Does Care By Design Have Programs for Low Income Seniors? Exploring Affordable Housing and Integrated Services

The growing population of older adults, particularly those with limited financial resources, faces significant challenges in accessing affordable housing that also caters to their evolving health and long-term care needs. This article delves into the critical issue of integrating health and social services within affordable housing settings for low-income seniors. Inspired by a conceptual framework initially designed to guide a demonstration project by the U.S. Department of Health and Human Services (HHS) and the Department of Housing and Urban Development (HUD), we will explore the various facets of this integration. While the phrase “Does Care By Design Have Program For Low Income” may not directly align with a specific known program name, it encapsulates the crucial question of whether care systems are intentionally designed to address the needs of low-income elderly individuals within housing environments. This exploration will consider existing models, potential strategies, and the systemic changes needed to ensure that affordable housing truly serves as a platform for comprehensive and supportive care for vulnerable seniors.

I. Understanding the Imperative for Integrated Services in Affordable Senior Housing

As the demographic landscape shifts and the baby boomer generation enters advanced age, the desire to “age in place” within their communities becomes increasingly prominent. This preference underscores the necessity for person-centered, holistic, and cost-effective approaches to support older adults, especially those with low and modest incomes. The conceptual framework initially proposed by HHS emphasizes that the quality of an individual’s living environment, including housing, profoundly affects their health and overall quality of life.

Building on decades of efforts to expand home and community-based services (HCBS), the Affordable Care Act (ACA) has further broadened opportunities to explore innovative models. Integrating services with affordable housing emerges as a potentially efficient strategy to reach a large population of lower-income seniors. The “Money Follows the Person” demonstration, aimed at transitioning individuals from nursing homes back to community settings, has highlighted the critical shortage of service-enriched affordable housing as a major impediment. Similarly, HUD recognizes the vital role of supportive services in enabling elderly residents to maintain their independence and safety within their housing units. Current HUD policies are increasingly focused on aligning new Section 202 housing developments with state and federal healthcare reform initiatives, aiming to better support seniors as they age in their communities.

This diagram illustrates a conceptual framework for linking housing with health and long-term care services, aiming to create a supportive environment for low-income elderly adults. The interconnection highlights the integrated approach needed to address their diverse needs.

The ACA also acknowledges the prevalent lack of coordination and integration within Medicare and Medicaid systems, especially for beneficiaries with multiple chronic conditions. To address this fragmentation, new entities within the Centers for Medicare and Medicaid Services (CMS) were established to spearhead payment and service reform demonstrations. Initiatives like Accountable Care Organizations (ACOs) and Medicaid Health Homes are testing novel methods to streamline care delivery and curb excessive costs. These evolving healthcare landscapes present unique opportunities to examine the role of affordable housing with integrated services in achieving the goals of these reform efforts. Furthermore, the American Recovery and Reinvestment Act has provided additional resources for delivering evidence-based preventative services to low-income elderly residents in subsidized housing and surrounding communities.

In essence, the overarching principle is the growing acceptance of a person-centered approach to service delivery, coupled with the widespread desire for seniors to age in place. Any successful models for affordable housing with integrated services must build upon these fundamental trends and align with ongoing federal and state policy reforms in healthcare and housing for low-income older adults. This necessitates a “care by design” approach, where services are thoughtfully planned and embedded within the housing environment to proactively support residents’ needs.

II. Defining the Policy Challenge: Affordable Housing and Service Gaps

A significant and rapidly expanding demographic group – low and modest-income seniors – confronts the twin challenges of securing affordable, safe housing that can adapt to their evolving needs as they age. Millions of older adults who rent or own their homes face excessive housing costs or reside in dwellings with serious physical deficiencies. Data from the 2009 American Housing Survey (AHS) reveals that approximately 1.8 million very low-income older adults (earning 50% or less of the area median income) spend over half their income on housing costs or live in substandard conditions. An additional 1.3 million elderly renters reside in publicly subsidized housing. Compounding these housing challenges, a growing proportion of these seniors experience chronic health issues, physical disabilities, cognitive decline, and mental health conditions.

