Research has helped promote housing plus services models and has demonstrated their value. Turning promise into policy is the greatest challenge.
A comprehensive planning process prompted leaders at A.M. McGregor Home to make significant changes to their organization’s strategic direction in 1999.
That decision had a direct and long-lasting impact on the Cleveland-based LeadingAge member. The decision also helped shape a decade of research at LeadingAge.
“We realized, even as early as 1999, that the nursing home model was already an unsustainable way of taking care of seniors, especially the low-income seniors we had committed ourselves to serving,” says Rob Hilton, who was chair of the organization’s board at the time, and now serves as its president and CEO. “We also recognized the appalling lack of appropriate housing for low-income seniors outside of institutional care.”
Hilton knew McGregor would need help to carry out its new commitment to “take services to seniors rather than taking seniors to services.” So, he called Robyn Stone, executive director of the Institute for the Future of Aging Services (now the LeadingAge LTSS Center @UMass Boston).
Hilton was not surprised when Stone suggested that his request warranted further research. He even agreed to help pay for it.
That initial conversation eventually led to a 2006 research report, funded by the newly established McGregor Foundation and the U.S. Department of Housing and Urban Development (HUD), which documented how housing providers around the country were meeting the growing need for housing-based services and supports among older adults with low incomes. Researchers also organized 4 regional workshops designed to develop a shared understanding of the models that were already being used to link affordable housing with health and supportive services.
The study and workshops helped McGregor decide to focus on providing clinical services to community-dwelling older adults through the Program of All-Inclusive Care for the Elderly.
“We were basically looking for guidance on how we would conduct our practice,” says Hilton. “That research was very influential in our own strategic planning.”
Not long after that first study began, Stone received a call from Dean Painter, president/CEO of Eaton Terrace (now Eaton Senior Communities), an affordable senior housing community in Lakewood, CO.
Painter and his colleagues at Golden West Senior Residence in Boulder and Hover Manor in Longmont, wanted to find out whether their investment in onsite services was helping residents age in place, and at what cost. That request led to a 2007 report, supported by the Retirement Research Foundation and the Murray and Sydell Rosenberg Foundation (affiliated with Greystone). The report documented strategies that the 3 housing communities were using to link residents with services. It also recommended several avenues for further research.
“We intuitively knew that our residents were healthier and happier than people who didn’t have (onsite) services, but we had no data to back that up,” says David Smart, who worked at Golden West at the time and is now president/CEO at Eaton. “So, when IFAS agreed to study what we were doing, it was very exciting.”
Nancy Eldridge was executive director at Cathedral Square Corporation, Burlington, VT, in 2005, when a group of housing providers who were members of the American Association of Homes and Services for the Aging (now LeadingAge) first began talking about the benefits of coordinating services for older adults living in affordable senior housing.
These early conversations about “housing plus services” aligned perfectly with Eldridge’s interest in exploring the role that housing communities could play in helping older people stay healthy and independent. Four years later, Eldridge would develop and pilot a housing plus services model called Support and Services at Home (SASH), which now uses funds from the Centers for Medicare & Medicaid Services (CMS) and the state of Vermont to serve 5,000 older adults living in 138 housing communities statewide.
The SASH model features an onsite team consisting of a service coordinator and a wellness nurse who assess resident health goals and needs, and then work with community partners to provide services and programs that will help SASH participants age in place.
“We were very engaged in conversations with LeadingAge from the beginning of SASH, about everything from how to pick the pilot site to what information we should collect through our resident assessments,” says Eldridge. “To me, these were all research questions. The message from LeadingAge has always been clear: You have to have credible data behind a good idea or it’s just going to be a good idea. That raised our awareness, so we set up a better program and we got better results.”
A Member-Driven Initiative With a National Impact
Stone is proud of the fact that LeadingAge’s early work in the housing plus services arena began in response to member requests for assistance.
“We offered a valuable service to housing providers who were looking for ways to help residents live safely in community and maintain their health and quality of life,” she says.
At the same time, however, LeadingAge’s early work served as an important foundation for a decade of research that Stone says has influenced policy and practice at the federal and state levels. Working with several research partners and myriad funders, Stone’s research team:
- Wrote case studies of housing plus services programs in Massachusetts, Connecticut, Vermont, California, Ohio, Oregon and New Jersey;
- Conducted a 2011 qualitative evaluation of the WellElder program in Northern California that reinforced the importance of the onsite service coordinator/wellness nurse team;
- Developed tools that housing communities could use to assess residents’ needs, train family caregivers and form partnerships with health entities to implement housing plus services models;
- Conducted quantitative research studies that documented the health conditions and health care utilization of HUD-assisted older adults, and the association between the availability of onsite services and resident health care utilization and spending;
- Evaluated the SASH program during the 5 years it received funding from CMS as part of Vermont’s participation in the federal Multi-Payer Advanced Primary Care Practice demonstration;
- Explored options for sustainability. A one-year project, funded by the Gordon and Betty Moore Foundation, is currently identifying financing mechanisms that could support housing plus services models; and
- Disseminated its research findings through journal articles, conference presentations, a Congressional research forum sponsored by the U.S. Senate Special Committee on Aging and Sen. Susan Collins (R-ME); a public workshop sponsored by the National Academies of Sciences, Engineering, and Medicine; webinars for state Medicaid policy makers; and a Housing Plus Services Learning Collaborative that helped housing providers develop housing plus services strategies.
