Does Care by Design Have Programs for Low-Income Seniors? Exploring Integrated Housing and Health Models

I. Understanding the Need for Integrated Care and Housing

As the population ages, particularly with the baby boomer generation entering their senior years, there’s a growing emphasis on enabling older adults to live independently and age within their own communities. This aligns with the principles of person-centered care, which prioritizes the individual’s needs and preferences, especially for vulnerable, low-income seniors. This approach recognizes that a person’s environment, crucially including housing, significantly impacts their health and overall well-being.

Building upon decades of expanding home and community-based services (HCBS), the Affordable Care Act (ACA) has further broadened Medicaid-funded options. This expansion presents unique opportunities to investigate how housing with integrated services can efficiently serve a large number of lower-income older adults. The “Money Follows the Person” demonstration, aimed at transitioning individuals from nursing homes back into communities, has highlighted the critical shortage of affordable housing options that also offer necessary services. The U.S. Department of Housing and Urban Development (HUD) also acknowledges the vital role of services in supporting elderly residents to age safely in their homes. Recent HUD policies underscore the importance of aligning new housing developments with healthcare reforms at both state and federal levels to better support seniors aging in place.

Recognizing the current fragmentation in service coordination for Medicare and Medicaid beneficiaries, particularly those managing multiple chronic conditions, the ACA established new entities within the Centers for Medicare and Medicaid Services (CMS). These aim to oversee innovative payment and service delivery models like Accountable Care Organizations (ACOs) and Medicaid Health Homes. These initiatives seek to reduce fragmentation and control escalating costs. These new avenues provide a chance to explore the role of affordable housing with services in achieving these healthcare reform goals. Additionally, the American Recovery and Reinvestment Act offers further funding for evidence-based preventative services for low-income elderly individuals residing in subsidized housing and nearby communities.

In essence, the concept of affordable housing integrated with services for older adults is gaining traction. This approach is driven by the growing adoption of person-centered care and the widespread desire for seniors to “age in place.” Emerging models in this area must leverage current trends and ongoing federal and state policy initiatives aimed at reforming healthcare and housing for low-income older adults.

II. The Purpose of Exploring Housing with Integrated Services

The HHS Office of the Assistant Secretary for Planning and Evaluation’s Office of Disability, Aging and Long-Term Care Policy, in collaboration with HUD and the Administration on Aging, commissioned the Lewin Group and associated experts to develop design options for a demonstration project. This project would focus on targeted and coordinated housing, health, and long-term care services and supports for low-income older adults. This framework serves as a guide for this project by:

Defining the policy challenge that the demonstration seeks to address.
Clearly stating the demonstration’s objectives and anticipated results.
Establishing the overall scope and limitations of the demonstration.
Presenting and comparing different strategies for targeting interventions, including their respective advantages and disadvantages.
Describing current practices and essential components that the demonstration might incorporate.
Identifying the key research and practical questions that the demonstration aims to answer.

III. Defining the Policy Problem: Affordable Housing and Service Gaps

A significant and rapidly growing population of low and modest-income seniors faces the intertwined challenges of securing affordable, safe housing that can adapt to their evolving needs as they age. Millions of older adults who rent or own homes struggle with excessive housing costs and/or live in dwellings with significant physical deficiencies. Data from the 2009 American Housing Survey (AHS) reveals that approximately 1.8 million very low-income older adults (earning 50% or less of the area median income) spend over half their income on rent and/or reside in substandard housing. An additional 1.3 million elderly renters live in publicly subsidized housing. As these individuals age, a greater number experience chronic health issues and/or debilitating physical, cognitive, and mental health conditions.