The current healthcare system, characterized by multiple payers like Medicare and Medicaid, provides limited incentives for collaboration among primary care, acute care, and chronic care providers. This lack of coordination is even more pronounced when considering the interface with affordable housing providers and aging and long-term care services. Consequently, when older adults are most in need of integrated support, they often encounter a fragmented and poorly coordinated service system, leading to detrimental outcomes. The ability of seniors with chronic conditions or disabilities to maintain independent living is often compromised, their health and safety are jeopardized, and public and private healthcare costs can escalate dramatically. This escalation stems from premature transitions to costly nursing homes or residential care facilities, frequent emergency medical service calls, repeated emergency room visits, and hospital readmissions.

This graph visually represents the increasing healthcare costs linked to the lack of integrated services for seniors. Fragmented care pathways often lead to higher emergency room visits, hospitalizations, and institutionalization, driving up expenses.

The aging baby boomer generation will further intensify the demand for affordable housing that incorporates health and long-term care supports. A viable policy approach to address this growing demand involves leveraging existing independent, publicly assisted rental housing, particularly senior-designated apartment buildings or rental properties with a significant senior population. These housing environments can serve as platforms for intentionally organizing coordinated health and long-term care service systems for residents and similar low-income seniors in the surrounding community. Innovative housing providers across the nation are already proactively developing diverse models of affordable housing with integrated services to support residents as they age. While research has extensively explored the benefits of supportive housing for vulnerable populations like the homeless, there is a relative scarcity of research specifically focused on the outcomes associated with subsidized senior housing linked to services. The existing evidence base remains inconclusive, highlighting the need for further investigation and robust demonstration projects.

III. Rationale for Demonstrating Affordable Housing with Integrated Services

Several converging factors are prompting policymakers, housing providers, service providers, and seniors themselves to seriously consider integrating services within affordable housing platforms. Publicly assisted housing properties often offer:

Concentrated populations of older adults: Many residents experience multiple chronic illnesses and functional impairments, creating potential economies of scale for preventative, primary, and long-term services and support providers.
Existing infrastructure conducive to service delivery: This includes physically accessible properties, communal spaces suitable for co-locating health services, and often the presence of service coordinators.

For any demonstration project to be successful and sustainable, it must offer value to all major stakeholders involved.

Federal and state health policy officials: Are increasingly focused on high-cost patients who frequently utilize emergency rooms and hospitals as a means to control rising healthcare expenditures. Introducing evidence-based interventions within subsidized housing settings can improve the health of community residents and potentially reduce overall healthcare costs.
Healthcare providers (acute, primary, and long-term care): Anticipated Medicare payment reforms and Medicaid revenue opportunities will incentivize providers to collaborate and improve care coordination for individuals with high healthcare spending, addressing the current system’s fragmentation.
Sponsors and managers of publicly assisted housing: An aging resident base and the associated rise in chronic illness and disability are compelling housing providers to consider greater service integration. Partnering with health and social service providers can lead to numerous benefits for property owners and managers, including:
- Reduced accidents, injuries, and emergency calls.
- Easier compliance with fair housing regulations and Olmstead requirements.
- Improved resident transitions between housing and hospital/rehabilitation settings.
- Enhanced resident and family security and satisfaction while promoting resident autonomy.
- Improved safety for all residents and reduced complaints regarding residents who are “too sick” to live independently.
- Reduced housekeeping and maintenance costs.
- Lower resident turnover and fewer evictions.
- Enhanced property image and improved marketing potential.
Low-income seniors: Affordable and accessible senior rental complexes, intentionally designed to provide health and long-term care services, can empower low-income seniors to maintain their desired autonomy in an independent living setting with readily available support as needed. This aligns with the “care by design” philosophy, ensuring that the housing environment proactively supports residents’ well-being.

