Commission delivered final report to Congress on June 28, 2002
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Philosophies of Care

The Eden Alternative
Independent Choices


Coming Home Program for Affordable Assisted Living


Public Housing and Assisted Living: Two Success Stories

Sarah's Circle: Intergenerational Supportive Housing

Coordinating Health and Housing Services

Friends Life Care at Home


Nursing Home Without Walls Program

Community Wide Approach to Care

Naturally Occurring Retirement Communities

East Boston - A Health and Housing Partnership


Additional Supportive Services

Umbrella Senior Services, Ltd.

Jewish Home and Hospital Transportation Department

Customized Health care: Meeting the Individual at the Point of Need

Home Repair: Insuring the Safety and Independence of Seniors

The Eden Alternative

742 Turnpike Road

Sherburne, New York 13460

The Eden Alternative is a radically different approach to long-term care. Although Eden Alternative programs focus on changing the culture of nursing facilities, the Eden ideology extends to all methods of long-term care service delivery. Founder Bill Thomas based the development of the Eden Alternative on his observation that individuals do not want to go to nursing facilities, primarily because many nursing facilities are undesirable places to both live and work. Nursing facilities are often institutional environments in which patients are treated. The Eden Alternative seeks to create a living environment in which care is exchanged, with residents and staff both giving and receiving.

After completing his training at the Harvard Medical School, and residency at the University of Rochester, Dr. Bill Thomas served as a physician in a nursing facility. That experience changed his life. Dr. Thomas came to believe that even the best nursing facilities were flawed; the patients were deteriorating despite the careful attention of doctors and staff. Dr. Thomas concluded that the fundamental problem with nursing facilities was that they were devoid of life. To improve the quality of life of the residents and as a result, the health of residents, Dr. Thomas felt the nursing facility should be infused with life. He and his wife Judy developed The Eden Alternative to address what they identified as the three plagues of the long-term care institution — loneliness, helplessness, and boredom; radically re-imagining the delivery of long-term care.

The Eden Alternative seeks to cure loneliness, not with medication, but by providing residents with companionship and surrounding them with life. A core philosophy of The Eden Alternative is that life creates life; the opportunity to care for other living things in a spontaneous environment, rather than the prescription of pills, can restore and maintain a individual's life no matter their age or physical impairment. Nursing facilities that adopt The Eden Alternative commit to changing the culture of their nursing facility, moving away from an institutional model to a team based model. The staff gets to know the residents, and provides the services and assistance that suit the individual's specific needs.

By emphasizing a culture change, The Eden Alternative addresses the major problems affecting nursing facility care today: staff turnover, low staff retention and quality of care. Thomas has found that when the staff is treated well, the elderly are treated well, increasing the quality of life for employees and residents alike. The intimate atmosphere creates a homelike environment, invigorating both the staff and the residents. Eden disbands the hierarchical management structure of the typical nursing facility. The certified nursing assistants, a major part of the nursing facility staff, have control over their schedules and help to decide how tasks and responsibilities should be divided.

In the over 300 nursing facilities that have adopted The Eden Alternative model, the most visible change is the presence of plants, animals and children. One of the ten principles of The Eden Alternative, "Loving companionship is the antidote to loneliness" encourages nursing facility staff, residents and administrators to fill the facility with plants, animals and children - all of which involve the planning and organization of residents and focus residents on giving care, not just receiving it.

Thomas sums up the philosophy of The Eden Alternative by stating:" In long-term care, love matters. And the heart of the problem is, institutions can't love. When we rethink our mass institutionalization of elders, when we do these things, we're not just making a better life for the elderly, we're making life better for everybody in every part of society.”

Write-up is based on:

Willging, Paul, "The Eden Alternative to Nursing Home Care More than Just Birds" Aging Today.

Salter, Chuck, "(Not) The Same Old Story" Fast Company February 2002.

PBS Newshour Interview with Susan Dentzer February 27, 2002

Independent Choices

Cash and Counseling Demonstration in Arkansas

IndependentChoices is a demonstration project funded by the Robert Wood Johnson Foundation and the US Department of Health and Human Services. The project is designed to measure the role of choice and flexibility in the quality of personal care services and to maximize the independence of Medicaid beneficiaries with chronic illness. The primary goal is to increase consumers' control over their personal care and assistance, enhance their satisfaction with that care, and meet their needs more fully without increasing costs.

Eligible Arkansas Medicaid beneficiaries, who are willing and selected, exchange their agency personal care services for a cash allowance. Participants use the cash allowance to purchase their own personal assistance services. Empowering consumers to make their own choices about their own care is expected to improve consumer's independence and quality of life. Consumers can hire family members, friends, or acquaintances to provide care or use their cash allowance to buy equipment and devices that increase their independence.

The state provides participants with a monthly cash allowance based on the number of hours of personal care that they require each week, as determined by a medical professional. The average monthly allowance is $350. Counselors help participants develop a spending plan. These counselors check in with participants on a monthly basis, and are always available to them by phone. Participants become employers when they hire a personal care aide. Bookkeepers are available to help participants with the paperwork required to pay an employee’s wages and withhold taxes. Participants who cannot or do not want to make the decisions regarding how to spend their allowance can rely on a representative decision maker, a relative or a friend, to help.