The current healthcare system, characterized by multiple payers like Medicare and Medicaid, provides limited incentives for collaboration among primary, acute, and chronic care providers. This lack of coordination is even more pronounced when considering low-income housing and aging and long-term care service providers. Consequently, many older adults encounter a fragmented and poorly coordinated service system precisely when they need integrated support the most, often with detrimental consequences. The ability of seniors with chronic conditions and/or disabilities to maintain independent living can be prematurely curtailed, their health and safety jeopardized, and public and private healthcare costs can escalate due to preventable issues. These include premature transitions to costly nursing homes or residential care facilities, frequent emergency medical service calls, repeated emergency room visits, and hospital readmissions.

The aging baby boomer generation will further intensify the already high demand for affordable housing that incorporates health and long-term care supports. One promising policy approach to address this demand is to leverage existing independent, publicly assisted rental housing, including senior-designated apartment buildings and rental properties with a significant senior population. These housing settings can serve as a foundation for intentionally building a coordinated system of health and long-term care services and supports for residents and similar low-income seniors in the surrounding community. Innovative housing providers across the nation, in collaboration with community organizations, have proactively developed various models of affordable housing with integrated services to support residents as they age. While research has explored the benefits of supportive housing for vulnerable, low-income populations like the homeless, there’s limited research specifically on the outcomes associated with subsidized senior housing linked with services. The existing evidence base remains inconclusive.

IV. Rationale for a Demonstration of Affordable Housing with Services

Several converging factors are prompting policymakers, housing providers, service providers, and seniors themselves to seriously consider integrating services into affordable housing platforms. Many publicly assisted housing properties offer inherent advantages:

Concentration of Older Adults: These properties house a significant number of older adults, many with multiple chronic illnesses and functional impairments. This concentration creates economies of scale for preventive, primary, and long-term service providers.
Existing Infrastructure: Many properties have infrastructure that facilitates on-site care coordination and health services, such as accessible buildings and common areas suitable for co-locating health services, and often have existing service coordinators.

For a demonstration to be successful and sustainable, it must provide value for all key stakeholders:

Federal and state health policy officials are increasingly focused on high-cost patients who frequently utilize emergency rooms and hospitals as a key area for controlling rising healthcare costs. Implementing evidence-based interventions within subsidized housing could improve the health of residents and reduce overall healthcare expenditures.
Anticipated Medicare payment reforms and Medicaid funding opportunities will incentivize preventive, primary, acute, and long-term services and support providers to collaborate to improve care for individuals who drive high healthcare spending due to the current fragmented system.
Sponsors and managers of publicly assisted housing may be compelled to consider greater service integration due to an aging resident base and the associated rise in chronic illness and disability. From their perspective, partnering with health and social service providers can help reduce accidents, injuries, and 911 calls from residents. It can also facilitate compliance with fair housing regulations and Olmstead requirements, improve resident transitions between housing and healthcare settings, enhance resident and family security and satisfaction while promoting resident autonomy, improve overall safety and reduce complaints about residents who are “too sick” to remain, lower housekeeping and maintenance costs, reduce resident turnover and evictions, and enhance the property’s image in the community, serving as a valuable marketing asset.
Affordable and accessible senior rental complexes, intentionally designed to provide integrated health and long-term care services and supports, can empower low-income seniors to maintain their desired autonomy in an independent living setting while having access to care as needed.

V. Policy and Practice Questions for Demonstration

This demonstration aims to address the following key policy and practice questions:

Can independent affordable senior housing (primarily subsidized congregate apartment buildings) effectively serve as a platform for addressing the health and long-term care service and support needs of low-income older residents (62+) and a proportion of similar individuals in the surrounding community?
Which housing with services models yield the most favorable outcomes?
Does targeting specific resident groups enhance the likelihood of achieving desired outcomes?
What capacities, infrastructure, and resources are essential within housing providers, their partners, and the communities to ensure the demonstration’s success?
To what extent can demonstration sites utilize existing federal and state data sources to identify potential sites and participants? What role should government play in data accessibility?
Which regulations from HUD, local housing authorities, financing agencies, and property owners (e.g., fair housing rules, service coordinator restrictions, financing for service coordination, accessibility features, live-in aide policies) pose significant barriers to implementing the proposed design and how can these be overcome? (Some issues may be defined in Housing Quality Standards (HQS)).
Which federal and state health and human service policies and/or regulations hinder demonstration implementation and how can they be addressed (e.g., state licensing for congregate settings providing health services, federal privacy rules, barriers to integrating services for dual-eligible individuals)?
What other obstacles to the demonstration need to be addressed (e.g., insurance liability concerns/costs, local fire and safety ordinances)? What types of properties are affected and how can these obstacles be overcome?