IV. Key Policy and Practice Questions for Demonstration Projects

A demonstration project in this area should aim to answer several critical policy and practice questions:

Can independent affordable senior housing (particularly subsidized congregate apartment buildings) effectively serve as a platform for meeting the health and long-term care needs of low-income older residents (62+) and a proportion of similar individuals in the surrounding community?
Which housing with services models yield the most favorable outcomes in terms of resident health, well-being, and cost-effectiveness?
Does targeting specific resident subgroups (e.g., those with specific health risks or needs) optimize the likelihood of achieving positive outcomes?
What essential capacity, infrastructure, and resources are required within housing provider organizations, their partner organizations, and the broader communities to ensure the success of such demonstrations?
To what extent can existing federal and state data sources be utilized to identify suitable demonstration sites and participants? What is the government’s role in facilitating data accessibility?
Which regulations and rules from HUD, local housing authorities, financing agencies, and property owners (e.g., fair housing rules, service coordinator role limitations, financing for service coordination, accessibility features, live-in aide policies) pose significant barriers to implementing integrated service models, and how can these be addressed or accommodated?
Which federal and state health and human service policies or regulations impede demonstration implementation, and what strategies can be employed to overcome them (e.g., state licensing requirements for congregate settings providing health services, federal privacy rules, barriers to integrating services for dual-eligible individuals)?
What other potential barriers must be considered and mitigated (e.g., insurance liability concerns, local fire and safety ordinances)? What types of properties are most affected by these barriers, and how can they be overcome?

V. Desired Outcomes: Structural and Resident-Focused

A successful demonstration project should assess both structural/system-level and individual resident outcomes.

A. Structural/System Outcomes

Improved service efficiency and coordination: Enhanced collaboration between affordable housing and health and long-term care providers, especially for high-risk, medically complex, and chronically disabled seniors.
Improved housing accessibility and property maintenance: Ensuring physical accessibility of housing units and common areas and supporting ongoing property upkeep.
Lower Medicare and Medicaid costs: Demonstrating cost savings through preventative care and better management of chronic conditions within integrated housing settings.
Assistance with Fair Housing rule compliance: Helping housing properties meet fair housing requirements related to accessibility and service provision.
Support for state Olmstead compliance and healthcare reform efforts: Contributing to states’ efforts to comply with Olmstead regulations, promote community integration, and implement healthcare reform and rebalancing initiatives, including Money Follows the Person programs.
Increased development of accessible affordable independent housing: Promoting the growth of housing options tailored to the needs of lower-income older adults.

B. Resident Outcomes

Improved resident health and functional ability: Enabling low-income residents of affordable senior housing and surrounding communities to maintain health and functional independence for as long as possible.
Enhanced resident safety, quality of life, and quality of care: Creating safer living environments and improving overall well-being and access to quality care.
Reduced resident turnover and evictions: Promoting housing stability through supportive services.
Increased service utilization and comprehensiveness: Expanding the range and depth of services residents receive.
Reduced unnecessary healthcare utilization: Decreasing avoidable hospitalizations, emergency room visits, and transitions to higher-cost institutional care settings like assisted living or nursing homes.

This image depicts a diverse group of seniors participating in a wellness activity within a communal space of an affordable housing complex. It represents the concept of proactive and community-based care designed to promote healthy aging in place.

C. Target Population Considerations

The demonstration project should target low and modest-income older adults who qualify for federal housing subsidies, including residents of Section 202 properties, public housing, Section 8 voucher recipients, and residents of Low-Income Housing Tax Credit (LIHTC) properties. Expanding the reach, seniors with similar income profiles residing near participating housing properties should also be included. Within this broad population, careful consideration should be given to targeting specific subgroups based on service delivery models:

Individuals with mild limitations in Activities of Daily Living (ADLs) or Instrumental Activities of Daily Living (IADLs) who are at risk for falls, medication errors, or other preventable issues.
Individuals with multiple chronic diseases and significant disabilities requiring more intensive support.
High Medicare spenders who could benefit from proactive care management.
Healthy and well older adults who could benefit from preventative and wellness services to maintain their health and independence.

