Presentation to
The Commission on Affordable Housing and Health Facility
Needs for Seniors in the 21st Century

January 14th, 2002
Miami, FL

by
Jane Johnson
Director of Housing
Florida Association of Homes for the Aging 1812 Riggins Road, Tallahaseee, FL 32308
850-671-3700 / fax: 850-671-3699 / jjohnson@faha.org

The Florida Association of Homes for the Aging represents over 160 HUD-assisted affordable elderly housing communities in Florida. Most of our member facilities are owned by non-profit, faith- and community-based organizations, whose mission is to serve the housing needs of low-income elders. Our association also represents assisted living, nursing home and continuing care retirement community providers; so as an organization, FAHA is keenly aware of both the long-term care and housing needs of the elderly.

The creation of the Senior Housing Commission comes at a critical time for elderly housing providers in Florida. Many of our member facilities were built over 20 years ago and are in need of renovation and repair. Additionally, as the number of low-income elderly in need of affordable housing continues to outpace the supply of available units, waiting lists throughout Florida are growing at an unsustainable rate, and many elders wind up being placed in institutional settings prematurely.

We are very excited about the Commission's commitment to address issues that directly impact our members' ability to meet the needs of the elderly in their communities and we look forward to seeing the results of your work. The task before you is a daunting one, and will require innovative thinking and unprecedented interagency collaboration; but among the members of the Commission, there is clearly an abundance of wisdom, experience and ingenuity, and we are optimistic about a positive outcome.

On behalf of our members, I would like to list the specific policy issues that we would like the Commission to address:

• In almost every city in Florida, there are long waiting lists of low-income seniors who are in need of affordable housing. As these seniors wait for housing that they can afford, they become more frail and go longer without the supportive services they need to remain healthy and independent. In many cases, by the time their name comes up on the waiting list, they have already been placed in a nursing home.



• We believe that funding additional units of affordable assisted housing will result in a corresponding savings to the Medicaid program by decreasing premature nursing home placement. Building an assisted housing unit that can serve many individuals over a 40 - 50 year period is significantly more cost effective than paying close to $40,000 to keep one person in a nursing home for one year. We urge the Commission to recommend that Congress increase funding for the Section 202 Supportive Housing for the Elderly program as a way to control skyrocketing Medicaid nursing home expenditures by meeting the needs of low-income seniors in their homes.

• We urge the Commission to consider funding a new interest-free loan or grant program to finance much-needed renovations and repairs in older projects. If HUD is reluctant to take on the administrative burden of a new program, we suggest channeling the funding to the state housing finance agencies, with the provision that the state match the funding with a percentage of its own dollars, and the money be used solely for repairs and renovations of nonprofit elderly facilities.

• Although HUD has been moving away from project-based Section 8 assistance in favor of tenant-based vouchers, tenant-based vouchers can actually put many elderly people at a disadvantage, because they are unable to get to the Housing Authorities to apply for the vouchers, or they avoid going for fear of having to stand in lines. For those who do get their name on a waiting list, the wait is often longer than they can handle. Project-based assistance is often a much more effective way to ensure that frail elderly receive the assistance they need.

• We urge the Commission to advocate for continued funding of the very successful Service Coordinator program. Service Coordinators play a vital role in HUD elderly facilities, and the support and assistance they provide to our residents translates into savings for the Medicaid program.



• In view of this fact, we would like the Commission to consider allocating a certain percentage of Medicaid funding for Service Coordinator positions to augment what HUD is already funding.

• We suggest that lead agencies be directed to allow Service Coordinators to perform assessments and make referrals for Medicaid home and community-based services. The current relationship between lead agency staff and HUD Service Coordinators is redundant and inefficient.



• Typically, a Service Coordinator will perform an assessment for a resident to determine that he or she is in need of some level of home and community based services. The Service Coordinator then calls the lead agency, and they send out their own person to perform the same assessment and conclusion. The resident is then put on a waiting list for services. Because the Service Coordinator works with the residents on a daily basis, he/she is clearly more familiar with their needs, and in a better position to make an accurate assessment.

• We recommend the development of a separate Medicaid waiver program targeted to residents of HUD elderly housing facilities. Such a program would address the needs of a vulnerable population clearly at risk of premature or unnecessary institutionalization - as is indicated in the AARP report. A separate program for elderly HUD residents will also mean that these residents aren't forced to compete with the community at large for scarce Medicaid resources.