Most enrollees are highly pleased with the care arrangements they’ve made; many have contracted with friends and family. The highly personal nature of the care provided, and the vulnerability of the recipients, underscores the importance of giving consumers the option of hiring familiar caregivers who treat them with dignity and respect. By hiring someone who knows and cares for them, the quality and consistency of care improves. The program has allowed some individuals to purchase equipment needed to help them remain independent (e.g., a microwave for an elderly woman, a washing machine for a blind man).

One Personal Story:

Lillie B. is 88 and never leaves her home, except to go to the doctor or the hospital. The woman who, at one time or another in her life, worked as a cotton picker, a woodchopper, a peach grader, and a nanny, now has a difficult time getting around on her own. She can’t cook her own meals, can’t bathe herself, or get herself into or out of bed. She spends her days in an easy chair in her living room and her nights in bed, assuming she has help moving from one to the other at the beginning and end of each day.

But Lillie knows how to take care of herself, even if she can’t manage it physically. This is why she was one of the first people to enroll in IndependentChoices. She likes to tell people: “I’ve been in four nursing homes, and I’ve escaped every one of them.”

Lillie uses her $662 monthly allowance from IndependentChoices to pay Barbara W., a former aide who’s become “like a daughter,” to visit her daily and help her with getting out of bed, bathing, dressing, preparing meals, and some housekeeping. “Barbara will come any time I call,” says Lillie. Barbara averages about six hours a week working for Lillie, but she can only help out in the day time during the week, so Lillie is currently training another personal care aide to assist her around Barbara’s schedule. Lillie also pays a family friend to do her grocery shopping once a week and plans to hire her 67-year-old son, David, to help her out a few times a week. And she uses part of her allowance to buy personal care items like facial tissue, bath tissue, and over-the-counter medications. “I like being able to have a say in who comes here and cares for me,” says Lillie. “It’s important to get someone who’s on the ball and can do the job.”

Write up is based on:

Stone, Robyn "Providing Long-Term Care Benefits In Cash: Moving to a Disability Model" Health Affairs Volume 20(6).

Brown, Randall and Foster, Leslie, "Cash and Counseling: Early Experiences in Arkansas" Issues in Brief Mathematica Policy Research December 2000.

University of Maryland Center on Aging

Coming Home Program for Affordable Assisted Living

National Cooperative Bank Development Corporation and Robert Wood Johnson Foundation

The National Cooperative Bank Development Corporation partnered with the Robert Wood Johnson Foundation to address the overwhelming need for affordable long-term care services, which could meet the needs of the frail elderly, and in1992, the Coming Home Program was established.

The Coming Home Program is designed to bring the benefits of assisted living to low-income, frail seniors living in rural areas. The rural elderly make up 25 percent of the population in some areas and often need services that are not available in their communities. As a result, many are forced to relocate or are unnecessarily institutionalized in nursing facilities. Assisted living can provide frail seniors with an alternative to such institutions as well as offer a “missing piece” in the continuum of care.

The Coming Home program focuses on smaller communities where there are fewer options for frail seniors, particularly those with modest incomes. In order for the Coming Home program to be successful, it must reach Medicaid-eligible seniors, for they are the most "at risk" for premature institutionalization. Individual states determine the financial criteria for Medicaid eligibility.

The Coming Home Program has taken on the challenge of creating housing that offers varying levels of service to meet the different needs of seniors, while remaining affordable to the very low-income elderly. The purpose of each project is to develop affordable assisted living facilities that integrate housing with services for frail or chronically ill seniors, and to assist them in living as independently as possible. This requires understanding both the intricacies of affordable housing development and the various funding sources, social and medical criteria that shape the delivery of services to the elderly with long-term care needs.

As a result, the Coming Home Program partners with area non-profits to combine the local knowledge of the market needs with the technical expertise of national researchers and developers, to overcome the obstacles that arise when trying to combine a range of subsidies and loans. The project's units are 100% affordable to seniors living at 60% of the area median income, and 50% of the units must be reserved for individuals whose income is at 50% or below area median income.

Success in Oregon: Rock Cove Assisted Living, a 30-unit facility located in The Dalles, Oregon, was created in response to an unmet need for decent housing and services for elderly of all income levels who were unable to live alone, but who did not need continuous skilled nursing care. Half of the units are targeted to low- to moderate-income seniors. Working in a collaborative effort with Columbia Cascade Housing Corporation (CCHC), they overcame challenges posed by the site and hostile community members, and obtained the financing needed to make the facility affordable to low-income elderly. A growing number of elderly who have lived and worked in the area all their lives can stay and live in dignity at an affordable rate. Parents of residents can live close to their children. Best of all, elderly of all income levels can enjoy the breathtaking setting in the scenic Columbia River Gorge, as well as receive the personalized services they need to remain as independent as possible and to age in place with self-respect.

Private pay residents comprise an estimated 50% of the occupants of the facility. These residents pay rates starting at $1,400 per month for a studio apartment. Rates include all utilities except for phone and cable TV, three meals a day and all services provided by facility staff. The rates are much lower than the rates for a nursing facility. Medicaid eligible residents occupy the remainder of the units. The amount these residents pay is based on their income. It is difficult to segregate the housing costs, but it is estimated that the housing costs of the 15 units targeted to low- income households is $285 per month, much lower than market rate rents in the area.

