Affordable Clustered Housing-Care: A Category of Long-Term Care Options for the Elderly Poor

ABSTRACT

What we label as affordable clustered housing-care options are making it increasingly possible for poor and frail older Americans to age in place comfortably and securely in residential-like settings combining both affordable shelter and long-term care. The hallmark of these housing arrangements is their sizable population clusters of low-income frail persons in need of supportive services. Despite their greater availability and the compelling factors underlying their growth, the diversity of their supportive services and operations cloud their identity resulting in uncertainty as to whether they have a common mission. In response to the need for a more careful delineation of this aging in place option, this paper describes the distinguishing features of these hybrid settings and constructs a typology of their representative exemplars or prototypes.     

The Prevalence of Factors Influencing Decisions Among Elderly Women Concerning Household Possessions During Relocation

This study identified the prevalence of factors influencing elderly women's decisions concerning their living room items during relocation. The 36 participants lived alone in identical one-bedroom apartments and had relocated within one year prior to the time this study was initiated. A structured focused interview consisting of open-ended questions was used to collect the data. Responses to open-ended questions were tape-recorded, transcribed, and content-analyzed. The prevalence of factors influencing decisions to eliminate, retain, and acquire furniture, accessories, and decorative items pertained to the usefulness of items, spatial dimensions, building regulations, family attachments, gifts, and the decorative compatibility of items with the living room.     

Supportive Housing Initiatives in Arkansas

Abstract

Arkansas has a significant need for improving the availability of affordable housing with access to supportive services for its large population of elderly and persons with disabilities. Factors that contribute to this need are the high level of poverty, general poor health, low employment rate for persons with disabilities, and the geographic and social isolation problems typical of a rural State.     

On Home Equity Conversion Mortgages for Elderly Homeowners

Analysis of reverse mortgage plans for elderly homeowners indicates that the compound interest charged by the lenders would capture more than half of the equity of the homeowners. The lenders further ask that the Federal Housing Administration (FHA) insure them against risks of unexpected longevity of the borrowers, creating an inderterminate risk to FHA.     

Assisted Living for Lower-Income and Frail Older Persons from the Housing and Built Environment Perspective

Abstract

This paper examines the linkages between housing and supportive services from the built environmental perspective. When it comes to linking supportive services, it is usually true that the wealthier an individual is the more private resources he or she has available to define a personal support system at every step in the aging process; the poorer the individual is, the fewer choices she or he has and the successful linkages of government subsidized housing, health and supportive services become more important to successful aging of that person. Low-income and aging individuals are the real testing ground for whether current policy allows holistic support linkages to occur and whether programs are available in both the quantity and quality to empower low-income older persons with options and support choices.

The discussion that follows is limited to supportive services and aging in place in conventional housing and affordable purpose built assisted living programs and facilities; it omits institutional living. For low-income older persons, institutional care provides few if any housing choices or individual power to control support delivery, and thus linkages between cooperating support professionals and programs becomes increasingly moot.     

Targeting Services to Those Most at Risk

Abstract

The budget crises facing many state Medicaid programs have increased interest in the goal of linking services and housing as a way to provide more options to people with disabilities at less cost than institutional care. This article examines some of the premises underlying this interest, especially with respect to linking supportive services and federally subsidized housing for older persons. The first section provides a brief history of the activity in this area. The second section examines the risk factors associated with nursing home admission and how those factors match the characteristics of renters receiving subsidies. The third section focuses specifically on the likelihood that subsidized renters will also become eligible for Medicaid. The fourth section explores the capacity of housing programs to meet the challenges associated with service delivery. Finally, the conclusion examines the implications for public policy decision-makers interested in linking services and housing in order to address the long-term care (LTC) needs of older persons with modest incomes.     

The Coming Home Program

Abstract

This paper describes barriers and opportunities to creating affordable assisted living facilities for older persons eligible for Medicaid services. This information is based on the practical experiences of the Coming Home Program, a project of NCB Development Corporation (NCBDC) with funding from the Robert Wood Johnson Foundation (RWJF). Begun in 1992, this national program has contributed to the creation and adoption of state policies including regulations, implementation of state programs, creation of development and operational feasibility analysis tools, and the identification and structuring of financing sources. It has also fostered and supported public-private partnerships that have resulted in 31 operational affordable assisted living demonstration projects with another 73 in development.

The paper explains the need for affordable assisted living, Coming Home's definition of affordable assisted living, and the structure of the Coming Home Program. Four case studies are presented that summarize the goals and outcomes of the Coming Home Programs in Arkansas, Florida, Washington, and Vermont. The paper's conclusions provide lessons learned during the program's first twelve years and their implication for state policies and programs.     

