Affordable Clustered Housing-Care: A Category of Long-Term Care Options for the Elderly Poor

ABSTRACT

What we label as affordable clustered housing-care options are making it increasingly possible for poor and frail older Americans to age in place comfortably and securely in residential-like settings combining both affordable shelter and long-term care. The hallmark of these housing arrangements is their sizable population clusters of low-income frail persons in need of supportive services. Despite their greater availability and the compelling factors underlying their growth, the diversity of their supportive services and operations cloud their identity resulting in uncertainty as to whether they have a common mission. In response to the need for a more careful delineation of this aging in place option, this paper describes the distinguishing features of these hybrid settings and constructs a typology of their representative exemplars or prototypes.

KEYWORDS:

• Long-term care
• affordable housing
• supportive services
• low-income elderly
• assisted living

Long-term care in the United States now broadly encompasses the “array of health care, personal care, and social services generally provided over a sustained period of time to persons with chronic conditions and functional limitations” with needs that “range from minimal personal assistance with basic activities of everyday life to virtually total care” (Institute of Medicine, 2001, p. 1). Over the past two decades, federal and state government programs have made affordable long-term care options more available to low-income older adults who want to age in place in their ordinary homes and apartments and thereby avoid or at least delay a nursing home stay (O'Brien & Elias, 2004). As one indicator, an increasingly greater share of the Medicaid program's long-term care expenditures is on services offered outside of nursing homes. In 2004, 36% of the long-term care expenditures of Medicaid were paying for such home- and community-based assistance, up from 14% in 1991 (Shirk, 2006). The most manifest consequence of these trends has been the declining share of older persons (both the old-old, 75–84 and very old, 85+) who now occupy nursing homes (Alecxih, 2006; Bishop, 1999; Mollica & Johnson-Lamarche, 2005).

Many stakeholders are interested in making noninstitutional long-term care solutions more available to low-income elders. Overwhelmingly, older Americans of all incomes prefer to deal with their vulnerabilities in their ordinary dwellings (AARP, 2000) and research shows that when poor older persons end up in nursing home beds funded under Medicaid, they may receive inferior care (Mor et al., 2004). State governments seeking ways to curb their Medicaid budgets have curtailed their nursing home growth and are more aggressively implementing community-based strategies to deliver long-term care, and thus divert and transition their frail and low-income elderly constituencies from nursing homes (Department of Health and Human Services, 2004; Doty, 2000; O'Brien & Elias, 2004; U.S. Congressional Budget Office, 2004). The managements of affordable rent-assisted apartment projects have to cope increasingly with their aging tenants, even as they have little experience as service providers, and their buildings were not designed to accommodate such vulnerable groups. They are looking for ways that their elderly tenants can age in place, yet avoid the management crises connected with addressing their long-term care needs (Golant, 1999; Heumann, Winter-Nelson, & Anderson, 2001). The 1999 Supreme Court Decision, Olmstead v. L.C. ruled that under Title II of the Americans with Disabilities Act (ADA) people with disabilities have a right to live in less institutionalized community settings. At the very least, this ruling has encouraged state policy makers to re-examine the institutional biases of their long-term missions (Mollica & Jenkens, 2001).

The focus of this paper is on a category of affordable housing arrangements that has emerged to help low-income older persons cope with their long-term care needs in their communities. These purposively planned or adapted housing options make it possible for their occupants to benefit from both affordable shelter (i.e., room and board) and long-term care. Today, they are known by different names: service enriched affordable housing, affordable supportive housing, affordable assisted housing, affordable housing plus services, subsidized NORC (naturally occurring retirement community) service programs, assisted living in public housing, and service coordinated housing. They share various similarities with private-pay models of seniors housing property types known as independent living communities and assisted living residences (National Investment Center & American Seniors Housing Association, 2005), but unlike most of these options do not cater to higher-income older persons (Golant, 1999; Kane & Wilson, 2001; Zimmerman et al., 2003). To emphasize their differences from other housing and long-term care strategies, we newly label these options, affordable clustered housing-care (abbreviated to “housing-care” in this paper).

What these conventional looking residential settings—usually multiunit apartment buildings—have in common is that they are occupied by a critical mass or sizable population cluster of low-income older adults who have at least some difficulties living independently because of their physical or cognitive impairments and chronic health problems. Onsite staff hired by the housing provider, outsourced or partnered home and community-based health and service providers, or a combination of these service delivery approaches supply these elder concentrations with an array of supportive services. These range from information, counseling, referrals, housekeeping, meals, monitored emergency alert systems and transportation, to personal care, health care, and nursing services. These are offered in a residential environment relying on a “social” as opposed to a “medical” model of care—emphasizing individual autonomy and choice.

Their proponents argue that where people grow old matters (Golant, 1984; Mollica, 2003) and that by offering assistance to geographically clustered rather than dispersed older persons, these planned housing-care arrangements enjoy economies of scale advantages over other settings. They maintain that these arrangements are thereby able to offer a more comprehensive array of services less expensively (lower per commodity/service unit costs), more effectively, and with better results (Evashwick & Holt, 2000; Golant, 1999; Ormond, Black, Tilly, & Thomas, 2004; Pynoos, Liebig, Alley, & Nishita, 2004). When the benefits of these service delivery strategies are combined with independent and comfortable residential quarters, proponents argue that these housing-care arrangements offer frail and low-income older adults attractive alternatives to their aging in place in their current homes and apartments.

Despite the greater availability and visibility of these housing-care arrangements and the compelling factors underlying their growth (Pynoos, Feldman, & Ahrens, 2004), their identity is clouded by their very different development and management origins, diverse offerings of both high- and low-acuity care, varied service delivery strategies, their both licensed and unlicensed statuses, and the absence of a dedicated nonprofit organization championing their merits. This has resulted in uncertainty as to whether they have a common and distinctive mission. These ambiguities are manifested by the lack of a coherent and compelling body of scientific evidence regarding their residents' quality of life and care (Pynoos, Feldman, & Ahrens, 2004).

