Linking federally assisted housing with services for frail older persons

Advocates of policies designed to link federally assisted housing with social services for the frail elderly have encountered barriers such as the historical separation of housing and services, political and bureaucratic fragmentation, and budget constraints. Over a 20-year period, they have attempted to address these issues by identifying the nature and extent of the problem, creating workable models, and developing a political constituency. Major reform, however, occurred only in 1990 when Congress passed the landmark National Affordable Housing Act (NAHA) which provided an "open policy window" for supportive housing legislation. NAHA's passage, however, still left many issues unresolved (e.g., targeting and funding for services). The future challenge is to develop new models of supportive housing and provide a range of residential settings and portable services to increase the choices for frail older persons.     

Political and organizational barriers to satisfying low-income U. S. seniors' need for affordable rental housing with supportive services

A substantial share of the low-income older tenants who occupy U. S. government-subsidized rental housing has physical and cognitive limitations. These older tenants are often women living alone in their 70s and 80s, who need help obtaining community-based services, demand-responsive transportation, help with apartment housekeeping and maintenance, self-care assistance, and design modifications made to their dwellings. Other low-income and frail older persons who have large housing expense burdens or occupy physically deficient dwellings also need affordable rental housing with these supportive services. The unmet supportive service needs of these groups persist even as this country's major political and professional stakeholders are aware of their problems and have solutions. This paper examines five major political and organizational barriers that have restricted the availability of supportive services in affordable rental developments. It offers 12 policy recommendations.     

Mental Health Needs and Supportive Services for Elderly and Disabled Residents

Abstract

This study longitudinally assesses the impact that the provision of supportive services has on the mental well-being of the elderly and disabled population living in independent housing developments. The results indicate that the use of supportive services by the mentally ill allowed them to overcome initial lower functional status and achieve a level of mental functioning virtually similar to that of the total resident population. Thus, it is argued that independent living facilities with supportive services can certainly be a successful and cost effective model for a number of frail elderly and mentally ill residents.     

Live-in Care Workers in Sheltered Housing for Older Adults in Israel: The New Sheltered Housing Law

Supportive housing schemes were historically aimed to provide group accommodation for older adults. With the aging of residents, facilities were required to enable them to receive care services in order to allow them to age in place. Thus, different countries and different facilities developed different models of housing with care, reflecting cultural and policy diversities. Despite all of the different models, there are many commonalities among the supportive housing schemes across countries. These include provision of dwelling units and care services provided by either the facility or by external agencies. The aims of this article are threefold: to describe the historical development of the ever-evolving supportive care housing phenomena; to point at variations in models of housing and care within the international context; and to present a new Israeli model that enables residents to privately hire live-in care workers to meet their care needs. This is a unique model in the international context that has not been reported before. The article describes the main ideas of the new model and discusses the challenges that it raises and pinpoints the unresolved issues associated with the presence of live-in care workers employed by residents of sheltered housing that should be addressed.     

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.     

Homes of Choice

Abstract

State policymakers increasingly recognize that housing is not only an important shelter resource for older persons, but also a key element of community-based care. Over the last two decades, significant state and local activity has led to an increase in service-enriched housing for older persons. Service-enriched housing refers to living arrangements that include health and/or social services in an accessible, supportive environment. Emerging forces are leading to increased pressure for the expansion of service-enriched housing. These forces include: a growing and diverse population of older renters; older adults' preferences to age in place; the increasing frailty of subsidized housing residents; the development of assisted living (AL); the enactment of Medicaid waivers; and implementation of the Olmstead decision. Although studies have not included cost-analysis, available research demonstrates that service-enriched housing promotes resident satisfaction, successfully provides services to frail populations, and supports aging in place.

Given both limited resources and research, this article addresses how states can adequately respond to and capitalize on these forces in order to best meet the long-term needs of older adults.     

State Units on Aging and Housing for the Elderly:

One major goal of the Older Americans Act (OAA) is to promote suitable housing for the elderly through the aging network that includes the State Units on Aging (SUAs). Little is known, however, about SUA activity in this area. This article reports on the results of a recent survey of SUA housing efforts and roles played, collaborations and networks, resources, and priorities, accomplishments and future initiatives. To better link housing and services and expand housing options as some SUAs are already doing-especially in services coordination in existing housing, board and care, home equity conversion mortgages and assisted living-they must redefine housing as part of community-based care, vigorously focus political and advocacy skills on housing issues, and expand their capacity building and expertise in housing by resetting priorities and reallocating budgets.     

