The fall 2013 edition of HUD's Evidence Matters (a journal put out by the U.S. Department of Housing and Urban Development (HUD) Office of Policy Development and Research) hits close to home for many families as they or their relatives age and consider their evolving needs.  Although aging in place was once the norm in U.S. society, modern land use trends and housing stock design make this goal increasingly difficult to achieve today.

The issue introduces the demographic trends and preferences of seniors to age safely and comfortably in the homes and communities of their choice. It outlines several of the strategies that seniors, local officials, and policymakers are pursuing to promote aging in place, with special attention to community-centered efforts in Atlanta, San Diego, and Newton, Massachusetts. 

The issue also surveys research efforts to measure the cost, health, and wellness benefits of aging in place.  

This edition highlights research underway  in conjunction with LeadingAge's Center for Applied Research, and models of achieving aging in place in non-subsidized settings as well.

The feature article, "Aging in Place: Facilitating Choice and Independence," reviews the trends underpinning the issue and looks at the federal, state, and local programs and policies for the elderly that are accommodating a shift away from institutional living and toward aging in place with supports.

The Research Spotlight article, "Measuring the Costs and Savings of Aging in Place," examines efforts to measure the potential health cost savings (as well as

improvements in well-being) to families and the government when individuals are able to age in their homes with assistance, reinforcing the argument that housing matters.

Finally, grassroots efforts to aid the elderly in their communities and provide practical solutions for the supportive services necessary to age in place are examined in the In Practice article, "Community-Centered Solutions for Aging at Home." 

Key Findings

  • Economic and demographic shifts are creating a rising need for affordable, age-appropriate housing options for seniors wishing to remain in their homes and communities as they age.
  • Homes can be modified, communities can be adapted, and seniors can be better connected to supports and services to facilitate aging in place.
  • Naturally Occurring Retirement Community Supportive Services Programs and Villages have shown promise in helping seniors remain in their homes with a high degree of independence and social engagement.
  • Research suggests that aging in place initiatives may yield cost savings to families, governments, and health systems as well as health, emotional, and social benefits to aging seniors and the broader community.

In this Issue:  

HUD held a briefing January 9, 2013 (Visions for Aging in Place: Challenges for the Future) with panelists including Alisha Sanders from the LeadingAge Center for Housing Plus Services to discuss elements of this report. Presentations were quick and informative. 

The webcast should be available shortly in the HUD webcast archives.



This edition highlights research underway in conjunction with LeadingAge's Center on Applied Research, and models of achieving aging in place in non-subsidized settings as well.

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Before the call, the members knew that they were all attempting to bring supportive services into affordable senior housing communities. They also were aware that each had received $25,000 from the LeadingAge Innovations Fund, which received a matching contribution from the NewCourtland Foundation, to support those initiatives.

But during the call, which was facilitated by the LeadingAge Center for Housing Plus Services, the grantees were surprised by how many common experiences they shared, in spite of the fact that their individual projects are so varied. Now, they are anxious to learn as much as they can from one another’s successes and challenges.

“We wanted to make all the grantees aware of each other’s projects,” says Alisha Sanders, manager of the Center for Housing Plus Services. “We hope that when they are struggling with common issues or hitting common barriers, they can serve as a resource to one another.”

Innovations Fund Grantees

The 4 Innovations Fund grantees were profiled recently in LeadingAge magazine:

  • Jewish Association on Aging (JAA) in Pittsburgh, PA is implementing a HomeMeds program through which a nurse and social worker use Internet-based software to catalog the medications of housing residents and flag issues that need attention from the residents’ physicians. 
  • Jewish Community Housing for the Elderly (JCHE) in Brighton, MA is working with the Alzheimer’s Association to train its housing staff in habilitation therapy. The therapy is designed to help older adults who are experiencing cognitive decline. 
  • Sayre Christian Village in Lexington, KY opened a primary care health clinic in one of its largest independent living communities. A part-time staff person serves as a liaison between clinic staff and housing residents.
  • Francis E. Parker Memorial Home in Piscataway, NJ is launching a social adult day program at 5 independent housing properties within a 5-10 miles radius of the home. 

Common Issues and Experiences

Research, partnerships, diversity and resident engagement were among the areas that grantees found they had in common.