We therefore need a more careful delineation of this aging in place option and its various versions. This is important to advance policy-relevant research that can demonstrate its favorable quality of care and life outcomes and to offer legislators a cogent rationale for increasing their commitment and funding (Pynoos, Feldman, & Ahrens, 2004). In response, this paper has two primary goals: (1) to describe the distinguishing features or attributes of these settings and the different strategies they use to achieve their long-term care mission; and (2) to construct a typology of their most representative exemplars or prototypes that illustrates their diverse appearance, functioning, and organization.

METHODS

We employ two analytical strategies. First, we emphasize what is unique about these affordable clustered housing care alternatives, by comparing them to what are arguably more widely available and recognized housing arrangements in which older persons with physical or cognitive disabilities and chronic health problems receive long-term care today—what we label affordable household-care . These are the ordinary owner- and renter-occupied households in which low-income seniors typically receive assistance and care that is mostly delivered by family members (often a spouse or a daughter) and to a lesser extent by (direct care) staff hired through state or local government programs.

Second, in the absence of any comprehensive and scientifically collected data by which to analyze systematically the distinguishing features of housing-care arrangements and their identifiable prototypes or exemplars, we empirically review a set of descriptive case studies that catalog and summarize their components and attributes. These literature sources constitute the “data” for this paper and include the following: Feder, Scanlon, & Howard, 1992; Golant, 1999; Harahan, 2005; Heumann, Winter-Nelson, & Anderson, 2001; Housing Assistance Council, 2006; Jenkens, Carder, & Maher, 2004; Kochera, 2002; Milbank Memorial Fund & Council of Large Public Housing Authorities, 2006; Pynoos, Feldman, & Ahrens, 2004; Pynoos, Liebig, Alley, & Nishita, 2004; Sheehan & Oakes, 2003; Stone, Harahan, & Sanders, 2008; Washko & Sanders, 2006; Wilden & Redfoot, 2002.

FINDINGS

Distinguishing Housing-Care from Household-Care Arrangements

Figure 1 and Figure 2 outline the nine components that delineate the multiple features of housing-care arrangements, denote their key attributes or elements, and distinguish them from affordable household-care arrangements. The following descriptive analysis compares and contrasts these two ways of delivering long-term care.

FIGURE 1 Nine Components Distinguishing Affordable Household-Care and Housing-Care Arrangements

FIGURE 2 Attributes of the Nine Components Distinguishing the Affordable Clustered Housing-Care Strategy

Development and Management Origins of the Housing Arrangements

Housing-care arrangements are a product of housing or service providers who intentionally construct or purposively adapt an affordable residential setting and arrange for the delivery of affordable long-term care to a targeted cluster or concentration of low-income older occupants who are having some difficulties living independently. Among the stakeholders initiating these settings: owners or administrators of government-subsidized affordable rent-assisted apartment projects; nonprofit organizations or government agencies providing affordable long-term care; and owners or developers of privately owned congregate care (independent living) or assisted living residences made affordable to low-income older persons through various government programs or by the financial assistance of charitable organizations. Multiple stakeholders—sometimes from both the private and public sectors—may be responsible for initiating any given project.

The combining of housing and care may have been the original intent of the sponsors of government-assisted rental housing properties, but they may have introduced supportive services only many years later in response to the demands of their frail older tenants. They may also only later have physically retrofitted the units and common areas of their properties to make them safer and more accessible and to accommodate the delivery of supportive services. Such design changes may have been mandated by state or local government regulations.

Sometimes housing-care arrangements are initiated through the cooperative efforts of the residents themselves occupying ordinary multiunit buildings—known as naturally occurring retirement centers (NORCs) (Hunt & Gunter-Hunt, 1985; Ormond, Black, Tilly, & Thomas, 2004) or deliberately occupied but unplanned elder residences (DOUERS) (Golant, 2002). The selective in- and out-migration and aging in place of the residents have resulted in the occupancy of these buildings by a large number of elderly residents who require long-term care. Sharing common needs, they self-organize themselves into a formal association and contract or partner with nonprofit organizations or public agencies to secure a steady stream of supportive services. Alternatively, the care initiatives originate from some nonprofit service organization or public agency that is alerted to the occupants' care needs.

Irrespective of their origins, the variation in the physical and service infrastructures required or allowed by states and local governments, fiscal limitations, the idiosyncratic motivations and philosophies of care held by individual housing providers, and locality differences in the incentives and constraints underlying the development of these options lead to a wide array of residential properties labeled as housing-care arrangements.

Household-care arrangements distinguish themselves from housing-care arrangements in that their origins are usually more spontaneous, less structured, and more uninformed. Their catalysts are typically one or more precipitating and sometimes unanticipated events that signal the physical or cognitive decline of an older person. At this point, an older person, family member, or professional care manager may obtain supportive services. Although households in need of such assistance may be concentrated in the same building, their care decisions are still being made independently, and they are not recipients of any building-wide organized or targeted affordable service delivery strategy.

Setting Context and Composition of Impaired Occupants

The hallmark of housing-care arrangements and what most fundamentally distinguishes them from household-care settings is that they are purposively occupied by a concentration or sizable population cluster of occupants—a critical mass—of low-income older tenants. These persons have to some extent chronic health problems, cognitive impairments, or activity limitations that result in a housing provider regularly offering them long-term assistance. In sharp contrast, affordable household-care arrangements are occupied by only one or two low-income older persons in need of long-term care—sometimes in a household also occupied by adult family members or paid live-ins—and their dwellings are typically geographically dispersed across different urban and rural neighborhoods.

What constitutes the minimum size of this concentration or critical mass of frail tenants will vary significantly among housing-care settings. This will depend on the homogeneity of its low-income and impaired occupants (that is, more homogeneity allows for smaller numbers with the same needs); the types and mix of their needed services (similar service needs are more likely to satisfy economies of scale conditions); the urban or rural location (housing projects in rural areas typically have smaller numbers of occupants); and the strategies used by providers to deliver assistance (certain strategies more than others may benefit from a larger consumer base).

