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LeadingAge magazine July/August 2011

Housing + Services Models Preserve Independence

by Dianne Molvig

Changing demographics, consumer preferences and an aging population in senior housing communities are feeding a natural movement toward more sophisticated housing-plus-services models.

Grace, 82, has lived in her own apartment in an affordable senior housing complex for 16 years. To her, this is home. She loves tending the plants she has on her small balcony, visiting with friends who live nearby, and whipping up batches of cookies for the meetings of the book club she and a few neighbors founded long ago.

But lately Grace has struggled a bit. She’s cut back on grocery buying to save money and has become lax about preparing balanced meals. Sometimes she simply forgets to eat. One afternoon she has a dizzy spell, and a neighbor finds her collapsed on the floor, disoriented. She’s whisked away to the emergency room and gets admitted to the hospital for observation. After two days, she’s sent home with advice about the importance of adequate intake of food and liquids. Three months later, Grace has a similar episode and again lands in the hospital.

Housing providers across the nation recognize residents like Grace in their midst. With a little help, she could stay in her apartment and remain independent for years to come. Without help, and unable to afford to hire someone to provide it, she may end up in a nursing home, even though she doesn’t need that level of care.

Some affordable housing organizations are creating solutions by providing more than a roof over people’s heads. They’re offering housing plus services to meet their residents’ physical, emotional, psychological and social needs.

Housing Becomes a Hub

One future of the housing-plus-services approach is unfolding in Vermont, through the Support & Services at Home (SASH) program. A one-year SASH test project at an 82-unit affordable housing site in Burlington found:

  • A 19 percent reduction in residents’ hospital admissions
  • A 22 percent decrease in falls
  • Dramatically reduced hospital readmissions among residents who had been previously discharged during the test year
  • A 10 percent drop in the number of residents who were physically inactive
  • A 19 percent reduction in the number of residents at moderate nutritional risk
  • No bounce-back to nursing homes among residents who had experienced a crisis and had a nursing home stay before returning to their apartments

“The key is the physical presence of the SASH coordinator who is on top of each resident’s needs. The coordinator can tailor support for that individual,” says Nancy Eldridge, executive director of Cathedral Square Corporation in South Burlington, Vt.

Eldridge recognized a need for a coordinated effort such as SASH, based on what she witnessed among residents in her housing organization. “Residents are staying longer, for 20 or 30 years,” she says. “They’re getting more frail, physically and cognitively. We know our residents. We can’t just let them live in risky situations or have to prematurely move to another setting, just because we haven’t figured out how to give them the support they need.”

SASH aims to give older Vermonters that kind of support. It was created through the collaboration of organizations, including housing organizations, the Vermont Health Foundation, the State of Vermont, LeadingAge, academic researchers, PACE Vermont, the Area Agency on Aging, hospitals, the Visiting Nurse Association and mental health agencies.

SASH 3 women walking J-A11
Cathedral Square Corp.

Mary (90), Rena (70) and Katie (93) return from “Eat Better, Move More,” an evidence-based program offered by SASH.

In the SASH model, each housing site has a SASH team, comprising various local service providers, which meets twice a month to review residents’ situations and discuss their needs. Anchoring that team are the SASH coordinator and a wellness nurse who work closely with residents at the housing site.

The SASH coordinator keeps tabs on residents’ well-being and changing needs. He or she tracks residents discharged from the hospital or nursing home to be sure they get the services they need after returning to their apartments. Plus, the SASH coordinator plays a key role in transforming the facility’s culture, so that all staff members—direct caregivers, maintenance workers and so on—understand and support the goal of helping residents remain in their homes as long as possible.

Six housing organizations, with about a dozen sites total, will launch SASH programs this fall. After that, a phased rollout will get underway statewide. By 2014, all 112 not-for-profit affordable housing sites for seniors in Vermont will be SASH service hubs. Eventually, those can be information hubs for all Medicare-eligible Vermonters, wherever they live in the community.

“Older people will have the resources they need at their fingertips,” Eldridge says. “They will know SASH is their safety net.”

At the same time, Vermont will save money. “We believe we will show significant savings on the hospital and nursing home sides,” Eldridge says. “We’ll show that by redirecting some of those savings back to prevention and on-the-ground, person-centered care management, you just keep on saving.”

