Now that Wisconsin’s dramatic June 5 recall election is over, it’s time for Gov. Scott Walker (R) and Wisconsin legislators to get back to the business of running their state. 

I certainly hope the future of long-term services and supports is on the agenda.

I recently had the opportunity to brief Wisconsin lawmakers about some of the issues I believe they should be addressing as they prepare for a 28% increase in their state’s over-85 population. 

But my remarks, offered during a meeting sponsored by the Evidence-Based Health Policy Project, really apply to all states, their legislatures and their regulatory bodies.

Shifting to HCBS

It’s no secret that many states are focusing quite intently on shifting the provision of long-term services and supports away from institutions like nursing homes and toward home and community-based settings. 

This approach makes sense for a variety of reasons. However, our collective enthusiasm for home and community-based services (HCBS) should not cause us to overlook the important role that nursing homes continue to play in communities nationwide.

Nursing homes face both short-term and long-term challenges during this time of shrinking financial resources and increasing concerns about a burgeoning older population. 

Taking deliberate steps to strengthen these organizations – and connect them more closely with other providers of long-term services and supports – is particularly important now. 

We need a variety of providers, working together, to help us ensure that older adults receive the right services, at the right time, in the right place and for the right reasons.

Short Term Challenge: Serving 2 Populations

Economic realities and the advent of health reform have spurred many nursing homes to offer post-acute care as a short-stay option on their menu of services. 

These organizations are also continuing to serve traditional nursing home residents, who typically stay for longer periods of time and are likely to have greater care needs and higher rates of dementia than ever before.

How will nursing homes meet the challenges associated with caring for both of these populations, which have very different care needs and who require a very different workforce? 

Legislators can help, in part by allocating additional funds and supporting regulatory changes that foster the recruitment and training of qualified workers who can provide complex care at both ends of the continuum. 

Long-Term Challenge: Renovation or Reinvention?

Will nursing homes have the infrastructure they need to support future demands for their services? If Wisconsin is any indication, the answer is no. 

The average Wisconsin nursing home is 31 years old – too old to incorporate modern design elements that are cost-efficient and person-centered. 

These aging nursing homes have 2 choices as they prepare for the future:

  1. They can update their infrastructures so they can do their current work more efficiently. 
  2. Or, they can transform themselves completely by moving away from traditional bricks-and-mortar delivery models to serve older adults in community settings and in collaboration with other providers. 

Legislators can help nursing homes choose the second option by introducing much-needed flexibility into the nursing home setting. For example, revised scope-of-practice regulations could enhance the delivery of person-centered care. 

Similar flexibility could help foster the development of models like Greenhouses, where older adults receive nursing care in an atmosphere similar to a small group home. A more flexible view of the continuum of care could erase the artificial demarcations that exist between institutional and community-based care. 

That way, providers and policy makers alike could focus their attention on the consumer, not on the care setting.

A Valuable Asset

Now is not the time to think about thinning the ranks of nursing homes in Wisconsin or in any other state. Instead, our challenging times call for innovative approaches that will help these facilities do their best work in the present and position themselves to help their states meet future challenges associated with an aging population.

LeadingAge members have long viewed themselves as active and important participants in the “Aging Network,” that complex, multi-level system that serves and represents the needs of America’s older adults. 

This designation has made sense for many decades. But now it’s time to also begin thinking of ourselves as integral partners in the nation’s public health system – and to help public health officials see themselves as our partners in serving older adults.

A new book called Public Health for an Aging Society tries to do just that. The book is designed to help future public health professionals incorporate the concerns of aging Americans into a field that has traditionally been focused on issues relating to children and youth, reproductive health and infectious disease. 

I co-authored a chapter in the book that educates readers about “Financing and Organizing Health and Long-Term Care Services for Older Populations.”

Aging and public health

My background in public health has convinced me that we can’t help our older population achieve significant and sustainable health gains unless we take a more holistic view of the challenges seniors face and the myriad strategies that can help address those challenges. 

The anticipated growth in the older population makes that holistic approach even more critical.

The coming age wave will obviously affect the elderly among us. But it will also affect every other population group living in our local communities. On the positive side, younger people could benefit from the “silver tsunami,” perhaps by participating in a potentially vibrant business sector that caters to the needs of older adults. 

But if we’re not careful, the burgeoning older population could unwittingly spur intergenerational competition for limited community resources.