The clusters of tenants that make up these critical masses in housing-care arrangements, however, can vary substantially as to the seriousness or acuity of their impairments or health conditions. Some housing providers more than others may seek to stay beneath the regulatory umbrella of their state's assisted living program (or equivalent program category) and thus refrain from accepting or keeping older persons who would require higher-acuity care necessitating state licensure. Other housing sponsors, relying on an outsourcing model of delivered care (where only the service providers are licensed), will accommodate a more vulnerable group of tenants. In other instances, the building codes of a municipality or state may influence the vulnerability profiles of the residents, such as by requiring that occupants of conventional buildings have the ability to evacuate in the event of a fire emergency.

Alternatively, when states license these housing-care arrangements under their assisted living programs, they are allowed to admit and retain residents only with specified impairment severities and to offer only certain types of care. States, however, differ substantially as to their licensing categories and their requirements (Mollica & Johnson-Lamarche, 2005). Even when they are licensed as assisted living properties (or equivalent state category), operators in most states may choose to admit older persons with less allowable serious impairments because they are less confident about their abilities as service providers, they believe housing providers should not be in the assisted living business, or they are reluctant to assume the concomitant fiscal and legal responsibilities of delivering care (Golant, 1999; Mollica & Johnson-Lamarche, 2005).

The government program that funds the long-term care services offered by a housing-care arrangement (e.g., a public housing project) may come with care restrictions. Medicaid Waiver funding for long-term services, for example, is often only available to older persons who are nursing home eligible—that is, who have sufficiently serious impairments that they would have qualified for skilled nursing home care.

A comparison of housing-care and household-care arrangements may not reveal any differences as to the frailty profiles of their occupants. When older persons, family members, or professionals are responsible for assistance or care decisions in household-care arrangements, there are usually no predetermined or necessarily precluded impairments or chronic health problems. Rather, what constitutes allowable frailty thresholds mainly depends on the capabilities of the caregivers and whether they feel constrained by their time commitments, their skills or finances, or their emotional makeup.

Housing Setting and Site Characteristics

Housing-care settings can variously consist of low- to high-rise apartment buildings, multi-unit condominiums, cottage units on a campus-like setting, single-family unit dwellings within the same neighborhood, or manufactured homes in a trailer park. Their occupants are usually renters, but they are sometimes owners, as exemplified by the occupants of limited equity cooperatives, condominiums, and manufactured home parks (Wilden & Redfoot, 2002). Architecturally, the building structures of housing-care settings are typically indistinguishable from those of household-care arrangements, and may be prominent only when they are sited on planned campus-like settings.

In contrast, most household-care arrangements are found in owned rather than rented dwellings. Furthermore, their buildings may be distinguishable only because of their poor physical condition. Early built dwellings of older homeowners, who have limited financial means, for example, may show visible signs of physical decline, if they have not been well maintained and periodically upgraded (Golant, 2003a).

Physical Design and Retrofitted Features for the Physically or Cognitively Frail

Although the buildings of housing-care arrangements are often not distinguishable from the outside, their interiors and sometimes their sites are more likely to have architectural or design modifications introduced by their owners or managements to make them safer and more user-friendly for their frail occupants (Schwarz, 1999). The design categories identified in Figure 2 only hint at the range of possible architectural responses. Regnier (2002) identifies at least one hundred critical building and site adaptations that are fundamental to good assisted living design. Among the most frequently identified design modifications: grab bars, accessible cupboards, no slip surfaces, emergency pull cords, lighting adaptations, and living areas that are accessible for persons in wheelchairs or relying on walkers. Housing-care arrangements may also have common areas intended for the dining, recreational, and religious activities of their residents and sometimes offices or clinics for their on-site care workers. Their sponsors may also have subdivided their housing setting into different physical spaces—different floors, wings, or buildings—specifically designed to accommodate older persons with varied assistance needs.

Still, we must generalize carefully because housing-care arrangements will vary significantly as to their interior room arrangements, design adaptations, and the extent to which they have been adapted for disabled populations (Schwarz, 1999). Beyond national accessibility requirements, the building codes and assisted living regulations in some states and localities have more stringent architectural or design requirements. Some housing sponsors obtain the financing to more extensively retrofit their buildings. Some rent-assisted buildings were constructed when federal housing programs emphasized a cost-containment policy resulting in smaller properties with limited common spaces and fewer special design features (Calkins & Weisman, 1999; Heumann, Winter-Nelson, & Anderson, 2001; Pynoos, Liebig, Alley, & Nishita, 2004; Regnier, 2002; Wilden & Redfoot, 2002; Wylde, Baron-Robbins, & Clark, 1994). Some otherwise residential-like housing-care settings have features that resemble those found in nursing homes as exemplified by two or more residents having to share their apartments and bathrooms. Other settings consist of residential units arranged not as apartments, but more like a dorm or ward. A minority of settings still have nursing stations (Wilden & Redfoot, 2002). Where older persons receive assistance in a building complex may also vary. Efficiency units accommodating the needs of more frail older occupants may be concentrated in one part of the building; alternatively, they may be dispersed throughout (Milbank Memorial Fund & Council of Large Public Housing Authorities, 2006).

Household-care arrangements will typically not have made physical design or architectural adaptations making their dwellings as safe or user friendly as those of housing-care arrangements (Gill, Williams, & Tinetti, 2000; Gitlin, 2000). Among elderly homeowners who had various disabilities making it difficult for them to fully use their dwellings, less than half had introduced at least one special design modification (U.S. Department of Housing and Urban Development Office of Policy Development and Research, 2001).

Types of Offered Long-Term Care

The factors that influenced the frailty profiles of the residents in housing-care settings will also account for the types of their long-term care offerings. These may consist of services as basic as information, counseling, and referrals from a service coordinator or help to perform their instrumental activities of daily living (IADLs), such as preparing meals, doing light housework, and keeping track of money. Other settings, however, may offer heavier care and provide their residents with assistance with performing their activities of daily living (IADLs), such as bathing, dressing, eating, grooming, walking, and administer selected nursing and hospice services (Crystal, 1987; Institute of Medicine, 2001). Thus, settings can broadly divide up into what Mollica and Jenkens (2001, p. 69) referred to as either “low service” or “high service” models of care. These characterizations, however, do not fully capture the spectrum of assistance offered in these housing-care arrangements, where even the most mundane “job descriptions” of staff ranging from service coordinators to personal aides can vary substantially depending on provider values, staffing practices, and regulatory constraints (Sheehan, 1992).