VI. Key Outcomes of Interest for Evaluation

The demonstration could evaluate both structural/system-level and individual resident outcomes, including:

A. Structural/System Outcomes

Improved service efficiency and coordination between affordable housing and health and long-term care providers, especially for high-risk, medically complex, and chronically disabled seniors.
Enhanced physical accessibility of housing and improved property maintenance.
Reduced Medicare and Medicaid expenditures.
Improved property compliance with Fair Housing regulations.
Support for states in adhering to Olmstead regulations and implementing healthcare reform and rebalancing initiatives, including Money Follows the Person.
Promotion of growth in accessible, affordable independent housing for lower-income older adults.

B. Resident Outcomes

Empowered low-income residents of affordable independent senior housing, and community residents, to maintain health and functional ability for as long as possible.
Improved resident safety, quality of life, and quality of care (both within housing and in the wider community).
Reduced resident turnover and evictions.
Increased and improved range and comprehensiveness of services received by residents.
Reduced unnecessary hospitalizations, emergency room utilization, and decreased or delayed transfers to higher-level care settings (e.g., assisted living, nursing homes).

C. Target Population for Services

The demonstration will focus on low and modest-income older adults eligible for federal housing subsidies, including residents of Section 202 properties, public housing, Section 8 voucher recipients, and residents of Low-Income Housing Tax Credit (LIHTC) properties. Seniors with similar income profiles living near participating housing properties will also be included. Within this broad group, the design team is considering targeting specific subgroups based on the selected service delivery model:

Individuals with mild activity of daily living (ADL)/instrumental activity of daily living (IADL) impairments at risk for falls, medication errors, etc.
Individuals with multiple chronic diseases and significant disabilities.
High Medicare spenders.
Healthy/well older adults who could benefit from preventative and wellness services.

VII. Potential Service Delivery Models and Targeting Approaches

Service delivery models can vary significantly, focusing on interventions at different stages of chronic health conditions and disability. A public health-oriented model would target all low-income older adults in participating housing and the surrounding community, aiming to improve overall health and quality of life. Conversely, a risk-based model would concentrate resources on a smaller subset of high-risk seniors. The demonstration could assess the cost-effectiveness, benefits, and implementation considerations of both broad and narrow models.

Health Promotion and Chronic Care/Disability Management Across the Life Course and within Publicly Assisted Rental Housing*
Stages
Level of Prevention
Nature of Intervention
Responsible Sectors
Intervention Goals
Each start requires a greater level of sophistication and involvement with health care providers on the part of subsidized housing owners and managers. * See the PDF version of this report for a graphic version of this table.

A crucial decision point in designing service delivery models will be the degree of service integration across settings and systems. While a universal definition of “integration” is lacking, key elements generally include: (1) comprehensive and flexible benefits; (2) extensive delivery systems encompassing community-based long-term care and care management; (3) mechanisms that truly integrate care (e.g., care planning protocols, interdisciplinary teams, integrated information systems); (4) overarching quality control systems with clear accountability; and (5) adaptable funding streams that incentivize integration and minimize cost shifting.

