Keeping Seniors Healthy (and Happy) in Affordable Housing
By Mark Olshaker
10 min read
In the senior affordable housing sector, a number of force fields are now coming together with the general aim of making older residents healthier and happier. While altruism is certainly a key component in this trend, the bottom line is good business. And the operators who are thriving in the current environment are the ones whose enlightened techniques and rigorous measures already represent best practices that all in the sector can learn from and implement.
Many believe that the first of these force fields is the aging of the Baby Boomer generation, whose numerical heft has focused both public policy and marketing strategies on each phase of its obsessively documented collective journey through life.
The second force field is passage of the Affordable Care Act – ACA – that had as one of its chief goals curbing Medicare’s steadily growing spending and a crackdown on unnecessary care and treatment for its senior population. So in 2012, Medicare began instituting financial penalties on hospitals that had too many readmissions – defined as an individual’s return as an inpatient within a month of original discharge. Astoundingly, a 2013 Robert Wood Johnson Foundation report found nearly one in five Medicare patients fit this category prior to institution of the penalties.
Not surprisingly, various studies have shown that poor, African-Americans and seniors without a support network of family or friends, tended to have the highest readmission rates, which parallels the challenge faced by affordable senior housing and assisted living facilities. And that is where the third force field comes into play.
Simply stated, it is an emphasis on wellness that, in many cases, can preempt an emphasis on sickness and infirmity. And it is paying off in measurable financial results for the facilities that have embraced the approach.
Wellness Programs
“Our goal is to keep people independent as long as possible,” says Pam Goodman, Chief Executive Officer of Beacon Communities LLC in Boston, which owns and manages more than 70 market-rate, affordable and senior communities throughout New England, Pennsylvania, Maryland and Virginia. “This has been a long-term interest of Howard’s and mine: to avoid more institutional settings than you really need,” she comments, citing Beacon board chairman and real estate attorney Howard Cohen.
What they found was that seniors with low incomes tended to have more complex medical issues. “There is a huge, huge need within this population of people with complex needs; even more so with mental health and cognitive problems,” Goodman notes.
Absent regular and readily available healthcare support, those people frequently ended up in emergency rooms, often leading to hospital admissions. And without available healthcare support, the cycle would be repeated over and over again.
“So we wanted to figure out what we could do to keep them out of the ER,” Goodman states.
Among the problems her managers saw repeatedly were misunderstanding of, and noncompliance with, prescription taking; inadequate nutrition; falls; lack of wound care; and inconsistent routine medical checkups. All of these factors contributed to hospital readmissions and residents having to move into nursing homes.
Under the heading of wellness programs, Goodman explains, “We created relationships with a wide range of providers: hospitals, universities, primary care physicians, dentists, visiting nurses, physical therapists, rehabilitation specialists and psychiatric social workers. They will see people in their apartments and in each residence’s wellness office. Basically, we established interdisciplinary teams at our facilities. Some are more robust than others; it doesn’t happen overnight. Our Richmond, Virginia program, for instance, has been an incredible success story. We’ve developed some pretty innovative programs with providers and our Resident Services Department is really committed.”
As she points out, “A lot of these people are providing these services anyway. We just found a cost-effective vehicle. We really act as the entity that finds and coordinates the groups. It just took a while to figure out what to do and how to do it. It’s a question of being imaginative and reaching out.”
Measuring Success
Part of the challenge is figuring out where to concentrate limited human resources. National Church Residences, based in Columbus, Ohio, is one of the most respected providers of affordable housing and services to seniors; particularly vulnerable seniors. Like other leaders in the sphere, the organization has always had a strong sense of mission. But there had to be some way to figure out if what they were doing was working, and using their resources most efficiently.
According to Erica Drewry, Vice President for the Home and Community Services Division, “There had been an anecdotal belief at
NCR that we were already making an impact on the health of our residents through our service coordinators. But we wanted to take that to a larger scale and solidify it in affordable housing. So what we aimed to do was much more purposefully develop relationships between our service coordinators and each patient so we could identify specific risk factors and put standard interventions in place.” NCR has a service coordinator in place in every property with a HUD support component and the service coordinators are funded by HUD grants.
“Our goal was to measure resident vulnerability, and we found that we were seeing a lot of chronic health problems and multiple ADL [activities of daily living] needs. It is amazing how much these evaluations are telling us. It gives us solid data on where we need to direct our resources and lets the service coordinator focus on how to get residents the kind of help they require.”
The effort resulted in what they call the “Care Guide,” that creates a health profile for each resident as well as the facility as a whole. “That way, if we see that one building has a high incidence of diabetes, say, we can concentrate our efforts there.”