The organizations charged with creating these housing-care options may introduce very specific service mix arrangements. For example, the Coming Home Program, a nonprofit organization that has achieved an impressive record of administratively and financially packaging these housing-care properties (mostly in rural counties), requires that “25% or more of its units and services [be made] available to persons using Medicaid to pay for services and SSI-level incomes to pay for rent and meals” and “excludes providers who offer only ‘light care’ programs intended as a pre-nursing home service” (Jenkens, Carder, & Maher, 2004, p. 181).

It is often not easy to distinguish housing-care arrangements from household-care settings based on their long-term care offerings. Households in ordinary dwellings have no inherent limits as to the services they can bring into their homes or apartments given the portability of medical and assistive devices and the feasibility of home-based skilled nursing care. Whether they offer light or heavy care will primarily depend on the motivations and capabilities of household members and their family caregivers to cope with their vulnerabilities without moving. Their eligibility for different types of government-sponsored home- and community-based care programs (if available) will be another factor. State-funded managed care programs targeting Medicaid waiver beneficiaries, for example, can offer them a full gamut of long-term care and acute care services, whereas a program funded through the personal care option of their Medicaid's state plan does not cover skilled nursing and therapy services (Mollica, 2003; O'Keeffe & Weiner, 2004; Stevenson, Murtaugh, Feldman, & Oberlink, 2000).

Modes of Long-Term Care Delivery

When older occupants of housing-care arrangements have some unmet need, they typically can depend on staff who can help them access the appropriate supportive services. Housing providers, however, often use very different long-term care delivery strategies to bring services to their tenants. Some housing-care settings directly offer most of their assistance with a dedicated on-site hired full- or part-time staff. A service coordinator or social worker, for example, will offer care counseling and service referral. Some housing-care settings complement this assistance by establishing a Professional Assessment Committee (PAC) (one housing-care arrangement refers to this as a “care consultation team”) (Washko & Sanders, 2006) to individualize and better target service and care coordination, consisting of members of local social service and health care government agencies, along with other social work and care professionals (Pynoos, Liebig, Alley, & Nishita, 2004; Sheehan & Oakes, 2004; Wilden & Redfoot, 2002). Other onsite hired staff will be variously responsible for offering regular housekeeping services, regular meals in a central dining area, recreational activities, transportation, and unscheduled (i.e., on demand) personal care.

Alternatively, housing-care providers may rely on what Mollica refers to as the “service model” whereby they partner or subcontract with outside vendors or agencies to deliver services in their buildings (Mollica & Morris, 2005). These may variously include volunteers, private businesses (e.g., restaurants), home care agencies, direct care staff, community-based nonprofit organizations, or government-sponsored service vendors. They may offer these services only as needed by their tenants or at regularly scheduled times at the housing site.

The service management styles of housing-care providers will also differ in other ways. In some settings, the older impaired tenants are restricted to one location—one wing or floor—while in others, they are scattered throughout a building (Wilden & Redfoot, 2002). Some providers only guarantee certain types of assistance on a 9 to 5 daily basis, whereas others offer care on a 24/7 basis. Some providers offer only separate packages of services, whereas others adopt an à la carte arrangement, whereby older occupants choose whether to opt for specific services and have more control over their care (Wilden & Redfoot, 2002). The residents in these latter settings may be able to choose, for example, how many meals they want each day. Housing providers who “bundle” services argue that this approach has pricing and accounting advantages and that a “voluntary” service selection approach weakens their economies of scale advantages of delivering services to a “guaranteed number” of tenants.

Another strategy is for housing providers to arrange for their occupants to receive services offered by the charitable organizations in their community—realized by having a nutrition site or an adult day care center co-located on, near, or sometimes in the building. These may respond to the very specific needs of older persons, such as hot meals, transportation, or wellness care, but alternatively may have a very comprehensive focus, as exemplified by the acute and long-term care services offered by the PACE (Program for All-inclusive Care for the Elderly) and state-organized Medicaid Waiver case managed programs (Stevenson, Murtaugh, Feldman, & Oberlink, 2000).

In household-care arrangements, decisions regarding how to provide care are typically the responsibility of the older occupant, usually with the assistance of a family member—a spouse or an adult child. About 78% of older persons who find they have long-term care needs rely exclusively on assistance from family members and friends; the remainder depend on some combination of informal care plus paid providers (8% paid help and 14% paid and family help) (Thompson, 2004). Care is typically delivered in the older person's dwelling or at community-based centers (e.g., adult day care; congregate meal sites). Family members are often learning for the first time about how to judge the need for care and the opportunities and constraints they face when securing assistance (Foundation for Accountability & The Robert Wood Johnson Foundation, 2001). Thus, the care regimen offered to the older person may be less timely, more incremental, and consist of more trial and error approaches.

On the other hand, when household-care arrangements include professional case or care managers (privately hired or employed by a government-funded social program), who conduct service assessments and make referrals, they may enjoy service delivery strategies that are undistinguishable from those found in housing-care arrangements.

Licensure and Regulatory Status

Regulatory oversight differs significantly across states and among their localities and helps to explain the variation in the service packages offered by housing-care arrangements and the acuity level of their residents. Some housing-care arrangements may be unlicensed as care settings, reflecting their offering of only “information” or “environmental care” (Figure 2), although they may have to meet state and locality building code standards. When they offer higher acuity assistance, such as personal care, how they are regulated will depend on the distinctive regulations of their state. Under what is called the “housing and services model,” the state will license the property or facility and restrict the older persons it can admit or retain based on the seriousness of their impairments and their types of needed services (e.g., skilled nursing services) (Mollica & Johnson-Lamarche, 2005). A state's assisted living regulations will often also impose building architectural requirements, such as specifying minimum dwelling unit sizes and requiring private bathrooms. The state and local governments may also have building design and physical infrastructure requirements (e.g., regarding fire evacuation, building height, or wheel-chair accessibility) based on American National Standard Institute (ANSI) or International Building Code (IBC) standards.