A. Public Health Model Examples in Subsidized Housing

A public health model would incorporate a wide spectrum of primary, acute, chronic, and long-term care services and supports. Service organization and delivery could be based within a single housing property or managed by a corporate owner of multiple properties in a region, or by a nearby community agency like a Federally Qualified Health Center, Area Agency on Aging (AAA), physician practice designated as a medical home, health plan, or local public health department. The housing property and its service coordinator would be essential partners. The housing provider would offer space, contribute to resident screening and assessment, assist in negotiating agreements with community providers, facilitate on-site partner visits, and help monitor service delivery and quality.

The public health model would be rooted in communities with high concentrations of low-income seniors and subsidized senior housing, ensuring a sufficient volume of elderly residents to potentially demonstrate cost-effectiveness for Medicare and Medicaid, the service delivery system, and payers. This model targets all low-income older adults in participating properties and the surrounding community, aiming to improve overall health and quality of life. Participants could include:

Healthier older adults who could benefit from preventative and wellness services like health education, blood pressure and glucose monitoring, and exercise programs.
Individuals at increasing risk who are aging and becoming frailer, making them more susceptible to illness and injury.
Specific populations with multiple chronic conditions, significant behavioral health issues, and/or disabilities who are at high risk for repeated ER or hospital visits and falls.
While focusing on the entire elderly resident population, public health models could range from modest interventions addressing prevention, psychosocial, and chronic care needs of select individuals to fully integrated programs covering the complete range of medical and social needs of residents and the surrounding community.

Examples of existing programs that exemplify this model include:

Lapham Park, Milwaukee, WI: A senior-designated public housing property providing a range of on-site services through community partners to address residents’ preventative, acute, and long-term healthcare needs. St. Mary’s Family Practice Clinic offers physician care to all residents. Community Care Organization, operating a Program for All-Inclusive Care for the Elderly (PACE), provides comprehensive care for nursing home-eligible residents enrolled in their program. The Milwaukee County Department on Aging provides a congregate meal site. Other community partners offer additional wellness programs, and S.E.T. Ministry provides case management.
Seniors Aging Safely at Home (SASH), Burlington, VT: A care management model coordinating health and long-term care services for residents of affordable senior housing and community members. A full-time SASH coordinator, employed by the housing property, leads a team of community service providers, including a home health agency nurse, an AAA case manager, a mental health provider, and representatives from other HCBS providers like PACE. A “health aging plan” is developed with participating residents, and the SASH coordinator facilitates its implementation through community partners.
Mable Howard Apartments, Oakland, CA: A community health center and PACE adult day health center co-located with low-income senior housing allows residents to age in place. Residents benefit from a spectrum of services, from flexible health center services to comprehensive medical and long-term care through PACE. The health center, a Federally Qualified Community Health Center, provides preventative care, primary care, case management (including mental health), podiatry, dental care, health education, screening, physical therapy, and home health referrals. PACE offers nursing home-eligible residents comprehensive medical, social, and long-term care services within an on-site adult day health center, with in-apartment care as needed.

B. Risk-Based Model Examples in Subsidized Housing

Risk-based models also require communities with a high volume of low-income older adults in affordable housing. However, community selection would also consider factors like higher concentrations of very elderly (85+) and/or chronically ill seniors. This model could target services to one or more high-risk senior subgroups (not mutually exclusive):

Dual-eligible individuals who are high utilizers of Medicaid and Medicare.
Individuals with three or more chronic illnesses.
Those at risk of nursing home admission for extended stays due to cognitive or physical impairments (e.g., multiple ADLs).
Individuals with significant behavioral health issues.
The top 5% or 10% of Medicare spenders.

Service organization and delivery are more likely to be managed by an entity outside the housing property, such as a health plan, primary care practice, community mental health center, medical home, or ACO for several reasons:

Most housing providers lack the capacity to manage the intensive level of care required.
Housing providers are often wary of the regulatory requirements of becoming licensed healthcare providers.
Individual properties may not have sufficient volume to support the business model, requiring an external entity with a larger population base.

