LeadingAge Magazine · July/August 2015 • Volume 05 • Number 04

Innovations in Housing Plus Services Rely on Expanding Staff Roles

July 12, 2015 | by Larry Beresford

New housing plus services models offer the promise of independence, affordability and better access to wellness-focused health care, but their success depends on a better-supported and growing workforce.

Demands on affordable housing providers are growing as their residents age in place with escalating medical and supportive care needs. More care, coordination and collaboration are required to help residents remain independent in their homes for as long as possible and manage their health effectively. Service coordinators, who are often the main interface with residents in need, also face growing demands in their jobs.

“Housing plus services” is a term coined by the National Low Income Housing Coalition to describe a variety of combined affordable housing and services initiatives for elders, adults with disabilities and others. The service coordinator role is central to this model as part of a team that can work holistically through purposeful partnerships with property managers and community organizations, says Alisha Sanders, director of LeadingAge’s Center for Housing Plus Services, launched in 2012 as a national catalyst for innovative housing strategies.

This role has been defined by the department of Housing and Urban Development (HUD), which funds many of these positions as a social services staff person hired or contracted to ensure that elder (and non-elder disabled) residents who are frail or at risk of health complications are linked to the services they need to continue living independently.

“But as residents’ needs have grown and intensified in many properties, the service coordinator role has also intensified,” Sanders says.

Resident service coordinators are generally understood as providing information and referral, not “hands-on” care—although it’s not always clear what hands-on means in this context, says Paula Carder, associate professor of community health at Portland State University in Portland, OR. Carder is now conducting research on a demonstration project in Portland that has brought together, as Housing With Services LLC, three housing property owners, a large health insurer and several health services providers covering 1,400 residents in 11 buildings. The Portland project, initiated by Cedar Sinai Park, is also one of 12 local teams participating in a national housing plus services learning collaborative piloted by Enterprise Community Partners of San Francisco with LeadingAge.

“At a recent meeting of service coordinators, I asked about the possibility of using nurses to teach unlicensed personnel to assist with medication administration in these settings. There was a kind of gasp that went up in the room,” Carder says. “They felt that this was over the line for service coordinators. Trying to identify that line is a big part of our project. We know that service coordinators sometimes do things they aren’t licensed to do simply because there’s no one else to do it. But that is often an uncomfortable situation for them. There’s also a regulatory line that may get crossed.”

The Portland project is trying to show that enhanced services, more care coordination and collaboration with health plans’ health navigators can reduce overall health care costs and improve health outcomes.

“The trending data are clear: Whether you call it a silver tsunami, or just a lack of affordable housing, if you want people to age in place and have good outcomes, you have to step up the service model,” says Howard Klink, the Cedar Sinai project director. “That means a greater coordination function, with additional services to address high-need problems. Sometimes those high needs fall into the resident service coordinator’s lap.”

Before this project, when complicated problems came up, unless a truly special service coordinator was involved, there were serious limits to what could be done for the resident, Klink explains. Now, the service coordinator is one player in a continuum of care. The resident may also be assigned a case manager, care coordinator or health navigator from a health plan or community agency. A service coordinators’ work group in Portland is developing job descriptions for the various roles, a chart to define their complex interactions, and a resource guide for other housing communities.

“By having this model in place, we’re implicitly raising the bar and having the players communicate regularly with each other,” Klink says. “We are learning how to teach housing people to speak health care and health care people to speak housing. We’re after both population health outcomes and individual health outcomes. In aggregate, we believe, the resident service coordinators and the enhanced coordination are bending the cost curve.”

LeadingAge Thrive provides resources to help members achieve peak effectiveness at serving seniors and their communities. The seven major topic areas in Thrive include questions designed to stimulate discussion among your leadership team and board of directors. Thrive also includes resources such as white papers, articles, tools, presentations and business intelligence.