On the other hand, under the aforementioned “service model,” the state does not license or certify the property to offer particular services, but rather licenses the outsourced or subcontracted service agencies or providers that offer assistance (Mollica & Johnson-Lamarche, 2005). Under this regulatory model, however, the states may also impose building and dwelling design requirements (Mollica & Johnson-Lamarche, 2005). States sometimes will rely on a combination of these licensure categories (Sheehan & Oakes, 2004).

In contrast, in household-care arrangements, most care and medication management provided by family members, volunteers, and privately hired staff is typically unlicensed and unregulated. Family members can often be trained to carry out a variety of nursing-related services—often by licensed professionals—but there is usually no oversight when they carry out these procedures. Only a small share of households will receive care from licensed home care agencies, sometimes under the auspices of a state-regulated community-based program.

Affordability of Room and Board (Shelter Component)

The shelter affordability of a large share of housing-care arrangements is made possible by their status as government-subsidized rental properties (Golant, 1999; Heumann, Winter-Nelson, & Anderson, 2001). These mainly include properties or units owned and operated by Public Housing Authorities, those funded by HUD (Department of Housing and Urban Development), Rural Housing Service, and Low-Income Tax Credit programs, and those funded by state or local governments.

These projects are able to charge more affordable rents than private-pay apartments because they have variously received construction or operating subsidies, grants, loans, below-market interest rates, vouchers, or tax breaks that lowered the building construction or rehabilitation costs, debt service, or subsidized their rents (Kochera, 2001; U.S. General Accountability Office, 2005). Financing affordable rental housing is often an especially complex endeavor because prospective housing providers must bundle together funding from multiple programs (e.g., from a city's public housing authority, low income housing tax credits, and community development block grant program). Some of these rental properties have benefited from deeper rent subsidies and thus can target extremely poor as opposed to moderately poor older populations. The rents of the properties and the incomes of the elder occupants will also reflect whether they are located in high- or low-cost housing markets (Commission on Affordable Housing and Health Facility Needs for Seniors in the 21st Century, 2002).

Housing-care arrangements may be occupied by older occupants who have affordable dwelling rents, fees, or debt service obligations even though they are not under the auspices of some government program. These include multi-unit limited equity cooperative buildings, high-rise condominiums, rent-controlled multi-unit apartment buildings, single room occupancy hotels, and manufactured home parks.

Concentrations of low-income and impaired elderly may also occupy the affordable units offered in privately owned assisted living facilities, mostly targeting higher-income markets. About 11% of the units in these properties are occupied by low-income persons (although a significant share are smaller board and care properties), often made possible through a combination of funds from the federal Supplemental Security Income and State supplements to this program (Mollica & Johnson-Lamarche, 2005).

Older persons in household-care arrangements will vary as to the extent that they have affordable dwelling expenses. A significant share of low-income elderly owners (over 40%) and renters (over 60%) pay over 30% of their income on their dwelling expenses (Commission on Affordable Housing and Health Facility Needs for Seniors in the 21st Century, 2002). Thus, after these households pay for their housing costs, they may have difficulty covering their out-of-pocket costs for their long-term care expenses.

Affordability of Long-Term Care

Housing-care arrangements typically rely on a different set of funding sources to make their long-term care assistance affordable. In a few notable exceptions, HUD programs (which typically help make only the shelter affordable) have at least partly subsidized the care component. A 1978 Department of Housing and Urban Development initiative, the Congregate Housing Services Program (still operates, but no longer accepts new applicants) offered privately owned HUD-subsidized rental projects funding of up to 40% of the costs of nonmedical supportive services, such as transportation, personal assistance, housekeeping, meals and the support of a service coordinator. Under the 1992 Housing and Community Development Act, HUD authorized the hiring of service coordinators as an eligible expense for all federally subsidized housing programs occupied by more frail older persons (U.S. Department of Housing and Urban Development, 1996). As a final example, since 2001, HUD's Assisted Living Conversion Program has funded the costs of physically renovating and retrofitting the apartment units and common spaces of rent-assisted federal properties (except public housing) so that they can be licensed by their states as assisted living properties (or equivalent). The grant funds, however, cannot be used to pay for service delivery (Commission on Affordable Housing and Health Facility Needs for Seniors in the 21st Century, 2002).

More commonly, housing providers, such as the owners or sponsors of privately owned multi-unit HUD rent-assisted properties and public housing projects, must look to different and multiple funding sources to bundle together fiscal support needed to make their long-term care affordable. These could include, for example, funding from private foundations, Older Americans Act programs, community development block grant programs, and state development agencies (Mollica & Johnson-Lamarche, 2005; O'Keeffe & Weiner, 2004; Stevenson, Murtaugh, Feldman, & Oberlink, 2000). The availability of these funding sources will vary substantially across states and counties and housing providers themselves have different abilities and motivations to harness these sources of financial assistance.

States are increasingly using their Medicaid programs to fund the delivery of long-term care outside of their nursing homes, although their coverage and reimbursement provisions can vary substantially (O'Keeffe & Weiner, 2004). Ten states do not offer Medicaid program coverage to subsidize housing-care properties as long-term care settings, although they can cover the services offered by outsourced service providers. Fourteen other states opt to cover the long-term care services provided by housing-care settings through the personal care option of their state plan. Thirty-six states rely on their Home and Community Based Services 1915(c) Waivers Program, and eight states rely on both of these approaches. Three states use all three sources (Mollica & Johnson-Lamarche, 2005).