Examples of current strategies illustrating this model include:

The Marvin, Norwalk, CT: Operates Connecticut’s Congregate Housing for the Elderly Program, a state-subsidized program for low-income seniors with temporary or periodic difficulties in one or more essential ADLs. Residents pay a minimum rent and a congregate service charge based on income, with state subsidies for those unable to afford the full service program cost. Services include housekeeping, emergency call systems, 24-hour security, community meals, social and recreational activities, wellness/prevention programs, and emergency transportation. The Marvin also participates in the state’s assisted living services program, providing an on-site nurse, 24/7 on-call nurse, personal care assistance with ADLs (dressing, grooming, bathing, toileting, transferring, walking, eating), and core services like housekeeping, laundry, and meal preparation. Assisted living services are funded through a Medicaid waiver or state funds for those exceeding Medicaid limits.
Just for Us, Durham, NC: A collaboration between Duke University Medical Center, Lincoln Community Health Center, Durham County agencies, and the City of Durham Housing Authority. Managed by Duke Community Health under contract with Lincoln Community Health Center, it targets low-income seniors and disabled adults with multiple chronic conditions who are homebound and struggle to access healthcare. Just for Us provides annual physicals, chronic condition monitoring and treatment, in-home acute care, lab tests, and health education. Patients receive regular physician/physician assistant visits and access to nutritionists or occupational therapists as needed. A social worker offers case management, benefit application assistance, and links to supportive services like Meals on Wheels and home health aides. Mental health services are also arranged.

VIII. Potential Selection Criteria for Demonstration Communities

Potential selection criteria for demonstration communities could include:

High concentrations of older adults residing in subsidized housing.
Large populations of income-eligible seniors living near subsidized senior housing.
Robust networks of aging services and medical care providers with a history of collaboration.
High prevalence of seniors with chronic health conditions, frequent healthcare utilization, and disabilities/impairments.
Communities in states committed to flexible spending for HCBS.
Communities in states with prior housing and services agency collaboration and/or a commitment to affordable senior housing.
Communities engaged in ACA and other demonstration initiatives (e.g., ACOs, medical homes, transitional care demonstrations, independence at home).

IX. Fundamental Demonstration Design and Research Considerations

Developing a demonstration to assess the outcomes and impact of integrating services into subsidized housing requires addressing fundamental design considerations, as detailed further in Appendix A.

A. Type of Evaluation

Should the demonstration employ a randomized experiment, treatment/control studies, or formative versus summative evaluation?
Should the design test a single standardized model across sites or allow for diverse models based on varying site resources and capacities? Should it implement a uniform intervention or build upon existing practices?

B. Selection of Demonstration Sites

What participant volume is needed per site, per model, and overall for effective evaluation?
What volume is necessary for affordability and sustainability?
Will the demonstration provide data collection infrastructure or will existing assessment and management information systems be a site selection requirement?

C. Identification of Target Population

Which targeting models, practices, staffing, and data are most effective, cost-efficient, and replicable for identifying, enrolling, and achieving desired outcomes for the target population?
What are the trade-offs between focusing solely on high-risk/cost groups versus a broader public health approach with tiered interventions?
What enrollment incentives are needed for program participants?

D. Assessment of Participant Service Needs

Which assessment and care management functions/practices are most effective, cost-efficient, and replicable for determining needs/preferences and coordinating services?
Should all participants be assessed, have care plans, and receive ongoing follow-up, or only a subset?
How frequently should participants be assessed?
Should a standardized assessment tool be used, or a more flexible tool based on site preferences and state policy context?
Should a core set of assessment questions be required across all sites, and if so, what should they be?

E. Delivery Models for Service Integration and Coordination

What role should service coordinators/case managers play to achieve desired outcomes?
What qualifications and training are necessary for service coordinators/case managers?
What essential services must be available to participants? Will these be uniform across the demonstration, or will they vary, and how?
Are the logistical aspects of a public health approach feasible within a housing setting?
What are the advantages and disadvantages of health or social service providers leading service delivery versus housing providers taking the lead?