A new way of thinking

We can avoid the latter outcome by exploring public health strategies that encourage us to think about the medical needs of the entire population, and to explore how the physical, environmental and social aspects of our communities can dramatically impact the health and wellbeing of all. 

Those LeadingAge members who take this broad, public-health view are more likely to find innovative and effective ways to:

  • Work with community partners to integrate, coordinate and finance services and supports for people with frailty and disability, no matter what their age. 
  • Take additional steps to safeguard the health of younger populations, including our employees, so we can become part of community-wide public health solutions.
  • Educate public health officials about aging, and explore how we can work together to meet public health goals. 
  • Distribute community resources equitably, sensibly and in relation to population needs. 
  • Invest in programs and services that enhance quality of life, prevent disease and foster aging in place.
  • Target limited resources effectively and use them efficiently so all receive the support they need.

LeadingAge members must continue working hard to improve the health of the older populations we serve. 

But by viewing our work through the public health lens, we have a good chance of creating a national health and wellness infrastructure that serves not only older adults, but the entire population. In my view, that’s a worthwhile goal to pursue.

I am pleased to share with you an announcement that the LeadingAge Center for Applied Research has received a $698,000 grant from the John D. and Catherine T. MacArthur Foundation.

Over the next 3 years, we will be conducting the first national effort to assess whether affordable housing settings can serve as effective platforms for meeting the health and long-term care needs of low-income older residents while helping to reduce care costs.

We are very excited about this research project because, among other things, it reinforces 3 of the LeadingAge Leadership Imperatives. Our Board of Directors believes that these driving forces will profoundly influence the fulfillment of LeadingAge’s mission over the next decade:

  • Strengthening not-for-profit leadership.
  • Creating the new financing paradigm.
  • Leading innovation.

We also believe the data generated from this project will support LeadingAge’s advocacy agenda around affordable housing and home and community-based services. And, as always, we are looking forward to involving a sample of LeadingAge members in our work through a limited number of case studies and a survey that will gather information about services available to residents of federally subsidized housing. 

Research staff and partners

Tremendous kudos go to the staff of the LeadingAge Center for Applied Research for their efforts in winning this grant: 

  • Alisha Sanders, senior policy research associate.
  • Natasha Bryant, managing director/senior research associate
  • Adrienne Ruffin, deputy director.
  • Felita Kamara, executive administrator. 

I am also grateful to all of the LeadingAge staff members who support our proposals and dissemination efforts.

In addition, I’d like to introduce our partners in this research project: The Lewin Group, a national health and human services consulting group, and Synovate, which provides expertise on a range of market and survey research activities.

For more information

For more information about the MacArthur-supported research project, please visit Center for Applied Research. In addition, I hope you will stay tuned for updates on this exciting work! We will keep you informed through regular reports on, in LeadingAge magazine, and during our conferences. 

The LeadingAge Center for Applied Research has released an easy-to-use tool that senior housing properties can use to assess the health and functional status of their resident populations. 

The Resident Assessment Tool, developed by the center in partnership with Enterprise Community Partners, gives housing providers the information they need to design programs and services that can help residents remain healthy and independent for longer.

“Whether by choice or by lack of choice, people in senior housing are aging in place in their homes,” says Cheryl Gladstone, program director for senior housing at Enterprise Community Partners, which has raised and invested approximately $1.7 billion to develop more than 30,000 affordable senior housing units since 1982.

“Enterprise has already seen how structured services can transform the lives of formerly homeless people living in our supportive housing properties," Gladstone said. "We wanted to see how services could improve the lives of low-income seniors living in our properties.”

Resident Assessment Package 

The Resident Assessment Tool represents a good first step for housing providers interested in integrating services into their housing communities. The tool is included in a 4-part package that LeadingAge members can download by clicking on these links:  

  • A Guide to Conducting Resident Assessments offers direction on using the self-assessment tool, which residents complete themselves or with help from housing property staff or an outside community partner. The guide also provides strategies that properties can use to respond to the needs identified through the survey process. guide
  • The Resident Assessment Tool Part II captures information about activities that interest residents, including services and programs in which they would willingly participate.
  • An Excel Spreadsheet helps properties tabulate the assessment results and view, in one place, an overall picture of their resident populations.

