The Center for Applied Research is partnering as a subcontractor to the Lewin Group to provide technical assistance to states and other organizations seeking to improve the recruitment and retention of individuals who provide support services for people with disabilities. 

The National Direct Service Workforce Resource Center was created to respond to the large and growing shortage of direct service workers. The resource center offers:

  • An on-line searchable database.
  • Access to information from a team of direct service workforce policy professionals.
  • Technical assistance for selected State Medicaid Agencies awarded through an annual application process.   

The project was funded by the Center for Medicare and Medicaid Services.

It seemed particularly fitting to mark the 50th birthday of the Senate Special Committee on Aging at the end of 2011, a year in which economic and social upheaval dramatically impacted our legislative agendas and the lives of our most vulnerable citizens. The Committee has been an important voice for aging Americans during many other times of economic and social upheaval. Older adults need its strong voice now more than ever.

The Aging Committee celebrated its anniversary on Dec. 14 during a Capitol Hill forum hosted by Committee Chair Sen. Herbert Kohl (D-WI) and former Chair Sen. Chuck Grassley (R-IA). I was invited to participate in the forum and to provide my perspective on the past, present and future of long-term care and housing policy.

During my testimony, I commended the Committee for its ongoing attention to nursing home quality, its promotion of home and community-based services, its support for the paid long-term workforce, and its commitment to service integration and care coordination. I also recommended that, over the next year, the Committee explore: 

  • How new models of service delivery might evolve in response to consumer preferences, the ability of consumers to purchase care, and changes in public policy.
  • Whether and how a quality, competent paid workforce will be developed to meet changing demands for services and supports.
  • How these services and supports can be made affordable for the vast majority of older adults who will need to use them. That affordability is critical, especially in our current economic environment.

Affordable Housing and Integrated Services

Five decades ago, one third of the elderly lived in poverty. That percentage decreased precipitously with the advent of Medicare and Medicaid, but the latest recession has dramatically expanded the gap between the “haves” and the “have nots.” 

And who suffers the most? Moderate-income older adults do, because they don’t have the wherewithal to purchase services and supports, and they don’t qualify for government help unless they spend down their assets and move to a nursing home. Only then will Medicaid pay both their housing and their service bills.

This scenario doesn’t make economic sense. And it’s not what consumers want. That is why I recommended that the Senate Special Committee on Aging host a national conversation that explores innovative ways to deploy our long-term care and housing resources more effectively.

Specifically, I challenged the Aging Committee to explore a model that could deliver integrated services and supports to large groups of seniors living in affordable housing properties. Several states, including Vermont and Oregon, are already pursuing this housing-plus-services model in the belief that it will produce service-related savings that can then be used to support housing affordability.

Affordable shelter and services are essential elements of any viable community-based long-term care option. As a bipartisan, investigative body, the Senate Special Committee on Aging is uniquely positioned to begin its 6th decade with a ground-breaking exploration of innovative models that link shelter and services as a way to keep older people healthy while reducing costs and honoring consumer preferences to age in place.

The 2007 National Home Health Aide Survey is the first national probability survey of home health aides. 

LeadingAge Center for Applied Research, in partnership with Social and Scientific Systems, Inc. (SSS), will be conducting analyses using this survey to provide technical assistance and policy analysis to the Office of the Assistant Secretary for Planning and Evaluation (ASPE). 

The goals of the analyses are to describe workforce characteristics and to evaluate the interrelationships among workforce characteristics, job quality, and other worker and facility characteristics and quality of care. 

The goal of analyses underpinning the "Workforce Characteristics" report is to understand the supply of workers by demand, geographic location, policy variation, agency characteristics, and recruitment strategies.

The team will prepare reports and manuscripts with results from these analyses.

This project is funded by ASPE and the Center is a subcontractor to SSS.

The aim of a our report, Community-Based Telemonitoring for Hypertension Management: Practical Challenges and Potential Solutions, is to summarize practical considerations related to operations and logistics of a unique community-based telemonitoring pilot study targeting rural seniors who utilize community-based senior centers. The reprot reviews the technological challenges encountered during the study and proposes solutions relevant to future research and implementation of telehealth in community-based, congregate settings.

Older adults residing in rural areas often lack convenient, patient-centered, community-based approaches to facilitate receipt of routine care to manage common chronic conditions. Without adequate access to appropriate disease management resources, the risk of seniors experiencing acute events related to these common conditions increases substantially. Further, poorly managed chronic conditions are costly and place seniors at increased risk of institutionalization and permanent loss of independence.

Novel, telehealth-based approaches to management of common chronic conditions like hypertension may not only improve the health of older adults, but may also lead to substantial cost savings associated with acute care episodes and institutionalization.

