Most seniors want to age at home rather than move to a senior living facility. But this choice brings many challenges, including the risks of social isolation, limited access to medical care and supportive services, and the potential for falls or other injuries that come from living in a home that is unsafe for a frail older adult.
But there are ways to reimagine community-based housing as a resource for senior services, rather than a frequent impediment. In a new paper, Stuart Butler and Marcela Cabello of the Brookings Institution describe some exciting models and make important recommendations for ways to use housing as what they call a “hub” for senior services.
A chassis for senior services
Their paper, Housing as a Hub for Health, Community Services, and Upward Mobility, reaches far beyond the needs of seniors. It also looks at how housing-based services can assist children and young families. But it includes important ideas for using housing as a chassis for services that are critical to seniors who want to remain in their communities. Full disclosure: I was a member of the advisory group that helped guide Stuart’s and Marcela’s work.
First, they identified the keys to allowing older adults to remain in their homes: To start, housing must be safe and affordable. This sounds obvious, but often old adults have housing that is neither or must choose between one and the other. Second, housing should include access to both direct services such as health screenings, and case management that helps them find and use important assistance such as home health aides, transportation, and the like.
They acknowledge the importance of recognizing the broad diversity in housing and service needs among older adults. For example, people of different ethnic backgrounds may have very different needs. In addition, an older adult living in a rural community faces very different challenges than someone living in a suburb or in a major city. And, by the way, don’t assume that suburbanites have the easiest time. They often face social isolation and delivering services to seniors in cul de sacs can be costly and time-consuming.
Then, Stuart and Marcela identify the impediments to combining safe and affordable housing with key services and supports.
There are the bureaucratic challenges: State Medicaid programs may not coordinate with housing or transportation departments and the eligibility rules for different services may vary widely. While you may qualify for Medicaid long-term supports and services, you may not be able to receive the transportation services that are essential to staying at home.
Government agencies may not share data, which can be critical to identifying where a community’s needs are most severe and what programs work best.
And, most challenging of all, payment systems discourage agencies from working effectively to improve the overall well-being of seniors. For example, state Medicaid programs pay for room and board for nursing home residents but, with rare exceptions, do not fund these costs for those living at home. Thus, a typical state may pay almost $4,000-a-month for a nursing home bed when care at home—even with rental and food assistance—may be far lower. Then, there are the cross-agency problems. Why should a state transportation department spend its funds on programs that reduce health care costs of seniors when none of those cost savings will ever find their way back to the agency?
A list of solutions
And then there is the communication issue. Real estate developers speak a vastly different language than social workers. And, I discovered from listening to our advisory group conversations, even housing, health care, and social services policy experts struggle to communicate with one another.
Finally, and most important, Stuart and Marcela, propose several key steps that communities, developers, health systems, and governments and can take to build out successful models to improve the well-being of seniors. They include:
- Better coordinate budgets, planning, and coordination among government agencies. In some cases, this can be done best through financial intermediaries that combine government grants outside of the normal bureaucratic channels. One way to do this: Give states more flexibility to use Medicaid dollars to for housing and incorporated services.
- Build partnerships between housing providers and health systems aimed at improving the well-being of patients. This could be as ambitious as health systems directly financing housing for at-risk patients, including seniors. Or it could simply mean staffing an on-site wellness clinic in an apartment building with a large senior population.
- Create opportunities within both Medicaid and Medicare managed care systems to support housing and housing-based care delivery. For the first time, the recently- passed CHRONIC Act will make this widely possible for Medicare managed care (Medicare Advantage).
- Build relationships with existing community organizations, such as faith communities and senior villages.
- Improve data sharing and collection, and provide the money to evaluate those data to learn what interventions work best.
The paper is the most recent in a series by Stuart, who has also looked at hospitals and schools as hubs for community services. They all are worth reading.