• Referrals for home and community based services are usually processed through lead agencies to several different service providers. The result is that in one facility, you might see five different home health aides visiting different residents on the same day.



• Under this program, lead agencies would be able to assign service providers to a particular facility. By giving a service provider a "contract" to serve a particular facility, the residents can expect more continuity of staff, scheduling of visits can be more flexible, and travel expenses for staff will greatly decrease.



• Many times, residents refuse services because they are afraid of having strangers come into their home. Residents are much more likely to feel comfortable if they see the same person coming into their building several times a week.



• There are obvious economic efficiencies that can be realized with a program that is directed to a more narrowly defined population group. A home health aide or homemaker can serve several clients in the same building much more efficiently than he/she can serve the same number of clients out in the community.



• We recommend that this program be limited to residents living in facilities with a Service Coordinator on staff. (This stipulation would also be an incentive to housing providers to hire Service Coordinators.)



• Service Coordinators should be allowed to perform assessments and make referrals, but lead agency staff should do the case management.



• Billing for services whould be run through the lead agencies, and the HUD facilities will be reimbursed by the lead agency for the assessments performed by the Service Coordinators.

• We support continued funding for the Assisted Living Conversion Program and we applaud HUD's expansion of the program to other facility types. The AARP report contains some very compelling data on the merits of linking affordable assisted living with HUD elderly housing. I encourage each Commission member to read through the report's findings.



• Assisted living is out of financial reach for most seniors, but the development of affordable assisted living remains a challenge. Without low-interest and grant financing for affordable assisted living, further production will not be possible.



• The Florida Housing Finance Corporation will be releasing an RPF next month for a $3 million zero interest loan program for nonprofits interested in developing affordable assisted living facilities. We would like the Commission to recommend that State Housing Finance Agencies throughout the country be charged with implementing similar programs to encourage development of affordable alternatives to nursing home care.

• While at the time the AARP report was being written, it was not a major issue, in the past 12 - 18 months, liability insurance for assisted living has become one of the most significant obstacles to affordable assisted living in Florida.



• One of our members in Jacksonville was a recipient of the first round of HUD's Assisted Living Conversion Program (ALCP) Grants. Although the grant was awarded in 2000, the owners have not been able to go forward with their project to convert studio apartments into assisted living units because they have not been able to procure liability insurance that they can afford.



• For HUD-funded assisted living facilities (those funded through the Section 232 program as well as the ALCP,) we recommend that the Commission explore some type of "sovereign immunity" provision for HUD-financed facilities. This immunity would consist of limits on the liability exposure for these facilities, so that insurance companies could better predict their risks and therefore charge lower premiums.



• One of our members with a HUD-financed ALF experienced a $300,000 increase in their insurance premium from 2000 to 2001. The increase had to be passed on to the residents and to HUD. This puts HUD in the position of channeling precious dollars to insurance companies instead of meeting the needs of the low-income elderly.



• Insurance industry representatives have testified before the Florida Legislature that until they can feel comfortable about their level of risk in insuring assisted living facilities and nursing homes, premiums and deductibles will be commensurate with potential losses. Limiting the payouts on claims against HUD-funded facilities will give insurance companies the predictability they need to keep premiums at a reasonable level.

• In the past 6 to 12 months, our member facilities have seen huge increases in their property and casualty insurance premiums. We are told these increases are due to several factors, including the poor performance of the stock market and the terrorist attacks of September 11th. These increases were not budgeted for and many facilities are struggling to find funds to pay their premiums.



• We recommend that HUD provide some type of short-term relief for facilities with extraordinary insurance premium increases, similar to the one time lump sum adjustment that was introduced in response to skyrocketing utility costs last year.

• Our final recommendation would actually result in a cost savings for HUD. We recommend that HUD eliminate its current requirement that facilities conduct a Comprehensive Needs Assessment (CNA) every five years. This requirement predates the REAC program, which is designed to achieve a very similar purpose. At a cost of approximately $5,000 per facility, the CNA is an onerous and unnecessary requirement. These costs are ultimately passed through to HUD, and when added to what HUD is already spending on REAC inspections, it seems excessive. Our understanding is that eliminating the requirement would require Congressional action, but we believe a strong fiscal argument can be made in support of its elimination.