States often favor the Waiver plan because unlike the personal care benefit, they can limit Medicaid eligibility to particular population groups and locations and establish waiting lists (Mollica & Johnson-Lamarche, 2005). They can also offer a fuller range of personal care services not covered under their state plan. When states rely on their personal care services benefit, the Medicaid-eligible older persons are typically less impaired (Summer & Ihara, 2005). Other states favor their Waiver program because it requires that their housing-care settings accommodate residents who have the same level of care needs as residents admitted to their nursing homes (and thus may offer comparable care at less cost). States, however, have very different nursing home admitting standards and some accept older persons with less severe impairments than others (O'Keeffe & Weiner, 2004; Summer & Ihara, 2005). Medicaid Waivers may also be favored because of their more liberal income level eligibility thresholds—older persons are eligible if they have incomes as high as 300% of the Supplemental Security Income benefit. On the other hand, if states rely on the Medicaid benefits under their personal care option, minimum income thresholds are typically lower—based on the federal poverty level, 100% of the Supplemental Security Income benefit, or the state's medically needy income standard (O'Keeffe & Weiner, 2004).

As identified earlier, some larger private-pay, for-profit assisted living facilities allocate some of their units to low-income older persons. To defray their long-term care costs, they rely on Medicaid subsidies and state supplements to the federal Supplemental Security Program. Providers vary as to whether they accommodate once private pay residents who have subsequently become Medicaid eligible because they have “spent-down” their incomes and assets. Most assisted living providers do not rely on Medicaid subsidies, however, because of the limited availability of Medicaid slots, because the program does not cover room and board costs, imposes limits on what they can charge, and because the Medicaid reimbursements for their long-term care are too low (O'Keeffe & Weiner, 2004).

Most long-term care provided to older persons in household-care arrangements is not assigned any monetary value despite the typically extensive time commitments of family members. Thus, the out-of-pocket long-term care costs incurred by older persons in household-care settings depend largely on the extent to which this informal care is supplemented by professional care. When they do require such assistance, older persons often rely on comparable government-sponsored home- and community-based programs as housing-care occupants.

Diverse Housing-Care Prototypes or Exemplars

Figure 3 identifies eight distinguishable prototypes or exemplars of housing-care arrangements now operating in the United States. Each has a sufficiently distinctive set of component attributes to set them apart from the others (Figure 2). Not every current housing-care setting will be neatly recognizable as a member of a particular exemplar, however. Some housing-care settings inevitably share key attributes common to two or more prototypes. Nonetheless, a housing-care setting's prototype categorization usually will reflect the prominence of one or more of its attributes.

FIGURE 3 Exemplars of Affordable Clustered Housing-Care Arrangements Based on Attributes of the Nine Distinguishing Components

This group of eight exemplars does not encompass some housing-care alternatives that might be included by other researchers and advocates. The “critical mass” requirement mostly rules out places such as adult foster care and board and care facilities that typically accommodate very small numbers of seniors. Most private-pay independent living facilities, assisted living properties and continuing care retirement communities (CCRCs) will also be excluded because either (or both) their entrance or monthly fees would put them out of economic reach of low-income seniors, even though their appearance and operating features would qualify them as housing-care arrangements. On the other hand, we would include some independent living facilities (congregate care facilities) and CCRCs when they are operated by faith-based organizations charging affordable fees; and also private-pay assisted living properties when some share of their units are occupied by Medicaid recipients.

Space prevents a discussion of all the iterations of the many possible attribute combinations (Figure 2) that argue for the identity of the eight housing-care arrangements, but below we highlight some of the most important distinctions.

The basis for identifying several of the Prototypes (1–5) in Figure 3, is the distinctiveness of their long-term care offerings and how their housing providers deliver them. Prototype 1, a minimalist housing-care arrangement, usually a government-subsidized rental housing project, typically offers its residents only the information and referral services of an on-site service coordinator, some environmental care, like housekeeping and transportation and an emergency response system. Its residents may also have access to a wellness clinic/nurse and common areas for recreation and socializing. Its residents are more likely to be overall less impaired—if only because the absence of an extensive array of offered long-term care services will lead to the selective departure of tenants with higher acuity needs. In contrast, Prototypes 2 and 3, although also government-subsidized rental projects, offer their typically more impaired residents a much broader range of long-term supports relying on more comprehensive and complex service delivery approaches. In turn, their buildings will contain more extensive physical design features and common areas consistent with the needs of a more vulnerable population. Prototypes 2 and 3 will offer some of their services with their own hired staff, but they will also rely heavily on contracts or partnerships with other nonprofit or public agencies to deliver assistance. Prototypes 2 and 3 in turn differ from each other because of the variations in the organizational origins of their delivered long-term care. Prototype 3 is a product of a comprehensive state-initiated long-term care program; whereas Prototype 2 is primarily the product of initiatives of housing sponsors and their managements.

Prototypes 4 and 5 distinguish themselves because the sources and delivery of their care more strongly depend on community-based services as opposed to the services offered by on-site building staff. Thus, although Prototype 4 will offer some of its services with its own staff, it relies extensively on a senior center for its meals, a home care agency offering ADL assistance, and on an organization that offers a health and wellness clinic (either on- or off-site) for preventative care. The identity of Prototype 5 is linked to its dependence on a co-located or nearby PACE center to deliver a comprehensive array of long-term (and often acute) care to its relatively more impaired older occupants.

Prototype 6 distinguishes itself from Prototypes 1–5, because it represents properties that are licensed (by a state government) as assisted living facilities (or equivalent category). Prototypes 1–5 usually will lack such licensing status because the building structure and its operations fall beneath the care or service threshold of their states' licensing criteria, or because they rely on out-sourced licensed service providers and agencies. The housing-care arrangements of Prototype 6 often will rely more heavily on their own in-house hired staff and services and its occupants will typically need higher acuity care.

Prototypes 7 and 8 are distinguished because of their development and management origins. NORC or DOUER properties (Prototype 7) often were not originally designed as housing-care arrangements and their concentrations of older residents with long-term needs have only emerged later in the history of these properties. The introduction of a care component in these buildings often reflects their cooperative's or condominium's tenant associations agreeing on the need to obtain some formal or permanent organized assistance. This response may also be spurred (and initiated) by the concerns of professionals from an outside social service agency (Ormond, Black, Tilly, & Thomas, 2004). Prototype 8 has a very different origin. A small share of private-pay assisted living providers has secured Medicaid (waiver) funding to make some of their units affordable to low-income frail older persons.