Write up is based on

Interview with Matthew Haas Illinois Initiative

Interview with Robert Jenkens Vice President National Cooperative Development Bank Community Development Corporation

Testimony of Robert Jenkens of National Cooperative Bank Development Corporation, Columbus, Ohio September 24, 2001.

Glashen, Leah "Assisted Living Creates Haves in Rural Areas: Coming Home Offers More Choice" AARP Bulletin July-August 2001.


Massachusetts Housing Finance Agency
1 Beacon Street
Boston, MA 02108

(305) 547-0418

ElderChoice is a program operated by the Massachusetts Housing Finance Agency (MHFA) that assists developers who are building and operating housing for seniors who need assistance to continue to live independently. The MHFA tackled the difficult challenge of building affordable housing with supportive services for low-income individuals by combining the lower interest rates provided through their tax exempt and taxable bond financing program with the subsidy of Medicaid waivers.

Developers interested in providing affordable assisted living need not navigate the financing and Medicaid services separately. The funding streams are coordinated by the MHFA and the developer need only apply to the MHFA, a one-stop shop. In the MHFA program, the affordable assisted living model requires that 20% of the units remain affordable to low-income residents, while the other 80% are market rate units.

The MHFA worked with the Massachusetts Medicaid office to qualify these developments for Group Adult Foster Care waivers. The waivers provide $34/day to fund the supportive services provided to the low-income residents of the assisted living facility. The guarantee of this waiver has allowed developers to move forward with their projects knowing that the funds for service delivery can be worked into the operating pro forma. By streamlining the funding process, the MHFA has been able to build 14 developments to date, producing over 1,200 assisted living units through the Elder CHOICE program.

Impetus for the program came from state health and human services professionals who recognized that assisted-living housing could help rein in Massachusetts’ rising Medicaid costs and, in the process, provide a more satisfying living environment than nursing facilities for many frail elderly.

The agency had tried to develop new housing with services for the elderly in the mid-1980s, but cutbacks in state housing subsidies prevented progress until other funding sources could be found. In 1992 the agency accepted, on a pilot basis, an application from a developer proposing to build assisted-living units, a portion of which would be reserved for low-income elders. The mix of housing and services made the application particularly complex. To speed its review, the agency assembled a working group of specialists in such areas as design, housing management, service delivery, and loan underwriting. This interdisciplinary group developed a comprehensive, streamlined method that has proven to facilitate loan approvals.

Financing for assisted living requires a creative mix of funds from multiple sources. Funding for the state’s assisted-living units comes from the sale of bonds to private investors, equity from private developers, proceeds from the sale of Federal Low-Income Housing Tax Credits, and other Federal sources.

Operating costs for Elder CHOICE developments come primarily from tenants’ rents, Supplemental Security Income, and Group Adult Foster Care, a Medicaid program for low-income elderly. The Massachusetts’ Division of Medical Assistance estimates that Elder CHOICE will save about $5,000 per year for every low-income elder residing in assisted living rather than in a nursing facility.

Write up is based on:

Testimony of Tom Gleason, Executive Director, Massachusetts Housing Finance Authority, Cambridge, Massachusetts, March 1, 2002.

Interview with Frank Creeden, Massachusetts Housing Finance Authority

1995 Innovations in Government Award, Kennedy School of Government

Public Housing and Assisted Living:

Two Success Stories

Helen Sawyer Plaza
Miami, Florida

Neville Place
Cambridge, Massachusetts

Helen Sawyer Plaza: The first public housing assisted living facility in the Nation, Helen Sawyer Plaza is a 104 unit facility operated by the Miami-Dade Housing Agency (MDHA). Originally built in 1976 as a center to house the frail elderly and handicapped, the changing needs of its residents forced the MDHA to rethink the traditional delivery of public housing. After a major conversion and remodeling, it re-opened in 1998 as an assisted living facility with 21 one-bedroom and 83 efficiency apartments. The Helen Sawyer Plaza provides a range of services to its residents, who are all Medicaid eligible and over the age of 60, to keep them in their apartments and out of institutions. Services include: attendant care, behavior management, companion services homemaking, intermittent nursing, medical administration, occupational therapy, personal care, physical therapy, access to specialized equipment and supplies, speech therapy and social and recreational activities.

The Helen Sawyer Plaza offers affordable housing to some of Miami's lowest income seniors, while insuring that they have the supportive services they need to remain independent as long as possible. The median income of residents in the Helen Sawyer Plaza is $7,451- just 35% of the area median income. Without an affordable assisted living option, most residents would be forced to move into nursing facilities. The project has received numerous awards and the support of the community, elected officials and funding partners. Helen Sawyer Plaza has been so successful that the Miami-Dade Housing Agency has plans to convert another one of its facilities, Ward Towers, into an assisted living facility.

Neville Place: Neville Place is a development of Neville Community Partners, a joint venture led by the Cambridge Housing Authority (CHA). CHA formed Neville Community Partners, a consortium of Cambridge-based housing and health organizations, to redevelop the existing Neville Manor Building into affordable assisted living. This is the first phase of a planned senior living campus providing a continuum of care for local seniors in need of health care services and housing. The second phase of the development is the construction of a skilled nursing facility, scheduled to open in 2003.

Neville Place is a mixed income, 71-unit assisted living facility, operated by the Cambridge Housing Authority. It was designed to address the growing needs of the Housing Authority and the Cambridge community’s elderly populations. The facility has expansive grounds, mature woodlands, community gardens and a public walking path that follows the perimeter of Fresh Pond.