Years in the Making 

The Center for Applied Research developed the Resident Assessment Tool during the course of several research projects that called for an assessment of resident health and functional status. After modifying the tool for use by housing properties, the center asked Presbyterian Senior Living, a LeadingAge member in Dillsburg, PA, to test the tool and recommend modifications.

“Conducting a resident assessment will help housing properties gain a comprehensive picture of their residents,” says Alisha Sanders, senior policy research associate at the LeadingAge Center for Applied Research. “This picture can help housing properties engage partners and focus on bringing the services and resources to their property that will meet the specific needs and interests of their community,”

Since 2005, the Center for Applied Research has been studying the role that housing with services could play in meeting the growing need for health and long-term services and supports among low-income elders. As part of that effort, Enterprise and the center collaborated on the National Summit on Affordable Housing and Services in May 2010 and the Summit on Aging in Public Housing in March 2011. 

In addition, the center provides a host of resources on Expanding Affordable Housing Plus Services.

Read about a Member's Experience

Presbyterian Senior Living (PSL), a LeadingAge member in Dillsburg, PA, helped the Center for Applied Research test its Resident Assessment Tool in two housing communities. Read more about how the tool brought benefits to PSL and its residents.


During my February trip to Singapore, I marveled at the intentional way in which our partners in this Southeast Asian city-state are approaching the anticipated growth in their nation’s aging population. Seven percent of Singaporeans are over age 65, but that figure is expected to reach 19% by 2030.

Singapore is responding to its coming “age wave” by looking beyond its national borders to find and replicate proven ways to support a growing older population. I’m pleased to report that through our participation in the International Association of Homes and Services for the Ageing (IAHSA), the LeadingAge Center for Applied Research has been able to assist in that effort.

The partnerships we’ve forged through IAHSA have brought me to Southeast Asia 5 times in the past 3 years. 

During each trip, I’ve been able to provide technical assistance to Singaporean researchers, aging advocates and government officials, and to participate in university lectures, workshops and conferences designed to explore promising aging-in-place strategies.

On my most recent trip, I offered several workshops on applied research to students in the Master of Gerontology program at SIM University (UNISim), a well-respected institution of higher education in Singapore. 

These workshops provided students, who work primarily in government agencies, with the tools they will need to carry out ongoing research as Singapore evaluates new aging-in-place models. 

The Impact of Partnerships 

With our help, Singapore has begun to view its plentiful supply of subsidized housing as a valuable asset that can be used to help older adults remain healthy and independent for longer. To help our partners take full advantage of this asset, the Center for Applied Research has been working hard to share what we know about the housing-with-services models that could work well in Singapore’s multigenerational “housing estates.”

My recent visit convinced me that this work is beginning to have an impact: 

  • Our research partner, the TSAO Foundation, is preparing to replicate the Program of All Inclusive Care for the Elderly (PACE), a U.S. model of capitated managed care featuring medical and social service delivery to frail elders living in the community.
  • The Singapore government is preparing to test a variety of aging-in-place strategies through demonstrations that will bring services into 4 housing estates and will explore ways to improve the physical environment of those housing communities so older adults can remain mobile and engaged.

These initiatives illustrate the important supportive role that American researchers and program experts – including the Center for Applied Research – are playing in Singapore’s efforts to plan age-friendly communities. 

Because Singapore is an economic leader among Asian nations, the models it develops will eventually influence the entire region, where IASHA has many members.

The countries of the world have much to learn from one another as we all deal with an unprecedented demographic phenomenon that will affect the health of our citizens, our workforces and our economies. 

The Center for Applied Research intends to continue sharing its research and expertise with the global community so that, together, the world’s nations can develop policies and practices that improve the lives of older people and their caregivers.

Late last year, the LeadingAge Center for Applied Research held a call with the state associations in the 15 states selected for the Center for Medicare and Medicaid Services (CMS) State Demonstrations to Integrate Care for Dual Eligible Individuals project to find out whether and how affordable senior housing settings were being considered in the states’ proposals. Following the call, Aging Services of California kicked it into high gear. 

JoAnne Handy, the association’s CEO, had already been attending stakeholder meetings held by the state, and had been the only one to bring up the role of housing. Aging Services of California convened a conference call with several of their affordable housing members to explore ways to capitalize on this opportunity to play a pivotal role in health care transformation. 

