Supportive housing refers to residential settings that offer additional services. These could be 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 older adults wish to remain outside of institutional settings. Thus, they differ significantly from institutional settings like nursing homes (see also Chapter 8, Long-Term Services and Supports—Quality and Consumer Issues In Licensed Residential Care Settings, Including Skilled-Nursing Facilities, Assisted Living, and Others).
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.
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.
In addition to private programs, supportive services are available through public programs. Some federal housing developments that accommodate older adults have expanded their mission by providing supportive services. The Department of Housing and Urban Development has funded thousands of service coordinators in housing developments for older adults. This has enabled many residents to age in place longer and more successfully.
However, many developments face challenges in offering these services. There can be financial, space-related and other barriers to offering services such as congregate meals and help with chores and personal care. Many do not generate enough operating revenue to provide adequate common services because of the “fair-market rent” guidelines. If it were easier for subsidized housing communities to provide additional services to their residents, it would help create an efficient network of support for residents with low incomes.
SUPPORTIVE SERVICES IN HOUSING: Policy
Housing with services
Policymakers should encourage coordination of housing, health services, and other supports to facilitate access and efficiencies in service delivery. Older adults who are vulnerable, including those who are frail and those with low incomes, are in particular need of these services. Supportive housing should promote residents’ autonomy and decision-making while ensuring high-quality services. Consumer protections should ensure safety for consumers, encourage a home-like atmosphere, and offer an individualized approach that ensures personal dignity and autonomy. The philosophy and consumer-oriented approach of assisted living facilities should become the model for all types of supportive housing.
Policymakers should expand the availability of high-quality supportive housing developments. They should expand subsidies for high-quality supportive housing to increase access for people with low incomes.
The Department of Housing and Urban Development (HUD) should develop higher fair-market rent standards for assisted living residences and other forms of service-enriched housing.
HUD programs for the construction or conversion of residences for older adults should include a range of housing options, including service-enriched housing and housing located in communities with access to transit, mobility options, and other amenities.
Federal regulators and state housing finance agencies should encourage innovative financial underwriting to incorporate the cost of services, service coordinators, and technology in housing development operating budgets (see also Chapter 10, Utilities - Telecommunications: Community Broadband Internet).
Federal housing policy should concentrate greater resources on frail older adults, particularly those who live alone, people from historically disadvantaged racial and ethnic groups, people living in underserved rural and inner-city areas, and people with disabilities.
Enhancing HUD and Department of Health and Human Services (HHS) coordination: HUD and HHS’s Administration for Community Living should better coordinate their efforts to facilitate client-based data collection and program development regarding residents’ service needs, facility retrofitting, development of supportive housing, and the cost-effectiveness of providing supportive housing that maximizes residents’ ability to age in place.
HUD and HHS should identify ways to enable housing providers to support resident services by taking into account savings to the health care system. Joint HUD-HHS regulations should make it easier to use existing funding streams.
Congress should establish a supportive-services grant program to replace the Congregate Housing Services Program and the Homeownership and Opportunity for People Everywhere for Elderly Independence program. Funded services should include access to necessary health and social services for residents aging in place.
HUD and other federal agencies should use the results of demonstration programs to develop effective strategies to meet the service needs of older adults in subsidized housing.
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):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: States should provide consumer-based financial assistance, including Medicaid home- and community-based waiver funds, to allow older adults with low incomes access to assisted living. State assistance should be coordinated with federal assistance programs.
Consumer protections: 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 (see also Chapter 12, Personal and Legal Rights—Private Enforcement of Legal Rights).
Meeting demand for supportive services: 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.
Promoting innovative models for aging in place: 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.
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.
Housing for people with disabilities: Congress should direct the HUD and the 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: 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: 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.