Empowering Communities for Successful Aging: Housing, Neighborhood Support, and Services

1. Empowering Communities for Successful Aging: Housing, Neighborhood Support, and Services Developing Senior Housing with Supportive Services: Challenges and Opportunities Alisha Sanders, Policy Research Associate The Institute for the Future of Aging Services Ken Harris, Director The Center for Senior Living and Community Services Saratoga Springs, New York Wednesday, November 12, 2008

2. Agenda Current Situation in Housing & Supportive Services Opportunity for Change NYS Long Term Care Reform Senior Housing Options Comparable Costs NYS Regulatory Considerations Developing Aging-Friendly Communities in NYS National Trends Challenges Providing Housing with Supportive Services Wellness Models Health Care Models

3. New York Senior Population Senior Population Growth in New York State By 2025, senior population is projected to grow from 3.5 million to 4.9 million. A 39 percent increase, comprising nearly 24 percent of the general population. 50 percent larger than the existing senior adult population. More culturally and economically diverse.

4. Housing Transitions for Seniors Transition of Seniors in Housing: One Scenario Seniors at home / congregate senior housing - health fails. Senior housing does not incorporate support services on- site. Seniors unable to access or arrange for health care and community resources (transportation, physician, socialization.) If private pay, possibly transfer to assisted living. Transitioned to nursing home, possibly unnecessarily.

5. Housing & Supportive Services Outlook New York Senior Housing & Supportive Services Outlook: Good News: New York state interested in promoting a “person-centered” home and community based services. Seniors desire to be in the most independent setting. Started discussions and planning toward transforming the long term care system. Bad News: No money to pay for the transformation (capital & services). Budget concerns over the “woodwork effect” for services.

6. NYS LTC Reform Initiatives New York State LTC Reform Initiatives Nursing Home Transition and Diversion Medicaid Waiver Money Follows the Person Initiative Money Follows the Person Housing Task Force Nursing Home “Rightsizing” New York Connects (Point of Entry) Long Term Home Health Care Program (LTHHCP) Medicaid Waiver Review

7. Federal LTC Reform Initiatives Federal Decisions, Laws, Programs and Proposals Fair Housing Act Olmstead Decision Americans with Disabilities Act Recent Litigation on Transfer Issues The Community Choice Act (proposed) Medicaid Waiver Programs

8. A New Federal Direction? President-elect Barack Obama endorses: Long term care choices not biased toward institutional care. Restoration of HUD operational housing subsidies. LTC Financing Reform: Community Living Assistance Services and Supports (CLASS)Act (S.1758 / H.R. 3001) Consumer choice and integration of services. Increased use of health information technology (HIT). Emphasis on wellness initiatives. Research and dissemination of information on best practices.

9. Senior Housing: A Crises Situation Affordable Senior Housing in NYS Five- to 10-year waiting list for affordable housing in some parts of the state. HUD Section 202 PRACs funds not adequate to complete construction – need additional funding sources. Properties need $$$ to renovate. Properties are “opting out” of their mortgages. Low-income housing tax credit programs hard to find financing.

10. NYS Budget & Medicaid Spending NYS Budget & Medicaid Expenditures NYS budget deficit of $1.6 billion in SFY 2008-09. Projected $30 billion deficit over the next three years. NYS has highest Medicaid expenditure in the nation at $47 billion. $12 billion in LTC Medicaid spending. Potential Medicaid cuts for nursing homes, home care and home / community-based services.

11. A New LTC Paradigm? Fiscal crisis is an opportunity to discuss and plan for a new long term care system. New York is embracing Medicaid waivers (LTHHCP & NHTDW). Senior housing could be a platform for LTC service delivery. Planning senior housing that incorporates building space (offices, parking, technology) for adding senior health services for residents and neighbors. Developing partnerships with housing providers, service agencies, local government and state agencies to bring in services to senior housing.

12. An Opportunity for Change With the reduction of traditional funding for senior housing and long term care services, there will be opportunities to develop aging-friendly communities that embraces flexibility, choice and independence. Cooperation, coordination and coalitions (3Cs) will be needed on the local level.