Bringing assisted living services into congregate housing: housing directors' perspectives

The purpose of this research is to explore the impact of an Assisted Living Services (ALS) program on directors of state-funded congregate housing. Using focus groups, we interviewed congregate housing directors about how adding the ALS program to their facilities impacted their management experiences. Four themes emerged from the analysis of the focus group data: (1) importance of assisted living services for promoting aging in place; (2) "costs" of offering ALS; (3) differences in how the ALS program was implemented; and (4) organizational issues emerging from the merger of housing and health-care models. Based on the present findings, we propose a number of policy issues that need to be addressed when services are added to existing housing.     

Impact of a supported housing prioritization system using vulnerability and high service utilization

For people experiencing chronic homelessness, supportive housing with intensive social, health, and behavioral health services reduces the likelihood of re-entering homelessness and the public costs of associated acute medical care, shelter use, and incarceration. Due to a limited supply of supportive housing, it must be allocated to those most in need. This paper examines findings from a unique, region-wide method for prioritizing individuals for supportive housing based on utilization of high-cost public services and vulnerability if left on the street. A sample of 196 individuals were prioritized for housing based on this method, while a comparison group of 102 were housed not using the method. Results showed that those housed under the prioritization method achieved greater reductions in utilization of high-cost public services, but were also less likely to have positive dispositions when exiting the housing programs, suggesting the need for a greater intensity of supports and/or multiple “doses” of supportive housing before stability can be expected. The method described in the paper can provide a starting point for developing regional, comprehensive systems of coordinated, prioritized entry into supportive housing, such as those now required by US Department of Housing and Urban Development.     

Naturally Occurring Retirement Community-Supportive Service Program: an example of devolution

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.     

Looking Back: The Experiences of Four Midwest Families After Receiving Foreclosure Counseling Services

The Great Recession produced significant job loss, which precipitated housing instability and the need for foreclosure prevention services for some households. To help meet the needs of struggling homeowners, housing counseling agencies provided education and assistance to offer support. However, after services ended and housing outcomes were identified, families returned to their daily life. Little is known about the experiences and needs of households during and after receiving housing counseling services. This qualitative, in-depth, phenomenological assessment gives voice to the experience of housing instability for families 3 years after initially receiving services from an agency in one economically challenged, urban, Midwestern community. The findings from this study highlight the experience of four Midwestern families, through the use of Seidman’s (Interviewing as qualitative research, 4th edn. Teachers College Press, New York, 2012) three stage interview design, in which the researchers conducted three distinct interviews with each of four participants and two interviews with former housing counselors from the same agency. The findings reveal four key supportive factors that emerged for participants. They include: the importance of faith, family, positivity, and income supports.     

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.     

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.     

Putting the pieces together for queer youth: a model of integrated assessment of need and program planning

Needs assessments require staff with the necessary expertise to design the study, collect the data, analyze the data, and present results. They require money, time, and persistence, because the people one wishes to assess often are difficult to access. This article argues for the centrality of a well-done needs assessment when developing services for LGBTQ youth. Needs assessment methodology and adjunctive uses of the needs assessment data also are discussed. The authors present a needs assessment of LGBTQ youth living in out-of-home care in San Diego, California, as an example of the purpose, practicality, and power of a comprehensive needs assessment. The needs assessment identified several issues, as well as additional data supporting the project's necessity. The data also identified the most significant obstacles youth face in accessing housing and supportive services. Through the data collection process, non-LGBT housing providers better understood their need for additional training, and housing and city leadership communities obtained and spread knowledge of the project.     

Aging in (Privatized) Places: Subsidized Housing Policy and Seniors

The market-based approach of delivering affordable housing has led to a net loss of traditional public housing and an increase in alternative subsidized housing options. For poor, physically frail older adult residents, subsidized housing and its associated services and support provide an important safety net. This article explores the implications and consequences of this movement for low-income seniors. Specifically, we look at the past and current housing policies, the focus on public-private partnerships, and the transition toward mixed-income communities. The article ends with suggestions for protecting vulnerable older adult populations in a market-driven arena.     

The Program of All-Inclusive Care for the Elderly (PACE)

Summary

This article examines the long-term care service system in the United States, its problems, and an improved long-term care model. Problematic quality of care in institutional settings and fragmentation of service coordination in community-based settings are two major issues in the traditional long-term care system. The Program of All-Inclusive Care for the Elderly (PACE) has been emerging since the 1970s to address these issues, particularly because most frail elders prefer community-based to institutional care. The Balanced Budget Act of 1997 made PACE a permanent provider type under Medicare and granted states the option of paying a capitation rate for PACE services under Medicaid. The PACE model is a managed long-term care system that provides frail elders alternatives to nursing home life. The PACE program's primary goals are to maximize each frail elderly participant's autonomy and continued community residence, and to provide quality care at a lower cost than Medicare, Medicaid, and private-pay participants, who pay in the traditional fee-for-service system. In exchange for Medicare and Medicaid fixed monthly payments for each participating frail elder, PACE service systems provide a continuum of long-term care services, including hospital and nursing home care, and bear full financial risk. Integration of acute and long-term care services in the PACE model allows care of frail elders with multiple problems by a single service organization that can provide a full range of services. PACE's range of services and organizational features are discussed.     

