How Hebrew SeniorLife Plans to Bring Wellness to Housing

CFAR | July 06, 2017 | by Geralyn Magan

An 18-month demonstration program implemented by Hebrew SeniorLife will test whether an onsite wellness team could help residents of affordable senior housing remain healthier and more independent.

When July 1 dawned in Boston, MA, 400 residents of 6 affordable senior housing communities began an 18-month experiment to see if an onsite wellness team could help them remain healthier and more independent.

The residents are participating in “Right Care, Right Place, Right Time” (R3), a $900,000 demonstration program being implemented by Hebrew SeniorLife (HSL), a LeadingAge member in Boston, with help from a collection of funders and partners.

Between now and December 2018, 2 onsite teams will coordinate the delivery of enhanced, person-centered wellness services to vulnerable older adults in 3 affordable senior housing communities operated by HSL and 3 communities operated by 2 other housing providers.

The demonstration is designed to establish best practices, measure outcomes, and create a sustainable model of supportive housing that can be replicated on a national level, says Kim Brooks, HSL’s vice president of senior living.

The Massachusetts Health Policy Commission’s Health Care Innovation Investment Program contributed $420,000 to the project. Another $480,000 comes from MassHousing, the state’s Department of Housing and Community Development, Enterprise Community Partners, and Beacon Communities.

The LeadingAge LTSS Center @UMass Boston will evaluate project outcomes after the implementation phase ends in late 2018.

Enhancing, Not Replacing

Providing supportive services in housing communities is not a new endeavor for Hebrew SeniorLife, which employs resident service coordinators in each of its 5 affordable housing communities. The R3 project will allow the organization to enhance that housing with services model in the demonstration sites, says Brooks.

“We are not trying to undo what already exists,” she says. “These teams will enhance whatever is already happening in a community. A resident service coordinator is not typically getting into the level of coordination or management of care transitions that we are hoping these enhanced teams will be able to do.”

Each enhanced wellness team consists of a full-time wellness coordinator and a full-time wellness nurse who are responsible for:

  • Assessing residents and collecting data: Wellness teams are conducting baseline assessments of every resident that enrolls in the R3 program. Teams will also conduct follow-up assessments in 18 months to measure the demonstration’s success relative to key performance indicators, including falls, medication adherence, emergency room trips, hospitalizations, and long-term care placements.
  • Engaging with health plans: Two health plans -- Tufts Health Plan and UnitedHealthcare – now serve on the R3 project’s advisory group, where they have offered guidance on how to design the project, and how to connect health care and housing most effectively. Brooks expects that the resident assessment process will identify additional partners that should be at the table because they serve residents in R3 housing communities. “We’re hoping to create a much more efficient model so our onsite teams can be the eyes and ears for a health plan, and help it manage residents’ care transitions and changes in condition,” she says.
  • Reaching out to first responders: The wellness teams are also tasked with reaching out to fire departments and ambulance companies that can provide key information about the cause and outcome of each emergency call they make to a housing community. The partners will then work together “to analyze and understand these trends and to figure out how we can reduce unnecessary trips and even some unnecessary calls,” says Brooks.
  • Conducting regular check-ins: The enhanced team will check in regularly with R3 program participants to follow up on issues that emerged during the baseline assessment, and to help residents set and reach health goals. “That involves understanding what is important to people and helping them get connected to programs and resources that may be of value to them,” says Brooks.

Program participants will experience “a more enhanced level of impact” from the R3 program, because they have signed agreements allowing the wellness team to communicate directly with their health care providers. But all residents of a housing community should benefit from the enhanced collaboration that the wellness team will develop with first responders and health plans, and from community-wide programming that the wellness team will develop to help residents address shared health concerns.

Looking to the Future

Brooks is confident that the R3 program will help reduce resident transfers to hospitals and emergency rooms, and result in substantial health care savings. With those outcomes in hand, she’d like to continue working with health plan partners to refine the R3 model so it is financially sustainable and nationally replicable.

“We’re in a great position to take a leadership role here by making it our mission to help others replicate this model,” says Brooks.