Through the creativity of the Cambridge Housing Authority, the development partnership was able to find a way to combine Section 8 vouchers with the Massachusetts Medicaid Waiver program (i.e., the Group Adult Foster Care Waiver), to provide both housing and services to the lowest income seniors.

Participation in the Group Adult Foster Care program also provides an important safety net for low-income residents who spend down their assets paying for assisted living at Neville Place. The state program offers assurance that any low-income resident who needs help with activities of daily living will not have to move from Neville Place due to depletion of savings and/or inability to continue to pay privately.

Services provided at Neville Place include daily meals, a wellness program, activities, scheduled transportation, laundry services, housekeeping, residence security, dementia care, personal care, medication monitoring, and computer/internet access.

Write up is based on:

Testimony of Dan Weunschel, Executive Director, Cambridge Housing Authority, Cambridge, Massachusetts March 1, 2002.

Interview with Jenn Faigan Cambridge Housing Authority

Testimony of Rene Rodriguez Miami-Dade Housing Authority Miami, Florida January 14, 2002

Sarah’s Circle: Intergenerational Supportive Housing

2551 17th Street, NW, Suite 103

Washington, DC 20009
202) 332-1400

Sarah’s Circle Inc., an award-winning example of supportive housing for the elderly in Washington, D.C., is an exemplary project that provides intergenerational programs for residents. In addition to the facility’s 38 residents, Sarah’s Circle serves over 250 seniors of the nearby community. Sarah’s Circle offers free lunch services five days a week, health maintenance programs, transportation, social services assistance and housekeeping.

It also offers intellectually stimulating programs, including an intergenerational program in which children from a nearby elementary school participate in weekly events organized by the Sarah’s Circle Senior Center. The executive director of Sarah’s Circle, Ruth Sachs, credits the services and residents’ meaningful involvement in the community with keeping these elderly out of nursing facilities.

Typically, Sarah’s Circle residents have incomes at or below 30 percent of the area median income and many are below the poverty level. The existing 34-unit project was started in 1983 with a $375,000 mortgage from CDBG funds. Rents are kept low by rent abatements raised through capital campaigns and donations. Yearly, Sarah’s Circle raises $100,000 for abatements. Rents range from $215 for an efficiency to $530 for a two bedroom, which is often shared by two persons. Of the yearly $540,000 budget, $190,000 is spent on the facility’s programs.

A pillar in its community, Sarah’s Circle Inc. is an example of an organization that has demonstrated ability to self-fund through government and charitable contributions in order to meet debt service and maintain operations. Yet, Sarah’s Circle is also an example of an organization that will require access to mainstream financing if it is to expand its services to benefit other residents.

The board of directors of Sarah’s Circle Inc. is currently seeking to purchase another building. However, this time around, it seeks a public/private partnership to include financing from a conventional lender. Sarah’s Circle and similar organizations across the country are facing a major challenge: underwriting standards for service-enriched projects are still under development. Credit enhancement, lender support by the Government Sponsored Enterprises and Federal Housing Administration, supportive Federal policies, and identification of best practice models for development and financing of service enriched housing will be required in order for the need to be met.

Friends Life Care at Home

1777 Sentry Parkway West Dublin Hall Suite 210
Blue Bell, Pa 19422-2246
Phone: (215) 628-8964

Friends Life Care at Home began through the partnership of two non-profit Quaker organizations, a Philadelphia area hospital and a retirement community. They came together to address the needs of the increasing number of elderly individuals in the community who desired to live in their homes as they aged. In 1985, the Robert Wood Johnson Foundation and the Pew Foundation funded a research project to explore how these two organizations could develop a program to provide long-term care services which would keep individuals in their homes as long as possible. After the research and demonstration project ended, Friends Life Care at Home began to enroll members. Presently 1,500 individuals are members, receiving a range of long-term care services that include everything from assistance with grocery shopping to 24 hour, 7 days a week home health care.

Friends Life Care at Home is a "hybrid" of long-term care insurance. An individual must be in good health and independent to join. All members are over the age of 50, but there is no upper limit on the age of applicants. Individuals pay a one- time entrance fee, followed by monthly fees to maintain their membership. The program is designed to provide care coordination that allows individuals to remain in their homes as long as possible, with adequate access to health care and supportive services to maximize their quality of life. There are six plans from which members can choose, all of which provide different packages of direct service. Those services include: proactive wellness and care coordination, home health care, homemaker services, emergency response system, home inspection, nutritional support, and adult day care. Additionally, some plans provide care in an assisted living or nursing facility.

Friends Life Care at Home measures its success on its ability to provide individuals with choice, flexible service options and the supports they need to remain in their homes as long as possible. The Friends Life Care at Home program has begun to expand outside its original service area in Pennsylvania, offering services in Maryland, Virginia, Washington, DC and Delaware.

Write up is based on:

Interview with Joe Lukach

Testimony of Peter Kaprielyan Friends Life Care at Home, Columbus, Ohio September 24, 2002


Boston region

CareConnections is a program operated by West Suburban Elder Services, the Area Agency on Aging serving the towns west of Boston, Massachusetts. Funded by the Older Americans Act and the Massachusetts Home Care Program, CareConnections makes the critical link between housing and services by providing service coordination and extended services to any housing agency within the West Suburban network, particularly senior public housing. While the services are tailored to the specific needs of each housing facility, services are available to those with subsidy as well as those who pay privately. They are affordable and flexible to provide individuals with the maximum benefit.