Under the “Workforce and Leadership Development” section of Thrive, see the resources connected to these questions:

  • Do we have a comprehensive orientation program for new employees across all staff levels and settings?
  • Do we conduct employee satisfaction and engagement surveys, provide employee feedback, and use the data to make organizational decisions?
  • Do we use evidence-based management best practices (e.g., supervisory training, open communication, empowerment of frontline staff, self-managed work teams, peer mentoring and support) to set organizational priorities, solve problems, improve the working conditions and the quality of the job and minimize turnover and instability in the workplace?
  • Do we offer competitive compensation and benefits for staff at all levels and across all settings?
  • Do we have specific plans to strengthen our workforce by putting into practice competencies and competency-based training? If so, do you build these competencies into your performance evaluations?
  • Do we have a comprehensive cultural competence strategy to support healthy staff-to-staff and staff-to-resident/client relationships and quality service delivery?
  • Do we have in place a comprehensive employee orientation program?

 

Under the “Quality” section of Thrive, see the resources connected to these questions:

  • What quality metrics define and differentiate our services?
  • How do we internally track and share publicly reported measures?
  • How do we use quality measurement for continuous process improvement?
  • Do we utilize your data and quality reports to differentiate your services to potential referral sources?
Under the “Strategic Planning” section of Thrive, see the resources connected to these questions:
  • Do we have a process to regularly and rigorously assess internal core competencies as well as external market opportunities and threats?
  • Do we have a mechanism to measure outcomes and evaluate progress to determine if the implementation of our strategy is successful?
  • Would you say your organization understands the needs, competition and the overall markets in which it operates?
  • Do we engage in partnerships and collaborations with other organizations to study, develop and offer new service/care models and practices to improve the quality of aging services and care?

Thrive is a LeadingAge member benefit, and access is limited to members. Use the MyLeadingAge login page to log in or create an account.

Visit the Thrive main page.

Volunteers of America, based in Alexandria, VA, operates 184 senior affordable housing plus services communities nationwide and deploys active service coordinators in 134 of them. According to the first 12 months of detailed data gathered with new software on more than 7,000 recipients of services in those 134 properties, 95% of the residents received services from a service coordinator, with an average of 21 annual interactions.

For the past two years, Volunteers of America’s Senior Director of Research and Outcomes, Jessica Meyerson, has helped the organization find evidence-based tools to better identify residents who are frail and at risk for conditions such as depression or social isolation. “Our service coordinators have done a really good job of reaching our seniors, providing a broad range of services, bringing in services, getting people out of social isolation,” Meyerson says. “What we’re trying to do is improve the tools they use, introducing tools that are more robust and research-based in order to intervene earlier and do more intensive care planning with residents.”

The service coordinators have been challenged to learn a new computerized database called ServicePoint by Bowman Systems. In 2014, they also began using an evidence-based depression screening tool called Healthy IDEAS (Identifying Depression, Empowering Activities for Seniors).

“[The] transition to the new computer system has been a long, slow, iterative process. It has not been easy, but we’re taking a multi-pronged approach. We’re providing as much training as we can,” Meyerson says. “It’s really important as we all go through this process of trying to make housing plus services more health-oriented that we listen to the field and define a role that’s appropriate for our service coordinators.”

“Our experience in general, not just in this professional community, is that if you start reforming and improving professional practices in what’s already a very demanding job, you naturally create more work for people, and you can generate some resistance. Even though research shows us it takes a lot of professional training and special tools to determine when someone is clinically depressed, it’s easy for the service coordinator to say, ‘I don’t need this—I already know when somebody is depressed,’” Meyerson says.

The organization offers training and orientation to the new tools, along with monthly webinars for service coordinators, quarterly conference calls, quarterly in-person meetings in some locales, and opportunities for service coordinators to attend national meetings such as the annual conference of the American Association of Service Coordinators. New service coordinators in their first 30 days of work take an online training course on the computer system and are certified in its use.

A quality assurance process has focused on helping service coordinators with these challenges and involving them in discussions about any proposed changes. Based on their input, “we decided to implement a much shorter, two-question depression screening tool for the frontline service coordinators,” says Donna Thurmond, Volunteers of America vice president of resident services and programs. “We’re also starting joint training for property management staff and service coordinators, to make sure they are all getting the same information.”

Fair Share Housing Development of Mt. Laurel, NJ, has a community, Northgate II, in Camden, a community with serious poverty and urban crime issues. Northgate II was identified as a health care “hotspot” within Camden’s socially isolated frail elder resident population, based on a data-driven process for timely identification of extreme patterns of health care utilization developed by the Camden Coalition of Healthcare Providers.

