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Empowering Communities for Successful Aging: Housing, Neighborhood Support, and Services


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Title: Empowering Communities for Successful Aging: Housing, Neighborhood Support, and Services

Empowering Communities for Successful Aging
Housing, Neighborhood Support, and Services
  • Developing Senior Housing with Supportive
    Services Challenges and Opportunities
  • Alisha Sanders, Policy Research Associate
  • The Institute for the Future of Aging Services
  • Ken Harris, Director
  • The Center for Senior Living and Community
  • Saratoga Springs, New York
  • Wednesday, November 12, 2008

  • Current Situation in Housing Supportive
  • Opportunity for Change
  • NYS Long Term Care Reform
  • Senior Housing Options
  • Comparable Costs
  • NYS Regulatory Considerations
  • Developing Aging-Friendly Communities in NYS
  • National Trends
  • Challenges Providing Housing with Supportive
  • Wellness Models
  • Health Care Models

New York Senior Population
  • Senior Population Growth in New York State
  • By 2025, senior population is projected to grow
    from 3.5
  • million to 4.9 million.
  • A 39 percent increase, comprising nearly 24
    percent of the
  • general population.
  • 50 percent larger than the existing senior adult
  • More culturally and economically diverse.

Housing Transitions for Seniors
  • Transition of Seniors in Housing One Scenario
  • Seniors at home / congregate senior housing -
    health fails.
  • Senior housing does not incorporate support
    services on-
  • site.
  • Seniors unable to access or arrange for health
    care and
  • community resources (transportation,
    physician, socialization.)
  • If private pay, possibly transfer to assisted
  • Transitioned to nursing home, possibly

Housing Supportive Services Outlook
  • New York Senior Housing Supportive Services
  • Good News
  • New York state interested in promoting a
  • home and community based services.
  • Seniors desire to be in the most independent
  • Started discussions and planning toward
    transforming the long
  • term care system.
  • Bad News
  • No money to pay for the transformation (capital
  • Budget concerns over the woodwork effect for

NYS LTC Reform Initiatives
  • New York State LTC Reform Initiatives
  • Nursing Home Transition and Diversion Medicaid
  • Money Follows the Person Initiative
  • Money Follows the Person Housing Task Force
  • Nursing Home Rightsizing
  • New York Connects (Point of Entry)
  • Long Term Home Health Care Program (LTHHCP)
  • Medicaid Waiver Review

Federal LTC Reform Initiatives
  • Federal Decisions, Laws, Programs and Proposals
  • Fair Housing Act
  • Olmstead Decision
  • Americans with Disabilities Act
  • Recent Litigation on Transfer Issues
  • The Community Choice Act (proposed)
  • Medicaid Waiver Programs

A New Federal Direction?
  • President-elect Barack Obama endorses
  • Long term care choices not biased toward
    institutional care.
  • Restoration of HUD operational housing
  • LTC Financing Reform Community Living
    Assistance Services and
  • Supports (CLASS) Act (S.1758 / H.R. 3001)
  • Consumer choice and integration of services.
  • Increased use of health information technology
  • Emphasis on wellness initiatives.
  • Research and dissemination of information on
    best practices.

Senior Housing A Crises Situation
  • Affordable Senior Housing in NYS
  • Five- to 10-year waiting list for affordable
    housing in some parts of the state.
  • HUD Section 202 PRACs funds not adequate to
  • construction need additional funding sources.
  • Properties need to renovate.
  • Properties are opting out of their mortgages.
  • Low-income housing tax credit programs hard to
    find financing.

NYS Budget Medicaid Spending
  • NYS Budget Medicaid Expenditures
  • NYS budget deficit of 1.6 billion in SFY
    2008-09. Projected
  • 30 billion deficit over the next three years.
  • NYS has highest Medicaid expenditure in the
    nation at 47
  • billion.
  • 12 billion in LTC Medicaid spending.
  • Potential Medicaid cuts for nursing homes, home
    care and
  • home / community-based services.

A New LTC Paradigm?
  • Fiscal crisis is an opportunity to discuss and
    plan for a new long
  • term care system.
  • New York is embracing Medicaid waivers (LTHHCP
  • Senior housing could be a platform for LTC
    service delivery.
  • Planning senior housing that incorporates
    building space (offices,
  • parking, technology) for adding senior health
    services for
  • residents and neighbors.
  • Developing partnerships with housing providers,
    service agencies,
  • local government and state agencies to bring
    in services to senior
  • housing.

An Opportunity for Change
  • With the reduction of traditional funding for
    senior housing and long term care services, there
    will be opportunities to develop aging-friendly
    communities that embraces flexibility, choice and
  • Cooperation, coordination and coalitions (3Cs)
    will be needed on the local level.