The distinctive ways that housing-care arrangements obtain funding to make their long-term care affordable is also the basis for distinguishing these exemplars. At one end of the spectrum are rent-subsidized buildings that must secure funding only to pay for the wages of a service coordinator (Prototype 1) or those relying on a narrow range of community-based services donated by a faith-based social agency (Prototype 4). Prototypes 2 and 6 rely on very different and more diverse funding sources consistent with the broader spectrum of their long-term care assistance. For example, to be eligible for assisted living state licensure, the owners or providers of a public housing or HUD project (Prototype 6) typically must obtain funding to retrofit their buildings (e.g., common rooms, clinics) and make architectural design adaptations (e.g., wheel-chair access, safety features). To subsidize their long-term care, they may rely on Medicaid waivers, tenants' Supplemental Security Income (SSI) benefits, state supplements to SSI and the donations from nonprofit, often faith-based organizations. Their task is further complicated because these funding streams must be compatible (e.g., eligibility of tenants) with their affordable housing financing packages (Jenkens, Carder, & Maher, 2004). Prototypes 3 and 5 distinguish themselves because they both offer a diverse array of long-term care services to their typically more frail older occupants that are funded by relatively large public programs: a state-sponsored managed care assisted living program or the PACE program. NORC or DOUER properties (Prototype 7), on the other hand, are typically securing assistance for their less impaired older tenants, and will often rely on a different package of funding sources. Their residents may not have sufficiently low incomes to qualify for Medicaid and their rents are often already affordable, so they may predominantly rely on Older Americans Act programs (income level is not an eligibility constraint), and the donated services from faith-based charities.

DISCUSSION

Advocates for this housing-care model believe that it holds promise for leveling the unequal planned aging in place opportunities typically available to low- and high-income older Americans. They also argue that these housing-care arrangements offer various advantages over where older persons predominantly age in place—what we labeled as household-care arrangements. Foremost, they benefit from the economies of scale of serving a relatively large and permanent concentration—a critical mass—of low-income older tenants with common needs. Thus, the whole spectrum of long-term care can be delivered more effectively and at lower cost than when it is offered to geographically dispersed seniors living in their ordinary homes and apartments (Evashwick & Holt, 2000; Ormond, Black, Tilly, & Thomas, 2004).

It becomes easier to justify the retrofitting of a building to make it safer and easier for their frail tenants to use, the hiring of a service coordinator or case manager, the purchasing of a transportation van, the offering of regularly scheduled on-site meals, and the introduction of a program of social and recreational activities. With a concentration of visible at-risk tenants, it becomes more feasible for on-site nurses to provide health maintenance checks and to introduce onsite personal assistance (Evashwick & Holt, 2000).

Service providers emphasize that they are more likely to be apprised of their target population's unmet and changing social, psychological, and practical needs and in turn can better educate the older tenants about how they can benefit from long-term care assistance (Evashwick & Holt, 2000). They claim that the organizational climate of these housing arrangements makes it more likely that frail older tenants can get needed help and do not have to act alone (Golant, 1999; Sheehan & Oakes, 2003). Thus, their occupants enjoy a more protective long-term care context than they would in the household-care arrangements of ordinary homes and apartments.

Providers argue that the multiple services often required by a frail older population can be better coordinated—the result being more effective scheduling of everything from staff assignments to special purpose transportation vans (Evashwick & Holt, 2000). Furthermore, they can more easily adjust their service time allotments to fit the clients' unique needs, and are less likely to offer duplicated services as would be the case if individual tenants were all making their own care arrangements (Mollica, 2003; Ormond, Black, Tilly, & Thomas, 2004).

In contrast, frail elderly living in household-care arrangements can usually receive assistance from direct care workers only on selectively scheduled days and during limited and inflexible time slots. Providers argue that this care cannot be delivered as timely, cheaply or productively as in housing-care arrangements because they are usually traveling to multiple neighborhoods to serve a geographically dispersed clientele (Medicare Payment Advisory Commission, 2001; Mollica & Morris, 2005). Traveling these distances also results in substantial transportation expenses, increasingly a more crucial budget component, given the higher cost of fuel (Harvey, 2005). When multiple public agencies provide the different types of help needed by these seniors, each governed by different eligibility and scheduling requirements, coordination is especially difficult (Lawler, 2001).

Without a family member to serve as spokesperson and gatekeeper, older persons may be especially disadvantaged. Thus, seniors relying on a household-care strategy may lack help when they most need it, unless they are in states and localities where they can receive a comprehensive case-managed program of home- and community-based assistance (Foundation for Accountability & The Robert Wood Johnson Foundation, 2001; Stevenson, Murtaugh, Feldman, & Oberlink, 2000). They also cannot typically realize the lower per service/commodity costs enjoyed by housing-care arrangements. Their household budgets will be further strained if their dwelling expenses are consuming a large share of their monthly income (Golant, 2003a).

Some of the strongest proponents of housing-care arrangements are the housing sponsors of affordable rent-subsidized buildings who adopted this model after having experienced a host of tenant crises in the absence of offering supportive services. In contrast, now they report (Golant, 2000, p. 3):

“Building morale will be higher, incidence of fires and accidents will decrease, unscheduled visits from human service professionals will decline, and fewer housekeeping and repair problems will erupt. Overall, fewer apartments will turn over. With fewer crises, administrators can devote more attention to the bricks and mortar tasks of building management.”

Even as advocates point to their many virtues, it is not easy to develop and manage these housing-care arrangements and potential sponsors confront various obstacles that either prevent or discourage their participation (Golant, 2003b). To make these options affordable, housing providers must secure funding to construct (or physically retrofit) and manage a building and to deliver affordable care. Finding financing to convert an ordinary rental building into one that is physically designed appropriately for offering supportive services is a challenge by itself; finding financing to also offer affordable long-term care greatly raises the property development bar. Although some state governments have organizational strategies to facilitate the packaging of such financing, housing sponsors are often saddled with this challenging responsibility (Wilden & Redfoot, 2002).