The program's primary goal is to support individuals as they age in place and prevent them from entering nursing facilities. Coordinators assess individuals to both determine their service needs and their eligibility for state and federally supported programs. Individuals are involved in their care, helping to subcontract services and insure quality and consistency of care. There is a 24-hour live-in aide in each facility or a combination of home health aides and personal care assistance, to provide continual access to care, no matter when the need arises.

The CareConnections program leverages the density in Boston area housing facilities to provide flexible and affordable care. Often, individuals only need 15-20 minute intervals of assistance (getting out of bed in the morning, assistance with lunch preparations, medication monitoring and preparing for bed at night). Normally these services are delivered in 1-2 hour blocks, more than an individual might need or could afford. CareConnections can coordinate services in a housing facility to deliver assistance in shorter service blocks, insuring that individuals receive the assistance they need, at a price they can afford. Additional services are provided as needed and include: meals-on-wheels, home health aides, personal care services, homemaker services, and medication distribution. Services are both regularly scheduled and available on an as needed basis.

As a result of CareConnections, elderly housing facilities in the Boston area have seen a decrease in the number of individuals who must leave their apartments and enter nursing facilities.

Write up is based on:

Testimony of Roberta Rosenberg of the Jewish Community Housing for the Elderly, Cambridge, Massachusetts March 1, 2002

Testimony of Sue Temper of West Suburban Elder Services, in Cambridge, Massachusetts March 1, 2002

Massachusetts Department of Elder Affairs

West Suburban Elder Services

Nursing Home Without Walls Program

New York and Hawaii

New York began the Nursing Home Without Walls program (also known as the Lombardi program, in recognition of its legislative sponsor) in the late seventies in an effort to reduce state expenditures on nursing facility care and provide individuals with the option they most desired- the option to stay at home rather than enter an institutional setting.

The program is designed to reduce Medicaid state expenditures by providing individuals whose physical or cognitive impairments require nursing level services, services in their homes. As long as the necessary health and housing programs can be provided in an individual's home at 75% of the cost of a nursing facility in the individual's community, the state will fund the required combination of home-based services.

Individuals must be Medicaid eligible and require nursing facility level of care. Services can include a range of health and personal care services, including housekeeping and chore services, home health aides, and medical equipment. Because the program is designed to allow individuals to remain in their homes rather than enter an institution, the program addresses the individual's health and housing concerns. Should an individual's home require repair (e.g., furnace replacement, plumbing or roof repair) or the individual's changing health require home modifications (e.g., grab bar installation, ramp construction, door way widening), the program can fund the necessary work. Individuals participate in the organization and supervision of their care plans as much as possible.

After New York's success, Hawaii developed a program based on the New York model. Hawaii employed the Nursing Home Without Walls model to address the challenges of the delivering long-term care across non-contiguous land areas. Hawaii has an extremely tight supply of nursing facility beds and a limited ability to construct new facilities. The Nursing Home Without Walls program allows individuals to combine a range of services, employ professionals and friends to provide the support needed to age in place as long as possible.

Write up is based on:

Interview with Dora Bluth- NY Long-term care

Interview with Fran Galdera Hawaii Nursing Home Without Walls

Testimony of Cullen Hayashida, Assisted Living Options Hawaii, Miami, Florida January 14, 2002

Naturally Occurring Retirement Communities

Penn-South and the Beginning of the NY State NORC Program

Penn South is a cooperative housing development of 2,820 units and 6,200 residents in the Chelsea area of Manhattan in New York City. It is a moderate-income, non-profit, limited-equity housing cooperative composed of ten high-rise apartment buildings. By 1985, more than 75 percent of Penn South’s population was over 60, and the co-op board began to investigate possible ventures to support the senior residents. As part of these investigations, the board came across the research of Michael Hunt and Gail Gunther-Hunt in which the term “Naturally Occurring Retirement Community,” or NORC, was coined. NORCs have generally been understood as buildings, apartment complexes, or neighborhoods, not originally planned for older people but where, over time, the majority of the residents have become elderly. The researchers recognized in a 1985 study that NORCs differ from the stereotypical retirement community, and “yet are the most common form of retirement community in the USA.”

Once the Penn South Co-op had begun to call itself a NORC, the co-op board set up a special committee, the Penn South Program for Seniors (PSPS), charged with developing programs to forestall nursing facility placement and encourage the elderly to remain in their own homes among family, friends and caring neighbors. PSPS selected three primary agencies to provide the programs and services to the NORC: Self-help Community Services, Inc., Jewish Home & Hospital for the Aged, Inc., and the Educational Alliances, Inc./UJA-Federation of New York, a major private philanthropic organization that contributed funds to assist the program. Many other social and health agencies in the community also agreed to bring their services to the co-op.

Within a few years of operation, PSPS had achieved a firm level of organizational integrity, acceptance within the co-op community, and recognition within the field. A new non-profit corporation had been organized called Penn South Social Services, Inc. (PSSS) to assume the fiscal responsibility for and policy determination over PSPS. PSSS enabled the NORC to formally contract with social and health agencies and to receive direct government and foundation grants. PSPS was now mobilized, sheltered within its own 501(c)(3) organization, and gaining momentum. Soon, both the acronyms “NORC” and “N-SSP” (NORC Supportive Service Program) would be written into state legislation.