“There had to be incremental steps to our work,” says Alisha Sanders, director of housing and services policy research at the LeadingAge LTSS Center @UMass Boston. “First, we needed to figure out what these models were and how they were being implemented. Then we needed to get access to data that could help us find out if housing plus services models were actually making a difference. Now that we have started to see that these models are producing good outcomes for public payer programs, we can have serious conversations about funding.”
Influencing Policy and Practice
The LTSS Center’s housing plus services work is nowhere near the finish line. But outside observers agree that several groundbreaking studies over the past 5 years have helped spur a growing enthusiasm for housing plus services models among housing providers, health care entities, and policy makers.
“In sum, over the last decade, this research has built a strong foundation for exploring leading policy questions in the health and housing arena rigorously and cost effectively,” says Carol Star, director of the Program Evaluation Division in HUD’s Office of Policy Development and Research.
A HUD Demonstration: The 2017 launch of a $15 million randomized control trial that HUD is implementing in 40 housing communities around the country is a prime example of the influence that research by LeadingAge and its partners has had to date.
The Supportive Services Demonstration/Integrated Wellness in Supportive Housing (IWISH) will test a housing plus services model that features an onsite team consisting of a wellness nurse and a wellness director who serves as an enhanced service coordinator. The demonstration will document participants’ health care utilization and costs. Findings are expected to be available after the demonstration ends in 2020.
The LTSS Center helped design the IWISH demonstration in collaboration with the Lewin Group during a 2014 study funded by HUD and the U.S. Department of Health and Human Services (HHS). The SASH evaluation, which the center conducted with RTI International, also influenced the demonstration. The LTSS Center serves on the implementation team for the demonstration, along with the Lewin Group and the National Well Home Network.
Health Conditions of HUD-Assisted Older Adults: Star reports that the 2014 HUD/HHS study influenced the IWISH demonstration by creating a dataset that linked HUD administrative data and Medicare and Medicaid claims data for all individuals living in HUD-assisted housing in 12 geographic areas.
“Ultimately, [that dataset] allowed us to employ a rigorous experimental design for the IWISH demonstration that relies largely on administrative data for analysis of impacts,” says Star. “Had this foundational study not happened, we would not have obtained Congress’s blessing to test the impact of the wellness nurse and wellness director in HUD’s senior housing.”
The 2014 HUD/HHS study also found that HUD-assisted older adults were more likely than other older adults to be dually eligible for Medicare and Medicaid, and more likely to have 5 or more chronic conditions than dual eligible older adults who were not HUD-assisted.
“That (study) has been an extremely powerful tool for us to help policy makers understand that older people living in subsidized housing have dealt with a lifetime of poverty and, therefore, face a lot of challenges,” says SASH Director Molly Dugan. “That report provides a lot of ah-ha moments for policy makers, I’ll tell you that.”
SASH Evaluation: The 5-year evaluation of SASH, which the LTSS Center conducted with RTI International, showed that the program is associated with a $122.24 per-beneficiary-per-month lower growth in total Medicare expenditures for some participants. Dugan maintains that the evaluation helped SASH make the case for its inclusion in the Vermont All-Payer ACO Model, a value-based reimbursement system for Medicare, Medicaid, and commercial payers that CMS launched in Vermont in 2017.
“We felt, and we were told, that this rigorous evaluation was a game-changer for CMS,” says Dugan. “It was also a key to getting policy makers here in Vermont to go to bat for SASH to be included in the all-payer model. They all supported SASH, but they had to be armed with information about our program, so they could talk to CMS.”
The SASH evaluation, which was funded by HUD and HHS, also had an important impact at the national level, says Star. That evaluation, she says, “served as inspiration to the eventual IWISH model … and informed our thinking about the design of the IWISH demonstration and evaluation.”
Looking Ahead
Despite these and other successes, Stone and Sanders admit that using research to influence policy and practice requires patience and a tolerance for challenges.
“Policy changes slowly, which means funding mechanisms change slowly,” says Sanders. “For me, the big hurdle here is we don’t yet have a sustainable, scalable financing mechanism. Until we have that, we are not going to see a big shift toward housing plus services.”
Sanders and Stone hope that the growing acceptance of Medicare and Medicaid managed care and value-based payments will provide an incentive for health plans, health providers, and housing communities to collaborate on helping low-income older adults better manage their health. No one knows how long it will take to normalize these housing-health partnerships, but the LTSS Center will continue working hard to reach that goal, says Stone.
“Our work in housing plus services is a real lesson in how applied research can lead to transformation, from building the original interest in an idea, all the way through to making the case for big policy change,” she says. “The message here is that if you don’t participate in this kind of research and work, you simply don’t have as much of an opportunity to make a difference.”