13. Affordable Housing Programs Subsidized Housing Programs for Seniors HUD Section 202 / 236 / 202 PRAC NYS Mitchell-Lama Program Low-Income Housing Tax Credit Program (LIHTCP) Mixed-Financed Housing (Section 202 & LIHTCP) Preservation and Recapitalization Community Leaders’ Challenge: Search Them Out. Support. Develop. Preserve. Enhance.

14. Rental Payment Supplemental Security Income(SSI): $761 monthly income for low-income individuals; $9,132 annual income. Section 8: an affordable housing rental subsidy program for low income seniors. Income-qualified residents pay 30 percent of their adjusted income for rent. Up to a five- to 10-year waiting list for Section 8 housing in several parts of the state, especially downstate.

15. Fair Market Rents in NYS Fair Market Rents (FMRs) in New York State FMRs gross rent estimates calculated by HUD including the cost of all utilities, (except telephones) for efficiencies / one bedroom: Buffalo: $601 / $602 Albany: $686 / $711 Westchester: $1,161 / $1,385 NYC: $1,091 / 1,180 With SSI at $761 per month, low-income seniors need Section 8 to afford housing.

16. Preservation / Recapitalization Preservation and Recapitalization Mortgage expiration for several HUD affordable housing built in 1960s and ’70s. Efforts needed to keep subsidized housing facilities from “opting out” of the HUD program to market-rate rents. Recapitalization of older buildings by refinancing the mortgage or financing through the LIHTCP maintains affordable housing.

17. Comparable Costs – SNF vs. Housing HUD Senior Housing in Albany – Monthly Costs to NYS 1. HUD Housing = $419* per person per month / NYS Share: $0. 2. SSI: $761 = Federal: $674 / NYS Share: $87 per month. 3. Long Term Home Health Care Program Medicaid Waiver Individual costs capped at 75 percent of regional NH rate Monthly Upstate Cost = $1,185 /NYS Share (40%): $474 Medicaid Eligible Senior in HUD Housing – NYS Cost Share Average Individual Monthly: $560 / Annual: $6,700 (* Rents vary from individual senior housing facilities)

18. Comparable Costs – SNF vs. Housing Albany Nursing Home Resident – Monthly Costs to NYS Albany nursing home average daily rate (Physical A&B): $131.06 Annual $47,836 / Monthly $3,986 NYS Share (40%): Monthly: $1,594 / Annual: $19,128 Cost comparison annual NYS share for Medicaid senior: SNF $19,128 - HUD with LTHHCP: $6,700 = Savings: $12,396. (Average rate – actual could be more or less) NYS savings for 100 seniors: $1,239,600

19. Comparable Costs – SNF vs. Housing There will always be a need for nursing homes and assisted living for the most infirm NYS residents. Cost savings can be realized transitioning or diverting “low-scoring” nursing residents to home- and community-based services. Nursing Home Transition and Diversion Waiver currently has seven registrants. Savings need be used to build infrastructure in existing senior housing and develop new facilities with service delivery capacity.

20. Additional NYS Housing Models Naturally Occurring Retirement Communities (NORCs) Congregate Housing and Supportive Services Neighborhood NORCs Delineated Neighborhood and Supportive Services Continuing Care Retirement Communities (CCRCs) Senior Housing / AL / Nursing Home Fee-for-Service CCRCs Retirement Housing with Supportive Services Cohousing & Colocation & Green Houses….

21. Assisted Living Programs Adult Care Facilities (ACFs) Enriched Housing – SSI ($36 day reimbursement) Adult Home – SSI Assisted Living Program (ALP) Medicaid funding Not enough – some expansion in state funding Assisted Living Residence (ALR) Enhanced ALR (EALR) Certificate (Age-in Place) Special Needs ALR (SNALR) (Dementia Programs)

22. Assisted Living Residence NYS Assisted Living Residence (ALR) Regulations ALR regulation adopted March 27, 2008, allows for residents to “age in place.” ALR defines “independent senior housing” drawing the line between independent housing and licensure. Incorporated services into ISH determined by DOH on a case-by-case basis. Discussion: 24-hour staff? Medical evaluation duties? Who employs the staff person….