F. Resource Development and Financing Schemes

What payment mechanisms will incentivize provider participation, effective service coordination, and appropriate service provision?
Can ACA provisions (e.g., health homes, ACOs) support such a model?

G. Quality Improvement, Performance Measurement, and Accountability

What monitoring/quality improvement strategies should be integrated into assessment, care management, service delivery, and service coordination? Should these be standardized across sites or build on existing practices?
How should quality and safety concerns be addressed, respecting resident autonomy in their own homes?
What outcomes will indicate demonstration success?

Bibliography

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Cohen, R. 2010. “Connecting Residents of Subsidized Housing with Mainstream Supportive Services: Challenges and Recommendations.” Washington, DC: The Urban Institute. Retrieved from: http://www.urban.org/UploadedPDF/1001490-Subsidized-Housing.pdf.

Ficke, RC, and Berkowitz, S. 1999. Evaluation of the HOPE for Elderly Independence Demonstration: Final Report. Prepared for the Office of Policy Development and Research, U.S. Department of Housing and Urban Development.

Golant, SM, Parsons, P, and Boling, PA. 2010. “Assessing the quality of care found in affordable clustered housing-care arrangements: Key to informing public policy.” Cityscape, 12(2): 5-28.

Harahan, M, Sanders, A, and Stone, R. 2006a. Inventory of Affordable Housing Plus Services Initiatives for Low and Modest-Income Seniors. Prepared for the Office of Disability, Aging and Long-Term Care Policy, U.S. Department of Health and Human Services. Available at: http://aspe.hhs.gov/daltcp/reports/2006/ahpsinv.htm.

Harahan, M, Sanders, A, and Stone, R. 2006b. “Linking affordable housing with services: A long-term care options for low- and modest-income seniors.” Seniors Housing & Care Journal, 14(1): 35-46.

O’Malley-Watts, M. 2011. Money Follows the Person: A 2010 Snapshot. Washington, DC: Kaiser Commission on Medicaid and the Uninsured. Retrieved from: http://www.kff.org/medicaid/8142.cfm.

Rabins, PV, Black BS, Roca, R, German, P, McGuire, M, Robbins, B, Rye, R, and Brant, L. 2000. “Effectiveness of a nurse-based outreach program for identifying and treating psychiatric illness in the elderly.” JAMA:The Journal of the American Medical Association, 283(31): 2802-9.

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Appendices

Appendix A: Examples of Relevant Existing Practices

This appendix provides examples of existing practices and operational aspects related to the demonstration design and research considerations outlined in Chapter IX. These examples, drawn from literature and current experience, illustrate how interventions might produce desired outcomes.

