Part II. CONVERGENCE: A CALL FOR COORDINATION OF SENIORS' HOUSING AND HEALTH CARE

Housing and Health Care Operate as Separate Systems; Policies and Programs Are Disconnected and the Need for Coordination Is Clear

The most striking characteristic of seniors' housing and health care in this country is the disconnection of one field from the other. With few exceptions, seniors obtain their housing from one source and their health care and other services from a completely different source.

Witness after witness before this Commission testified to this problem and the consequences of its continuation. "This lack of coordination and integration results in enormous inefficiency in the use of economic and social resources," William L. Minnix, president of the American Association of Homes and Services for the Aging, told the Commission at its San Diego hearing. Commissioners themselves, experienced in both housing and health care, found that those with expertise in one field had inadequate understanding of the other. In that, they mirrored their counterparts across the country.

Through exchanges in their own meetings, Commissioners have come to appreciate that:

• Some policy disconnects have long histories and may not be easily resolved;



• Poor communication, differing vocabulary, and few opportunities to share experiences separate professionals, policymakers, academics, and even the media in the two fields;



• Lack of coordination and integration between housing and health care is characterized by different and distinct financing systems and regulatory structures; and



• Most difficult of all, government is structured at both legislative and administrative levels in ways that inhibit coordination.

The historical disconnect between housing and health care demands attention before the Baby Boomers reach retirement age. Coordinating these systems will take considerable time, effort, and commitment.

Two Views Divide Housing and Services

How does a housing provider deal with the concept of "aging in place"? How does a health services provider deal with a senior's desire to "live in the community"? Even casual conversations with these providers begin to show the first signs of separation - language.

Housing professionals speak of dwelling units, turnover rates, replacement schedules, and subsidies. They want to know seniors' income as a percentage of area median income (AMI). Health services professionals speak of beds, length of stay, and insurance. They want to know seniors' activities of daily living (ADL), their maintenance needs allowance (MNA), and their ability to access and pay for community service options. One witness, Arthur Y. Webb, president and chief executive officer of Village Care of New York, told the Commission about the confusion that surrounds models for care that exist, citing uncertainty about the meaning of "assisted living, continuing care retirement communities, life care communities, supportive housing, adult care facilities…."

History, finances, and even legislative structures play a role in extending housing and health service disconnects. Federal housing and health issues are, for example, assigned to different committees in Congress, and State authority in these fields falls within the jurisdiction of different committees in State legislatures. The programs are administered in different departments - housing principally in the U.S. Department of Housing and Urban Development and health principally in the U.S. Department of Health and Human Services. Their headquarters, only a few blocks apart in Washington, are miles apart in understanding each other or working collaboratively. As one seasoned former HUD executive told the Commission, "There's no coordination because it's nobody's job to coordinate."

The U.S. Supreme Court decision in Olmstead v. L.C. (1999), affirming the right of persons with disabilities to live and receive services in the least restrictive setting they desire if at all possible, gives even greater urgency to the issues of government coordination.

Private and non-profit housing and health service providers face a bewildering array of funding sources: the private markets for a mortgage or equity loan, perhaps a municipal bond issue, or the credit sale, and - often most important of all - government funding from half a dozen different programs. Government programs are most often Federal in origin, but some are administered through State agencies. Each program has its own eligibility requirements, application deadlines, funding schedule, and recipient reporting requirements, to name only a few. One program's maximums might be another program's minimums. Witnesses before the Commission spoke of many consultants who make their living by advising sponsors on how to apply for these programs, how to write applications and reports, how to "cobble" together a layered funding package, and how to keep up with the relentless demand for more and more reports. Needless costs are associated with this complexity.

The ultimate consumer - the senior citizen - faces the daunting task of obtaining shelter and care from these two disconnected sources. Confronted with complex entry requirements, insurance coverage limitations, and high costs, many seniors become overwhelmed just when they need help the most. The shelter and care one needs should not require understanding complex systems. Shelter with services should not demand that providers work with multiple programs and funding sources. A senior with financial resources may navigate these passages more easily than one without, but in many instances, particularly in rural areas, the shelter and care options may simply not exist at any price.

A Call for Coordination

The crisis in housing and services for seniors demands a new approach. The Nation can no longer afford the inefficiency of the current disconnect between housing and health service systems for seniors. The time has come for coordination among Federal and State agencies and administrators. Coordination should begin in the halls and committee chambers of Congress and should spread through all branches of government and society. In the private sector, housing and health services providers are aware of the disconnect, but they need help in making the critical connections.

A first step in coordinating programs is to develop a common vocabulary, common age for eligibility, common definition of poverty, and common standards for programs.

The now distinct worlds of housing and health care must begin to acknowledge each other, listen to and speak to each other, and learn to integrate efforts for their mutual benefit and the benefit of their senior clients. Such understanding and coordination are essential underpinnings to the success of reforms proposed in this report and in many other forums.

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