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

1
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
  Services
• Saratoga Springs, New York
• Wednesday, November 12, 2008

2
Agenda

• Current Situation in Housing Supportive
  Services
• 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
  Services
• Wellness Models
• Health Care Models

3
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
  population.
• More culturally and economically diverse.

4
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
  living.
• Transitioned to nursing home, possibly
  unnecessarily.

5
Housing Supportive Services Outlook

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

6
NYS LTC Reform Initiatives

• New York State LTC Reform Initiatives
• Nursing Home Transition and Diversion Medicaid
  Waiver
• 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

7
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

8
A New Federal Direction?

• President-elect Barack Obama endorses
• Long term care choices not biased toward
  institutional care.
• Restoration of HUD operational housing
  subsidies.
• 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
  (HIT).
• Emphasis on wellness initiatives.
• Research and dissemination of information on
  best practices.

9
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
  complete
• 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.

10
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.

11
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
  NHTDW).
• 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.

12
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
  independence.
• Cooperation, coordination and coalitions (3Cs)
  will be needed on the local level.

13
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.
  Enhance.

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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.

15
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.

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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
  rents.
• Recapitalization of older buildings by
  refinancing the mortgage
• or financing through the LIHTCP maintains
  affordable housing.

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Comparable Costs SNF vs. Housing

• HUD Senior Housing in Albany Monthly Costs to
  NYS
• 1. HUD Housing 419 per person per month / NYS
  Share 0.
• 2. SSI 761 Federal 674 / NYS Share 87 per
  month.
• 3. Long Term Home Health Care Program Medicaid
  Waiver
• 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
  6,700
• ( Rents vary from individual senior housing
  facilities)

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Comparable Costs SNF vs. Housing

• Albany Nursing Home Resident Monthly Costs to
  NYS
• Albany nursing home average daily rate (Physical
  AB) 131.06
• Annual 47,836 / Monthly 3,986
• NYS Share (40) Monthly 1,594 / Annual
  19,128
• Cost comparison annual NYS share for Medicaid
  senior
• SNF 19,128 - HUD with LTHHCP 6,700 Savings
  12,396.
• (Average rate actual could be more or less)
• NYS savings for 100 seniors 1,239,600

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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
  services.
• 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.

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Additional NYS Housing Models

• Naturally Occurring Retirement Communities
  (NORCs)
• 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.

21
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)

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Assisted Living Residence

• NYS Assisted Living Residence (ALR) Regulations
• ALR regulation adopted March 27, 2008, allows
  for
• 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.

23
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.
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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.
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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.
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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

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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

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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
  services

29
Challenges Providing Housing with Services

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

30
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
  Living
• Exerstart starting an exercise program safely
• Residents pay minimum fee (established for LSS
  properties)
• Locations in Albany, Rochester, Syracuse
  www.oasisnet.org

31
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
  fundraising)
• Provide rehab following hospital stay or at
  doctor request (Medicare-funded)
• Conduct educational activities (open to all
  residents)
• Open five days per week

32
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
• Nursing students visit property 1 day per week
• Take blood pressure, vitals, etc. lead a chair
  exercise class hold annual health fair

33
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

34
Wellness (education, fitness, nursing)

• Piedmont Hospitals Sixty Plus Program, Atlanta,
  GA
• Partnership with 4 affordable senior housing
  properties Send nurse to each property one day a
  week
• 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
  programs
• Paid for by the hospital

35
Health Care(clinics, medical house calls)

• St. Lukes Place, Edgemere, MD
• Physician practice operates on-site clinic 3
  days/week
• Residents can walk in for appt., if space
  available
• 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

36
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
  clinic
• 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

37
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
  insight
• NP updates service coordinator on patients so she
  can help bring in supportive services that might
  be helpful

38
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

39
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)

40
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
  balance)
• 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

41
IFAS / NYAHSA

• 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.

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Contact Information

• Ken Harris, Director
• The NYAHSA Center for Senior Living and Community
  Services
• 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