Affordable assistance: with innovative programs such as "pre-assisted" living, Milton Residences for the Elderly brings quality care to limited-income seniors. (Not-for-Profit Report).

Since 1968, Milton Residences for the Elderly, Inc., (MRE) has been serving the senior community in Milton, Massachusetts, by providing homes and services across three different residential settings. MRE's primary purpose has been to provide affordable housing for seniors with limited incomes, without skimping on services. MRE has evolved over time to meet the needs of its population, and that evolution continues today. However, it's actually the services they don't provide that make MRE unique.

Perhaps MRE's most notable innovation has been the concept of pay-as-needed services, sometimes called "pre-assisted" living. While all residents have access to a regular schedule of on-site social and educational programs, each resident can select and pay for optional services on an as-needed basis. The arrangement has been embraced by residents, not only because of the obvious budgetary advantages, but because the system allows residents more independence. The program offers a more supportive environment than a simple senior housing environment that offers reasonable rent, but no services. Some residents choose a completely independent lifestyle, while others take advantage of the full range of services offered, and still others maintain a middle ground. These optional services include nursing, personal care, housekeeping, and meals.

"I think the residents typically enjoy the flexibility that an 'a la carte' program gives them because, philosophically, our programs rely heavily on their control of decision making versus ours," says MRE's CEO Timothy Martin. "There's an engagement in the relationship that's different because they're not paying for something they don't want. I think that's the philosophical underpinning of unbundling and a la carte.

"The majority of assisted living has followed the bundled model, where there's a monthly fee for a minimum of one or two meals a day plus personal care and housekeeping," Martin continues. "Many nursing homes have converted to assisted living because it's a lesser regulatory environment. Our model, because of the proliferation of purpose-built assisted living in Massachusetts, and because of its unbundled nature and lower cost, is considered pre-assisted living--people can drop in and out of services every day, month, or week. We've found that our residents move from here, when their needs are more than our program can satisfy, into assisted living facilities, whereas 15 years ago, they would have moved into a SNF."

While the concept may seem like common sense from the resident's standpoint, the program is a management challenge. "It's very difficult when you're relying on an unbundled system, in terms of budgeting and staffing predictions, and food preparation. In the purpose-built assisted living or nursing home setting, you know that you're managing, for example, 100 clients a day, and there's a guaranteed, predictable staffing pattern you can rely on," Martin explains. "We have 456 units of independent living, and the staff literally from day to day doesn't know what might happen to their staffing assumptions. Many of the residents have a routine and a predictability to them, but there's a component that says, 'I don't want services next week, because I feel pretty good, so why don't we wait a week.' It creates a little bit of havoc, but it's something we've imposed on ourselves."

In fact, despite the financial and psychological benefits for residents, Martin believes that the unpredictable nature of pre-assisted living makes it difficult for similar new programs to develop. "We've done a lot of consulting work around it, and a lot of people who come look at what we do end up saying, 'There's no way I'm going to that. The variables are too significant and the profit margin isn't significant enough,"' says Martin.

In these financially troubled times, it is common to see facilities struggling to keep their heads above water, let alone maintaining multiple affordable options for their residents. So how does Martin explain the success that MRE has had with its program? "Ultimately, the best way to deal with these things is through good case management," he says. "If the social work staff, the home health aides, and the managers of the various facilities begin with a clear delineation of the psychological and clinical needs they're dealing with, then a solid relationship is established, with less variability. Every week and every year that we do this, we learn something more about how to prevent the unknowns from happening. But in the healthcare industry, there are certain things that you can predict and control, and there are things that you can't. We have a stable infrastructure that gives us that certainty in some areas, but when you're dealing with human beings, you can't control or predict everything."

In addition to the pre-assisted living program, MRE has also recently taken the unusual step of applying for (and receiving) a grant from the United States Department of Housing and Urban Development (HUD) to renovate and expand buildings at its Winter Valley site to create 16 state-certified assisted living units. The project, set to open in late April/early May 2003, links four garden-style apartment buildings by enclosing a common courtyard and converting it into an attractive common space featuring a dining room, living room, and community room/library.

The project is one of only 16 in the country to be funded by a HUD grant, acknowledging MRE's reputation as a model of affordable assisted living. In keeping with that tradition, monthly rent will be set at 30% of the resident's adjusted gross income. Martin anticipates that MRE will apply for a second grant this year to add another 16 assisted living units to Winter Valley.

And as if that weren't enough, MRE is branching out with yet another new program. "We still have 450 people on waiting lists for our facilities," Martin explains, "so, starting on June 1, we're initiating a new 'stay at home' program that provides many of the services that we offer within our service programs to people in their own homes in the community. We're offering them the assisted living model as a membership program, receiving such AL services as housekeeping, meals, and personal care."

With MRE's long history of creativity and willingness to adapt to their residents' needs, gamblers would be well-advised not to bet against more changes occurring there in the future. Those looking to MRE as a model, though, would be best served to look to their own creativity rather than following directly in MRE's footsteps. "With severe cuts to Medicare and Medicaid, and because of vacancies in nursing homes, alternative models are going to be sought in which providers address those vacancies and figure out ways to increase their facilities' census and occupancy," says Martin. "Whether they look at our model or purpose-built assisted living models like Sunrise, I think there's going to be more of this unbundled, or unconventional, assisted living because the revenue streams to support traditional long-term care are drying up."

Timothy Martin has been the CEO of MRE since 1981, and does consulting work for communities, non-profits, and organizations that are looking to address the challenges associated with affordable assisted Living or housing with services. For more information on Milton Residences for the Elderly, call [phone] or visit www.mreinc.org. To comment on this article, e-mail [e-mail].