Housing for Older People in Iceland: Apartments and Nursing Homes

The first residential and nursing homes in Iceland were built in the early 1920s, and the first apartments for older people in the early 1970s. Most of the existing housing for older persons was built in the last 30 years. Legislative provisions on housing and particularly on assisted living have not changed significantly since laws relating to the affairs of the elderly were first passed in 1983. While approximately 90% of older people in Iceland own their own home and the primary stated goal of the government is to support independent living, official policy relies on placement in nursing homes. Services and care at home, provided by social and home healthcare services, has not been developed to the same extent as in the other Nordic countries. Clearer guidelines on integrated service housing are needed to reach the government's primary stated goal. Placing more emphasis on delivering services, care, and rehabilitation to people living in the community could shorten individuals’ length of stay in hospitals, delay admission to nursing homes, and better meet the expectations of older people for independent living.     

Meeting the Needs of Visually Impaired People Living in Lifetime Homes

ABSTRACT

This article explores perceptions on the suitability and effectiveness of Lifetime Homes standards (LTHS) for those with visual impairment in Northern Ireland. LTHS are a series of mandatory United Kingdom public-sector housing design interventions, providing a model for ensuring accessible and adaptable homes throughout an occupant's life span. An aging demographic with increasing incidence of diabetes has led to rising numbers of elderly, visually impaired people wanting to remain in their homes for longer. Qualitative semi-structured interviews were conducted with 13 key stakeholders and thematically analyzed. Although findings show that employing LTHS offers benefits to visually impaired residents, shortcomings were also identified. Evidence indicates a need for policy makers, health-care professionals, and housing associations to modify practices to better meet the housing needs of visually impaired people. Findings may also be applicable to those with other impairments and disabilities in relation to housing for elderly residents.     

The Supportive Community

Abstract

This study examines supportive community programs in Israel, which aim to improve the quality of life of the elderly. These innovative programs pool existing resources to provide a benefits package that includes medical services, an emergency call switchboard, a “neighborhood facilitator,” and social activities. Data were collected in 2000-2001 using qualitative and quantitative methods. The program provides specific services to meet needs that otherwise are not adequately addressed. The major contributions of the program reported by the members was increasing their personal security (two-thirds), easing the burden on their children (one-third), and enabling them to remain at home (one-quarter). The supportive community program enriches the variety of services available, thus providing the elderly with the choice of staying within their familiar surroundings of their homes and neighborhoods. This model appears to be both a cost-effective way to facilitate aging in place and a way to meet many of the elderly's essential needs, thereby maintaining their quality of life.     

Technology-Based Innovation for Independent Living: Policy and Innovation in the United Kingdom,Scandinavia, and the United States

Interest in utilizing technology to help older adults remain living at home is growing; however, uptake remains low. We present a conceptual framework for understanding independent living technology innovation within health and social services. Public policy and innovation in the United States, the United Kingdom, and Scandinavia are profiled as case studies. In all profiled countries, independent living technology is more rapidly advancing than associated state policy, regulation, and payment systems. The findings from this comparative analysis reveal areas for further exploration, including policy subsystem environments in which technologies and services are regulated, as well as trends and desires of older adults and their caregivers within particular cultural contexts.     

Naturally Occurring Retirement Community-Supportive Service Program

Summary

Devolution is defined as the transfer of power or authority from a central government to a local government. This article addresses federal policies on housing for the elderly and the devolution of funding for federal senior housing and describes two aspects of devolution of federal housing policy for the elderly. One, it points out the decreasing interest in senior housing by federal authorities as indicated by the decreased amount of funds allocated for this purpose. Two, it emphasizes the need for supportive, assistive services for residents of senior housing and how federal funds have not addressed this need adequately or sufficiently. As a consequence, there have emerged Naturally Occurring Retirement Communities (NORCs) in New York State, a housing arrangement that provides supportive and health services to all eligible residents. The article concludes with a discussion of policy implications and the need for additional research before replicating this model.     

Building Affordable Rental Housing for Seniors: Policy Insights From Canada

ABSTRACT

In the context of healthy aging, we explore newly constructed, unassisted affordable rental housing with respect to design, location, and the involvement of seniors in decision making. We do so from the perspectives of seniors and project sponsors. Overall, the themes that emerged from these two groups of participants diverge. Seniors spoke about the importance of shared space, design-related barriers to aging in place, and problems accessing transportation. They also expressed a range of views regarding participation in decision making, from conveying it was not necessary to requesting resident involvement. Project sponsors spoke about cost, feasibility, and, in certain cases, learning how to build housing; they also evinced disparate views about the nature of the housing they were providing and the importance of seniors' involvement. Recommendations include linking housing to health and social policy, implementing guidelines for sponsors related to design and location, and providing increased funding to offset new costs.     

Aging in Place in a Retirement Community: 90+ Year Olds

Aging in place, an image of growing old in one's home and maintaining one's daily routine, is desired by most older adults. To identify variables promoting such independent living in the oldest-old, we examined the association between living situation of a population-based cohort of 90+ year olds with health and lifestyle variables. Of 1485 participants, 53% still lived in their home at a retirement community designed to foster wellness. Those living at home tended to be healthier, with smaller proportions having chronic diseases or hospitalizations in the preceding year and a greater proportion having normal functional ability. Dementia was the chronic disease most significantly related to living situation. In addition to not having dementia, not using a wheelchair or bath aid, receiving meals on wheels, and being married were jointly related to living at home. With the help of family and friends and with a medical and social support system, many 90+ year olds can age in place. This is often because they have a caregiving spouse or paid caregiver.     