VI. Exploring Potential Service Delivery Models: Public Health vs. Risk-Based Approaches

Service delivery models for integrated housing and services can vary considerably, focusing on interventions at different points along the continuum of chronic health conditions and disability. Two primary models to consider are the public health model and the risk-based model.

A. Public Health Model within Subsidized Housing

The public health model adopts a broad approach, aiming to improve the health and quality of life for all low-income older adults within participating properties and the surrounding community. It incorporates a comprehensive range of primary, acute, chronic care, and long-term care services and support. Service organization and delivery could be managed by a single housing property, a corporate owner of multiple properties, or a partnering community agency such as a Federally Qualified Health Center, Area Agency on Aging (AAA), medical home, health plan, or local public health department. The housing property and its service coordinator would play a crucial role in this partnership, providing space, assisting with screening and assessment, facilitating agreements with community providers, and monitoring service delivery.

This model is best suited for communities with a high concentration of low-income seniors and subsidized senior housing, allowing for potential economies of scale that can demonstrate cost-effectiveness for Medicare and Medicaid programs and the service delivery system as a whole. Participants could encompass:

Healthier older adults benefiting from preventative and wellness services like health education, health screenings, and exercise programs.
At-risk individuals who are becoming frailer and more susceptible to illness and injury.
Special populations with multiple chronic conditions, behavioral health issues, or significant disabilities who are at high risk for emergency room visits, falls, and hospitalizations.

Examples of existing programs illustrating the public health model include:

Lapham Park (Milwaukee, WI): A senior-designated public housing property offering a continuum of on-site services through community partnerships. These services encompass preventative, acute, and long-term healthcare needs, including physician care, PACE programs, congregate meal sites, case management, and wellness programs.
Seniors Aging Safely at Home (SASH) (Burlington, VT): A care management model coordinating health and long-term care services for residents in affordable senior housing and surrounding communities. A SASH coordinator, employed by the housing property, collaborates with a team of community service providers to develop and implement “health aging plans” for participating residents.
Mable Howard Apartments (Oakland, CA): A community health center and PACE adult day health center co-located with low-income senior housing. This integration provides residents with a spectrum of services, from flexible health center services to comprehensive medical and long-term care within a managed care plan.

B. Risk-Based Model within Subsidized Housing

The risk-based model, while also requiring communities with a significant volume of low-income seniors in affordable housing, focuses on targeting services to specific subgroups of high-risk seniors. Community selection for this model might prioritize areas with higher concentrations of very old adults (85+) or those with a higher prevalence of chronic illnesses. Target subgroups could include:

Dual-eligible individuals who are high utilizers of Medicaid and Medicare services.
Individuals with three or more chronic illnesses.
Those at high risk of nursing home placement due to cognitive or physical impairments.
Individuals with significant behavioral health issues.
The top percentage of Medicare spenders.

In the risk-based model, service organization and delivery are more likely to be managed by an entity outside the housing property, such as a health plan, primary care practice, community mental health center, medical home, or ACO. This is primarily due to:

The complexity of managing the high level of care required for high-risk populations.
Housing providers’ reluctance to assume the regulatory burdens of becoming licensed healthcare providers.
The need for a larger population base to support the business model, often exceeding the volume within a single housing property.

Examples of programs using a risk-based model include:

The Marvin (Norwalk, CT): Operates Connecticut’s Congregate Housing for the Elderly Program, providing subsidized housing and services to low-income elders with temporary ADL limitations. Services include housekeeping, emergency call systems, meals, social activities, wellness programs, and participation in the state’s assisted living services program, offering on-site nursing and personal care services.
Just for Us (Durham, NC): A collaboration between Duke University Medical Center, Lincoln Community Health Center, and other community agencies. This program targets homebound, low-income seniors and disabled adults with multiple chronic conditions, providing in-home medical care, chronic disease management, and social work case management.

