Housing

Although the continuum of housing identifies a range of housing types, there is increasing recognition that frail older persons do not necessarily have to move from one setting to another if they need assistance. Semidependent or dependent older persons can live in their own homes and apartments if the physical setting is more supportive and affordable services are accessible. Figure 1 Average Monthly Rent and Fees in Assisted Living Facilities SOURCE: Copyright © American Health Care Association, 2000. Reprinted with permission. Indeed, most older adults express a strong desire to age-in-place in their own homes and communities. Yet often, these older adults live in physically unsupportive environments, disconnected from services. Instead of facilitating older persons' ability to grow old safely, independently, and with dignity, many settings have instead become a source of the problem itself. The following section examines various methods and programs that enable older adults to age-in-place.

Home modifications. Home modifications are adaptations to home environments that can make it easier and safer to carry out activities such as bathing, cooking, and climbing stairs. Increasing evidence suggests that home modifications can have an important impact on the ability of chronically ill or disabled persons to live independently (Mann, 1999). In addition, environmental factors such as lack of privacy or insufficient space may impede family and formal caregiving (Newman, 1985; Newman et al., 1990).

Estimates by the National Center for Health Statistics indicate that 7.1 million persons live in homes that have special features for those with impairments (La Plante et al., 1992; see Table 2). In conventional homes and apartments of persons 70 and older, grab bars and shower seats are the most common home modifications at 23 percent, followed by wheelchair access inside the home such as wide hallways (9 percent), special railings (8 percent), and ramps at street level (5 percent) (Tabbarah et al., 2000). However, a large number of older persons who report health problems, mobility limitations, and dependency in ADLs and IADLs (instrumental activities of daily living), live in housing without adaptive features. It is estimated that at least 1.14 million households occupied by older persons need additional supportive features (HUD, 1999).

The overall low incidence of supportive features in the home is due to three major barriers. First, there is a lack of professional and consumer awareness concerning problems in the home environment. For example, several studies have Table 2 Frequent Home Adaptations by Numbers of Households SOURCE: La Plante, M. P.; Hendershot, G.;E.; and Moss, A. J. "Assistive Technology Devices and Home Accessibility Features: Prevalence, Payment, Need and Trends." National Center for Health Statistics. Advance Data 217 (1992): 1–12 found that many disabled persons, especially among the elderly, have a low level of awareness of the risks that the environment presents or a lack of knowledge of how home adaptations might make living safer and easier. In fact, older persons are often reported as having adapted their behavior to the environment (e.g., stopped taking baths or showers because of the danger of falling) rather than having adapted their environment to their changed capabilities (e.g., installing a handheld shower, adding a grab bar). Among professionals such as doctors, knowledge about home adaptation also is low. Concern has been expressed that even case managers, the gatekeepers for many long-term care services, may overlook home modifications.

Second, some home modifications may be unaffordable. The cost of home adaptations ranges from less than $100 for the purchase and installation of a simple handrail or grab bar to more than $1000 for a roll-in shower or several thousand dollars for a stair lift.

A third barrier reported by individuals and social service agencies in obtaining home modifications has been the delivery system (Pynoos). Simple home adaptations are often made by persons with disabilities and their family members. However, many persons lack the ability to identify environmental problems and make adaptations. Even installing an uncomplicated grab bar on a wall requires the ability to attach it to a stud and locate it at the correct angle and height in relation to the person using it. It is often necessary to employ a provider to assess problems and make changes, especially those that are complex, such as a roll-in shower. Overall, the modest nature of many jobs, the need for specialized skills, the low income of many persons who need adaptations, concerns about the reliability of private providers, and the difficulty of accessing specialists, such as occupational therapists, contribute to service delivery problems in home modifications.

Clustering services. Clustering services involves consolidating fragmented services for multiple clients. This strategy can reduce travel time and costs, enable more efficient worker assignment, and lead to service of more consumers. Since the 1990s, there has been a growing realization that economies of scale, as well as opportunities for peer support, exist in providing services to large numbers of frail elders living in one place. In addition to assisted living, several demonstrations and programs have been carried out in more conventional housing settings to test models of planning, organizing, and providing services.

