Owners and administrators of government-subsidized rental housing are acutely aware of their older tenants’ changing profile. More than ever, seniors in today’s affordable housing are likely to be in their 70s and 80s. This group is vulnerable, tending to be women living alone, members of ethnic and racial minorities, and those reliant on Social Security. Most importantly, they often experience health problems and declines in physical and mental functioning.
Often without family assistance, these seniors must turn to community- and home-based services. Under any circumstances, finding appropriate and affordable supportive services is stressful and difficult. Those who are less educated, have trouble speaking English, or are easily intimidated by bureaucratic ways often find the task overwhelming.
Community-based service providers compound this problem by either underestimating these elder tenants’ needs, identifying them as a lower-priority group, or offering only overly narrow care. Sometimes service providers are simply too over-committed to reach this group. Moreover, even after receiving help these older tenants often cannot accurately judge the quality of their assistance. They nonetheless tenaciously hold on, rightly fearing that if they have to move, it will be to a living situation that limits their autonomy and assaults their dignity.
Thus, the problems of such elderly tenants become the housing administrator’s problems, especially when more severe or stemming from mental disorders or alcohol abuse. To be sure, not all subsidized housing providers are similarly affected, but at least some seniors occupy most project-based facilities in the United States. Resources to help these administrators deal with older tenants also vary greatly, as do administrators’ budgets and management styles. Funded by diverse government programs, the rental housing stock itself is diverse, including a blend of older and newer facilities in different physical condition, with different amenities (such as a recreation room or central dining room), technology levels (such as air conditioning or sprinkler and fire safety systems), and architectural design features sensitive to the vagaries of aging. Even facilities funded under the same government program differ substantially due to historical shifts in funding commitments and regulations. HUD’s Section 202 program exemplifies how facilities’ size, design, and fiscal condition depend on when they were built.
Three characterizations of the field nonetheless appear valid: first, today’s federal regulatory environment, even with its volumes of rules, is flexible enough to allow sponsors or owners to respond to aging tenants in different ways. Second, HUD has largely failed to provide significant and permanent funding of supportive staff and services that facility administrators need to help their more physically and socially vulnerable elderly remain independent and take care of their apartments; and third, formal and needed cooperation between HUD and the Department of Health and Human Services is absent.
To address these issues, the two-year, CASERA Project (“Creating Affordable and Supportive Elder Renter Accommodations”) began in Florida in 1997. Funded by the Retirement Research Foundation of Chicago, the project had three broad missions: assess the extent of elder occupants’ difficulties in remaining independent in Florida’s government-subsidized rental apartments; understand housing administrators’ challenges in dealing with these problems; and develop a set of politically and economically acceptable solutions. The project surveyed administrators of affordable housing and their elder tenants and examined exemplary projects throughout Florida and the country and extensively documented their characteristics and practices.
The CASERA investigation established that a sizable percentage of the more than 80,000 older residents in Florida’s subsidized rental apartments were having trouble living independently. Depending on the rent-assistance program, administrators judged that 14 to 17 percent of elder tenants were having trouble remaining responsible for themselves and that 11-17 percent were confused, abusive, or depressed. Elder tenants themselves reported higher self-estimates of their dependency, and only 37 percent of them felt that if they were sick or disabled, they could rely on someone to help them as long as needed. The top two services they felt lacking: handrails or grab-bars in their bathroom and transportation to and from a doctor’s appointment. When elder tenants were asked where they would move if they had to vacate their apartment, over a third had no idea. On average, 30 percent of the tenants who did annually vacate their apartments entered a nursing home.
Subsidized housing administrators typically respond emotionally to such situations in four very different ways. First: “I can show you wonderful examples of affordable rental facilities to help all but the most extremely frail elders live independently in their apartments.” Second: “I agree frail elders should receive assistance to live independently but simply lack the resources to address their needs.” Third: “I recognize that seniors need help remaining in their apartments but feel this is not my responsibility, any more than it is the responsibility of private, market-rate apartment operators to assume this service provider role.” Fourth: “I feel something should be done but fear that helping older tenants will turn my facility into an institution, which will incur the wrath of my more healthy tenants and of regulators, who will accuse me of crossing the line.”
Such different viewpoints offer wonderful fodder for philosophical and ethical debates about what role government-subsidized affordable housing should play in the care of our poor and vulnerable old. But rental housing administrators increasingly confronting elderly tenants in crisis must deal with practical realities and make immediate decisions.
The good news is that while difficult, successfully alleviating the supportive service needs of frail elder tenants is possible. Even modest efforts produce positive outcomes. Importantly, not just older residents in need will benefit. 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.