Local and Regional Governments and Age-Friendly Communities: A Case Study of the San Francisco Bay Area

The purpose of this study was to assess the extent to which cities, county departments of adult and aging services, county transportation authorities, and public transit agencies in the San Francisco Bay Area have in place age-friendly policies, programs, and infrastructure in the areas of community design, housing, transportation, health care and supportive services, and opportunities for community engagement. The most common age-friendly features include those that target alternative forms of mobility (for example, incentives for mixed-use neighborhoods and changes to improve the accessibility of public transit), while the least common policies and programs are those that aim to help older adults continue driving, such as driver education programs, driver assessment programs, and slow-moving vehicle ordinances. The article concludes with policy and research implications of these findings.     

The Needs of Elders in Public Housing: Policy Considerations in the Era of Mixed-Income Redevelopment

A number of studies have followed the changes in the lives of public housing residents forced to relocate because of redevelopment. From 2002 to 2007, researchers followed the residents of a public housing development from the first year when residents learned of the pending demolition through 4 years of resettlement. Elder residents dispersed throughout the city provide insights into what life is like for low-income seniors leaving their homes and entering as strangers into new neighborhoods. The article concludes with recommendations for rethinking aging in place for poor elders.     

Mom and Pop Versus the Big Boys: Adult Family Homes as Providers of Medicaid-Funded Residential Care

This paper compares assisted living apartments (ALs), adult residential care facilities (ARCs), and small adult family homes (AFHs) for Medicaid residents in Washington State, with particular emphasis on the settings, staffing, services, and policies of AFHs. We targeted for enrollment all residents entering an AFH, ARC, or AL setting on Medicaid/state funding in a three-county area of Washington State. We obtained information on 199 settings, interviewing administrative and direct care providers. AFHs are smaller than ARCs and ALs and less likely to be part of a chain, with no significant difference in staffing ratios of registered nurses and licensed practical nurses. Sixty-four percent of AFH residents were receiving public funds compared to 32% of AL residents. AFHs report admitting residents with more activities of daily living needs, health conditions, and behavior problems. They are less likely to have autonomy-related policies, and they provide more services and fewer activities. While attention should continue to be paid to staff supports, policy and practice should support the continued role of AFHs, which are of special interest because of their potential to provide more homelike, less costly care but with possible trade-offs compared to larger facilities.     

TigerPlace,A State-Academic-Private Project to Revolutionize Traditional Long-Term Care

ABSTRACT

The Aging in Place Project at the University of Missouri (MU) required legislation in 1999 and 2001 to be fully realized. An innovative home health agency was initiated by the Sinclair School of Nursing specifically to help older adults age in place in the environment of their choice. In 2004, an innovative independent living environment was built and is operated by a private long term care company, as a special facility where residents can truly age in place and never fear being moved to a traditional nursing home unless they choose to do so. With care provided by the home care agency with registered nurse care coordination services, residents receive preventative and early illness recognition assistance that have markedly improved their lives. Evaluation of aging in place reveal registered nurse care coordination improves outcomes of cognition, depression, activities of daily living, incontinence, pain, and shortness of breath as well as delaying or preventing nursing home placement. Links with MU students, faculty, and nearly every school or college on campus enrich the lives of the students and residents of the housing environment. Research projects are encouraged and residents who choose to participate are enjoying helping with developing cutting technology to help other seniors age in place.     

Living in Affordable Housing and Duration of Tenure: Do Older Adults Stay in Low-Income Housing Tax Credit Projects as They Age?

Compliance data for the low-income housing tax credit program in Ohio was examined to identify factors associated with affordable housing tenure. Residents aged 55 and older reported a median tenure duration of 2.7 years. Cox regression was used to explore time until exiting housing, controlling for demographic factors, and the date the housing project was placed into service. Results suggest that duration of tenure was predicted by age and race. Modifications to the state Qualified Allocation Plan guiding development under the low-income housing tax credit program should be considered to promote aging in place in affordable housing. Reasons for exiting and subsequent housing choice should be explored.     

Who Pays for Seniors Housing and Care Communities? Evidence from the Residents Financial Survey

To examine the financial characteristics of residents in assisted living and independent living communities and to see how they currently pay for their care arrangements, we surveyed 2,617 residents in assisted living and independent living communities. We asked them how they pay for their current costs and verified their answers by examining self-reported information on their cost and income. Residents stated that they are largely paying for their community costs independently. Approximately one third of respondents reported using their assets and income to cover their current costs. The data supported the notion that individuals living in assisted living and independent living communities are largely mid- to high-income elderly. However, the cross-sectional analysis showed that length of time in the community was positively associated with paying for their expenses independently out of income, after controlling for many confounders including age, education, and lifetime earnings to try to rule out differential longevity and differential selection over time. Further longitudinal analysis is needed to understand the cause and the implications of the positive correlation between ability to pay one's bills out of income and the length of time in the community before conclusions about spend-down can be made.