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Expanding Long-term Care Choices for the Elderly

Aging in Place


Nancy Whitelaw, Ph.D, Vice President for Research and Demonstration, National Council on Aging, Washington, DC.

Larry McNickle, Director of Housing Policy, American Association of Homes and Services For the Aging, Washington, DC.

Jean Blaser, Manager, Long-term Care, Department of Aging, Springfield, IL.

In 1990, 94 percent of seniors lived at home. More than 27,000 community organizations support aging in place within the home. These include:

  • Senior centers.
  • Adult day service centers.
  • Area Agencies on Aging.
  • Senior housing.
  • Meals programs.
  • Multipurpose organizations.
  • Faith-based organizations.

Services provided include:

  • Congregate and home-delivered meals.
  • Case management.
  • Counseling and education.
  • Day care.
  • Respite care.
  • Health promotion and prevention.
  • Homemaker and chore services.
  • Information and assistance.
  • Personal care.
  • Socialization and support.
  • Transportation.

Most of these organizations and services are not considered "health care" in many sectors, yet they are key to delaying disability and maintaining quality of life for older Americans.

Positive outcomes for frail and disabled older adults utilizing community-based services include:

  • Improved health and quality of life.
  • Increased knowledge, attitudes, and behaviors, including increased self-care knowledge among older adults themselves and increased efficacy of caregivers.
  • Service-related outcomes, including increased access and improved quality.
  • Improved community health.
  • Reduced inappropriate health care use.

Funding for community services comes from a great variety of sources, including: Medicaid State plan, home and community-based waiver programs, Social Service Block Grants, Older Americans Act (although Dr. Whitelaw pointed out that this accounts for only 5-10 percent of all funding), various State programs, various local sources, national and local foundations, and private pay clients. Dr. Whitelaw described the institutional bias of long-term care (LTC) funding; for example, although Medicaid spends $41 billion on institutional care, only $11 billion is spent on home and community-based services.

Too often in the past, large and influential organizations, such as hospitals and State and local health agencies, have not recognized the capabilities of community-based agencies to support aging in place. However, this traditional view is changing for the better. A much more positive outlook is the result of a number of factors, including:

  • Greater national visibility for the accomplishments of community organizations and better data on innovative programs and best practices.
  • Greater standardization and predictability across programs.
  • Better integration of community programs.
  • More attention to increasing empowerment and self-efficacy of older adults.
  • Greater attention to outcomes measurement.

Almost one-quarter of elderly households are renters. Approximately 1.5 million older adults receive some Federal housing assistance; they make up nearly one-third of the people in public housing, more than one-half of Section 8 rental assistance (either voucher- or project-based), and more than 300,000 of Section 202 Elderly Housing.

The single most successful Federal housing program for elders is Section 202 Elderly Housing. The program includes loans, grants, and subsidies given to nonprofit organizations. Participants in the program pay rent equaling 30 percent of their incomes. The program serves very-low-income (defined as 50 percent of the area median income) people; the average age of a resident is over 80 years. Section 202 does not pay for supportive services.

The Congregate Housing Services Program (CHSP) provides matching grants to assist frail elders or persons with disabilities. The 60 CHSP programs each include one meal (7 days) and services, a service coordinator (whom Larry McNickle asserted is key to providing services in housing), and a Professional Assessment Committee (made up of people from different disciplines) to conduct eligibility assessments.

The reauthorization of Section 202—H.R. 202, the Affordable Housing for Seniors Act—includes options for rehabilitation and conversion of Section 202 units to assisted living units and allows Section 8 vouchers to be used in assisted living facilities. The U.S. Department of Housing and Urban Development (HUD) published a Section 202 Conversion to Assisted Living Notice of Funding Availability (NOFA) in the spring; currently 29 applicants are vying for these competitive grants. The NOFA requires that each applicant demonstrate the following:

  • Tight cap on operating expenses.
  • Medicaid Home and Community-Based waiver services available—because HUD will not pay for services, it assumes that these will be delivered through Medicaid.
  • Three meals per day (funded through other sources).
  • Twenty-four-hour staff (funded through other sources).
  • Preference for very-low-income persons, with current residents having top priority and people on 202 waiting lists having second priority.
  • A market analysis, showing evidence of need for assisted living units, especially among current residents.
  • A narrative of the number of units being converted, design features of both the units and facilities (including architectural sketches), and how the design will facilitate service delivery and changing needs of the residents.
  • A description and timetable of how the conversion activities will be carried out.
  • Budget.
  • Firm commitment letters outlining how services will be provided.

