Promoting Sustainability in Housing with Services: Insights From the Right Care, Right Place, Right Time Program

Despite the widely-acknowledged potential of housing with services for improving the lives of low-income older adults, ensuring their financial sustainability has been challenging. This study aimed to address this issue, drawing on 31 key informant interviews and three focus groups with payers, housing providers, and community partners involved in the Boston-area Right Care, Right Place, Right Time Program, which enrolled about 400 older adults. Transcripts were qualitatively analyzed using thematic coding. Participants agreed on the program's value, but there was little consensus on mechanisms for securing ongoing funding. The broadly distributed responsibility for individuals in housing sites, which involves health insurers, hospitals, and community service providers, provides little incentive for investment by these entities. Findings suggest that governmental mechanisms, probably at the federal level, are needed to channel funding toward these supportive services. Without such reliable funding sources, replication of supportive housing models for low-income older people will prove difficult.

Association of Chronic Diseases and Functional Limitations with Subjective Age: The Mediating Role of Sense of Control

OBJECTIVES

This study examined the relationships between chronic diseases, functional limitations, sense of control, and subjective age. Older adults may evaluate their subjective age by reference to their younger healthier selves and thus health and functional status are likely to be determinants of subjective age. Although sense of control is also a potential predictor of subjective age, stress-inducing factors associated with disease and functional limitations may reduce older adults' sense of control, making them feel older.

METHODS

Using the 2010 and 2014 waves of the Health and Retirement Study, structural equation modeling was performed on a sample of 6,329 respondents older than 50 years to determine whether sense of control mediated the relationship between chronic diseases, limitations in instrumental/basic activities of daily living (ADLs, IADLs), and subjective age.

RESULTS

Chronic diseases and limitations in ADLs had a positive, direct association with subjective age (β = 0.037, p = .005; β = 0.068, p = .001, respectively). In addition, chronic diseases and limitations in ADLs and IADLs were positively, indirectly associated with subjective age via a diminished sense of control (β = 0.006, p = .000; β = 0.007, p = .003; β = 0.019, p = .000, respectively).

DISCUSSION

As predicted by the Deterioration model, the findings showed that chronic diseases and functional impairment are associated with older adults feeling older by challenging the psychological resource of sense of control. Appropriate interventions for dealing with health challenges and preserving sense of control may help prevent the adverse downstream effects of older subjective age.

HOUSING AND COMMUNITY PARTNER VIEWS ON THE BENEFITS OF THE R3 PROGRAM

Housing with services programs have potential to benefit residents and operators of affordable senior housing communities. This study aimed to understand housing and community partner views on the benefits of the R3 program. Data derived from 31 interviews with R3 program managers and wellness team members, executives and direct service staff at the intervention sites, and community partners. Overwhelmingly positive overall assessments of the R3 program were reported. Concrete benefits to residents included receiving additional attention and support; connecting with family and health care resources; enhancing group programming; preventing ambulance transports; helping with transitions; and improving health and quality of life. Psychosocial benefits to residents included: empowering program participants; providing socio-emotional support; and alleviating psychosocial distress. Benefits to housing sites included augmenting staffing levels, skills, and capabilities; proactively tracking and responding to resident needs; lowering resident turnover; and learning from and adopting procedures and processes underlying the R3 philosophy.

ACHIEVING SUSTAINABILITY IN HOUSING WITH SERVICES: INSIGHTS FROM R3 PROGRAM

There has been a long-standing interest in developing housing models that integrate the supportive services that older people need to remain at home as long as possible. This approach has boomed for better-off people who can afford the cost of private-pay independent living and assisted living environments. For those with fewer resources, however, options are limited, given that they are largely dependent on public financing. This study focuses on how to develop sustainable models of housing with services for low-income older people. Using data from 31 key informant interviews and three focus groups, it reports and analyzes expert perspectives on how programs such as R3 can achieve financial sustainability. Four major themes emerged: (1) funding as the key to sustaining housing with services; (2) funding housing with services through participating health plans; (3) other potential funding sources for housing with services; and (4) gaining buy-in for housing with services.

Barriers and Facilitators to Housing With Services: Lessons From The Right Care, Right Place, Right Time Program

The Right Care, Right Place, Right Time initiative (R3) was developed to enable seniors to remain at home as long as possible, while reducing health care costs. It was implemented in four senior housing communities in the Greater Boston area, and consists of two on-site wellness teams (wellness nurse, wellness coordinator), each responsible for about 200 participants across two housing sites. This study aimed to understand barriers and facilitators to implementing R3. Data derived from 31 semi-structured interviews with R3 staff, housing personnel, and community partners (e.g., first responders), as well as 150 key program documents. Facilitating factors in implementing R3 included: top-level management support; formal and informal mechanisms of communication between wellness team members and building staff; substantial discretion, flexibility, and creativity provided to wellness team members; and daily ambulance reports from first responders. Barriers to implementing R3 included: impediments to resident recruitment/engagement; initial role confusion between wellness team members and existing building staff; limited wellness team time at individual intervention sites; challenges establishing systematic relationships with case management staff from the hospitals, AAAs, and insurance companies; and the decentralized approach to data tracking and information exchange. This study suggests several lessons for implementing housing with services initiatives such as R3. Top-level support and buy-in at the organizational level is essential to program development and implementation. Despite early challenges, key program elements can improve over time (communication, data processes, role clarity). Establishing trust with both R3 participants and housing staff is key to building relationships that promote program success.