Research: Several of the grantees are depending on research to ensure and measure their success. For example, JAA selected its HomeMeds software after reviewing evidence that the tool helps to reduce medication-related medical issues that can lead to hospitalization, falls and confusion. 

Parker will be looking at its measures of success when seeking charitable funding to sustain the social day program after the pilot ends. And JCHE has already arranged to have researchers at the University of Massachusetts Boston Gerontology Institute conduct a process evaluation to determine the effectiveness of its dementia training program.

“Habitation therapy has been used in nursing homes and in assisted living but it has not been used in an independent housing setting,” says Caren Silverlieb, director of strategic planning and partnerships at JCHE. “We will be testing how successfully this therapy can be applied in this setting so it can be replicated in other independent housing settings.”

Partnerships: All the grantees are working with community partners to help them implement their Housing Plus Services initiatives. JCHE is offering its dementia training program in collaboration with the Alzheimer’s Association. JAA will begin implementing its HomeMeds program in a 200-unit housing community where it already delivers home health services. 

Sayre Christian Village could never have launched its health clinic without the help of a large primary care practice. Service Coordinator Charlotte Potter attributes the success of that program to the willingness of medical partners to honor residents’ loyalty to their own primary care physicians.

“We started out and are still accepting episodic visits,” says Potter. “Anybody who has a cold or needs a Vitamin B-12 shot can come into the clinic and get that taken care of. Our clinic staff will transfer that information to their primary care physician.”

Diversity: Two grantees have found it challenging to deliver services in buildings with diverse resident populations. Just under half of the 1,500 residents living in JCHE’s 6 housing properties speak Russian while 22% speak Mandarin or Cantonese. Similarly, Francis E. Parker Memorial’s social day programs will serve a high concentration of older adults from Russia, China and Korea.

Finding qualified individuals to run these programs has been a tall order for both organizations. After much searching, JCHE found a Russian bilingual service coordinator who has dementia training and the skills to train other staff members. Parker found more candidates for its program coordinator position after changing that position from a temporary to a permanent staff slot.

“At first, we were being very cautious and referring to it as a temporary position until we could see how successful we are,” says Gloria Zayanskosky, Parker’s quality and operational excellence officer. “But we decided that it was not realistic to ask someone to sign on for a temporary position. We believe in our hearts that the program is going to be extremely successful.”

Resident engagement: Housing residents have shown universal support and enthusiasm for all the Innovations Fund-supported programs. For example, the clinic at Sayre Christian Village has become so popular during the past year that the physicians group recently doubled its on-site hours. And local housing residents are already clamoring to participate in JAA’s HomeMeds program.

“We met with residents and families a few weeks ago,” reports Mary Anne Foley, executive director for hospice and home health programs at JAA. “They were truly delighted when they heard that this program is free, that a nurse will be providing community outreach, and that this will all be done under the supervision of their physicians. We walked out of there with a long list of people who wanted to be first.”



An informal conference call on a recent Friday afternoon convinced representatives of 4 LeadingAge member organizations just how much they had in common.

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The SASH program uses not-for-profit housing as a platform for coordinating and delivering health and supportive services to seniors and people with disabilities. SASH participants live in the housing properties and their surrounding communities. The interdisciplinary SASH team includes a SASH coordinator and wellness nurse who are based at the housing property, and representatives from a network of community-based service providers.

Cathedral Square Corporation in South Burlington, VT, developed the SASH program, which is currently being rolled out to 112 housing sites through Vermont’s Multi-payer Advanced Primary Care Practice (MAPCP) demonstration.

The demonstration, funded by the Centers for Medicare and Medicaid Services, is designed to support state efforts to improve the quality and coordination of health care services through team-based “medical homes.”

