Testimony to
The Commission on Affordable Housing and Health Facility
Needs for Seniors in the 21st Century
September 24, 2001
by
JANICE C. MONKS
Executive Director
American Association of Service Coordinators

Madam Co-Chairs, members and staff of the Commission on the Future of Affordable Housing and Health Facility Needs in the 21st Century: My name is Janice Monks and I'm the executive director of the American Association of Service Coordinators (AASC) based in Columbus. Thank you for giving AASC the opportunity to testify about the influence that service coordination is having within the affordable housing industry and the future impact it can have on the future generations of elders as it pertains to issues of costs as well as consumer choice and quality of life.

AASC is a national, grassroots nonprofit organization of more than 900 members who serve more than 135,000* residents living in affordable housing facilities. Our membership consists of service coordinators (SCs), case managers and social workers, housing managers and administrators, housing management companies, public housing authorities, state housing finance agencies, state and local area agencies on aging and a broad range of national and state organizations and professionals involved in affordable, service-enhanced housing. It should be noted that 25% of our members come from private ownership and recognize the benefits of service coordinators as part of "doing good business".

AASC members serve low-income families, frail elderly persons and persons with disabilities who live in and around a variety of federal and state subsidized housing programs including the Section 202 programs, the Section 8 programs, public housing programs, the Congregate Housing Services Program (CHSP), the Low-Income Housing Tax Credit (LIHTC) program and even a variety conventionally financed, market-rate housing programs.

While service coordinators shoulder a wide variety of responsibilities and duties, their work mainly is focused on helping our most vulnerable Americans: They

• Maintain independence and avoid premature, more costly institutionalization;
• Link with appropriate and sometimes life-saving health, social and other services;
• Locate child care and other family services;
• Gain job training, employment and transportation; and
• Receive a wide range of educational opportunities

But service coordinators do much more than help residents who live in and around the properties where they work. The advent of service coordination into low-income properties and neighborhoods has had a much greater impact than probably anyone ever imagined. In fact, almost every property that has added a service coordination component to its operation has benefited from significant improvements. For example, service coordinators actually save management companies time and money. Examples of their influence includes:

• Decrease in legal fees/evictions/time in court
• Decrease in vacancy loss
• Decrease in bad debt
• Reducing the number of off-hour emergency calls to management and local paramedics
• Fewer apartment turnovers
• Fewer failed unit inspections
• Resident issues are addressed before reaching the 'crisis' level
• Improved relationships with providers
• Stabilized resident population and increased satisfaction of residents and their families
• Increasing the visibility and marketability of the facility
• Decrease in damage to the property and improving the overall image of the property within the community, among many other things.

Additionally, SCs can significantly influence the financial burden associated with assisted living or nursing home care by finding the resources necessary to keep residents living in a less structured environment (see attachment A). At present, there is no national research that can clearly identify the cost/benefit savings of service coordination, although several AASC member management companies have conducted program evaluations that show consistency in program success as well as savings to their company, and residents. THEORETICALLY, if we take the monthly cost savings listed in attachment A (non-subsidized Assisted Living vs. tax credit facility) and apply it to an average number of frail residents* served by the AASC membership, there is a potential savings of more than $55 million per month. The savings may be even be greater in HUD funded programs such as the 202 or 811 program where the resident pays less in rent than in a tax credit facility. Please view a recently produced video that details and chronicles the work of service coordinators and the important contributions that they and the others on the housing management team are providing for elders and families living in affordable housing environments (a copy has been provided to the commission).

AASC believes that the future of affordable long-term care will be based on a model of service-enhanced housing with a service coordinator who will take the lead in handling resident issues, allowing management to deal with the increased responsibility and myriad of property issues that have developed over the last several years. The SC will ensure that residents have access to various levels of off-site, on-site and in-home care, provided in array of settings more residential in nature and more homelike in design than today, and as integrated as possible into the community.

For the Commission's consideration, AASC proposes some broad suggestions in addition to the expansion of the service coordination program. In light of the national emergency that has occurred, we recognize the many hurdles and challenges facing our country on a variety of levels. The task of the Commission is even more challenging when much of our nations funding and resources will be dedicated to the safety and security of all our citizens. Our proposals include long and short-term solutions, of which, many are a matter of developing 'inter' and 'cross' departmental communication and education of existing programs.