Adults living in publicly assisted housing are primarily 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. 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.

The August issue of the online American Medical Directors Association publication features an article - Making Public Housing LTC Housing - by Dr. Robyn Stone on the need for publicly assisted, service-enriched senior housing and its potential for helping older adults to age in the community. This housing model responds to the preferences of most elderly residents – and their families – that these individuals age in place even as their health declines. 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.

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. Dr. Stone's article highlights several studies that suggest positive results with these types of models and programs.

Drawing on its years of experience studying housing-with-services models, the LeadingAge Center for Applied Research is working in partnership with the Virginia-based Lewin Group to design a housing-with-services demonstration program by Spring 2012 for the assistant secretary for planning and evaluation (ASPE) at the U.S. Department of Health and Human Services (HHS).

Operational Insights from Case Studies  

LeadingAge has already developed a conceptual framework for housing-with-services models as part of the ASPE grant. That document outlines the policy issues associated with housing-with-services, sets broad parameters for the soon-to-be-designed demonstration and specifies the research and practice questions the demonstration will seek to answer. The Center is now in the process of collecting information from a variety of sources to fill out that framework and design a demonstration that, if funded at a later date, could help researchers measure whether housing-with-services models actually improve health and quality of life among older residents while saving health care dollars.

By early June 2011, Center researchers had completed site visits to several housing providers that are currently incorporating services into their communities. Four LeadingAge members participated in the site visits: 

Researchers also visited Lapham Park in Milwaukee, WI, and Mable Howard Apartments in Berkeley, CA. Lincoln Square, a naturally occurring retirement community in New York City, will be included in a future site visit.

“We wanted to learn about how their programs work, who their partners are and how they are working together,” says Alisha Sanders, senior policy research associate at the Center for Applied Research. “We also were looking to identify their successes and challenges and the kinds of barriers they have encountered. Our ultimate goal is to identify the critical elements and components that need to be included as we design a demonstration. We also wanted to identify the lessons these progressive housing-with-services providers learned as they rolled out their programs so we can incorporate those lessons into the demonstration.”

During individual site visits researchers met with property managers, service coordinators and other property staff as well as executive, administrative and frontline staff from the housing property’s service partners. They also interviewed representatives of local and state public funding agencies when applicable. As the Center for Applied Research evaluates and synthesizes the site visit findings it will also be working closely with a 15-member technical advisory group composed of housing providers, outside researchers, service providers and government officials.

Population View from Merged Database 

In addition to the demonstration program design, the groundbreaking ASPE project calls for the first-ever merging of a number of databases from U.S. Department of Housing and Urban Development (HUD) and the Centers for Medicare and Medicaid Services. When combined with the case study findings, that hard data will offer researchers a unique view of the populations living in affordable housing buildings. 

“Both sets of information will work together very nicely,” says Sanders. “The database will help us know who the population is and to think about the types of interventions that they are going to need. And the case studies will give us valuable insights into how you actually operationalize these interventions in a way that’s successful.” 

The project is funded by the ASPE at HHS, the Administration on Aging, and HUD.

In March of 2011, LeadingAge convened the Summit on Aging in Public Housing, which brought together a select group of public housing authorities, service providers, and public-housing residents to discuss the opportunities and challenges presented by an aging resident population. The summit was supported by a grant from the Atlantic Philanthropies and organized in partnership with Enterprise Community Partners, a Maryland-based nonprofit that provides development capital and expertise to create affordable homes and rebuild communities.

Providing housing with services to their older residents is a relatively new activity for public housing authorities, which have traditionally focused on helping younger residents attain social and financial stability. But as more residents of both senior-designated and family buildings are aging in place, public housing authorities around the country are beginning to pay more attention to the challenges facing their older populations. Unfortunately, says Alisha Sanders, senior research associate at the LeadingAge Center for Applied Research, many public housing providers find themselves dealing with these challenges in relative isolation. 

During the 2-day summit, many participants met their counterparts from other cities for the first time to discuss and share various strategies for supporting residents who wish to remain safely in their own homes. For example: 