In 1994, New York State passed legislation providing support for NORC Supportive Service Programs. The N-SSP legislation established a channel to fund housing and social services in a coordinated manner. The program sought to prevent costly housing problems common to senior residents, and strengthen intergenerational ties in the housing complex. It was endorsed by both political parties in the legislature and was approved by two governors of opposing political parties. As the result of the program’s early successes, New York City also took an interest in NORC programs, and their highly organized blocks of voting constituents, and created its own local N-SSP legislation to supplement the state program.

Fourteen N-SSPs now operate in New York State under the N-SSP legislation and funding. These programs represent more than the individual demands of a senior population: they save public dollars by requiring each housing entity that requests state funds to match the grant with its own funds, as well as to attract philanthropic dollars. Each N-SSP is designed as a collaborative venture between New York State, a housing company, and social service and health agencies. The N-SSPs often receive collateral benefits by providing attractive sites for private medical providers, home-care agencies, and other service providers. These private providers take advantage of the efficient service delivery produced by concentrated populations of seniors. As a result of partnerships with private providers, New York state dollars have leveraged almost four times as many dollars in private investment, above and beyond the required philanthropic match. According to the New York state legislature, N-SSPs have saved the state an estimated $11 million over three years by forestalling 460 hospital stays and 317 nursing facility placements.

Village Care, New York: Recent Developments in the NORC Model

Village Care of New York is designed to confront the problems of an aging community through an "Urban Village" model, a model that provides an array of residential and community services seeking to provide the most appropriate service in settings that offer choice, safety and independence. Village Care first conducted a series of focus groups to better understand the needs of the elderly in the immediate community. They found that the need for adequate housing generally included a desire for personal care, housekeeping, meal preparation in a way that can be affordable to middle income households and low-income households, with the application of entitlements. When constructing this enriched housing environment, Village Care invented its own balance of appropriate rents, service delivery pricing and marketing that responded to the community's specific needs, yet could remain financially feasible.

Write up is based on:

Testimony of Arthur Webb of Village Care, New York in Syracuse, NY July 30, 2002.

Testimony of Freda Vladeck of Aging in Place Initiative in Miami, Florida January 14, 2002.

Interview with David Smith, Penn South Co-op

Interview with Nat Yalowitz, Penn South Co-op.

Interview with Cheryl Kliger, Strickers Bay Building NORC

Bassuk, Karen and Nat Yalowitz. “Innovative Social Policies: The NORC Programs.” Presentation to the Asia-Pacific Regional Conference for the International Year of Older Persons, Hong Kong; April, 1999

East Boston- A Health and Housing Partnership

10 Grove Street
East BostonMA,02128

In response to the lack of appropriate elderly housing and facilities, the East Boston Neighborhood Health Center and the East Boston Community Development Corporation combined expertise and resources to construct a series of community adult day centers, community health centers and elderly housing in the East Boston community. This partnership represents the necessary links between health and housing services to promote the choice and flexibility American seniors desire.

The East Boston Neighborhood Health Center had been operating the East Boston Home Care program since 1973. The Health Center provided the health and personal care services seniors needed to remain in their homes and in the East Boston community. In 1982, the program administrators began to hear of the success of On Lok, the San Francisco demonstration using capitated Medicaid and Medicare services to deliver comprehensive community based care to the frail elderly. The East Boston community became one of the first PACE (Program for the All Inclusive Care of the Elderly) sites, bringing the success of San Francisco to Boston.

It became apparent that, while the East Boston Neighborhood Health Center could now more adequately address the health needs of individuals in the community, housing needs also had to be addressed or individuals would be forced to leave in order to find appropriate housing. At the same time, the East Boston Community Development Corporation began to notice that its residents had grown more frail. The building management was spending more and more time addressing the service needs of the tenants. Just providing a roof over their head was not enough. Elderly residents needed some supportive services to remain in their apartments safely.

The partnership between the East Boston Neighborhood Health Center and the East Boston Community Development Corporation formed to increase the available affordable senior housing in the community and insure that the proper level of services could be provided to support individuals in their housing. Over the last two decades, these two East Boston groups have created a series of affordable housing developments with adult day care centers and supportive services.

Now, even as the residents of East Boston are growing older and more frail, those who age in the community can stay in the community and receive the care they need.

Write up is based on

Testimony of John Cradock of East Boston Neighborhood Health Center, Cambridge, Massachusetts March 1, 2002

Testimony of Al Caldarelli of East Boston Community Development Corporation Cambridge, Massachusetts March 1, 2002


South East Senior Housing Initiative

10 South Wolfe Street
Baltimore, MD 21231

In late 1989, discussions among several organizations that serve Southeast Baltimore City centered on the growing aging population in the community. Of constant concern were the increasing physical obstacles impeding the ability of older residents living in Baltimore row homes to remain independent, the problems these older residents faced trying to maintain their homes, the neighborhood deterioration that results when homes are not maintained, and the lack of affordable housing options within the community for older residents. The community in general and the elderly residents, more specifically, were at risk as these problems continued to grow.

