building bridges: making a difference in long-term care 2005 Colloquium June 25, 2005
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building bridges: making a difference in long-term care 2005 Colloquium June 25, 2005 Boston Funded by the Commonwealth Fund Conducted by AcademyHealth THE COMMONWEALTH FUND AFFORDABLE CLUSTERED HOUSING CARE FOR OLDER AMERICANS A Promising But Still Immature Long-Term Care Strategy Stephen M. Golant, Ph.D. University of Florida Paper Presented at AcademyHealth Colloquium Boston, June 25, 2005 DRAFT: DO NOT CITE OR DISTRIBUTE Increased Appearance of Affordable Planned or Organized Settings Integrating Housing and Care These hybrid shelter-care integrations known by various names ¾Service enriched housing ¾Affordable supportive housing ¾Affordable residential care ¾Affordable congregate housing ¾Assisted living in Public Housing ¾Service coordinated housing ¾Affordable assisted living DRAFT: DO NOT CITE OR DISTRIBUTE 3 Basic Characteristics of Integrated Housing and Care Settings Conventional multiunit rental buildings, cooperatives, or cottages, or on campus setting Cater to a sizable population cluster of lowincome frail older adults Deliver wide range of long-term care services Practice a “social” rather than a “medical” model of care Usually harness multiple public/nonprofit sector funding streams to make both housing setting and long-term care context affordable DRAFT: DO NOT CITE OR DISTRIBUTE 4 These Hybrid Integrations Deserve Own Label AFFORDABLE CLUSTERED HOUSING CARE STRATEGY or AFFORDABLE HOUSING-CARE DRAFT: DO NOT CITE OR DISTRIBUTE 5 Why Recognize Their Emergence Now? Various Catalysts Not new, but now more numerous and mainstream, organizationally visible The courts have spoken State governments more interested in less expensive long-term care alternatives New public policies New organizations focused on creating affordable housing-care options DRAFT: DO NOT CITE OR DISTRIBUTE 6 Why Recognize Their Emergence Now? Unequal Dual Long-Term Care Markets One set of options for the wealthy, another for the poor Nursing homes dominated by poor elderly Private pay assisted living too expensive Aging in place in conventional owned or rented dwellings more difficult for lower- than higherincome frail older persons We label this usual aging in place strategy: Affordable Household Centered Care DRAFT: DO NOT CITE OR DISTRIBUTE 7 Downsides of “Household Centered Care” for Poor Elderly: Inappropriate Dwellings Most older persons receive long-term care in their conventional apartments and owned homes Significant share paying an excessive amount of their income on their housing costs Dwellings sometimes suffer from physical deficiencies in their plumbing, heating, cooling, and structural integrity Design problems make accommodations difficult or unsafe to use DRAFT: DO NOT CITE OR DISTRIBUTE 8 Downsides of “Household Centered Care” for Poor Elderly: Caregiving Challenges Most depend on informal care Caregiving is unplanned and delivered by inexperienced albeit usually caring persons Caregiving efforts exact a heavy emotional, physical, and financial toll Older persons who cannot rely on spouse or children especially disadvantaged Home setting is often an almost totally unregulated care environment DRAFT: DO NOT CITE OR DISTRIBUTE 9 Downsides of “Household Centered Care” for Poor Elderly: Problems Accessing Public Sector Long-Term Care Solutions Lack of knowledge Confront organizational barriers when bundling together needed services Services administered by different agencies with different regulations, eligibility requirements Less educated, women living alone, members of minority groups especially confront access challenges DRAFT: DO NOT CITE OR DISTRIBUTE 10 Downsides of “Household Centered Care” for Poor Elderly: More Difficult Long-Term Care Delivery Older persons live in dispersed or scattered low-density suburban and rural locations Spread out geographic markets result in greater travel costs More difficulty making shorter duration but timelier visits DRAFT: DO NOT CITE OR DISTRIBUTE 11 Affordable Clustered Housing Care Strategy Housing setting (residential accommodations, neighborhood, and community) matters Influence the long-term care experience and outcomes Older persons receive assistance not just because they are frail Rather, because they occupy a housing setting deliberately planned or organized to provide long-term care Older persons needing long-term care do not have to act alone 12 DRAFT: DO NOT CITE OR DISTRIBUTE Housing-Care Strategy: Key Distinguishing Features Buildings have design features making them user-friendly and safe Common areas for dining and recreational and office/clinic spaces for staff Occupied by critical mass or sizable cluster of impaired lower-income older persons DRAFT: DO NOT CITE OR DISTRIBUTE 13 The “Critical Mass” Influence Hallmark of the housing-care