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.”


In December of 2010, the National Housing Conference and its research affiliate, the Center for Housing Policy, released two reports identifying specific regulatory and administrative changes the U.S. Department of Housing and Urban Development (HUD) could adopt to improve access to mainstream supportive services by residents of subsidized housing and facilitate and encourage the development and preservation of affordable and workforce housing in location-efficient areas.

The McHugh Long-Term Care Nursing Academy was established at the Center for Applied Research in 2005 to support quality nurse managers in long-term care settings. The Academy has published Scanning the Field: Nursing Leadership in Long-Term Care, a report that explores management training and leadership development programs and highlights major observations, cross-cutting themes, promising practices and issues for future consideration and action.


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