Finding increased resources to invest and reinvest in affordable housing:

AASC urges the Commission to consider:

• Using possible future surpluses generated by the FHA insurance fund to develop new housing stock, and to maintain and renovate existing housing stock. Over the past few years, for the first time in its history, FHA has generated surpluses. Under current laws and regulations, however, that money-estimated at more than $4 billion and rising-is to be returned to the U.S. Treasury. Since the surplus was created by the housing industry, let's reinvest it in housing, and in the process help create more jobs and greater economic opportunity for all Americans.
• Readjusting federal, state and local tax codes to once again offer attractive incentives for developers and investors to build and maintain affordable housing. Until the 1986 tax reform when Congress eliminated a number of important multifamily housing tax breaks, building and maintaining affordable housing was more profitable, less risky and more popular. Additionally, allow tax credit facilities to apply for existing 3 year SC grants requiring a resource match of 6 years beyond the initial grant. Encourage state housing finance agencies to give substantial incentives to owners and developers who, 1. include and then implement an SC program in their Qualified Application Plan as Ohio does; 2. utilize a portion of their developer fee to create a funding source for services or to offset the cost of the SC position. States could set-up a funding source from the fees donated by developers (who could receive extra points for the donation), include a yearly match from the state (the formula to be determined by the state).
• Create a per-unit mortgage interest tax deduction for multifamily housing owners based on a model similar to the popular home mortgage interest deduction program. Then structuring it so that a large portion of whatever annual rebates owners receive must be used to maintain or renovate the facility, to add services or to otherwise benefit the residents. Additionally, encourage owners (through incentives) who participate in refinancing of their mortgage to re-invest the savings in developing 'satellite service centers' that house senior service providers and other private-sector businesses whose products benefit seniors. Revenue from office rental can be used to offset costs of the service coordinator or other services.
• Increase incentives for banks, lenders and other financial institutions requiring them to invest more resources in developing affordable elderly housing, services and health facilities to comply with the Community Reinvestment Act (CRA) requirements. Provide them with documentation of existing service programs, such as service coordination, utilizing research done by private, as well as nonprofit owners that identifies the positive implications that can influence the financial health of their investment.
• Create incentives for nursing homes and assisted living facilities to provide limited services to existing affordable housing owners such as food service and transportation. · Allow service coordinators to charge fees for Information and Referral services to clients/families living outside of the facility that employs them (recognizing restrictions associated with liability).
• Work with insurance companies who offer professional and property liability coverage to re-evaluate their formula to determine premiums to reflect the differences between 'independent housing' and other housing options (i.e. assisted living, nursing home). If a facility includes a service coordinator program, then there is a potential for reduced liability as outlined earlier in this testimony.
• Current funding for public housing service coordinators comes through limited grant programs. Nationally, 40% of those living in PHA's are 65 years and older who have the same service needs as in assisted housing. We suggest the creation of a separate set-aside for service coordinators in the public housing funding formula.
• We should make budget-based service coordinators a reality decreasing the competition and need for expanding the SC grant program, eliminate the confusing SC grant renewal system and ensuring all residents of assisted housing receive the benefits of service coordination. Additionally, the cost of a service coordinator should be exempted with in the Fair-Market Rent (FMR) Cap Exemption regulation.

Create consumer- and worker-friendly systems easier to understand, access and serve:
Even for long-time professionals, the current "crazy-quilt" tapestry of services and shelter options make it difficult to fully grasp their complexities, let alone try to access them. The result are confusion amongst consumers, duplication of service delivery, government agencies not knowing who supplies what service or that some services even exist, reduction in qualified service workers, regulations that impede dedicated service providers from providing the service they were hired and want to perform.

To begin addressing some of these specific challenges, AASC urges the Commission to consider:

• Creating a new cabinet-level department that encompasses in one entity housing, health care and other federal support programs serving the elderly to better focus federal policy and regulatory efforts, in conjunction with states and communities.
• Requiring insurers and employers to offer affordable long-term care insurance options through existing private insurance and through Medicare and Medicaid
• Expanding educational funding and opportunities for health-care careers for high school and college students through federal grant and loan programs, work-study/mentoring programs, and tuition subsidy and forgiveness programs.
• See that all service coordinators are administered from one HUD office instead of two. Currently, oversight of federal service coordinator programs is handled by two offices within the HUD bureaucracy-the Office of Housing and the Office of Public Housing-causing unnecessary confusion and inconsistency in the administration of these programs.