strategy Facilitates all aspects of long-term care delivery More economically and organizationally efficient to deliver long-term care services More feasible to hire on-site staff of multiple case managers Social worker or nurses can set up office hours Reduced likelihood of duplicated services Allow for more efficient scheduling More diverse communication approaches to educate residents DRAFT: DO NOT CITE OR DISTRIBUTE 14 Long-Term Care Found in These Housing-Care Settings On-site hired trained staff, volunteers Outsourced community-based service providers Co-located with nutrition site or adult day care center Long-term care services range from service coordination to personal care addressing all levels of impairment DRAFT: DO NOT CITE OR DISTRIBUTE 15 Basis of Diverse Prototypes of Affordable Housing-Care Strategy Combinations of the following components and features: ¾Type of housing setting ¾Physical design features ¾Type of long-term care ¾Service delivery approach ¾Affordable housing setting: type of program/funding support ¾Affordable long-term care: type of program/funding support DRAFT: DO NOT CITE OR DISTRIBUTE 16 Diverse Prototypes of Affordable HousingCare Strategy (examples) Multi-unit stand-alone rental building subsidized by HUD with hired service coordinator Multi-unit stand-alone rental building subsidized by HUD with hired service coordinator and outsourced Older Americans Act services Multi-unit stand-alone congregate or cooperative housing offering meals, housekeeping, and personal care with both onsite staffing and outsourced services with funding from nonprofit organization DRAFT: DO NOT CITE OR DISTRIBUTE 17 Diverse Prototypes of Affordable HousingCare Strategy (continued) Multi-unit stand-alone HUD rent-subsidized building converted to assisted living facility with Assisted Living Conversion Program with hired service coordinator and outsourced services, ranging from housekeeping to personal care funded under Medicaid Waiver Program. Multi-unit stand-alone private-pay assisted living residence, with selected units made affordable with SSI state supplements and Medicaid Waiver funding. DRAFT: DO NOT CITE OR DISTRIBUTE 18 The Good and Bad of Diversity Older frail consumers benefit from more choices But diversity contributes to a possible identity crisis Affordable housing-care options may not constitute a unique and coherent long-term care strategy An eclectic product line may confuse consumers and make selecting an appropriate facility more difficult Marketing, insurance underwriting, financing may be discouraged 19 DRAFT: DO NOT CITE OR DISTRIBUTE Financial, Organizational, and Political Barriers Restrict Public and Private Sector Solutions Intra-Organizational Barriers (HUD, HHS) Inter-Organizational Barriers ¾A different language of eligibility ¾Philosophy of care conflicts ¾Frailty levels required by Medicaid too high ¾Out of sync government rental subsidies ¾Out of sync affordable rent-assisted programs DRAFT: DO NOT CITE OR DISTRIBUTE 20 Multiple Evaluation Categories to Judge Quality of Life Various indicators offer insight into the quality of life and care offered by housing-care facilities Sparse literature, but generally consistent findings State governments primarily interested in singular basis to justify expansion ¾Saving long-term costs by delaying institutionalization ¾Most difficult-to-meet standard of success DRAFT: DO NOT CITE OR DISTRIBUTE 21 Quality of Life and Care Evaluation Categories 1) Traditional indicators: affordability and physical adequacy 2) Accessibility, safety, and user-friendliness of dwelling and its site 3) Compatibility of the social situation of the housing-care setting—age composition and frailty profiles 4) The quality of life of the surrounding neighborhood and community 5) Maintaining or improving independence and behavioral functioning 6) Long-term care setting as a “social” vs. “medical” model of care 7) The integration of the housing setting and long-term care context 8) Delaying an institutional quality of life and saving long-term care costs DRAFT: DO NOT CITE OR DISTRIBUTE 22 Going Forward: Unanswered Research Questions 1) Describing patterns of affordable housing-care occupancy and long-term care use 2) Assessing quality of life and care in affordable housingcare settings 3) “Quality” tradeoffs: household centered vs. clustered housing care strategies 4) Multiple effects of “critical mass” on long-term care delivery 5) Prioritizing barriers preventing expansion of housing-care options and implementation 6) Comparing on-site staffing, outsourcing, and co-located service models of long-term care delivery 7) Models of successful housing-care developments DRAFT: DO NOT CITE OR DISTRIBUTE 23 building bridges: making a difference in long-term care 2005 Colloquium June 25, 2005 Boston Funded by the Commonwealth Fund Conducted by AcademyHealth THE COMMONWEALTH FUND