Affordable Housing Programs
  • Subsidized Housing Programs for Seniors
  • HUD Section 202 / 236 / 202 PRAC
  • NYS Mitchell-Lama Program
  • Low-Income Housing Tax Credit Program (LIHTCP)
  • Mixed-Financed Housing (Section 202 LIHTCP)
  • Preservation and Recapitalization
  • Community Leaders Challenge
  • Search Them Out. Support. Develop. Preserve.

Rental Payment
  • Supplemental Security Income (SSI) 761 monthly
  • income for low-income individuals 9,132
    annual income.
  • Section 8 an affordable housing rental subsidy
    program for
  • low income seniors.
  • Income-qualified residents pay 30 percent of
    their adjusted
  • income for rent.
  • Up to a five- to 10-year waiting list for
    Section 8 housing in several parts of the state,
    especially downstate.

Fair Market Rents in NYS
  • Fair Market Rents (FMRs) in New York State
  • FMRs gross rent estimates calculated by HUD
    including the cost of all utilities, (except
    telephones) for efficiencies / one bedroom
  • Buffalo 601 / 602
  • Albany 686 / 711
  • Westchester 1,161 / 1,385
  • NYC 1,091 / 1,180
  • With SSI at 761 per month, low-income seniors
    need Section 8 to afford housing.

Preservation / Recapitalization
  • Preservation and Recapitalization
  • Mortgage expiration for several HUD affordable
    housing built in
  • 1960s and 70s.
  • Efforts needed to keep subsidized housing
    facilities from
  • opting out of the HUD program to market-rate
  • Recapitalization of older buildings by
    refinancing the mortgage
  • or financing through the LIHTCP maintains
    affordable housing.

Comparable Costs SNF vs. Housing
  • HUD Senior Housing in Albany Monthly Costs to
  • 1. HUD Housing 419 per person per month / NYS
    Share 0.
  • 2. SSI 761 Federal 674 / NYS Share 87 per
  • 3. Long Term Home Health Care Program Medicaid
  • Individual costs capped at 75 percent of
    regional NH rate
  • Monthly Upstate Cost 1,185 / NYS Share
    (40) 474
  • Medicaid Eligible Senior in HUD Housing NYS
    Cost Share
  • Average Individual Monthly 560 / Annual
  • ( Rents vary from individual senior housing

Comparable Costs SNF vs. Housing
  • Albany Nursing Home Resident Monthly Costs to
  • Albany nursing home average daily rate (Physical
    AB) 131.06
  • Annual 47,836 / Monthly 3,986
  • NYS Share (40) Monthly 1,594 / Annual
  • Cost comparison annual NYS share for Medicaid
  • SNF 19,128 - HUD with LTHHCP 6,700 Savings
  • (Average rate actual could be more or less)
  • NYS savings for 100 seniors 1,239,600

Comparable Costs SNF vs. Housing
  • There will always be a need for nursing homes
    and assisted living for
  • the most infirm NYS residents.
  • Cost savings can be realized transitioning or
    diverting low-scoring
  • nursing residents to home- and community-based
  • Nursing Home Transition and Diversion Waiver
    currently has seven registrants.
  • Savings need be used to build infrastructure in
    existing senior
  • housing and develop new facilities with
    service delivery capacity.

Additional NYS Housing Models
  • Naturally Occurring Retirement Communities
  • Congregate Housing and Supportive Services
  • Neighborhood NORCs
  • Delineated Neighborhood and Supportive Services
  • Continuing Care Retirement Communities (CCRCs)
  • Senior Housing / AL / Nursing Home
  • Fee-for-Service CCRCs
  • Retirement Housing with Supportive Services
  • Cohousing Colocation Green Houses.

Assisted Living Programs
  • Adult Care Facilities (ACFs)
  • Enriched Housing SSI (36 day reimbursement)
  • Adult Home SSI
  • Assisted Living Program (ALP)
  • Medicaid funding
  • Not enough some expansion in state funding
  • Assisted Living Residence (ALR)
  • Enhanced ALR (EALR) Certificate (Age-in Place)
  • Special Needs ALR (SNALR) (Dementia Programs)

Assisted Living Residence
  • NYS Assisted Living Residence (ALR) Regulations
  • ALR regulation adopted March 27, 2008, allows
  • residents to age in place.
  • ALR defines independent senior housing drawing
    the line
  • between independent housing and licensure.
  • Incorporated services into ISH determined by DOH
    on a
  • case-by-case basis.
  • Discussion 24-hour staff? Medical evaluation
    duties? Who
  • employs the staff person.