As stated before, AASC understands the challenges and restraints that the Commission may and most likely will encounter since terrorists attacked our country on September 11, 2001. We also recognize the importance of moving forward and not allowing fear to replace freedom or control our ability to be of service to others-something Americans do best!

AASC offers its assistance to this Commission in the coming year to shape and refine these suggestions in order to build a strong and flexible foundation for a seamless continuum of care in the 21st century. We believe that by tapping and possibly merging a variety of existing resources and adapting existing policy and regulatory efforts we can meet a more targeted set of national goals that will be based on consumer satisfaction and improved care of our nations elders.

Thanks to the following AASC members for supplying material for this testimony:

• Association of Ohio Philanthropic Homes & Services for the Aging (AOPHA)-Columbus, OH.
• Cardinal Ritter Institute-Hazlewood, MO.
• Lutheran Housing Services-Toledo, OH.
• National Church Residences-Columbus, OH.
• Preservation Management, Inc.-Portland, ME.

* The number of residents served by an SC can vary from 20-1000 with few documented statistics available. AASC membership stats indicate that 71% serve 101-1000 residents with 56% serving 100-300 residents. We are using an average of 150 residents per member in this testimony

** HUD's definition of 'frail' are residents needing assistance with 3 out of 5 ADL's - the same eligible criteria for nursing home admissions in most states

Case Study
From Assisted Living to Independent Apartment (Cost Savings)
Case study Submitted by:
Deb Damschroder-Social Services Supervisor
Lutheran Housing Services
Toledo, Ohio
Chair: Standards of Practice Committee-American Association of Service Coordinators (AASC)

A female in her mid 80's moved to one of our tax credit communities from an assisted living community because she was depleting her funds and was afraid she would be placed in a long-term care facility if she was not financially independent. She is healthy and able to care for herself with minimal assistance. Her sister lives in our building and encouraged her to move to this community so they could be close. It would enable her to save a substantial amount of money and still have her needs met.

Before making application the sister asked the service coordinator to meet with the potential applicant and explain the services that would be available on site. The applicant was accustomed to receiving two meals per day, light housekeeping and weekly laundry service in the assisted living community. She also paid additional fees to the assisted living complex for transportation to medical appointments. Applicant did not need assistance with medications. She enjoyed participating in activities in the Assisted Living community and wanted to be in a community offering opportunities for socialization.

After moving to our community, the service coordinator arranged for *3 meals to be delivered daily from Mobile Meals at a cost of $4.90 per day. A *housekeeper who charges $15.00 for 1 1/2 hours of cleaning and laundry, was also contracted by the resident with the referral assistance from the service coordinator. *Mobile Market, a non- profit grocery store on wheels, stops at our community weekly so she is able to do her grocery shopping independently. The *community van also provides free trips to local banks, malls and pharmacies on a weekly basis. *Transportation is also provided for special events. Additionally, the *hospitality Van from the local hospital provided medical transportation at no charge. The *bookmobile makes monthly visits and there are *bi-weekly wellness clinics that provide blood pressure readings, blood sugar checks and prescription medication education. A *Podiatrist is also available for home visits. *The resident council provides many activities and opportunities to socialize. There is also a *beautician and fully equipped salon on-site.

This resident often commented that she was amazed at the services she was able to receive in her independent apartment at a substantial savings over the assisted living community. She loves her larger ground floor apartment with a private patio. She also commented that she was not asked for additional funds every time she has a personal request. She also feels more "independent" and less "institutionalized" in the independent community. As a healthy 84 year old woman with few medical problems, independent living was a realistic option and provides a tremendous financial savings to this individual. If and when she becomes frail or needs additional medical care we have discussed Passport (Medicaid waiver program) or In- Home Services.

Savings:

Assisted Living
Rent (includes meals ,cleaning, laundry): $2,200.00/mo plus additional expenses for additional services
Transportation: dependent on mileage Typically $5.00 - $15.00 per trip - average $30.00/mo
Total Monthly Expenses: $2,230.00