Fair Share, which received an Innovations Fund grant from LeadingAge and the NewCourtland Foundation in 2014, used the award to hire a community health worker as part of expanding its social services for residents, reports Director of Social Services Marilyn Mock. In addition to working with the Camden Coalition, Mock says, “We partnered with an agency called the Camden Area Health Education Center, which placed medical students in our building to help identify residents at high risk for negative outcomes.” Together these agencies belong to the first Medicaid accountable care organization in New Jersey.

“Our service coordinators are not trained social workers. But we have a full complement of staff, who all see their jobs as advocating on behalf of residents. It’s really soup to nuts—whatever people need, running the gamut, whatever we can provide,” Mock says. In 2013 the Camden Coalition did a follow-up analysis and found that Northgate II is no longer a health care hotspot.

“I’ve been blessed with a very committed team—all on board with our goals. We do a careful and thorough hiring process in which the team participates,” Mock says. “I used to work at Macy’s years ago, and I remember a sign in the office that said: Hire for attitude, train for skills.” It’s also important to give staff opportunities to talk about the difficulties of their work.

“We’ve learned we can’t do everything. So contracting with other community agencies is essential,” Mock says. As with the other projects profiled in this article, enhancing housing plus services doesn’t necessarily require increasing the housing provider’s staff. Effective collaborations with health providers and additional layers of case management, care coordination and information and referral are expanding the capacity of these communities to prevent emergency room visits, rehospitalizations and other negative outcomes. Still, many service coordinators and managers complain about staffing shortages and the resulting heavy caseloads.

Springpoint Senior Living, Wall Township, NJ, is helping create homes for older adults who were harmed by Superstorm Sandy. The New Jersey Housing and Mortgage Finance Agency (NJHMFA) recently awarded Springpoint a $7.8 million grant that will help the organization convert an underused building on its Crestwood Manor CCRC campus into affordable rental housing for Ocean County seniors who were impacted by Sandy.

The source of the funds is the Community Development Block Grant Disaster Recovery (CDBG-DR) program.

The new community, Manchester Senior Housing, will include 58 one-bedroom apartments with monthly rents averaging $750 and 11 two-bedroom apartments with monthly rents averaging $900, for seniors age 62 and up. The 26-year-old building, located on the edge of Springpoint’s Crestwood Manor CCRC campus in Whiting, NJ, was a 70-unit independent living building that was about half occupied, according to Pam Smith, Springpoint’s senior vice president of strategy.

“The affordable aspect of the project is great, and we have to give priority to Sandy-impacted residents. We couldn’t have done this without the grant,” says Smith. Prospective residents must be 62 or older and meet income criteria set by the state.

The renovations will cost around $12 million, according to Smith. Springpoint will use low-income housing tax credit equity and NJHMFA financing to cover the balance of the costs. The number of units will be slightly reduced, and five units will be reserved for the disabled. The building will have its own private entrance and parking lot and will not be physically connected to Crestwood Manor. The first new residents will likely move in next spring.

Christine Hazzard is a service coordinator in a less urban setting, with Brattleboro Housing Partnerships, a public housing authority in Brattleboro, VT. “Our housing organization manages six properties, three for seniors and adults with disabilities, who often have somewhat similar needs. We meet people where they are when their ability to live independently is constantly changing. We also collaborate with other agencies, including the Council on Aging, also called Senior Solutions, and with the hospital’s community health care team. We work with Visiting Nurse and Hospice for Vermont and New Hampshire, and with Health Care & Rehabilitation Services, the mental health agency for Southern Vermont,” she says.

Hazzard is also part of the innovative Support And Services at Home (SASH) program for enhancing the service coordinator role in senior housing programs across the state by pairing up service coordinators with wellness nurses. SASH has been shown to slow the rise of total annual average Medicare expenditures for participating seniors.

“If I could have a wish list, I’d wish for more staff. I’ve hired four other service coordinators since I’ve been here, and we’ve all been successful, even with big caseloads,” Hazzard says. “Very few of the residents I’ve worked with ended up in a nursing home for any extended period. We give them confidence. We find the small pieces that help people live independently. We see that a little bit of support goes a long way. But if we had more staff, we’d be even more successful.”