Editor’s note: The John A. Hartford Foundation, the Administration for Community Living (ACL) and The SCAN Foundation fund the Aging and Disability Business Institute, led by USAging. The mission of the Aging and Disability Business Institute is to build and strengthen partnerships between aging and disability community-based organizations (CBO) and the healthcare system. As partners in the Institute, ASA and USAging are collaborating on a series of articles and case studies in Generations Today that highlight community-based integrated care networks.
Hebrew SeniorLife, which has been providing service-enriched housing for 120 years, is this year’s winner of The John A. Hartford Foundation’s Business Innovation Award, for its program integrating healthcare with housing. The award, presented annually by the Aging and Disability Business Institute, recognizes aging and disability community-based organizations for innovative approaches used in reducing healthcare costs and improving the well-being of elders and people with disabilities through partnerships with healthcare entities.
Kim Brooks is COO of Senior Living for the Boston-based Hebrew SeniorLife, and has spent her entire career working with older adults, in long term care, PACE, home care and housing. During the recent past she has focused on affordable housing with services, and with the success of the demonstration program, she is elevating this work to reach other organizations and older adults more broadly.
Hebrew SeniorLife, which is a Harvard Medical School affiliate, provides direct services to about 3,000 older adults in the Boston area each day, across six campuses and in people’s homes. Almost all of those served are Medicare eligible and about two thirds of them are either on MassHealth (Medicaid), are dual eligible or are receiving housing subsidies. Hebrew SeniorLife offers many levels of care, from transitional to facility-based long-term care to assisted living, independent living and home care.
The organization has waitlists 100s deep and there is a significant need for housing, says Brooks, so they’re actively developing more affordable housing communities, too.
Incorporating Healthcare Into Housing
For many years Hebrew SeniorLife had been providing service-enriched housing, and Brooks says many healthcare systems and other payers saw the value in such a system, but they needed proof, “they kept saying you have got to show it to us, you have to prove it to us, you have to track it, measure it—we want to really understand it better before we’re willing to invest.”
Brooks had drafted a demonstration concept paper on embedding preventive wellness into housing, so when the Massachusetts Health Policy Commission made grant funding available through its Healthcare Innovation Investment Program, Hebrew SeniorLife applied and was awarded funding. This instigated grant monies from additional sources, allowing them to build out the model and test it. Brooks points out, however, that the model is not the only way to run such a program, it’s just one way to fully integrate housing and services and care. She says that in typical senior housing there is often a resident services coordinator who focuses on needs-based items that come up—whether people need connecting to food stamps or help with applications or some other service.
Payers needed proof of outcomes before they’d invest.
The Hebrew SeniorLife pilot differs in that it is a proactive wellness model. The organization assesses everyone who lives in a building, risk-stratifies them, understands their needs, understands what’s important to them, their goals and how they want to live their lives, and then makes connections to CBOs and service providers, etc., to ensure residents get the services they need to remain as independent as possible for as long as possible.
This all happens with a wellness team (a nurse and a social worker) embedded in the existing small housing team, across multiple affordable housing sites. Because they are shared across sites, the cost is kept to a minimum for each community.
It’s a unique position for the nurses, as they’re not involved in direct care, but more involved in coordination and communication and data-tracking. Or as Brooks says, “a little bit of triage, and a lot of education and outcomes measures.” They tend to recruit nurses from community-based care settings.
Data-tracking is critical as it’s the only way to prove to potential payers that the model works. The wellness team performs proactive wellness checks, keeps track of who goes to the hospital, helps with transitions upon residents’ return from the hospital, and partners with emergency responders to analyze the data responders collect and prevent unnecessary future trips to the hospital. Emergency department transfer data included monthly activity that was analyzed for frequency and trends, as well as daily reports that supported immediate follow up with residents. The team strengthens connections to the persons’ care team—the health plan, the AAA or whoever is involved in their care—and coordinates communication among entities.
It’s a lean model, which makes it financially viable. At Hebrew SeniorLife it began with four people working across seven sites, and those four remain in place years later. They have recently added an eighth site, and have two more in the pipeline over the next few months.
Education and Collaboration
The model’s educational aspect also is critical to prevention. If 30 residents in one building are known to have diabetes, the team brings in a diabetes educator to explain ways to maintain a healthy status, and if a group of people have been found to be struggling with mental health or food insecurity, “the team focuses on those issues and makes sure we have resources in place to support them,” says Brooks. The wellness team can provide residents education on help that’s available through their health benefits as well.
The payer and housing provider share wellness and prevention goals.
Also there’s an educational element involving housing staff, colloquially called “eyes on” training, wherein people who work in maintenance, housekeeping, at the front desk and in transportation are trained in what to do when they see a change in a resident’s condition, and how to communicate the information effectively. Topics in the training include communication tips, warning signs for UTIs, isolation, potential elder abuse, and basics on falls risk and dementia.
Hebrew SeniorLife partners with Commonwealth Care Alliance, a managed health plan and integrated care system, and Brooks says beyond funding, the two organizations share the same overarching goals, which is better for the residents and for the healthcare system. Both organizations work to prevent falls, to make sure people have healthcare proxies in place and are having the right conversations about advance directives. They both aim to keep people out of the hospital unnecessarily, practice preventive health and wellness, make sure residents are connected to physicians and have all the services in place to help them live independently. Hebrew SeniorLife has outlined all of these goals and built them into their contract with Commonwealth in such a way that if Hebrew SeniorLife fails to deliver on said goals Commonwealth gets a piece of its money back.
Now they’re hard at work reducing redundancies. Hebrew SeniorLife is assessing how to streamline the system to reduce duplication so that one provider completes assessments, care and communications are coordinated and services are delivered efficiently, leveraging the congregate living platform with multiple people living under one roof.
The pilot has shown a 19 percent reduction in trips to the emergency department compared to baseline, a 16 percent decline in inpatient hospitalization at demonstration sites compared to a 6 percent increase at comparison sites; a 22 percent decline in 30-day hospital readmissions versus a 55 percent increase at comparison sites; and a 90 percent achievement in closing the gap on key risk areas such as mental health, cognition, nutrition, food security, and Emergency Department/hospitalization.
Brooks also anticipates such a program could potentially be replicated across the country as, she says, “Figuring out the sustainable funding is definitely the challenge. The good news is that there is an existing infrastructure that we could tap into for implementing the program nationwide that includes the AAAs and housing providers. Some of the AAAs are already providing supportive housing programs that could be built upon, and many housing providers like us are committed and willing to deliver enhanced services once funding is available.”
Photo: A fitness instructor coaches a resident at Hebrew SeniorLife.
Photo credit: Courtesy of Hebrew SeniorLife.