Creating Aging-Friendly Communities
  • Considerations for Incorporating Senior Housing
    and Supportive Services into Aging-Friendly
    Communities within New York State

One A shift from silo systems (separate
housing, health services, aging services) to an
integrated system will take state and local
understanding and leadership. Two Local
leaders need to find and preserve existing senior
housing and build new ones. Three State and
federal funding for senior housing (rent subsidy,
property taxation, etc.) will be needed to meet
current and future demand.
Creating Aging-Friendly Communities
Four Local and state leaders must continuously
discuss, plan, develop and advocate for an
integrated aging-friendly community. If not you,
who? Five Cost savings at the institutional
level needs to be invested into senior housing
building capital and supportive services.
(NYAHSAs Planned Affordable Retirement Community
(PARC) concept.) Six Section 8, home care /
supportive services and Medicaid waivers must be
enhanced to transform from institutional care to
home- and community-based care.
Creating Aging-Friendly Communities
Seven State regulations need to be developed
that encourage incorporating health and
supportive services into senior housing. Eight
A new way to fund long term care must be
developed soon that would include home- and
community-based care. Nine Technology will
need to be encouraged and deployed in senior
housing (efficiencies, work-force shortages,
etc.) Ten Innovative New York state and
national home and community-based programs need
to be explored and replicated at the local level.
The Institute for the Future of Aging Services
  • The Institute for the Future of Aging Services
    (IFAS) is an independent research organization
    dedicated to bridging the worlds of policy,
    practice and research to advance the development
    and diffusion of high-quality aging and long-term
    care services and supports. IFAS is the applied
    research arm of the American Association of Homes
    Services for the Aging (AAHSA).
  • Alisha Sanders
  • IFAS Policy Research Associate

The Trends
  • About 2 million older adults live in federally
    subsidized housing
  • They are growing older half of subsidized
    senior renters are 75 and almost 14 are 85
  • Relationship between older age, chronic illness
    and disability, and higher use of health and
    long-term care services is well established
  • Subsidized senior renters twice as likely to be
    disabled as home owner counterparts 1/3 have
    difficulty with routine activities and 12 have
    cognitive impairments

The Trends
  • One study of 3 affordable senior housing
    communities in Denver
  • 23 perceived their health as fair or poor
  • 18 suffered from 3 chronic conditions
  • 18 needed support with 1 ADLs
  • Residents desire to age-in-place
  • Limited options for purchasing needed support

Challenges Providing Housing with Services
  • State regulations
  • Housing provider capacity to provide services
    (skill, staffing level)
  • Range of resident needs
  • Funding
  • Property
  • Residents

Wellness (education, fitness, nursing)
  • Lutheran Senior Services, Missouri
  • Partnership with OASIS, a national nonprofit
    educational organization designed to enhance the
    quality of life for mature adults
  • Offers on-site programming
  • Peer counseling program
  • Active Living Everyday 20-week behavior
    modification program
  • Healthy Eating Everyday - similar to Active
  • Exerstart starting an exercise program safely
  • Residents pay minimum fee (established for LSS
  • Locations in Albany, Rochester, Syracuse

Wellness (education, fitness, nursing)
  • Golden West Senior Residence, Boulder, CO
  • Partner with Medically Based Fitness, a PT and
    rehab company, to operate on-site wellness center
  • GW provides space/equipment MBF staffs center
    with a PT and exercise physiologist
  • Design and monitor exercise program for wellness
    center members (residents pay a monthly
    membership fee, subsidized for many by property
  • Provide rehab following hospital stay or at
    doctor request (Medicare-funded)
  • Conduct educational activities (open to all
  • Open five days per week

Wellness (education, fitness, nursing)
  • Canterbury House, Charleston, SC
  • Partnership with Medical University of SC School
    of Nursing
  • Student nurses do community nursing rotation
    visit property 2 days/week
  • Check vitals (blood pressure, blood sugar, etc.)
    and hold periodic education sessions (diabetic
    wellness/nutrition, hydration issues, etc.)
  • Robert Sharp Towers I II, Miami, FL
  • Partnership with Miami Dade College School of
  • Nursing students visit property 1 day per week
  • Take blood pressure, vitals, etc. lead a chair
    exercise class hold annual health fair