Older Adults’ Subjective Age as a Potential Psychological Resource in Clinical Management of Chronic Illnesses

Subject age is predictive of future morbidity and mortality and can be potentially viewed as a psychological resource. However, there seems to be a reciprocal relationship between subjective age and health. In a series of analyses, we demonstrated that various measures of health status such as number of chronic illnesses, self-rated health and sensory impairment have an adverse association with older adults’ subjective age. Specifically, chronic illnesses seem to have a period effect and age effect. Living with chronic illness over a period of time seems to attenuate its association with subjective age. Similarly, the association between chronic illnesses and subjective age gets weaker with increase in older adults’ chronological age. Therefore, asking those living with chronic health conditions and specifically younger older adults about their subjective age and providing appropriate resources, counseling and reassurance about chronic illness management may prevent the downstream negative health effects of increased subjective age.

R3 PROGRAM MANAGEMENT AND WELLNESS TEAM VIEWS ON BARRIERS AND FACILITATORS TO IMPLEMENTING THE R3 PROGRAM

Implementing programs such as R3, which adds health-focused supportive services into senior housing sites, can be complicated. This study aimed to understand program management and wellness team views on barriers and facilitators to implementation. Semi-structured interviews were conducted with managers, social workers, and wellness nurses who implemented the R3 program. Facilitating factors included monthly phone calls between wellness team members and program participants, which strengthened relationships and provided valuable information; top-level management support, which was critical in building community partnerships; and daily ambulance reports from local emergency responders, which provided actionable information about participants. Barriers included the need for more wellness team time at individual intervention sites, challenges connecting R3 staff with participants’ hospitals and insurance companies, and refining the technological approach used to facilitate work flow and information exchange. Although obstacles were encountered during implementation, the findings provide support for the beneficial effects of enhanced services within senior housing.

LESSONS FROM THE RESIDENT EXPERIENCE WITH THE R3 PROGRAM

Understanding the resident experience is a critical step to creating a sustainable and replicable model of affordable resident-centered housing with supportive services programs. This study thus draws lessons from focus groups with participants in the R3 program for designing and implementing such initiatives in affordable senior housing. Findings indicate that the R3 program brings value to residents: they benefit from reliable information on health-related issues, as well as emotional support and assistance with accessing appropriate care. By focusing on prevention and ensuring timely access to services, findings suggest how the intervention could promote seniors living independently longer and lower health system costs. Results also suggest ways to improve the effectiveness of housing with services programs, including providing clarity regarding the purpose of the program, its components and staffing, building trust between program staff and residents, addressing concerns about privacy and confidentiality, and implementing a multipronged marketing and promotion strategy.

WALKING AWAY FROM LONELINESS: THE MEDIATING ROLE OF SOCIAL ISOLATION

This study examines the relationship between physical activity (PA) and loneliness among older adults. Participation in walking enables individuals to come into contact with other people, thus social isolation may mediate the relationship between walking and loneliness. The study uses participants from the Leave Behind Questionnaire of the 2016 data wave of the Health and Retirement Study with a sample size of 6,157. The dependent variable, loneliness, is measured using the 11-item UCLA Loneliness Scale and the independent variable, walking, is measured as participants who walk 20 minutes or more per day. The mediator, social isolation, is measured using a standardized 9-item score, including closeness and frequency of contact with children, friends, and other family members, and participation in group activities. We analyzed the effect of walking on loneliness and the role of social isolation as a mediator of that relationship using structural equation modeling. Our results suggest that walking is significantly associated with lower levels of both social isolation (B=-.10) and loneliness (B=-.05). As well, there is a positive association between social isolation and loneliness, as social isolation increases, so does loneliness (B=0.31). Moreover, results from the mediation analysis using bootstrapping suggest that social isolation partially mediates the relationship between walking and loneliness (B=-.03). Our findings confirm the benefits of PA on wellbeing. This research provides evidence that suggests establishing walking programs may decrease the risk of loneliness. Future interventions concentrated on lowering social isolation through PA among older adults should consider the opportunity to reduce loneliness.

COLLABORATION WITH FIRST RESPONDERS IN R3: THE CRITICAL ROLE OF COMMUNITY PARTNERS IN HOUSING WITH SERVICES

Because seniors represent a rising proportion of Emergency Medical Services (EMS) provider activity, there is a growing focus on determining how EMS providers can better serve the aging population. Multifamily senior housing properties benefit from reductions in resident turnover; EMS providers aim to improve community health and minimize unnecessary and low-priority callouts. Developing partnerships between the two service sectors can help both meet their individual goals while reducing health system costs. Drawing on experience with the R3 initiative, this study describes how a partnership between EMS providers and supported housing sites has led to reductions in ambulance transfers to hospitals and reinforced falls reduction programs within senior housing. The R3 program represented an effort to work closely with EMS providers and, by doing so, provides an example of how collaboration between the two sectors can work to the advantage of both parties by identifying residents who would benefit from intervention.

THE IMPACT OF THE R3 PROGRAM ON SERVICE UTILIZATION, COSTS, AND QUALITY OF LIFE

Relatively few housing with services evaluations employ rigorous multiple group quasi-experimental designs rather than simple before/after research designs. This study employs a pre-post experimental design with a comparison group to analyze whether the R3 program led to reductions in certain key utilization measures, including emergency department visits, inpatient hospitalizations, ambulance usage, and skilled nursing facility admissions, over 18 months. Also examined is whether resident quality of life indicators changed over the period. Data derive from assessments with 410 residents in four intervention sites and 227 residents in five comparison group sites. Also obtained was data on emergency department transfers from first responder services and Medicare fee-for-service data from the local quality improvement organization. Results suggest that the program has positive implications for service utilization, costs, and quality of life. Early detection and intervention inherent in the R3 program may improve resident quality of life while lowering service utilization and costs.