Applicants must also have a detailed Supportive Services Plan, showing:

  • How services needed by residents will be provided.
  • The role of the Service Coordinator.
  • How services provided will meet resident needs.
  • ALF operation, including general operating procedures, philosophy, staff training plans, and relationship to existing 202.
  • Individual monthly rate for board and services. (Note: The project may charge fees for some or all of the cost of board and supportive services.)
  • Estimate of total annual cost of board and services.
  • Letters of support/commitment from identified funding sources.
  • Letter of support from the State's licensing agency.
  • Past experience in arranging and delivering services.

In Illinois, 20 percent of the Department of Aging's clients reside in congregate settings, most often public housing. To meet the aging-in-place challenge, as well as staffing challenges, the State recently created the Community Care Program (CCP). This program provides in-home and community based services—including case management, homemaker, and adult day service—to 38,400 eligible seniors each month.

The State has two other options for housing with services:

  • Congregate Community Care (CCC): These 10 sites are largely within public housing facilities; there is an average of almost 33 units per site. More than 300 people are served. Ms. Blaser noted that the local housing authorities are willing to work with the Aging Department to maintain high occupancy of these units. Services provided to all clients include case management and homemaker services; some clients also receive congregate meals and adult day services.
  • Community Based Residential Facilities (CBRF): These three sites have an average of more than 75 units, serving more than 200 clients total. These clients pay rent and the State funds their services. Services include:
    • Case management.
    • Homemaker services.
    • Personal care.
    • Meals.
    • Adult day services.
    • Transportation.
    • Medication management.
    • Intermittent health services.
    • Health assessment counseling.
    • Social/educational services.
    • Twenty-four-hour emergency response.

The State has three reimbursement strategies for these programs:

  1. Conventional fee-for-service for individual services, in which a unit of service equals a unit of labor.
  2. Congregate fee-for-service, in which a unit of service does not equal a unit of labor, resulting in a richer reimbursement base.
  3. Capitation (for CBRF), in which a fee is paid for each client and all services are bundled. Eight reimbursement levels have been determined based on a person's assessed level of impairment; these range from $280 to $1,887.

Funding sources for these programs include: State general revenue funds, Medicaid HCBS waiver, Older Americans Act, Robert Wood Johnson Coming Home Projects, Illinois Housing Development Authority Low Income Housing Tax Credit Qualified Allocation Plan, and HUD Section 8 and Section 202 projects. Ms. Blaser explained that this can cause some confusion among providers, who must determine which funding source is billed for which service and resident. As the entire program is operated as a waiver, the State reports bundled services to the Health Care Financing Administration as part of the rate.

Common themes of these programs are:

  • Case management and individual plan of care for each resident.
  • Combination of funding sources.
  • Partnership between housing and services.
  • Services provided contractually by a third party in order to avoid designation as a nursing facility.
  • Enthusiastic, energetic staff with low turnover rates. (Ms. Blaser noted that to achieve economies of scale, one provider had to be contracted for each building, but the high quality of the staff has resulted in broad acceptance as demonstrated by required customer satisfaction surveys.)

Issues faced by these programs include:

  • When are clients too impaired to reside in these programs?
  • Should populations of both elders and nonelderly people with disabilities be mixed?
  • What makes a nursing facility? How does this relate to services offered and delivery system?


Affordable housing for seniors and families act. Washington (DC): American Association of Homes and Services for the Aging; 2000 Jul.

Co-location to link supportive services with elderly housing. Washington (DC): American Association of Homes and Services for the Aging; 1999.

Commission on affordable housing and health care facility needs for the 21st century. Washington (DC): American Association of Homes and Services for the Aging; 1999 Oct.

FY 2000 HUD appropriations. Washington (DC): American Association of Homes and Services for the Aging; 1999 Nov.

Grants for conservation of elderly housing to assisted living facilities. Washington (DC): American Association of Homes and Services for the Aging; 1999 0ct.

Housing our elders: a report card in the housing conditions and needs of older Americans. Washington (DC): American Association of Homes and Services for the Aging; 1999 Nov.

HUD FY2001 budget proposal builds on recent success. Washington (DC): American Association of Homes and Services for the Aging; 2000 Feb.

In brief: developing an affordable continuum of care: impact on assisted living and elderly housing. Washington (DC): American Association of Homes and Services for the Aging; 2000 Mar.

Use of Section 8 assistance for assisted living facilities. Washington (DC): American Association of Homes and Services for the Aging; 1999 Oct.

Community based residential facilities demonstration paper. Springfield (IL): Illinois Department on Aging, Bureau of Planning and Program Development, Division of Long-term Care; 1999 Apr.

Community care program: congregate community care demonstration project. Springfield (IL): Illinois Department on Aging, Bureau of Planning and Program Development, Division of Long-term Care; 1999 Apr.

McNickle L. Breakthrough in elder care. Health Progress 2000 May-Jun;44-51.

The coming home program: affordable assisted living for the rural elderly a creative alternative for Illinois and America. Oakland (CA): NCB Development Corporation; 1998.

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