The Program of All-Inclusive Care for the Elderly (PACE): an innovative long-term care model in the United States

This article examines the long-term care service system in the United States, its problems, and an improved long-term care model. Problematic quality of care in institutional settings and fragmentation of service coordination in community-based settings are two major issues in the traditional long-term care system. The Program of All-Inclusive Care for the Elderly (PACE) has been emerging since the 1970s to address these issues, particularly because most frail elders prefer community-based to institutional care. The Balanced Budget Act of 1997 made PACE a permanent provider type under Medicare and granted states the option of paying a capitation rate for PACE services under Medicaid. The PACE model is a managed long-term care system that provides frail elders alternatives to nursing home life. The PACE program's primary goals are to maximize each frail elderly participant's autonomy and continued community residence, and to provide quality care at a lower cost than Medicare, Medicaid, and private-pay participants, who pay in the traditional fee-for-service system. In exchange for Medicare and Medicaid fixed monthly payments for each participating frail elder, PACE service systems provide a continuum of long-term care services, including hospital and nursing home care, and bear full financial risk. Integration of acute and long-term care services in the PACE model allows care of frail elders with multiple problems by a single service organization that can provide a full range of services. PACE's range of services and organizational features are discussed.     

The association between aging inmate housing management models and non-geriatric health services in state correctional institutions

One of the current debates in the literature on aging inmates asks, what is the most efficient housing/health care model for this "special needs" population? State and federal correctional systems place elderly inmates either in specialized segregated housing units away from the general inmate population, consolidate elderly inmates in housing units within the prison, or provide a combination of both models. In general, proponents of the segregated housing model argue that aging inmates will receive specialized medical services in geriatric units. However, proponents of consolidated housing model argue that aging inmates will have the benefit of both geriatric and non-geriatric health services. This paper examines the association between the type of housing management model for aging inmates and the availability of non-geriatric physical and mental health services. Data for the analysis come from the 2000 Bureau of Justice Statistics Census of State and Federal Adult Correctional Facilities. The results suggest that institutions offering consolidated geriatric care provide more mental health services and that these effects are independent of the characteristics of prison facility.     

Bureaucratic encounters “after neoliberalism”: Examining the supportive turn in social housing governance

It is well established that encounters between welfare bureaucracies and their clients have been reconfigured under neoliberalism to address the problem of “welfare dependency.” Contemporary bureaucratic encounters therefore entail measures to activate clients’ entrepreneurial/self-governing capacities, and conditionality/sanctioning practices to deal with clients who behave “irresponsibly.” Despite the dominance of the neoliberal model, recent research has identified a counter-trend in the practices of housing services away from entrepreneurializing and punitive strategies and towards a more supportive approach. This paper examines this counter-trend and its implications for neoliberal welfare governance. To do this, it presents findings from research into social housing governance in Queensland, Australia, where the neoliberal focus on welfare independence, conditionality and sanctioning has been tempered by a new supportive approach focused on assisting vulnerable clients to maintain and benefit from access to welfare/housing support. Following Larner, we argue that this shift signals the emergence of an “after neoliberal” governmental formation, wherein key features of neoliberal governmentality are replaced by, or redeployed in the service of, progressive initiatives that address neoliberalism’s failings at the street level, but leave broader neoliberal policy settings undisturbed. We also challenge recent sociological accounts that construe supportive welfare practices as a function of an all-encompassing neoliberal project, arguing instead for appreciation of the contingency of these developments and the progressive political affordances that they entail.     

Housing Historic Role Models and the American Dream: Domestic Rhetoric and Institutional Decision-Making at the Tenement Museum

How does a social history museum end up obfuscating issues it intends to highlight? How does the Tenement Museum—an institution committed to “challenging the future” by “revealing the past”—come to obscure structural issues related to housing, immigration, and poverty? Through a comparison of participant observation of tours and analysis of institutional archives at the Tenement Museum, I show how decisions made for pragmatic reasons and materialized into domestic spaces obfuscate structural issues, both in the past and the present. Specifically, I demonstrate how the museum advances historic role models and the American Dream through depictions of tenement apartments, thereby displacing the very issues that tenement housing encapsulates. It is not news to sociologists that museums depict selective narratives that reinforce cultural tropes. Nor is it surprising that museums use domestic space as a mnemonic vehicle through which to portray the narratives they select. What is surprising, however, is that this happens in a museum that is invested in challenging the narratives it ends up depicting. Unpacking how this happens is especially pertinent because of the prevalence of museums that depict domestic spaces of the past, given the increased necessity for museums to educate in order to secure funding, and in light of contemporary political debates over housing and immigration.