Supportive Housing Options

Background

Supportive housing refers to residential settings that offer services such as group meals, transportation, help with housekeeping, and personal care. Supportive housing options increase an individual’s ability to live longer in a community setting and to age in place. Such options are expanding partly because of a desire by older adults to remain outside of institutional settings. Thus they differ significantly from institutional settings like nursing homes (see Chapter 8, Long-Term Services and Supports—Assisted Living and Residential Care).

Definitions of supportive housing are continually shifting in response to the rapid pace of change within the supportive housing industry. No federal guidelines exist that would standardize terms and reduce inconsistencies across states. For instance, “adult foster home” and “personal care home” generally refer to smaller settings that provide care, but the terms can have considerably different meanings from place to place. In addition, not all options exist or are regulated in every state.

Despite this lack of clarity, there are several common types of supportive housing.

Congregate housing is typically an apartment building for people who are living independently but want common services, such as one meal a day or light housekeeping. Congregate housing does not generally offer personal care or oversight.

Continuing care retirement communities (CCRCs) provide shelter, social activities, health care, and supportive services under a variety of contractual arrangements that often include substantial up-front fees. Typically they include guarantees of increasing levels of services as needed. CCRCs are usually campus-like complexes, with most residents living in private apartments, and usually include an assisted living building and a skilled-nursing home.

Assisted living residences are residential group settings that provide personal care to residents who need assistance with daily activities. Such activities include bathing, dressing, taking medication, and preparing meals. Assisted living residences are not licensed as nursing homes. They typically house fewer than 100 residents in apartment-like rooms. Amenities include central dining facilities and activity rooms. These residences generally offer more help than other types of supportive housing options. They provide physically and cognitively impaired older adults with personal and health-related services. Residents age in place in a home-like environment that maximizes dignity, privacy, independence, and autonomy.

Lately most legislative and regulatory activity regarding supportive housing has focused on ways to implement the philosophy of assisted living, which combines more services than congregate housing while providing residents with greater autonomy and independence than do most skilled nursing facilities. Major goals include:

  • Maximizing the ability to age in place—state definitions of assisted living, as well as implementation of related regulations, vary significantly. Some states require mandatory discharge when a resident’s physical or mental capacities deteriorate beyond a specified level, while others allow or even require more intensive services.
  • Balancing safety and autonomy—assisted living residents may wish to participate in potentially risky activities or behaviors, just as they did before entering the facility. Some facilities use negotiated risk agreements to balance residents’ need for autonomy and independence with the provider’s responsibility to ensure resident safety (and perhaps the family’s peace of mind).
  • Maximizing privacy—privacy is important for maintaining dignity, and private rooms protect residents’ autonomy.

Many states recognize the important role of assisted living and have pursued Medicaid waivers that help states finance assisted living for residents with limited assets and income.

Supportive Housing Options: Policy

Assisted living options

In this policy: State

The philosophy and consumer-oriented approach of assisted living should become the model for all types of supportive housing. Consumer protections must provide basic safety for consumers, encourage a home-like atmosphere, and offer an individualized approach that ensures personal dignity and autonomy.

States should define “assisted living” as supportive housing with:

  • a residential setting that provides or coordinates flexible personal care services, 24-hour supervision, assistance (scheduled and unscheduled) with activities of daily livingActivities of daily living (ADLs) include: bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating. , and health-related services;
  • a services program and physical environment designed for aging in place; that is, facilities that minimize the need for residents to move within or away from the setting to accommodate their changing needs and preferences;
  • an organizational mission, a service program, and a physical environment designed to maximize residents’ dignity, autonomy, privacy, and independence;
  • a process for legitimate negotiated risk agreements between facilities and residents, allowing residents to enhance their autonomy and independence and allowing providers to maintain a safe and appropriate environment; and
  • private living units—with sleeping, living and food preparation areas; storage facilities; and a bathroom—shared only at the resident’s request.

Providers with existing facilities that need renovation to create private baths, kitchenettes, and other improvements should have incentives for making such changes.