These difficulties are illustrated when housing providers try to combine Medicaid (waiver) assistance with affordable rental assistance. They are often put off by the inability of the Medicaid program to guarantee the availability of future waiver funding (the time span of waiver programs is usually less than the loan finance repayment period of the property) (Mollica & Johnson-Lamarche, 2005). As another disconnect, the incomes of the residents eligible for housing-care residences (in higher priced housing markets) may be too high for them to qualify for Medicaid, especially in states that rely on their personal care plan. In buildings that are in rural settings, it is often prohibitively expensive to add the physical infrastructure required for a state's assisted living licensure.

When packaging their funding, housing sponsors must typically deal with the bureaucracies of governmental agencies that treat housing and care as very separate domains. Thus, while “new affordable senior housing development is possible… it may involve leaving the comfort zone of some providers' experience” (Van Ryzin, 2006). As Congressional testimony by a large nonprofit service provider emphasized (Volunteers of America, July 17, 2001):

“Providers of long-term housing finance typically do not understand the terminology or analytic framework of the health care community. Health care regulators are unaware of the requirements of housing finance. The need to get participation and approvals for transportation, social service, and other regulatory bodies further complicates the discussion. Housing sponsors often must spend inordinate amounts of time and energy as a go-between because different disciplines give different meanings to important words.”

The result is that housing providers have difficulty trying to package services funded by programs that differ as to their applicants' minimum income and asset qualifications and the types and severity of their covered physical disabilities, the share of the service cost they subsidize, where the services must be delivered, and their performance requirements (Lawler, 2001). Thus, providers often “confront an organizational puzzle where the pieces do not match up” (Golant, 2003a, p. 37). This contrasts with nursing homes that can depend on a single (Medicaid) subsidy to run their operations and are seldom required to separate out their shelter and care costs. It also differs from private-pay assisted living residences catering to a higher income clientele that do not usually have to separate out their shelter and long-term costs for public sector scrutiny or approval.

Potential housing developers, operators, and their investors have other concerns. They worry that their developments will begin to resemble nursing homes or assisted living facilities and that they will incur the wrath of their more healthy tenants who do not want to be surrounded by frail neighbors (Golant, 1999). Others fear that their operations will run afoul of outside regulators who will accuse them of providing too much care; and they will incur higher and financially intolerable insurance liability premiums (Aon Risk Consultants, 2005).

The many disincentives confronting the stakeholders, who develop, fund, manage, regulate, and insure these alternatives result in their needing especially compelling evidence to justify their participation. Although there is much anecdotal and case study evidence arguing for the strengths and advantages of this option, there is a shortage of scientifically valid research that has demonstrated that this housing-care alternative can achieve acceptable quality of life and care outcomes. Specifically, evidence is lacking that these housing arrangements can help their occupants improve or stabilize their behavioral functioning, delay or postpone their needs for a nursing home stay, and reduce the overall costs (as opposed to per household) of publicly funded long-term care (Doty, 2000; Shirk, 2006).

The various versions of these housing-care arrangements have made it especially difficult to generalize about their successes and failures (Sheehan & Oakes, 2004). Thus, we lack comparable research findings on issues such as the following: the quality of care consequences of housing-care arrangements variously relying on outsourcing, on-site staffing, or co-location strategies to offer long-term care; the quality of care consequences of licensing the property as opposed to the service provider; what constitutes an operationally feasible critical mass size; what program features most influence resident care outcomes (e.g., minimum hours of on-site care by personal aides or nurses); and how housing-care settings compare in costs and quality of life and care outcomes with household-care strategies or private-pay assisted living residences. Furthermore, there has been little careful debate regarding the minimum set of attributes that these settings must possess to qualify as “alternatives” to more high-acuity care facilities like private-pay assisted living properties or nursing homes (Ficke & Berkowitz, 2000; Fonda, Clipp, & Maddox, 2002; KRA Corporation, 1996; Mollica & Johnson-Lamarche, 2005; Pynoos, Liebig, Alley, & Nishita, 2004; Research Triangle Institute, 1996; Sheehan, 1999; Sheehan & Oakes, 2003; Sheehan & Oakes, 2004). Such studies are necessary to respond to the concerns of those skeptics (especially in the nursing home industry) who argue that because these housing-care arrangements are less stringently regulated, they cannot provide competent care to the very frail (U.S. Senate Special Committee on Aging, 2003).

Thus, the multiple prototypes of this housing arrangement may be a double-edged sword. On the one hand, low-income older consumers benefit from more choices catering to both their varied housing preferences and very different long-term care needs. A diverse product line acknowledges that one size does not fit all. On the other hand, such variability has contributed to the failure of research to reach generalizations about the worth of these options. An eclectic “product line” obfuscates the identity of these housing-care settings as long-term care solutions and casts doubt on whether they have a distinctive mission and a relatively unique set of core features. This can lead to confusion among consumers and make it difficult for them to make informed choices. Judging the appropriateness of a housing setting becomes especially confusing if potential consumers or their health care and social work advisors lack confidence that it offers a predictable set of services. Furthermore, if there are any incidents of abuse or poor care, the media will quickly dismiss the whole category of options as unreliable, even if they involve only unrepresentative housing-care outliers.

Advocates for this long-term care alternative for poor seniors sometimes mistakenly assume not only that there is consensus as to the mission of these options, but also that all the key players agree that they constitute a valuable addition to the long-term care resources of this country. These perspectives are embodied in the optimistic words of a nationally prominent housing consultant: “When speaking of affordable housing buildings linked with affordable supportive services, you no longer have to explain what they are any more, why they are needed, why they are beneficial to vulnerable seniors” (Bretos, 2004). This paper has shown that it is far from a straightforward task to distinguish the diverse housing-care exemplars that presumably share a common mission. As a result, we now have insufficient knowledge to make unequivocal evaluations about the strengths and weaknesses of these housing arrangements as long-term care alternatives, even as advocates claim they have been around for a long-time, have successful track records, and are occupied by thousands of satisfied seniors successfully aging in place.

Paper was originally commissioned for 2005 “Building Bridges” Boston Colloquium sponsored by Academy Health and The Commonwealth Fund. My thanks to Penny Hollander Feldman, Vice President, Research and Evaluation, Visiting Nurse Service of New York, for comments on an earlier draft of this paper.