Wellness (education, fitness, nursing)
  • Westerly Apartments, Lakewood, OH
  • Partnership with local hospital
  • Weekly nurse for blood pressure checks, lab tech
    to draw blood (with doctors order), MD gives
    monthly talks on different illnesses, meds, etc.
  • Partnership with Eliza Jennings Nursing Home
    (home health arm)
  • Operate a wellness clinic in the senior center
    area of building
  • Staffed by NP and RN 8 hrs/day, 5 days/week
  • Blood pressure checks, wound care, medicine
    management and general health check-ups NP can
    diagnose and write prescriptions
  • Make house calls, if needed triages if someone
    falls or has accident
  • Provide PT/OT out of clinic, provide in apartment
    so helping resident work within and adapt to
    their specific surroundings
  • Bill Medicare for services

Wellness (education, fitness, nursing)
  • Piedmont Hospitals Sixty Plus Program, Atlanta,
  • Partnership with 4 affordable senior housing
    properties Send nurse to each property one day a
  • Nurse does
  • Individual appointments
  • Post-discharge follow-ups with residents
  • Checks on residents at request of
    hospital-affiliated physicians
  • Help coordinate follow-up appts. or other
    health-related resources
  • Conducts health fairs and other educational
  • Paid for by the hospital

Health Care(clinics, medical house calls)
  • St. Lukes Place, Edgemere, MD
  • Physician practice operates on-site clinic 3
  • Residents can walk in for appt., if space
  • Many residents were from the surrounding area and
    already seeing these physicians
  • Also see patients from outside the property
  • Property has an MOU with them for use of the
    space doctors provide certificate of liability
    insurance and professional license

Health Care(clinics, medical house calls)
  • Saint Elizabeth Place, Providence, RI
  • Partnership with Rhode Island Hospital to operate
    on-site clinic
  • Open 3 days a week
  • Staffed by nurse (employed by the property,
    supervised by MD) NP comes once/week MD at
    least once/month
  • Hospital residents do geriatric rotation in
  • Become a member of the clinic, means MD becomes
    your PCP
  • Property provides space and employs nurse
    Hospital provides insurance, credentialing and
    everything necessary to operate a clinic

Health Care(clinics, medical house calls)
  • St. Marys Court, Washington, DC
  • Partnership with George Washington Hospital House
    Call Program
  • MD/NP team
  • See chronically ill and frail residents who have
    difficulty getting to MDs office
  • See monthly or as needed can respond quickly to
    urgent situations
  • Service coordinator calls NP to check on
    residents when concerned
  • NP discusses patients with service coordinator
    when necessary because she knows SC has valuable
  • NP updates service coordinator on patients so she
    can help bring in supportive services that might
    be helpful

Health Care(clinics, medical house calls)
  • Just for Us, Durham, North Carolina
  • Collaboration between Duke University, a
    federally qualified health center, County
    Department of Social Services, County Health,
    Housing Authority
  • House calls program primary care, social
    services, nutrition services, occupational and
    physical therapy, care management
  • Operates in ten subsidized senior properties in
    Durham County

Personal Care Rehab
  • Reisters View Reisters Clearing, Reisertown, MD
  • Partnership with Friends Care Communities
    Services, Inc., a home care provider
  • Provide services on a sliding scale fee (average
    cost in area is 18/hour)
  • Reduced minimum time block (1 hr vs 4hrs)

Personal Care Rehab
  • Canterbury House, Charleston, SC
  • Partnership with local nursing home to operate
    satellite rehab clinic
  • Property provides space old activity room that
    was underutilized
  • NH staffs a PT (full-time) and an OT (part-time)
  • Residents can access services post hospital or NH
    stay or at doctors request (e.g. to improve
  • PT invites residents to have balance testing
    couple times a year, if poor encourages to talk
    to doctor
  • Paid for through Medicare (with doctors order)
  • Property has bought exercise equipment so that
    residents can continue on own after rehab PT
    shows how to use safely

  • The Institute for the Future of Aging Services
    (IFAS) is an independent research organization
    dedicated to bridging the worlds of policy,
    practice and research to advance the development
    and diffusion of high-quality aging and long-term
    care services and supports. IFAS is the applied
    research arm of the American Association of Homes
    Services for the Aging (AAHSA).
  • Founded in 1961, the New York Association of
    Homes Services for the Aging (NYAHSA)
    represents not-for-profit, mission-driven and
    public continuing care providers, including
    senior housing, adult care facilities, nursing
    homes, continuing care retirement communities,
    assisted living and community service providers.
    NYAHSA's more than 600 members employ 150,000
    professionals serving more than 500,000 New
    Yorkers annually.

Contact Information
  • Ken Harris, Director
  • The NYAHSA Center for Senior Living and Community
  • Albany, N.Y.
  • 518-449-2707
  • kharris_at_nyahsa.org
  • Alisha Sanders, Policy Research Associate
  • The Institute for the Future of Aging Services
  • Washington, D.C.
  • 202-508-1211
  • asanders_at_aahsa.org
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