States should allow and provide technical guidance to Public Housing Authorities and owners and operators of Section 202 housing who want to convert certain properties into assisted living facilities to meet the needs of older adults. Such conversion must meet the industry’s best-practice standards of safety, must support services, and must not cause displacement of existing residents.

Continuing care retirement communities (CCRCs)

In this policy: State

States should:

  • require CCRCs to provide all services promised to residents in their rental or sales agreement, unless that agreement is voluntarily modified by a resident or resident council following a specified procedure that was set out and disclosed to residents prior to admission;
  • establish standards for sound financial planning and management practices to ensure the CCRC’s ability to deliver the services promised to residents;
  • address such issues as reserve funding, refund policies, escrow accounts and interest, marketing practices, audits, accounting practices, plain-language disclosures, and the role of resident councils in administering facilities; and
  • require CCRCs to notify state licensing agencies of any developments that could lead to bankruptcy or a change in ownership, with severe penalties for failing to provide these required notifications.

Financial assistance to residents

In this policy: State

States should provide consumer-based financial assistance, including Medicaid home- and community-based waiver funds, to allow low-income older adults access to assisted living. State assistance should be coordinated with federal assistance programs.

Consumer protections

In this policy: State

Regulations should explicitly recognize a resident’s dwelling as private, thus providing them with the consumer protections of the Fair Housing Amendments Act of 1988.

States should permit residents the right to pursue a private right of action when housing providers violate their legal rights.

Meeting demand for supportive services

In this policy: FederalState

States should encourage assisted living developments in order to meet consumer demand. State guarantees should be used to mitigate any risks associated with state Medicaid reimbursement policies.

As supportive housing services increase, states should examine ways to integrate funding streams in order to further the development of client-based systems that lead to a seamless housing and services system.

To promote innovation, cost-effectiveness, and responsiveness to consumer needs, states should foster competition among providers. Certificates of need, license moratoria, or other artificial restrictions on the supply of assisted living or other types of supportive housing should not be used. Rigorous license review should be used to promote quality, not restrict supply.

The Federal National Mortgage Association (Fannie Mae) and the Federal Home Loan Mortgage Corporation (Freddie Mac) should fund and encourage the development of supportive housing facilities for older adults.

Reform of the Federal Housing Administration (FHA) should include broadening the agency’s general authority to develop mortgage products that promote innovation in and expanded access to supportive housing. The FHA should also use risk-sharing authority and technical assistance to develop the capacity of state housing-finance agencies, government-sponsored enterprises, and other financial institutions to promote innovative approaches to delivering supportive housing services.

Quality supportive services

In this policy: FederalState

Standards, regulations, and underwriting criteria for supportive housing should promote residents’ autonomy and decisionmaking while ensuring high-quality services, including enhanced communication with residents about services.

Federal and state funding and underwriting criteria for supportive housing should promote residents’ privacy and autonomy by requiring adequate private rooms and baths, kitchenettes, and sufficient public rooms for services and community activities.

Promoting innovative models for aging in place

In this policy: FederalState

Federal, state and local governments should encourage and provide start-up funds and technical assistance to develop, expand and sustain programs that support aging in place, such as Villages, in order to enable older adults and people with disabilities to live more independently.

 

Federal and state governments should conduct research and evaluate the capacity of supportive programs to help vulnerable older adults with deteriorating health age in place. Research on how these models can be replicated in communities with limited resources is critical.

Housing for people with disabilities

In this policy: Federal

Congress should direct the Department of Housing and Urban Development (HUD) and Centers for Medicare & Medicaid Services to develop a comprehensive strategy to support home- and community-based housing services for people of all ages with disabilities, including standardized definitions of available options.

Data on supportive housing

In this policy: Federal

Congress should direct the Census Bureau to define and collect data on supportive housing settings, including board and care homes, assisted living residences, and congregate housing. Survey measures and data reports should recognize the residential nature of these settings and not classify them as nursing homes or other institutions.

Congregate housing

In this policy: Federal

Congress should expand programs for supportive services in congregate housing for both new and existing subsidized projects. Programs should collect client-based data to quantify the cost-effectiveness of a seamless system of housing services that would maximize residents’ ability to age in place.