They also developed a white paper to be shared with housing providers, health care providers and state health and housing officials about what affordable senior housing settings can offer to complement CMS’s three part aim of better care, better outcomes and lower costs for dual eligibles. 

Capitated managed care model

Like several of the states developing demonstrations, California will lean on a capitated managed care model to provide dual eligibles seamless access to a full continuum of medical care and social supports and services. 

The state recently released a Request for Solutions to identify applicants who can fulfill this role. As recommended by Aging Services of California, applicants are asked to describe how they would “partner with housing providers, such as senior housing, residential care facilities, assisted living facilities, and continuing care retirement communities, to arrange for housing or to provide services in the housing facilities for beneficiaries.” 

In early March, Aging Services of California will hold a roundtable with select leaders of affordable senior housing, managed care plans, and state health and housing departments to explore ways in senior housing properties can benefit health care providers and managed care organizations by facilitating interventions within their communities that promote independence and healthy outcomes.

Oregon and Vermont are driving solutions, as well. Cedar Sinai Park and LeadingAge Oregon have been working with the state to include a small pilot within their state’s demonstration proposal that would include a consortium involving health care, mental health, substance abuse treatment, home care and care management professionals working as a multi-disciplinary team to provide services in affordable housing services. 

Likewise, Cathedral Square Corporation and LeadingAge Vermont are dialoguing with the state to include the Senior’s Aging Safely at Home (SASH) program in the state’s demonstration. 

SASH is a care coordination program, anchored in affordable senior housing properties, that links health and supportive services to the home to support older adults’ ability to manage their care needs and age in place.

The disturbing workforce statistics included in a new report from PHI (the Paraprofessional Healthcare Institute) won’t come as a surprise to providers of long-term services and supports. But the report’s data, which describe the plight of home health workers, do serve to remind us of the significant workforce issues facing every single LeadingAge member. 

These issues must be addressed; they are not going away anytime soon.  

According to Caring in America, A Comprehensive Analysis of the Nation’s Fastest-Growing Jobs: Home Health and Personal Care Aides, our home and community-based workforce faces a number of serious hardships, including: 

  • Low wages: In 34 states, average hourly wages for personal care aides were below 200% of the federal poverty level wage ($10.42) for full-time workers in 1-person households.
  • Economic insecurity: More than half of home health aides (56.2%) relied on Medicaid or food stamps in 2009. More than a third (37%) had no insurance.  
  • A hazardous profession: Home health care workers are twice as likely as general industry workers to lose workdays due to on-the-job injuries or assaults.
  • Inadequate training: Only 5 states meet the 2008 Institute of Medicine recommendation that certified nursing assistants and home health aides receive 120 hours of training.

What do the Numbers Mean for Us? 

Our nation is hurtling toward a time in the not-so-distant future when we will need many more frontline workers to provide services and supports to our rapidly growing older population. Yet, the workforce we’re depending on to care for this future aging cohort is clearly undervalued. 

These workers hold the country’s lowest paying jobs. Their training requirements are both inadequate and poorly aligned with wages. They have paltry health coverage, high injury rates and unpredictable hours. They rely heavily on public benefits.

LeadingAge and its Center for Applied Research provide a host of resources to help aging services organizations change these troubling statistics. For example, we’re currently working on a project, in partnership with Social and Scientific Systems, Inc., to analyze the 2007 National Home Health Aide Survey for the Office of the Assistant Secretary for Planning and Evaluation in the U.S. Department of Health and Human Services. 

Over the next few months, we’ll be evaluating the interrelationship among the characteristics of this workforce, their job quality and the quality of care they provide. We’ll keep you posted on this work.

In the meantime, I urge you to review the materials that we’ve developed, in collaboration with LeadingAge members, during several workforce initiatives. These initiatives include:  

  • Better Jobs Better Care, which identified and tested myriad strategies aimed at changing long-term care policy and practice in order to reduce vacancy and turnover rates, and improve workforce quality.
  • The LeadingAge Commission on Ethics in Aging Services, which made a number of recommendations to help providers develop ethical workplaces that provide fair wages, good benefits and career ladders.

These and other resources are the tools LeadingAge members need to become part of the workforce solutions that our field and our nation so desperately need. I hope you will use them to change the lives of the people who work for you, improve the quality of care they provide, and set a shining example that other organizations will follow.


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