Demonstration Design/ Research Considerations	Relevant Existing Practices
Type of Evaluation — Degree of standardization	– Channeling demonstration used randomized controlled design had a uniform service package, both basic and complex models, an assessment and case management approach defined by the government so there was consistency across sites. – Cash and Counseling demonstration used randomized controlled design and standard intervention frameworks, but relied upon existing practices for assessment, service packages and service coordination. – Medicare Care Coordination demonstration used randomized controlled design, but allowed each demonstration site to implement its own service coordination model. – Better Jobs Better Care demonstration targeted changes in policy and practice that focused on recruitment and retention of direct care workers. The applied research and evaluation program focused on workplace and public policy that addressed recruitment and retention of direct care workers.
Selection of Demonstration Sites	– Identifying candidate communities and subsidized housing–Census data could be used to identify urban areas with higher than average concentrations of older adults. HUD and State Housing Agency administrative data could then be employed to identify within these census tracts communities where there are clusters of HUD subsidized senior housing and LIHTC properties located in close proximity to one another. By combining data from HUD administrative files with data available in the CMS Chronic Condition Warehouse, which includes Medicare and Medicaid enrollment and claims, and assessment data based on Outcome and Assessment Information Set for Medicare home health recipients, the characteristics of housing residents and residents of the surrounding community can be analyzed and compared. Other tools for assessing the health status of older adults could include the use of public health surveillance strategies, public health records and other tools. – Determining necessary volume–Volume of individuals in the demonstration will be a consideration from two aspects: (1) power requirements necessary to detect a particular impact; and (2) implications for a business model in the real world. – Existing management information systems–Most housing properties do not use electronic assessments, although a few may have electronic care management systems, but these are often not standardized. Community-based organizations have varying degrees of electronic assessment and participant tracking, which are often based on the state’s Medicaid HCBS waiver system requirements. Increasingly, health care providers have adopted electronic health records and some communities are standardizing protocols for the exchange of health information across providers, some even including community-based organizations.
Identification of Target Population	– Soliciting referrals from community providers of individuals who meet the risk criteria. – Predictive modeling techniques could be developed based on data from public health records and or Medicare/Medicaid claims to identify high risk residents. – Residents of the housing property could be asked to complete a short assessment of their health status and services needs.
Assessment of Participant Service Needs	– Candidate tools for assessing participant needs include: the CARE Tool under development for CMS, state assessment tools for Medicaid HCBS, the Minimum Data Set Resident Assessment Instrument. Alternatively, the housing property could develop its own assessment tool and processes.
Potential Delivery and Financing Models	– Models that integrate health and long-term care services to varying degrees (e.g., PACE program, Evercare, Arizona’s’ Medicaid Managed Care Program, Minnesota’s Senior Health Options, Massachusetts’s SHO program). – ACA models which attempt to link integrated care delivery with payment incentives that encourage providers to collaborate with one another to improve patient care and reduce costs–“Medicaid Health Homes,” ACOs, and the Independence at Home Demonstration. – Standardized integrated care models (e.g., Guided Care developed by researchers at Johns Hopkins (Dr. Chad Boult), the GRACE model developed by Dr. Steve Counsel, the Care Transitions Program led by Dr. Eric Coleman, and the Transitional Care Model developed by Dr. Mary Naylor). – Necessary core services–Core services might include a needs assessment, case management (at least for high risk participants); access to primary care and chronic care management (possibly onsite), transportation for medical appointments, housekeeping and social services, personal care, medication management, behavioral health services, and health and wellness services. Such services would be offered to residents on a voluntary basis and delivered in increments that meet need and maximize efficiency. Access to assistance on a 24/7 basis for emergencies may also be crucial to maintaining resident safety and reducing the revolving door between the ER and a resident’s apartment (e.g., PACE or health plan help line). Whether that could be delivered by an offsite agency or must be present in-house is a question for the design team. Some integrated care models also rely on enhancing patient self-care and “health coaches”—non-professional staff who can work with individual participants on health issues. – Lead agency–A variety of organizations, including the housing property itself, could manage and implement the demonstration. However, there may only be handful of housing sponsors and properties which are large enough or have sufficient capacity to act as the lead agency (e.g., Good Samaritan, Presbyterian Homes and Services, Mercy Housing). All participating housing properties would at a minimum need an onsite service coordinator dedicated to recruiting and assessing residents for participation, providing information and referral, acting as an intermediary to the provider network, assisting with services planning and arrangement, monitoring implementation and providing