Linking Affordable Housing and Supportive Services
While many states are seeking to expand or strengthen their community-based long-term services and supports (LTSS) services, they face challenges from a lack of affordable, accessible housing and shortages of interested and available workers to provide services. This paper highlights three state programs that proactively link housing with services as the platform for helping low-income LTSS beneficiaries successfully remain in their communities.
Subsidized housing properties for older adults provide a strategic platform for efficiently reaching concentrations of older adults using home and community-based services (HCBS). Clustering care delivery in the housing settings has the potential to stretch limited workforce and funding resources, enhance quality of care delivery, extend the ability of people with increasing LTSS needs to remain in their homes and communities, and avoid the need to pay for higher cost settings such as nursing homes.
Providing Medicaid or State-Funded HCBS Services to Subsidized Housing Residents in Three States
Massachusetts – Supportive Housing Program
The state contracts with private, not-for-profit entities to provide and pay for services for people living in state-funded public housing properties designed for older adults and people with disabilities. The program funds coordination and linkages to services, 24-7 emergency response, congregate meals, and social activities. Residents are not charged for any services provided by the Supportive Housing program.
Connecticut – Assisted Living Program
Licensed Assisted Living Services Agencies (ALSAs) provide onsite assisted living services to residents of affordable senior housing communities, including the state’s Congregate Housing for the Elderly Program properties. Staff are onsite for a certain number of hours per day and an on-call nurse is always available. The Connecticut Home Care Program for the Elderly (CHCPE) pays for these services. Residents who are not eligible for the Medicaid waiver-funded component of the program but are eligible for the state-funded component CHCPE are responsible for 9 percent of the cost of services.
New Jersey – Congregate Housing Services Program
Housing communities partner with a licensed assisted living program provider to deliver services onsite to residents. New Jersey had wanted to extend its LTSS services to residents in HUD-subsidized housing properties, but its own assisted living licensure requirements were incompatible with regulations for HUD properties. So, the state developed an assisted living model that would be compatible, and, after a successful pilot program, amended its regulations to create an assisted living program that is delivered in subsidized housing communities. Staff deliver the same services available in licensed assisted living residences and must provide or arrange for assistance with personal care, nursing, medications, and dietary and social work services. Services are paid for through the state’s Medicaid HCBS waiver for older adults. Residents who are not financially eligible for waiver services can pay privately.
Enhanced efficiency and effectiveness of care coordination: The clustering created by the Connecticut and New Jersey programs allows onsite aides to assist multiple residents almost simultaneously, reducing the number of aides needed to serve the same number of people, and allowing them to see participating residents more flexibly and responsively throughout the day at the client’s convenience and during emergencies.
Housing and Service Provider Staff Collaboration: Purposeful coordination can minimize disruptions from health issues that can lead to evictions. Service providers can also help residents apply for and maintain public benefits that address needs related to social determinants of health and physical and mental health.
Aging in Place: Locating supports in residential settings helps facilitate aging in place, with residents accessing tailored supports as their needs change.
Licensing/Regulatory Flexibility: States modified their assisted living regulations to fit the realities of existing physical property designs, housing regulations, and the potential volume of individuals who could participate within one housing property to support these innovative changes.
Financial sustainability: The volume of resident participation must be high enough to make collaborative arrangements financially viable for service providers.
Limiting factors include residents who are not functionally eligible to receive assisted living services through Medicaid, and those who are eligible may be dispersed among multiple providers through a Medicaid waiver program where services are arranged individually and delivered one-on-one, limiting the volume for each vendor. This can lead to providers discontinuing programs or being reluctant to start new ones.
This report is part of the AARP Public Policy Institute’s LTSS Choices initiative. This initiative includes a series of reports, blogs, videos, podcasts, and virtual convenings that seeks to spark ideas for immediate, intermediate, and long-term options for transforming long-term services and supports (LTSS).
Harrell, Rodney, Shannon Guzman, Alisha Sanders, and Robyn Stone. LTSS Choices: Increasing Independent Living Choices through Coordinating Affordable Housing and Medicaid: Housing as an Indicator in the 2020 Long-Term Services and Supports State Scorecard. Washington, DC: AARP Public Policy Institute, October 2022. https://doi.org/10.26419/ppi.00173.001
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