Integrating assisted living with independent living.

At first glance it seems like such an obvious idea: instead of building or developing a special-purpose assisted living facility, why not bring assisted living services to the independent living unit? Is it as easy and beneficial as it sounds? Nursing Homes Magazine asked two independent living managers to reflect on their experiences in trying this. Their comments follow:

Barbara Grant, Administrator, MI Residential Communities, Lawrence, MA: "We actually have two assisted living programs in our 304-unit Section 202/8 senior housing complex, totalling 28 units in all and scattered throughout the complex: Our Medicaid-funded 'Group Adult Foster Care Program,' which provides such services as daily personal care, 24-hour emergency response, medication cueing and reminding (with RN and social work oversight and planning) and laundry and housekeeping, but no meals. The other is a private pay program in which, in addition to those services, meals are provided twice a day in the dining room. We plan to add 10 more participants by the end of this year. We have also considered clustering the participants in 26 units on two floors, but have hesitated because of all the work involved in moving existing residents off the floor, moving the participants onto the designated floors and dealing with HUD vacancy management rules and regulations.

"Our facility - three mid-rise structures with 17 entrances and exits off common areas - is clearly not designed for assisted living, so we are doing this in a very small-scale, incremental way for only those people who can live safely outside a clustered environment. In Massachusetts, senior housing providers are servicing small numbers of residents with such programs and are doing so outside a state certification and regulatory process with which it would be too expensive and difficult for all but the largest, most sophisticated providers to comply. Our program prohibits us from providing skilled nursing services, although Medicaid does cover visiting nurse services as needed and two days of adult day care a week.

"About two-thirds of our assisted living participants are supported by Medicaid and the rest are private pay. Our rates are $1,050 a month for the assisted living service package, with another $200 a month for rent (under 30% of income rules), for a total of $1,250 a month. This compares very favorably with rates of $3,500 and more for freestanding assisted living facilities in neighboring communities. Even though we're located in a relatively poor urban environment with an abundance of Section 8 senior housing units and vacancies, our program has become very popular, even without advertising. Section 8 waiting lists went from five years long some 13 years ago down to six months just before our programs started, and are now back up to a year-and-a-half. Half our residents come from the outside community, and half are aging in place.

"What is interesting about this approach is that virtually any independent housing unit that has some scale - say, 100 units - could fairly easily infuse services such as these, and by sidestepping development costs be able to offer an affordable product. You still need to deliver a daily bath, medication reminders, meals and so forth, but you don't need chandeliers to do that.

"I would say that if there are any problems associated with this affordable model of assisted living, they are problems that are shared universally by the industry, such as getting people to accept daily personal care. People will accept housekeeping, laundry, meals and shopping assistance before they'll accept bathing assistance. No doubt we will have operational problems if and when we move toward clustering the units. But, in general, the benefits of providing this service far outweigh the problems. We have developed a way to meet residents' need to age in place, a 'resident retention' program in a geographic area of high vacancies, and a magnet for people in the community needing a service-rich environment that they can afford."

Barbara Caley, Administrator, Allied Jewish Apartments, Denver, CO: "About 15 years ago we noticed a developing 'wall' of people in our three adjoining HUD housing projects who were aging in place but had no place to go other than nursing homes. So, about 12 years ago, we converted three floors of our 14-story high-rise to assisted living (and we clustered them because the building was simply too big to do it otherwise). In essence, it was quite easy to do, and we were able to create a smaller, warm community within the large buildings. We had the HUD mandatory meals program and, of course, rental assistance supplied by HUD, and we had staffing for support services funded through Colorado's Medicaid waiver (and I believe we were the first subsidized HUD project in the nation to do assisted living). As a result, we provide assisted living residents with three meals a day, personal care, medication assistance, activities, housekeeping/laundry, social worker oversight and escorts for trips outside the building. We also provide space for a home health agency that contracts with the residents and is Medicare-reimbursed.

"We have 26 units overall, 10 of which are slotted for Medicaid recipients. We decided early on that we would not double-dip for Federal funds, so we charge market rate for the apartments. Overall, we're coming in at about $900 a month. We are licensed by the city Department of Health and State Department of Social Services.

"This really has helped people to stay longer in the building. Some, in fact, actually move back to the independent living units when they feel no longer in need of assisted living. And this is working for a variety of HUD clients in our buildings - Section 202, 236 and 221(d)3. About our only major expense was the addition of a new fire alarm system for our 26-year-old building.

"Still, it is not easy, in this day and age, to get money for services for people who don't have money. This remains a very difficult challenge."