August 09, 2011

By Robyn I. Stone, DrPH

According to the Census Bureau’s 2009 American Housing Survey, 1.9 million elderly people live in publicly assisted housing. That’s more older adults than live in nursing homes.

Dr. Stone

Most are low-income single women in their mid-70s to early 80s. Findings from a range of studies indicate that significant numbers of these people experience chronic illnesses, disabilities, or both. Even healthy seniors face the challenge of finding and maintaining housing that can accommodate them should they become ill and/or disabled.

Left unmet, this population’s needs compromise their health and quality of life, reduce their ability to continue independent living, contribute to higher Medicare and Medicaid costs, burden housing managers, and pose a safety risk to themselves and others. Over the next 20 years, a rapidly aging population will exacerbate these challenges. A potential policy approach is to capitalize on independent, publicly assisted, multiunit rental properties either designated for low-income seniors or located where many of them live.

Publicly assisted, service-enriched housing responds to the preferences of most elderly residents – and their families – that these individuals age in place even as their health declines. A growing body of literature has shown this potential for helping older adults to age in the community. With an existing infrastructure (public housing) and paid service coordinators (facility managers) already working in many of these buildings, the core of a housing system that is affordable for low-income seniors yet is linked to services is already in place. These properties, for the most part, are not subject to state-level assisted living licensing requirements.

A number of publicly assisted senior housing providers have taken the lead in developing a wide range of service-enriched housing models and programs that link residents with health and supportive services. Some have partnered with PACE (Program of All-Inclusive Care for the Elderly) programs and federally qualified health clinics, sometimes located within a public housing facility.

Results to Date

A new study in the journal Nursing Outlook analyzed 4 years of health and cost data from an independent-housing facility (TigerPlace in Columbia, Mo.) that combines home health services with nurse-coordinated acute care, Medicaid home- and community-based services, and Medicare home health (Nurse Outlook 2011;59:37-46). The study found that the costs of the service-enriched program (as well as a continuing care retirement community also studied) were substantially below nursing home costs for a comparable population.

Some other recent studies also suggest positive results. A 2008 HUD study found that service coordination appeared to lengthen housing tenure by an average of 6 months. While the authors speculated that service coordination forestalls or prevents institutionalization, the study lacked any direct measures of institutionalization rates among properties with and without service coordinators. The evaluation also found a high level of satisfaction with the coordinated-service program and a strong perception among property managers that service coordination improves residents’ quality of life.

Another HUD study that year, admittedly using crude data, suggested significant cost savings from deferring institutionalization among residents in the department’s "Section 202" program. It funds the creation and maintenance of housing with supportive services such as cleaning, cooking, and transportation for very low-income elders.

Evaluations of service-enriched housing programs have found high satisfaction among residents and correlations with social functioning, well-being, and mental health. Property managers in service-enriched public housing have reported reductions in resident conflicts related to mental illness, police calls to apartments, emergency department visits, and better social interaction.

A study of the "Just for Us" program, a Durham, N.C.–based effort that provides primary care, physician house calls, care management, and mental health services to elderly subsidized-housing residents, found that the program improved health and shifted Medicaid expenditures away from ambulances and hospital services and toward pharmacy, personal care, and outpatient visits (Gerontologist 2005;46:271-6).

A study of the Senior Living Enhancement Program in Washington, D.C., found that seniors who frequently took advantage of the program’s nursing, health promotion, social-service coordination, and social and recreational opportunities in 12 publicly assisted apartment complexes showed significant improvements in a number of health and health behavior indicators. They were getting regular immunizations, controlling their blood pressure and cholesterol, and combating depression (Journal of Housing for the Elderly 2008:22:263-77).

A 2005 study of TigerPlace found that the residents fared better than a matched nursing home sample on measures of cognition and activities of daily living (Nursing Research 2005;54:202-11). A qualitative evaluation of the WellElder program in Northern California, which uses wellness interventions and health education, health monitoring, and individualized service coordination by nurses and health educators, found that residents in the program felt they were better able to manage their health care, maintain their quality of life, and age in place safely. The challenges of and potential for expanding affordable housing with services for older adults are described in "The Assisted Living Residence: A Vision for the Future" (Baltimore: Johns Hopkins University Press, 2008, pp. 329-50).

With state Medicaid programs shifting their resources from institutional to home- and community-based care, and with consumers preferring to age in place as long as possible, it is critical that physicians and other practitioners explore residential alternatives that will meet the needs of low- to modest-income older adults. Publicly assisted housing that is linked with services is a potentially viable option for many of these people and their families. Such housing – located in most communities across the United States – needs partners who are trained in geriatrics, if communities are to meet the surging needs of this population.

Because publicly assisted housing serves critical masses of elderly residents in discreet locations, it offers an economy of scale in organizing, delivering, and purchasing services. Such housing also makes possible on-site staff who can respond to residents’ health and other needs as they arise.

Incorporating communities, including the medical community, into service-enriched housing strategies may further increase their power to improve seniors’ health while lowering medical and long-term care costs.CfA

Dr. Stone is the executive director of the Center for Applied Research at LeadingAge (formerly the American Association of Homes and Services for the Aging). She has held senior research and policy positions in both the U.S. government and the private sector. She was the assistant secretary for aging within the Department of Health and Human Services in 1997. Bill Kubat, LNHA, director of mission integration for the Evangelical Lutheran Good Samaritan Society, coordinates this column.

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