The CASERA Project identified three distinctive categories of serious management problems for subsidized housing administrators who house elderly tenants. First, they reported problems dealing with lifestyles linked with the traumas of getting old. Most notably, they had to deal with tenants who were mentally confused or felt very alone. Also topping their list of difficulties was securing transportation for tenants and dealing with those who had drinking problems or were abusive. A second category of concerns revolved around dealing with the practical manifestations of having physically frail elder tenants. Foremost was dealing with poor housekeeping and dealing with tenants who had temporary illnesses or self-care problems. A third group of serious management problems derived from their relationships with service providers. These encompassed a variety of disagreeable tasks, such as dealing with social service agencies, arranging for home care, and filtering out the inappropriate requests by tenants for assistance.
Housing administrators trying to remedy these problems confronted several different categories of obstacles. First, they recognized their own or their site’s deficiencies. They frequently identified obstacles such as a lack of time or expertise or a social worker/service coordinator on staff or uncertainty about whom to call. Second, they were often unable to access needed help, and they pointed to the unavailability of family members, the difficulties of getting service providers to come, and the unaffordable costs of their services. Third, administrators complained about the unavailability of community-based adult day care centers and senior centers. A fourth group of obstacles was created by the way some elder residents coped. They included residents who would not admit to having a problem, did not want the facility to get involved, and who feared having to enter a nursing home. Finally, administrators felt organizational hurdles such as restrictive HUD rules, liability risks, high insurance costs, and restrictive Medicare rules sometimes tied their hands.
Alternative Service Delivery Models
The combination of these unmet needs, management problems, and perceived obstacles all pointed to the need for better solutions to address the aging-in-place needs of frail elders in subsidized housing. The CASERA Project made more than 30 specific recommendations directed to housing and service providers and state government agencies. The project also proposed five alternative service delivery models to link older tenants more effectively with assistance in remaining independent in their apartments.
In-house Service Coordinator Model
The housing facility hires an on-site service coordinator, full- or part-time, and charges that person with listening to the problems of elder tenants and assisting them in finding and arranging for needed home- and community-based services.
In-house Staffing Model
The housing facility hires one or more on site staff, again full- or part-time, who regularly provide supportive services (e.g., meals, transportation, counseling, assess self-care needs, housekeeping, or health screening) to elder tenants.
Housing Facility Design Modification Strategy
The housing facility makes building modifications to make it safer and easier for older persons to accomplish everyday tasks. These include structural modifications (e.g., adding ramps, converting an apartment to a clinic, modifying kitchen cabinets); addition of assistance devices (e.g., grab bars, lifts, toileting aids); improved building design (e.g., lighting, flooring, smoke alarms, emergency egress); and addition of security systems (e.g., emergency response system, dwelling/building locks and alarms).
Multiservice Assisted Living Facility Conversion
A traditional elder-occupied public housing or Section 202 facility changes to an assisted living complex that provides a range of supportive services, both scheduled and unscheduled, such as personal care, meals, shopping, housekeeping, 24-hour emergency services.
Housing Facility and Community-based Agency Collaboration Model
The building initiates contracts, partnerships, or special arrangements with community or home-based senior organizations and human service agencies, managed care providers, other housing sponsors, or with nurses, social workers, or volunteer groups to ensure more regular and timely delivery of supportive services.
The above strategies offer opportunities irrespective of whether housing administrators favor a bricks-and-mortar or service provider management style. They obviously present, however, very different ways of connecting the more frail old with supportive services, and they demand very different organizational and financial commitments and skills. Only a very few housing providers, for example, are likely to attempt the ambitious task of converting their facilities to a licensed assisted living facility. On the other hand, acquiring a service coordinator is at least administratively straightforward. For housing providers not able or willing to assume the legal, financial, or moral responsibilities entailed by their functioning as service providers, the fifth strategy may be more appropriate. This approach may additionally require providers to have appropriate management and negotiation skills to develop partnerships with local human service agencies and other nonprofits. Yet more proactive administrators who feel knowledgeable about needed services and who want to control the quality of the service delivery process may be better suited to the in-house staffing model strategy.
However organizationally or personally disposed housing providers are to these alternatives, their feasibility will obviously depend on the availability of federal, state, and local community resources. To that end, the recent HUD budget offers a glimmer of hope, but in light of the latent demand and expected growth for this assistance, current funding levels are clearly inadequate. Unfortunately, too, our older seniors’ need for new affordable and more supportive rental accommodations will not be easily satisfied by expanding the housing voucher program. Dispersing low-income elders throughout many different apartment buildings rarely yields the economies of scale necessary to successfully implement several of the most workable service delivery strategies.
Failing to consider the elder-occupied rent-subsidized facility as a major service delivery target would be a badly missed opportunity. Fortunately, elders are benefiting from increased awareness of their distinctive shelter and care needs among policymakers at all levels of government. Thus, perhaps we can cautiously but optimistically expect actions that will benefit this large and growing tenant group.