Getting Commitment

A program such as SASH aligns with the nonprofit responsibility, as Eldridge sees it. “Our 501(c)(3) tax status is in exchange for community benefit,” she says. “As nonprofits, we’re able to go into a project for the long haul. A for-profit partner won’t get in there and slog it through for five to 10 years.” Planning for SASH, for instance, began in 2008, and won’t reach full implementation until 2014.

The SASH hub model benefits older citizens with at-your-fingertips access to services. Still, a collaborative effort such as this has inherent challenges. Budget axes are falling everywhere, and service providers feel vulnerable. Turf protection naturally sets in. But, through collaboration, SASH partners “have committed to nonduplication of services,” Eldridge says. She feels that kind of commitment can better assure everyone’s future.

“When proposals emerged to eliminate Medicare as we know it today,” she says, “it was ‘Hello, folks, this is what we’re talking about.’ We either hold hands together in a serious way and eliminate the costs that are criminal, that we’re letting happen by our inaction, or we all just get slammed with cuts.”

Patrick Flood, deputy secretary for the Vermont Agency for Human Services, agrees SASH’s collaborative approach, with housing providers playing a central role, has benefits all around. “It’s more efficient and effective,” he says. “The state of Vermont will get better outcomes for the people we serve. We’ll achieve savings in both Medicaid and Medicare. If you reduce expenditures there and move that money back into the home community system, then the community service providers, the housing providers and the residents all win. Nobody loses.”

What’s more, the SASH model can work anywhere, Flood believes. A statewide program can work in Vermont because it’s a small state, having a community-based system, “so everybody knows everybody,” he observes. “But any state can do this. You could do this on a regional basis within a state or in a city. I’ve often thought about what it would be like to do this in Manhattan or Brooklyn or even just a city block. You would have the same good outcomes and save the same kind of money. There is no reason this isn’t replicable anywhere.”


Better Living

While the SASH program’s eventual goal is to serve all elderly Vermonters, no matter where they live, many housing providers offer extra services to help their own residents remain independent. One of them is Tower One/Tower East in New Haven, Conn., which has 336 units housing 350 residents with an average age of 87.

“Speaking as a former nursing home administrator for 21 years, I’d say a significant number of our residents would be in a nursing home if we didn’t offer added services,” says Richard Slutsky, president/CEO.

Tower East is subsidized-rent housing; Tower One is a mix of subsidized and market-rate apartments. Among total residents, about one-third live independently, and an equal proportion live in assisted living apartments. The remaining third are in apartments outside of the assisted living section, but receive various home-based services.

Tower One/Tower East contracts with Utopia Home Care, Inc., as a fee-for-service provider, although residents may choose to hire another agency. Residents may qualify for state aid to help pay for these services.

“We keep folks off Title 19 longer,” says Mark Garilli, chief operating officer. “Even though they receive state aid for some services, that amounts to a fraction of the cost the state would pay if those individuals had nowhere to go but a nursing home.”

Four Tower One/Tower East service coordinators, each assigned to a quarter of the residents, work directly with residents to ensure they’re getting needed services. The service coordinators perform multiple functions, from helping a resident understand a cable bill to making sure support is in place for a resident returning from the hospital.

One way that Tower One/Tower East monitors residents’ well-being each day is through the “I’m okay” check. Residents get “I’m okay” stickers to put outside their apartment door in the morning if all’s well. If no sticker appears, security personnel knock, then call and then enter if necessary to make sure nothing is amiss.

Primary health care is readily available at the onsite health clinic, operated by a local hospital. A private geriatric psychiatry practice also has an onsite office. As of July, residents will have onsite physical, occupational and speech therapy services available, as well.

“In the Northeast, transportation is a major issue for the elderly,” Slutsky says. “We try to bring in as many services as possible so they don’t have transportation issues.”

In Slutsky’s view, “housing plus services” is aligned with his organization’s mission: to provide older persons of varying means with high-quality living arrangements and services based on Jewish values and traditions. “We have a saying here,” he notes, “that we don’t necessarily add years to residents’ lives. We add life to residents’ years.”