feedback for quality improvement purposes. Other candidates for lead agency might include the local Area Agency on Aging, a community health center, a Special Needs Health Plan, and a multidisciplinary physician group (medical house calls programs, medical homes) etc. – Formal and informal strategies for service delivery–Multiple and diverse strategies have been used in the past to staff a housing with services program and to link resident to needed services. Some housing properties have onsite staff including service coordinators who help residents identify needs and locate services, and nurses who operate a wellness clinic providing health education and preventative services. Other properties negotiate informal and formal agreements with local hospitals, community health centers or physician practices so that nurses, nurse practitioners and geriatricians come to the property at regularly scheduled times. Agreements have also been formalized between the property and academic health centers so that students can carry out clinical rotations and provides needed health services. Some properties co-locate services such as a PACE site, adult day care center, senior center or physician office to bring selected services to residents. Others recruit volunteers and other trained lay people from the property or the community to assist residents with managing their health issues. In some cases, housing properties are part of a larger campus that includes an assisted living facility and/or nursing home to provide more nighttime coverage or provide additional services such as personal care. A few properties own and operate licensed home health agencies that serve residents and the broader community, while some others partner with home health agencies to negotiate more affordable rates for homemaker and personal care services. (Harahan, Sanders & Stone, 2006b; Golant, Parsons & Boling, 2010). Achieving a comprehensive and integrated system of care for property residents is likely to require stronger, more formal relationships between health care providers and the housing property than has been previously implemented in housing with services programs.
Resource Development/ Financing Schemes	– Program funding: (1) for program development, staffing, infrastructure and services not covered through Medicaid or Medicare because many residents are not eligible for Medicaid-funded HCBS and Medicare does not currently pay for comprehensive service coordination; (2) to augment a housing properties’ services coordinator with a full-time nurse or social worker; and (3) to design, implement and manage data systems to track performance. – Modifying existing policies and regulations: (1) Changing HUD rules to allow properties to identify a select number of services as a budget line item within their operating budget. Specific services could be required based on their demonstrated effectiveness to improve resident outcomes/lower cost. (2) Allowing properties under common ownership to pool residual receipts, reserves and excess cash flows (while assuring an adequate amount of reserves for all properties) and direct them to where they are most needed to strengthen resident services. (3) Making it easier to use residual receipts for resident services by clarifying HUD policy. (The Section 202 reform bill recently passed does clarify that unexpended funds from refinancing proceeds and residual receipts can be used for services). Although this may provide housing providers with more flexibility to pay for services, it is unlikely to generate enough revenue to support a services program. (Cohen, 2010). (4) Develop a new waiver that allows housing properties to combine housing and services resources as long as it is in the aggregate less costly than current practice. – Creating targeting incentives–Reward developers/sponsors for targeting older adults with services needs and insuring that needed services are available to them. For example, in cases where the developer agrees to admit a certain proportion of residents based on predictors of health risk and high health and long-term care costs, new Section 202 Housing for the Elderly awards and the allocation of LIHTC designated for seniors could include a bonus, part of which would go to the developer and part to fund services. This approach is similar to the new 811 Program under the Melville Act. – Giving preference in admissions–to high risk seniors identified by Medicaid HCBS providers, physicians groups, VA hospitals and clinics, and other community agencies in return for their willingness to guarantee an appropriate services package to the prospective resident. – Providing partnering incentives–to large housing sponsors with multiple properties to become stakeholders in the growing number of health care organization and delivery models such as medical homes, ACOs, and Medicare Special Needs Plans. Housing sponsors could be given a special bonus to be designated for gap filling services in return for their participation. Good Samaritan, Presbyterian Homes and Services and Mercy Housing likely have sufficient resident volume to be attractive to these health care delivery plans. Cathedral Square in Vermont is part of the shared savings activity in the Medicare Medical Home Demo.
Quality Improvement/ Performance Measurement and Accountability	– The Health Indicators in Naturally Occurring Retirement Community (NORC) Programs initiative has developed promising quality improvement strategies and tools to help NORC providers identify and manage the care of NORC residents most at risk, focusing on heart disease, diabetes and increased risk of falls. Standards of Practice which reflect best practices and clinical guidelines in self-care, medical care and community supports have been developed which include detailed measures relating to each standard (Vladeck, et al., 2010). The COLLAGE effort (Kendall and Hebrew Senior Life program) is trying to collect standardized data across participating housing properties to use for benchmarking and accountability.