  • The Atlanta Housing Authority (AHA) collaborated with LeadingAge to survey residents about their physical, mental health and functional status as well as their health care utilization, physical activity, support networks, computer usage, spirituality, service needs and activity interests. Armed with this knowledge, AHA is now developing wellness programs and making physical changes to its properties to support resident needs and facilitate programming and service delivery.
  • The New York City Housing Authority (NYCHA) carried out a similar assessment through a survey that was administered among a random sample of NYCHA residents by the City University of New York. NYCHA is now identifying programs and services, including a smoking cessation and diabetes self-management program, which will help address some of the needs uncovered by the assessment.
  • The Brattleboro Housing Authority in Vermont participates in Seniors Aging Safely at Home, a statewide care management model that is currently being rolled out to help coordinate health services and long-term services and supports for residents living in affordable senior housing properties and the surrounding communities.
  • A local health system provides monthly clinics at 9 properties managed by the Denver Housing Authority.
  • The Housing Authority of the City of Milwaukee has worked in partnership with its residents' association and other community organizations to establish a continuing care-like community in 1 property and to link with an assisted living facility in another property.
  • Partnerships with a federally qualified health center and LeadingAge members Baptist Village Communities and Daily Living Centers have helped the Oklahoma City Housing Authority offer an onsite adult day center and wellness clinic and to facilitate offsite health appointments.

Possible Next Steps 

Participants' receptiveness to the summit's sharing and networking opportunities convinced LeadingAge and Enterprise that all senior housing providers could benefit from a learning circle collaborative that would offer regular opportunities for knowledge and information sharing about housing-with-services options. Sanders suggests that such knowledge transfer might take place through a variety of vehicles, including in-person gatherings, conference calls, web-based events and a website where users could exchange documents and information.

“Housing authorities face a few challenges that other housing providers don’t have, including the diffusion of their older residents in family buildings or in the community, in addition to their elderly-designated buildings,” says Sanders. “But they also face many of the same challenges as other housing providers that have an aging resident base. By using their communities as a delivery platform for community-based services, these housing authorities can support their residents in a more efficient way and perhaps produce better outcomes for them.”

The Patient Protection and Affordable Care Act (ACA) promises to transform the way our nation delivers and pays for long-term services and supports, but the new law can't be successfully implemented without the creation of a “substantially different health and long-term care workforce than exists today,” according to Dr. Robyn Stone, executive director of the LeadingAge Center for Applied Research, in a new Journal of Aging and Social Policy article. 

ACA: Workforce Challenges and Opportunities 

According to Stone, the ACA established a number of demonstration programs and payment reforms to encourage better service coordination and integration for older adults with multiple chronic illnesses and disabilities. At the same time, the new health care reform law also called for an expansion of home and community-based services as a way to increase choice and lower care costs for older people in need of long-term services and supports. Both approaches to reform have important implications for the eldercare workforce, she says.

For example, says Stone, the new models of integrated service delivery outlined in the ACA require that care and management staff understand how to coordinate care both at the organizational and consumer level, work in interdisciplinary teams, document and share clinical information, and place the elderly consumer at the center of care decisions.

In addition, the ACA’s emphasis on expanding home and community-based care requires a substantial increase in the number of direct-care workers and management staff as well as a concerted effort to strengthen the competencies of this workforce in such areas as medication management, dementia care and palliative care, she says.

Thanks to advocacy groups like the Eldercare Workforce Alliance (EWA), of which LeadingAge is a member, the ACA acknowledges the additional demands that its provisions will place on the workforce, says Stone. A number of ACA workforce provisions promise to increase educational opportunities in the areas of geriatrics and gerontology and provide incentives for individuals to enter and remain in the field. Other workforce-related provisions support the development of relevant curricula that provide workers with the competencies they will need to care for a growing older population with increasingly complex needs.  

As promising as these workforce provisions appear, however, their mere presence in the ACA legislation won't guarantee the availability of a knowledgeable, skilled and competent health and long-term care workforce, says Stone. For this reason, the EWA continues to advocate for the implementation and funding of these provisions and the inclusion of workforce elements in all future payment and delivery reforms, she says.    

“System reform doesn’t happen magically,” says Stone. “Health reform will only become meaningful reform if we make sure that workforce issues are really addressed at every step along the way. You can’t bring about these kinds of reforms simply by changing policy. You have to recognize that because the system is so labor intensive, reforming that system has to involve paying close attention to the human capital.”

Calling Attention to Workforce Issues 

Stone first began calling attention to ACA-related workforce issues when she served as guest editor of the Winter 2010-2011 edition of Generations, the journal of the American Society on Aging. In an introduction to that issue, she suggests that both the ACA, and the 2008 Institute of Medicine report Retooling for an Aging America, have helped to raise workforce issues “to a priority level in both policy and practice areas.”

Those same themes were reflected in Stone’s June 2011 presentation at the prestigious Annual Research Meeting of AcademyHealth, a national organization promoting health services research to improve health care. The organization uses a peer-reviewed process to select the researchers who will present findings from their published work at the annual research meeting. In addition to participating in a session called “The Affordable Care Act and Long-Term Care: Meaningful Reform or Just Tinkering Around the Edges?” Stone chaired a separate AcademyHealth session on “Quality of Long-Term Care.”



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