SASH Evaluation Activities 

During the 3-year evaluation, the Center for Applied Research and RTI International will examine the development and implementation of the SASH program as well as outcomes for program participants. Primary study activities will include:

  • An annual statistical comparison: Researchers will compare SASH participants, SASH non-participants and a Medicare beneficiary comparison group. The comparison will look at acute care utilization, Medicare expenditures, transfers to nursing homes and adverse medical events. Cost-effectiveness and cost-benefit analyses at the end of the third year will quantify the net savings to Medicare and Medicaid.
  • Survey of beneficiary groups: A survey of SASH participants, SASH non-participants and a Medicare beneficiary comparison group will help researchers assess outcomes that are not available from Medicare and Medicaid claims data. These outcomes will focus on issues related to general health status, functional status, quality of life, polypharmacy and diet. The survey will also examine reasons for non-participation among older adults who are eligible for the SASH program. 
  • Calls and site visits: Researchers will communicate with SASH program staff through quarterly calls. They will also conduct interviews with program staff, community partners and other stakeholders during annual sites visits. These interviews will examine key features of the SASH initiative and how they evolve over time; implementation barriers and facilitators; perceived pros and cons for program participants; and lessons learned.

Implications for Providers

At the end of the MAPCP demonstration, the HHS Secretary has the option of making demonstration activities a permanent component of the Medicare program. The evaluation findings could help inform this decision.

Evaluation results could also inform policy efforts at the federal and state level related to the role that affordable housing linked with health and supportive services could play in addressing health and long-term care reform goals.

For more information about the SASH evaluation, contact Alisha Sanders at 202-508-1211.



The LeadingAge Center for Applied Research is working with RTI International on a newly awarded contract to evaluate the Supports and Services at Home (SASH) program. The U.S. Department of Health and Human Services (HHS) is funding the evaluation.

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The PHCAST Program grants come from a $253 million Prevention and Public Health Fund. The fund, which was authorized by the Affordable Care Act, is designed to improve the primary care workforce. The PHCAST program will provide policymakers, educators, providers, workers and consumers with important insights about PHCA workforce preparation.   

Findings from the evaluation are expected to:  


  • Help Medicare and Medicaid officials determine the value and efficacy of establishing more standardized training requirements for the PHCA workforce, as well as the nature and scope of training programs that should be supported and in what settings.  
  • Assist educational institutions and providers in designing and implementing more appropriate and effective instructional methods and suitable content for the various groups of PHCAs.  
  • Ultimately improve the recruitment and retention of a competent workforce, and the quality of life and care received by consumers of long-term services and supports and their families. 


  The project is administered and funded by the Health Resources and Services Administration at HHS



 The Personal and Home Care Aide State Training Program (PHCAST) is a 3-year federal demonstration program designed to develop core competencies, pilot training curricula and establish certification programs for personal and home care aides (PHCAs). LeadingAge Center for Applied Research is partnering with Walter R. McDonald & Associates, LLC to evaluate PHCAST teaching methods and to ascertain the impact of core competencies training on key outcomes.

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Walter R. McDonald and Associates Inc. and the LeadingAge Center for Applied Research received with a grant from Health Resources and Services Administration (HRSA) to design and implement a national evaluation of the Affordable Care Act (ACA) Personal and Home Care Aide Training (PHCAST) program. PHCAST supports the development, evaluation, and demonstration of a competency-based and uniform curriculum to train qualified personal and home care aides. 

The national evaluation will assess the following outcomes specified in the ACA for the PHCAST program:

  • Assess the impact of states’ core competencies training programs on job satisfaction of trainees, trainees’ mastery of job skills acquired through the training, direct care recipient and family caregiver satisfaction with services received, and other relevant measures identified by HRSA.
  • Assess the impact of providing the core competencies training on the existing training infrastructure and resources available to states for training personal and home care aides. 
  • Assess the minimum number of hours of initial training that should be required for personal and home care aides.

Six states received PHCAST grants. California, Iowa, Maine, Massachusetts, Michigan, and North Carolina are using their PHCAST grants to design and operate demonstration projects that develop and implement curricula and certification programs and to improve their infrastructure for the training. The demonstrations seek to strengthen the direct care workforce by ensuring that personal and home care aides trained through PHCAST can bring their acquired skills to any job market in the country.

The national evaluation will provide findings about the ACA outcomes for the PHCAST program as a whole. It will also describe differences among the states’ programs and associated outcomes, taking into account the State environments within which the programs operate.



Walter R. McDonald and Associates, Inc. and the LeadingAge Center for Applied Research received a grant from Health Resources and Services Administration (HRSA) to design and implement a national evaluation of the Affordable Care Act Personal and Home Care Aide State Training program.