Adds Pamela Monroe, Vice President for Property Management, “We are able to target the needs of residents so much better than we could in the past. And Erica has done such a good job that we know who our best service coordinators are and who might need more help and training.”
“There is a lot of opportunity to have an impact,” states Drewry. “What we believe we’re doing is changing the face of what affordable housing is for a vulnerable population. We’re helping them to continue to live and age in this place they call home.”
Good Business
Few have been as innovative and imaginative in marshaling funds and resources to serve low-income senior housing as Conchy Bretos, founder and principal of Mia Senior Living Solutions of Miami, Florida. So far, Mia has worked in 23 states, establishing its own facilities and managing and/or consulting on others.
“This started out as a moral issue for us – enabling seniors to age with dignity, in good accommodations, with good care and things that improve their health. But we had to prove that it wasn’t just about altruism. It was good business.”
Mia’s affordable senior facilities are renown for their levels of comfort and care. “If these people are going to grow old, we wanted them to live better,” says Bretos. “And when you look at the new regulations, we’ve been providing these services and livable conditions for 18 years already.”
Like Beacon and National Church Residences, Mia relies heavily on measurable metrics in evaluating and adjusting programs. Evaluation instruments ask residents how they feel as well as track medication compliance, falls, hospitalizations and readmissions, and length of time residents remain in Mia communities before having to move to more extended care facilities.
As an example, in 1998, in conjunction with the Miami-Dade Housing Authority, Mia established the Helen Sawyer Plaza, a 100-unit assisted living facility for low-income seniors. The concept was based on the total coordination of services to care for and improve the lives of public housing residents. It featured a menu of services ranging from three meals a day, daily housekeeping and laundry, transportation to doctor’s appointments, assistance with tasks of daily living and medication management. An evaluation by Florida International University revealed marked improvement in the residents’ health, lowest attrition rate in the nation and unprecedented low absenteeism and turnover of staff.
“We had a large number of residents with impaired cognitive and physical health at Helen Sawyer,” Bretos recalls.
“But when we instituted our plan of services, we were able to cut down on the number of medications prescribed, had fewer falls, fewer hospitalizations, stemmed the flow of people to nursing homes and had fewer EMT calls and emergency room visits. With improved nutrition and physical therapy, we were literally able to get people out of their wheelchairs.
“Little did we know that [these metrics] were going to be our ammunition to go to the federal government.”
Persuading Government to Partner
Through trial and error, Bretos and her team have honed their approach to government funding. “The government has a spiritual blind spot. They don’t realize that what they do involves human beings. To me, this is a moral issue: people were rotting away. But when I decided to go back and say, ‘By the way, we can save you money,’ then they got interested. We went to HHS and said, ‘We want Medicaid waivers to take care of these people and we can do it for one fourth the cost of putting them in nursing homes. And Helen Sawyer became the tangible thing to prove to government that we could substantially cut their Medicaid and Medicare costs.
“Now, the government is our partner. Ultimately, they would like to do the right thing, but the way you sell it to them is financial.” This partnership materialized in the Affordable Care Act through the Community First Choice Option provision that marries housing and health care.
Admittedly, the complex combination of funding necessary to provide affordable housing, nutrition and health care services for seniors can be an intimidating challenge. As Bretos says, “We’ve put together Medicaid, Medicare, veterans’ services, HUD grants and local housing authorities. To do this, you not only have to know everyone’s ground rules, but mesh them together. We understand stacked, categorical funding. We’ve been pioneering low-income tax credit assisting living, which is an emerging market.” She concedes, “Low income tax credits are not for the faint of heart, but we’re learning!”
Bretos’s operating philosophy has been the team approach, partnering with municipal authorities and developers to let each one do what they do best.
“We like to team up with affordable housing developers. One developer had tried in the past and failed, but he came to us for another try and we worked together.”
Bretos feels that the 70 to 100-unit facility is most efficient in terms of providing services and she likes to cluster properties close to each other to take advantage of networks and accumulated knowledge. Mia has managed to do this in Florida, Georgia and Indiana, and is looking at other areas. She says through this approach they have obtained operating margins in the range of 24 percent.
“We’re always mindful of giving developers a return on their investments.”
These kinds of facilities, programs and services require a tremendous amount of coordination in terms of funding, providers and in-house services. But as Beacon’s Pamela Goodman notes, “It’s a matter of empathy and compassion; just something that seems to make sense to us. And with the ACA, others are realizing this makes a lot of sense, and saves a lot of money.”