23. Creating Aging-Friendly Communities Considerations for Incorporating Senior Housing and Supportive Services into Aging-Friendly Communities within New York State: One: A shift from “silo” systems (separate housing, health services, aging services) to an integrated system will take state and local understanding and leadership. Two: Local leaders need to find and preserve existing senior housing and build new ones. Three: State and federal funding for senior housing (rent subsidy, property taxation, etc.) will be needed to meet current and future demand.

24. Creating Aging-Friendly Communities Four: Local and state leaders must continuously discuss, plan, develop and advocate for an integrated aging-friendly community. If not you, who? Five: Cost savings at the institutional level needs to be invested into senior housing building capital and supportive services. (NYAHSA’s Planned Affordable Retirement Community (PARC) concept.) Six: Section 8, home care / supportive services and Medicaid waivers must be enhanced to transform from institutional care to home- and community-based care.

25. Creating Aging-Friendly Communities Seven: State regulations need to be developed that encourage incorporating health and supportive services into senior housing. Eight: A new way to fund long term care must be developed soon that would include home- and community-based care. Nine: Technology will need to be encouraged and deployed in senior housing (efficiencies, work-force shortages, etc.) Ten: Innovative New York state and national home and community-based programs need to be explored and replicated at the local level.

26. The Institute for the Future of Aging Services The Institute for the Future of Aging Services (IFAS) is an independent research organization dedicated to bridging the worlds of policy, practice and research to advance the development and diffusion of high-quality aging and long-term care services and supports. IFAS is the applied research arm of the American Association of Homes & Services for the Aging (AAHSA). Alisha Sanders IFAS Policy Research Associate

27. The Trends About 2 million older adults live in federally subsidized housing They are growing older – half of subsidized senior renters are 75 + and almost 14% are 85+ Relationship between older age, chronic illness and disability, and higher use of health and long-term care services is well established Subsidized senior renters twice as likely to be disabled as home owner counterparts – 1/3 have difficulty with routine activities and 12% have cognitive impairments

28. One study of 3 affordable senior housing communities in Denver: 23% perceived their health as fair or poor 18% suffered from 3 + chronic conditions 18% needed support with 1+ ADLs Residents desire to age-in-place Limited options for purchasing needed support services The Trends

29. Challenges Providing Housing with Services State regulations Housing provider capacity to provide services (skill, staffing level) Range of resident needs Funding Property Residents

30. Wellness (education, fitness, nursing) Lutheran Senior Services, Missouri Partnership with OASIS, a “national nonprofit educational organization designed to enhance the quality of life for mature adults” Offers on-site programming Peer counseling program Active Living Everyday – 20-week behavior modification program Healthy Eating Everyday - similar to Active Living Exerstart – starting an exercise program safely Residents pay minimum fee (established for LSS properties) Locations in Albany, Rochester, Syracuse – www.oasisnet.org

31. Golden West Senior Residence, Boulder, CO Partner with Medically Based Fitness, a PT and rehab company, to operate on-site wellness center GW provides space/equipment; MBF staffs center with a PT and exercise physiologist Design and monitor exercise program for wellness center members (residents pay a monthly membership fee, subsidized for many by property fundraising) Provide rehab following hospital stay or at doctor request (Medicare-funded) Conduct educational activities (open to all residents) Open five days per week Wellness (education, fitness, nursing)

32. Wellness (education, fitness, nursing) Canterbury House, Charleston, SC • Partnership with Medical University of SC School of Nursing • Student nurses do community nursing rotation; visit property 2 days/week • Check vitals (blood pressure, blood sugar, etc.) and hold periodic education sessions (diabetic wellness/nutrition, hydration issues, etc.) Robert Sharp Towers I & II, Miami, FL • Partnership with Miami Dade College School of Nursing • Nursing students visit property 1 day per week • Take blood pressure, vitals, etc.; lead a chair exercise class; hold annual health fair

