Housing plus Services” • Click on “Housing plus Services Publications” • Contact • Robyn Stone – rstone@leadingage.org • Alisha Sanders – asanders@leadingage.org