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Impact of Blood Pressure Telemonitoring on Hypertension Outcomes: A Literature Review
Author: Azza AbuDagga, Helaine Resnick and Majd Alwan
Publication Date: September 2010

A literature review was conducted from 1995 to September 2009 to collect evidence on the impact of blood pressure (BP) telemonitoring on BP control and other outcomes in telemonitoring studies targeting patients with hypertension as a primary diagnosis. The findings showed that BP telemonitoring resulted in reduction of BP in all but two studies; systolic BP declined by 3.9 to 13.0mm Hg and diastolic BP declined by 2.0 to 8.0mm Hg across these studies. These magnitudes of effect are comparable to those observed in efficacy trials of some antihypertensive drugs. Although BP control was the primary outcome of these studies, some included secondary outcomes such as healthcare utilization and cost. Evidence of the benefits of BP telemonitoring on these secondary outcomes is less robust. Compliance with BP telemonitoring among patients was favorable, but compliance among participating healthcare providers was not well documented. The potential role of BP telemonitoring in the reduction of BP is discussed and suggestions on priority populations that can benefit from this technology are presented. 

Community-Based Telemonitoring for Hypertension Management: Practical Challenges and Potential Solutions
Author: Hovey, L, Kaylor, MB, Alwan, M and Resnick, HE
Publication Date: August 2011

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. The aim of this report 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. This article reviews the technological challenges encountered during the study and proposes solutions relevant to future research and implementation of telehealth in community-based, congregate settings.

Diabetes in U.S. Nursing Homes, 2004
Author: Helaine Resnick, Janice Heineman, Robyn Stone and Ronald I. Shorr
Publication Date: February 2008

The 2004 National Nursing Home Survey collected cross-sectional data for 11,939 nursing home residents aged >65 years representing approximately 1.32 million individuals. That year, 24.6% of nursing home residents had diabetes as a primary admission and/or current diagnosis. Diabetes was present in 22.5% and 35.6% of white and nonwhite residents, respectively. Diabetic residents were admitted more often from acute care hospitals (42.5 vs. 35.3%), were more likely to have a length of stay >100 days (22.6 vs. 20.1%), and took more medications (10.3 vs. 8.4). Diabetic residents had 39% higher odds of having emergency department visits in the previous 90 days and 56% higher odds of having a pressure ulcer at the time of the survey. In the U.S. in 2004, one in four nursing home residents aged >65 years had diabetes, and these residents had increased odds of several unfavorable outcomes that are important for care planning. 

Documentation of Sleep Apnea in United States Nursing Homes, 2004
Author: Helaine Resnick and Barbara Phillips
Publication Date: 2008

This report defines the prevalence of documented sleep apnea in U.S. nursing home residents and examines characteristics associated with sleep apnea in this population. The key findings were up to 16 diagnoses were abstracted from the medical record at the time of the survey and residents with any of 10 ICD-9 codes for sleep apnea were identified. Sleep apnea was documented in 0.5% of U.S. nursing home residents. The unexpectedly small proportion of NH residents with documented sleep apnea precluded analyses of correlates of this condition in U.S. nursing home residents. In 2004, sleep apnea was virtually undocumented among U.S. nursing home residents. The near absence of recorded apnea may be due to selective mortality associated with sleep apnea, a perception on the part of physicians that apnea is a low priority or low impact condition in the context of the multiplicity of comorbidities in this patient population, or a combination of these and other factors. 


Our research on the topics of chronic disease and wellness.

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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. 


A $698,000 grant from the John D. and Catherine T. MacArthur Foundation will help the LeadingAge Center for Applied Research assess whether affordable housing settings can serve as effective platforms for meeting the health and long-term care needs of low-income older residents. The groundbreaking research project will also reinforce 3 of the LeadingAge Leadership Imperatives.

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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 online 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.


Center for Applied Research provides technical assistance to states and other organizations seeking to improve the recruitment and retention of individuals who provide support services for people with disabilities.

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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.



LeadingAge Center for Applied Research, in partnership with Social and Scientific Systems, Inc. (SSS), will be conducting analyses using the 2007 National Home Health Aide survey to provide technical assistance and policy analysis to the Office of the Assistant Secretary for Planning and Evaluation (ASPE). This project is funded by ASPE and the center is a subcontractor to SSS.

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