One of the earliest of these demonstrations, the Congregate Housing Services Program (CHSP), authorized under Title IV of the Housing and Community Development Act of 1978, provides a service-enriched setting for frail older persons. Advocates for the CHSP promoted it on the basis that it would prevent "premature" institutionalization of elderly and handicapped residents of federally subsidized housing. The CHSP was carried out initially in sixty-three public housing and Section 202 sites, using HUD funds to pay for services such as meals, homemaking, and transportation to select groups of tenants with three ADL and/or IADL needs. A service coordinator and professional assessment team oversaw eligibility for and organization of the services. Between 1979 and 1985, approximately $28 million was spent on services to 3,500 residents of sixty-three public housing and Section 202 projects.

Because of controversy about whether the CHSP actually prevented institutionalization and HUD's continued reluctance to pay for services, the program did not expand until the early 1990s (Redfoot and Sloan) with the passage of the National Affordable Housing Act of 1990. By this time the CHSP, initially funded solely by HUD, required a significant state and local match that discouraged many sites from applying. Nevertheless, by 1994 the program had grown to more than one hundred sites.

The concept of clustering services has been the basis of several other innovative delivery systems. For example, the New York City Visiting Nurses Association (VNA) has used Medicaid waivers to provide services to groups of residents living in government-assisted housing. Personnel and health care staff are assigned to clusters of frail residents in senior housing. Staff can therefore move from one resident to another, performing various tasks, rather than spending long blocks of time with individual residents. An evaluation of the VNA project found that it saved money, although residents were somewhat less satisfied because individually they received less service (Feldman et al.).

Service coordination. The concept of service coordination is an outgrowth of the CHSP and the Robert Wood Johnson Foundation's Supportive Services Program in Senior Housing demonstration. Through the Housing and Community Development Act of 1992, Congress authorized expenditures for a service coordinator program. Service coordination is often described as the glue that holds a program together or the linking mechanism between residents of housing complexes and services. It is a less intensive model than the CHSP and relies more on linking residents up with services rather than providing them directly.

Services coordinated for residents include meals-on-wheels, in-home supportive services, hospice care, home health care for those who eligible for Medicare or Medicaid, transportation services, on-site adult education in areas of interest, and monthly blood pressure checks. There is also assistance with locating other living arrangements, such as an assisted living facility or a nursing home, when it becomes necessary, but the primary focus is on assisting residents to continue living in their current apartments.

Though the coordinators in this program do not have budgetary authority for services, they can serve a broad group of frail older residents. By 1999 there were approximately a thousand service coordinators connected with public and Section 202 housing complexes across the country. An evaluation of the program revealed that service coordinators successfully marshal a number of new services for residents, who report high levels of satisfaction with the program.

In 1999 HUD acknowledged responsibility for adapting its stock of housing for the elderly into more supportive settings linked with services. HUD's Housing Security Plan for Older Americans, approved by Congress as a part of its 2000 budget, includes $50 million to expand the service coordinator program and $50 million to convert some existing Section 202 housing for the elderly into assisted living.

A comprehensive system of community-based care. The Program of All-inclusive Care for the Elderly (PACE) is a major health care– based demonstration project that provides a range of services to older adults in the home. PACE, which is expected to include approximately fifty sites and ten thousand participants by 2005, attempts to replicate the On Lok Senior Health Services Program in San Francisco, which integrates Medicare and Medicaid financing and provides medical and long-term care services to frail persons who are eligible for a nursing home in a daycare setting. Participants in the program are assigned to an interdisciplinary team for regular needs assessment and care management. PACE's purpose is to address the needs of long-term care clients, providers, and payers. The comprehensive service package allows clients to continue living at home while receiving services, rather than in institutional settings. Nevertheless, many PACE sites have added housing, having found that a number of participants live in deficient settings or need more supervision and help with unscheduled needs than can be provided in individual home settings.

The challenges to incorporating housing into an integrated continuum of care are evident. Much must be done to develop housing as an environment that supports health, particularly as people age and/or become disabled. Conversely, health care providers and payers must recognize the impact that housing situations can have on health. Then, efforts can be made to integrate housing and health services. Housing settings can begin to develop informal affiliations and strategies that enable services to be coordinated on a client-specific as well as a buildingwide basis, taking advantage of the economies of scale inherent in delivering or "clustering" services for groups of older people living together. The organizations that have integrated housing with health care should be examined as models of how such integration works and what the potential would be to increase the integration in the future.