33. Wellness (education, fitness, nursing) Westerly Apartments, Lakewood, OH Partnership with local hospital Weekly nurse for blood pressure checks, lab tech to draw blood (with doctor’s order), MD gives monthly talks on different illnesses, meds, etc. Partnership with Eliza Jennings Nursing Home (home health arm) Operate a wellness clinic in the senior center area of building Staffed by NP and RN; 8 hrs/day, 5 days/week Blood pressure checks, wound care, medicine management and general health check-ups; NP can diagnose and write prescriptions Make house calls, if needed; triages if someone falls or has accident Provide PT/OT out of clinic, provide in apartment so helping resident work within and adapt to their specific surroundings Bill Medicare for services

34. Wellness (education, fitness, nursing) Piedmont Hospital’s Sixty Plus Program, Atlanta, GA • Partnership with 4 affordable senior housing properties Send nurse to each property one day a week • Nurse does: • Individual appointments • Post-discharge follow-ups with residents • Checks on residents at request of hospital-affiliated physicians • Help coordinate follow-up appts. or other health-related resources • Conducts health fairs and other educational programs • Paid for by the hospital

35. Health Care(clinics, medical house calls) St. Luke’s Place, Edgemere, MD Physician practice operates on-site clinic 3 days/week Residents can walk in for appt., if space available Many residents were from the surrounding area and already seeing these physicians Also see patients from outside the property Property has an MOU with them for use of the space; doctors provide certificate of liability insurance and professional license

36. Saint Elizabeth Place, Providence, RI Partnership with Rhode Island Hospital to operate on-site clinic Open 3 days a week Staffed by nurse (employed by the property, supervised by MD); NP comes once/week; MD at least once/month Hospital residents do geriatric rotation in clinic Become a member of the clinic, means MD becomes your PCP Property provides space and employs nurse; Hospital provides insurance, credentialing and everything necessary to operate a clinic Health Care(clinics, medical house calls)

37. Health Care(clinics, medical house calls) St. Mary’s Court, Washington, DC Partnership with George Washington Hospital House Call Program MD/NP team See chronically ill and frail residents who have difficulty getting to MD’s office See monthly or as needed; can respond quickly to urgent situations Service coordinator calls NP to check on residents when concerned NP discusses patients with service coordinator when necessary because she knows SC has valuable insight NP updates service coordinator on patients so she can help bring in supportive services that might be helpful

38. Just for Us, Durham, North Carolina Collaboration between Duke University, a federally qualified health center, County Department of Social Services, County Health, Housing Authority House calls program – primary care, social services, nutrition services, occupational and physical therapy, care management Operates in ten subsidized senior properties in Durham County Health Care(clinics, medical house calls)

39. Personal Care & Rehab Reisters View & Reisters Clearing, Reisertown, MD Partnership with Friends Care Communities Services, Inc., a home care provider Provide services on a sliding scale fee (average cost in area is $18/hour) Reduced minimum time block (1 hr –vs– 4hrs)

40. Personal Care & Rehab Canterbury House, Charleston, SC • Partnership with local nursing home to operate satellite rehab clinic • Property provides space – old activity room that was underutilized • NH staffs a PT (full-time) and an OT (part-time) • Residents can access services post hospital or NH stay or at doctor’s request (e.g. to improve balance) • PT invites residents to have balance testing couple times a year, if poor encourages to talk to doctor • Paid for through Medicare (with doctor’s order) • Property has bought exercise equipment so that residents can continue on own after rehab – PT shows how to use safely

41. IFAS / NYAHSA The Institute for the Future of Aging Services (IFAS) is an independent research organization dedicated to bridging the worlds of policy, practice and research to advance the development and diffusion of high-quality aging and long-term care services and supports. IFAS is the applied research arm of the American Association of Homes & Services for the Aging (AAHSA). Founded in 1961, the New York Association of Homes & Services for the Aging (NYAHSA) represents not-for-profit, mission-driven and public continuing care providers, including senior housing, adult care facilities, nursing homes, continuing care retirement communities, assisted living and community service providers. NYAHSA's more than 600 members employ 150,000 professionals serving more than 500,000 New Yorkers annually.

42. Contact Information Ken Harris, Director The NYAHSA Center for Senior Living and Community Services Albany, N.Y. 518-449-2707 kharris@nyahsa.org Alisha Sanders, Policy Research Associate The Institute for the Future of Aging Services Washington, D.C. 202-508-1211 asanders@aahsa.org