VII. Community Selection Criteria for Demonstration Projects

Selecting appropriate communities is crucial for the success of a demonstration project. Potential selection criteria could include:

High concentration of older adults in subsidized housing.
Large population of income-eligible seniors in proximity to subsidized senior housing.
Strong network of aging services and medical care providers with a history of collaboration.
High prevalence of seniors with chronic health conditions, frequent healthcare utilization, and disabilities.
States with a commitment to flexible spending for HCBS.
States where housing and services agencies have existing collaborations or a demonstrated commitment to affordable senior housing.
Communities actively participating in ACA and other healthcare demonstration initiatives (e.g., ACOs, medical homes).

VIII. Fundamental Design and Research Considerations

Designing a robust demonstration project to evaluate the impact of integrated services in subsidized housing requires careful consideration of several fundamental design and research elements.

A. Type of Evaluation

Should the evaluation employ a randomized controlled trial design?
Should it compare treatment and control groups?
Should it focus on formative evaluation (process evaluation) or summative evaluation (outcome evaluation)?
Should the demonstration test a single standardized model across all sites, or allow for diverse models tailored to site-specific resources and capacities?

B. Selection of Demonstration Sites

What participant volume is necessary at each demonstration site and overall to ensure statistically meaningful evaluation results?
What volume is needed to ensure the financial sustainability of the model?
Will the demonstration provide infrastructure for data collection, or should existing data systems be a prerequisite for site selection?

C. Identification of Target Population

Which targeting approaches, data sources, and staffing models are most effective, cost-efficient, and replicable for identifying and enrolling the target population and achieving desired outcomes?
What are the trade-offs between focusing exclusively on high-risk/high-cost groups versus adopting a broader public health approach with tiered interventions?
What enrollment incentives are necessary to engage program participants?

D. Assessment of Participant Service Needs

Which assessment and care management functions and practices are most effective, cost-efficient, and replicable for determining individual needs and preferences and coordinating services?
Should all participants undergo comprehensive assessment and care planning, or only a subset?
How frequently should participant assessments be conducted?
Should a standardized assessment tool be used across all sites, or should flexibility be allowed to accommodate site-specific contexts?
Should a core set of assessment questions be required for all sites?

E. Delivery Models for Integrated Services

What role should service coordinators or case managers play in achieving desired outcomes?
What qualifications and training are necessary for service coordinators?
What core services must be available to demonstration participants, and should these be standardized or vary across sites?
Are the logistical aspects of a public health approach feasible within a housing setting?
What are the advantages and disadvantages of healthcare providers versus housing providers taking the lead in service organization and delivery?

F. Resource Development and Financing Schemes

What payment mechanisms can incentivize provider participation, effective service coordination, and appropriate service provision?
Can ACA provisions (e.g., Health Homes, ACOs) be leveraged to support integrated housing and service models?

G. Quality Improvement, Performance Measurement, and Accountability

What monitoring and quality improvement strategies should be integrated into assessment, care management, service delivery, and service coordination functions? Should these be standardized or build upon existing practices?
How can quality and safety concerns be addressed while respecting resident autonomy within their housing units?
What key outcomes will indicate demonstration success?

IX. Conclusion: Designing Care for Low-Income Seniors in Affordable Housing

Addressing the complex needs of low-income seniors requires a “care by design” approach that proactively integrates health and social services within affordable housing environments. While there may not be a program explicitly named “Care by Design,” the underlying principle emphasizes the intentional and thoughtful design of care systems to improve outcomes for this vulnerable population. Demonstration projects, guided by rigorous research and evaluation, are essential to identify effective models, overcome systemic barriers, and ultimately create sustainable and scalable solutions. By focusing on both structural improvements and resident-centered outcomes, we can move towards a future where affordable housing truly serves as a platform for health, independence, and well-being for all seniors, regardless of their income.

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