From these shared concerns, the South East Senior Housing Initiative (SESHI) was developed. Safe Home is a program of SESHI, which allows aging individuals to remain in their homes and continue to play a vital role in the community. A unique partnership, this program combines the resources and expertise of the Baltimore Medical System- a neighborhood- based health care system, Johns Hopkins School of Public Health, Banner Neighborhoods, Neighborhood Housing Services of Baltimore and the Baltimore City Commission on Aging and the South East Senior Housing Initiative to prevent falls and keep seniors in their homes.

The project attempts to address some of the particular challenges of individuals aging in Baltimore row houses--townhouses with 2-3 stories and the bathroom located on the second floor. The partnership promotes independent living for low to moderate-income seniors in their own homes through a program of integrated environmental modification, intervention and support. They maintain community health and stabilization by keeping independent older adults in their homes as long as possible.

The Safe at Home program coordinates the services of health providers, local non-profits and community organizations to facilitate the supportive services, home modifications, and health care that the elderly residents need. Doctors, nurses, senior center staff, social workers or family members, refer clients to the program. The City Commission on Aging performs a complete assessment on the home evaluation of both the health and housing needs of the individual. A plan for home modifications and other services may be developed and then shared with client, caregivers and physician.

The program connects individuals to the necessary health and supportive services and can provide home repair and home modification services. The program also has a community loan closet to distribute free durable medical goods, a volunteer program to assist individuals with chores and shopping, and an emergency loan fund that provides interest free loans for more extensive home repairs. Service coordinators maintain on-going supportive relationships with clients, and provide periodic contact and revisits to assess changing needs and conditions.

Write up is based on:

Interview with Peter Merels of South East Senior Housing Initiative

Umbrella Senior Services, Ltd.

108 Erie Boulevard

Schenectady, New York 12306

(518) 346-5249

Founded in 1988 on Long Island, NY, Umbrella Senior Services now serves seniors in New York, Florida and Montana. Umbrella is designed to respond to the basic needs of aging seniors who wish to remain in their homes, but find that many of the ordinary chores and tasks involved in maintaining a home are more than they can handle.

The basic membership is $200/year for a single-story house and $250/year for a two-story house, after which services are charged on an hourly basis. Services include 24-hour emergency response, 7 days a week, annual home maintenance inspection, smoke alarm battery replacement, gutter cleaning, handyman services ($8.00/hr), domestic chores and shopping ($5.00/hr), parts and materials discounts, fixed rates for licensed plumbers and warranties on handyman services.

The handyman service is the center of Umbrella operations. When a problem arises, the handyman goes to the member's home to perform an on-site inspection. In an emergency, the handyman is at the home within the hour. The handyman assesses the problem and, at the owner's discretion, either repairs the problem directly or makes the appropriate referral. The handymen are most often seniors themselves. The goal of the Umbrella Services is to prevent deferred maintenance by addressing a minor repair problem when it occurs, rather than waiting until a major repair is required.

Umbrella Senior Services also conducts a home audit, identifying potential problems and assessing the need for a range of home modifications including grab bars, higher wattage bulbs, and a simple yet critical reorganization of the kitchen, moving all the essential items within reach.

At the most basic level, Umbrella Senior Services, Ltd. provides home repair services to seniors, helping them to maintain and preserve the value of their home. On a much broader level, Umbrella Senior Services provides seniors with the security of knowing that they will receive high quality repair and modification services, by individuals they can trust.

Based on:

Jewish Home and Hospital Transportation Department

New York (Bronx, Manhattan and Westchester)

Frank Lipari

(718) 579-0241

The Jewish Home and Hospital in New York solves the challenge of decreasing mobility through its transportation department. For over 20 years, the Transportation Department has insured that the region's seniors can access the recreational, health and social services they need. The department primarily serves the clients of the Jewish Home's Adult Day Health Center; however, the recent restructuring of Medicaid reimbursement will allow the department to respond to the frequent requests to expand their services. Currently the department's 24 para-transit vans run 77,000 trips annually.

Quality Makes a Difference. The Transportation Department of the Jewish Home and Hospital seeks to provide quality transportation for those it carries. All drivers are certified and CPR-trained, and receive extensive training in serving the aging and disabled populations. Drivers get to know their clients and work to provide special assistance to those with dementia, Alzheimer's disease and those needing physical assistance. Pick-up and drop-off routes are specially arranged to minimize waiting and trip time. Jewish Home drivers wear uniforms and vehicles are clearly marked to insure services are delivered with professionalism, trust and respect.

As Director Frank Lipari explained, the focus of the work at the Transportation Department is not on moving bodies from one place to another, it is about helping someone's grandmother or someone else's father to continue to live independently. "We know their name, before we know their apartment number. It's not about picking up the lady in apartment 3B, it's about taking Ms. Jones to the doctor, seeing her through the appointment and returning her home safely. It's about reminding Mr. Smith that he shouldn't eat chocolate on the bus because he is a diabetic, while making sure he enjoys that afternoon's recreation." The training and dedication of their drivers reflect this commitment to the individual, delivering quality service from door to door.

Write-up based on:

LINK Newsletter of the Jewish Home and Hospital Winter 2001

Interview with Frank Lipari

Customized Health Care: Meeting the Individual at the Point of Need

House Call

Washington Hospital Center

110 Irving Street, NW, Suite 2B-39
Washington, DC 20010-2975

(202) 877-0218

The Washington Hospital Center House Call Program began in 1999 as a response to the needs of the frail elderly. Dr. George Taler and Dr. Eric DeJonge along with the support of Washington Hospital CEO, Ken Samet, set out to establish a patient centered system of care, and to support the needs of the frail elderly aging in place. Rather than place the office as the focus of outpatient care, the House Call program puts the individual, where they live, as the focus of care. Using portable technology, the House Call program provides personalized care, including diagnostic tests and treatment, in an individual's home.

