1. Integrated Services and Supports for Residents of Affordable Senior Housing
Partners:
November 2, 2017

2. Integrated Services and Supports Objectives
Overall objective:
Demonstrate value of integrated care in providing enhanced services and supports among residents of affordable senior housing, using pooled financing across payers, with a potential for reduced medical spending.
Secondary objectives:
Demonstrate value of enhanced care coordination in an integrated approach. The value of:
“eyes and ears” (with a goal of evening and weekend coverage)
a centralized mechanism to triage requests and information
a pooled financing approach across payers – sustainable, replicable
shared training resources and standards

3. Current Relationship of Health Plans and Senior Housing
Plan A
Senior Housing A
Care Manager
Plan B
Senior Housing B
Care Manager A
Plan C B
Care Manager C
No managed care plan

4. HHP Proposed Relationship of Health Plans and Senior Housing Plan A
Senior Housing A
HHP
Housing + Healthcare
Pool
Plan B
Senior Housing B
Plan C A B C
No managed care plan

5. Participating Organizations
8 Housing Communities, 5 SCOs, 2 PACE, 1 ACO
Housing:
Hebrew Senior Life
Jewish Community Housing for the Elderly (JCHE)
B’nai B’rith Housing
Preservation of Affordable Housing (POAH)
Allston Brighton Elderly Housing
Rogerson Communities
The Community Builders
Beacon Communities
Health Plans:
Commonwealth Care Alliance (SCO)
Fallon Health (SCO)
BMC HealthNet (SCO)
United Healthcare (SCO)
Tufts Health Plan (SCO)
Upham’s Elder Service Plan (PACE)
Element Care (PACE)
Harbor Health ESP (PACE)
Atrius (ACO)
McNamara House

6. Potential Shared Services Provided in Senior Housing
Enhanced Service Coordinator/Care Manager
Wellness Nurse
Assessment
Emergency Response
Falls Prevention
Chronic Disease Self-Management
Nutrition Services
Medication Adherence
Screenings
Mental Health Assessments

7. Expected Outcomes
Demonstrate the benefit of a concentrated resident population to:
Enhance care coordination on site
Provide a point of contact in-building for plans – connected with plan teams
Reduce duplication of care coordination and prevention activities of plans
Provide “eyes and ears” on the ground 24/7 to:
Improve prevention and wellness
Head-off failures in support and care (including prevention of falls)
Reduce unnecessary ER visits and hospitalizations
Improve care continuity
Keep residents in their preferred housing arrangements longer, and avoid or defer institutionalization
Provide better support to family caregivers and residents to improve satisfaction
Support replication by publication of evaluation results and development of a toolkit for other communities
Goals/Challenges the Program Can Address
Housing
Housing organizations need additional supports for residents as their care needs increase – to prevent a premature transfer to a nursing facility when care needs outstrip the building’s capabilities and to support aging in place.
These resources would provide 24/7 in-building status monitoring response capability, along with preventative services to assess the needs of residents on an ongoing basis and get ahead of issues as they are developing.
Housing organizations need resources to maintain a residential service
coordinator (RSC) function, to provide training to improve the capabilities of RSCs that exist, and to connect to residents’ health plans to allow for better coordination.
Housing organizations would benefit from resources that would help them better inform residents of the features of different types health plans and assist with plan choices that better match each individual resident’s needs.
Health Plans
Enrollment of a critical mass of a housing entity’s residents in integrated health plans is needed to enable support a high-level of in-building services. The health plans need an opportunity to work with senior housing entities in educating their residents on the benefits of integrated care in order to grow enrollment in integrated plans overall. Housing organizations can help residents with educational forums, understanding plan choices, and enrollment.
Health plans could benefit from extensive on-site care coordination and care management, to the extent that these services for each resident are well-connected to the resident’s own health plan, do not duplicate existing services, and enable sufficient bi-lateral, bi-directional communication between the on-site coordinator and the plan.
Health plans need assessment of member needs and stratification of each member’s level of need to ensure that intensive care management can be directed to those who would benefit the most.
PACE organizations are insurers and providers -- have been able to create supportive housing programs by getting sufficient numbers of individuals in any one building to enroll in PACE.

8. For more information Amy Herr Director, Health Policy
West Health Policy Center
westhealth.org
@westhealth
Helping seniors successfully age in place, with access to high-quality, affordable health and support services that preserve and protect their dignity, quality of life and independence.