The primary objective of the program is to change a person's lifestyle. "Understanding where a patient lives allows me to make better recommendations regarding their treatment and care", says Dr. DeJonge. The House Call program allows doctors and other medical professionals to monitor home compliance with treatment and identify illness before it becomes an expensive emergency. Dr. Taler explains, "Our program has a built-in early warning system, allowing us to prevent illness and hospitalization." In fact when comparing the year prior to enrollment in the House Call program and the year after enrollment, individual Emergency Room visits dropped 45% and hospitalization rates dropped 20%.

At present, 480 individuals are enrolled in the House Call program. Clients are frail elderly, ranging in age from 75 to 100. They are the individuals at risk for the greatest medical needs and the greatest medical expense. A majority of enrollees, though not all, are house bound. At a minimum, individuals receive monthly in-home visits. Should an individual require hospitalization, he or she is admitted to the geriatrics wing at the Washington Hospital Center. This continuity of service allows the same doctors to provide both outpatient and inpatient care, saving time, expense and improving the overall quality of care. Doctors do not have an office practice, in addition to their House Calls. The sole mission of the program is to provide compassionate and high quality care at the home.

The House Call team not only cares for the individual patient but works closely with the individual's family, providing support and reassurance. House Call visits are part medical treatment, part counseling, and part education/training. The social worker on staff provides community resources for the support of the caregiver and family. The House Call program is available to a family 24 hours a day, 7 days a week. The personalized approach to health care and the delivery of services in an individual's home fosters a strong and personal relationship between the House Call team, the patient and the patient's family. This relationship can ease the transition to terminal care at home.

House Call provides a national model, demonstrating a new way to deliver health care services to an aging population. The program is based on four principles: providing medical care for elderly persons that meets the needs of the patient and their family, reestablishing a humanistic approach to care of the elderly, providing state of the art diagnostic tests and treatment in the home, and coordinating all home and hospital services to promote communication and continuity of care. The current model of health care is one that requires the patient to go to the doctor, and does not meet the needs of the frail elderly. Instead, House Call brings the doctor to the patient, customizing care to fit an individual's particular need. This radical approach to health care not only recognizes the transportation challenges of an aging person, but the House Call model is a flexible model of care, understanding an individual's specific health care needs within the context of the of how an individual lives, particularly, the place they call home.

Write-up based on:

Transcript from ABC Nightly News May 12, 2002

Interview with Dr. Eric DeJonge

Interview with Dr. George Taler

Materials furnished by the House Call Program

Home Repair: Insuring the Safety and Independence of Seniors


Emergency Home Repair Program for the Elderly

New York State

The New York State Legislature appropriates funds annually for the repair of owner occupied elderly homes. Each year, not-for-profit programs submit proposals detailing how they will administer the funds including the selection of eligible recipients, construction managements(?), and program compliance. Those programs that are awarded funding serve individuals over the age of 60, with incomes at or below 80% of the area median income.

Repairs concentrate on the remediation of hazardous conditions that may threaten the health and safety of the elderly owners. Total repair costs cannot exceed $5,000. To date the program has completed more than 3,500 repairs throughout 58 counties in the state of New York.

Community Housing Resource Center

753B Cherokee Avenue, SE

Atlanta, Georgia 30315

(404) 624-1111

The Community Housing Resource Center (CHRC) serves the home repair needs of elderly and disabled individuals inside the City of Atlanta. Designed to address the health and safety hazards in a home, the CHRC's Home Repair Program focuses on critical repairs often too expensive to complete on a fixed income. Services include roof repair, plumbing repair, furnace repair or installation, and electrical system replacement. The CHRC also provides minor home modification and constructs wheelchair ramps. Since the repair program began in 1999, the CHRC has completed over 750 home repairs.

To qualify, individuals must be either disabled or over age 62 and have an income below 50% of the area median income. Priority is given to individuals with an annual income below 30% of the area median. Community Development Block Grant funding from the City of Atlanta and private philanthropic sources fund the repair program.

Recently, the CHRC has formed a number of alliances to address the comprehensive needs of their clients, the majority of which are frail, elderly women struggling to age in place. The CHRC has partnered with the Visiting Nurses Association to coordinate the health and housing services of the lowest income seniors. The VNA administers the state Medicaid Waiver program (Community Care Services Program), providing home health and personal care services to low-income, frail seniors. While caseworkers assess the social service and health needs of an individual, the CHRC inspects the home, completing any needed repairs, particularly those that could affect an individual's health concerns. For example, if an elderly individual is suffering from a respiratory illness and receiving in home health care, the CHRC can inspect the heating system and replace the furnace or supply weatherization services to insure that a home repair problem is not exacerbating their health problem. If an individual is having difficulty with balance, the CHRC can insure that there are no floorboards or doorways that present a potential hazard. In a similar relationship, the CHRC has partnered with the local Adopt-a-Grandparent program to repair the homes of "adopted" elderly individuals. Residents receive the social supports they need to remain in the community while the CHRC insures that their home remains a safe and adequate place to live.

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The page was last modified on July 22, 2002