Case Study. Peter Sanborn Place, Reading, MA Conducted May Affordable Senior Housing Plus Services

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1 Affordable Senior Housing Plus Services Case Study Peter Sanborn Place, Reading, MA Conducted May 2011 This case study describes the strategy employed by Peter Sanborn Place to help support the needs of the property s older adult residents. The study details how the strategy evolved, the available services and supports and how they are delivered, and the strategy s perceived successes and challenges. Any noted challenges are not intended as criticisms of the housing property or its partners, but merely highlight issues faced when programs and organizations are working together in new and different ways. The intention is to inform providers of concerns they may face when creating and operating housing plus service programs and/or to highlight needed policy and regulatory changes. This case study is current as of the date it was conducted. It is possible that property and/or program components and characteristics may have changed in the interim. The study was conducted via a site visit and interviews with staff from the housing property, service partners and local and/or state officials. Any noted in the case study are the responsibility of the authors. Overview Sanborn Place is a 73-unit property opened in 1983 and originally financed through the U.S. Department of Housing and Urban Development s Section 202 Supportive Housing for the Elderly program. The property was refinanced in 2003 through a loan from MassHousing, the state s housing finance agency, but still retains the Section 202 eligibility restrictions and receives Section 8 rental subsidies. In the mid-1990s, Sanborn Place s Board of Directors grew concerned that the original resident population had aged and several were being prematurely institutionalized because they could not afford to purchase private services or move to an assisted living residence. At the time, no services were available at the property. In 1996, the Board formally acted to expand Sanborn Place s mission and develop an aging in place model of services for the property and the community at large. The Board brought in the current CEO to develop a supportive living environment. Her first step was to bring on a service coordinator. After assessing residents situations, they identified home care assistance as a common need. At the time, there were no home care agencies serving the Reading community. In response, Sanborn Place developed a sister agency, Sanborn Home Care, in The agency is located onsite at Sanborn Place and serves residents as well as individuals in the surrounding communities. The services available at Sanborn Place and provided by Sanborn Home Care evolved over time, generally expanding in response to the changing needs of residents and the community. In 2010, the Sanborn group acquired an adult day program. The program was going out of business, which would 1

2 pose a loss to residents of Sanborn Place and the community who attended the program. The Sanborn group believed it fell within their mission to keep the program running, and the organization operating the program worked with them on the acquisition. While the three organizations are legally separate entities, some staff are shared across common functions and allocated accordingly in each budget. Shared staff help achieve administrative efficiencies while also helping to maintain the collaborative nature between the three entities. The three affiliates hold a weekly joint staff meeting to review resident and organizational issues and concerns, develop plans and make announcements. Staff from the three affiliates are often cross trained in other areas, particularly resident services. Everyone needs to be able to step into resident services and help out; they re our main focus, says the CEO. For example, one staff member who works in the finance area has also worked in resident services and can step in when the van driver is on vacation or can go on outings with residents. A new finance person is learning to change an oxygen tank so that he can help, if ever needed. Sanborn Place describes itself as a supportive living community whose mission is to assure in a professional manner at the most feasible cost, quality housing and support services, promoting and supporting the philosophy of aging in place." Sanborn Place has a targeted tenant selection plan that reserves 20% of units for residents who do not require or may choose to use services, 33% for residents who need some scheduled services during the week and 47% for residents who need a single service to multiple services per day. The plan was adopted and approved by HUD in According to Sanborn Place s CEO, the ratio of levels allows for a mix in the population and a cost-efficient volume of services. Individuals interested in moving into Sanborn Place complete an application in which they select which level they are applying for and are asked to provide documentation of their service needs, if any. Sanborn Place is allowed to ask for evidence of service needs because the tenant selection plan targets individuals of different need levels and the waiting list is maintained by these different levels. If a dispute arises concerning an applicant s need status, an outside entity, Mystic Valley Elder Services, provide an assessment of determination. Sanborn Place would typically not move a new resident in who is bedbound, but if an existing resident progressed to that stage they could remain in the property and Sanborn Home Care could support their needs. For example, one resident moved in with early stage Huntington s disease. Her previous home had stairs, which she would eventually not be able to master. The family was aware of Sanborn Place and thought it was the best place for her because as her disease progresses she will not have to move to a nursing home and then hospice. Here, her daughter says, she won t have to move, we won t have to worry about it, we have her home and care for the future figured out. The CEO states that the only type of person who generally cannot stay in the property is a person with Alzheimer s who has a high anxiety level, because they cannot provide the constant engagement and attention a person with these symptoms requires. Individuals with Alzheimer s who do not require this intensive degree of interaction, however, could stay at the property as staff can provide periodic check-ins and safety mechanisms have been put in place (e.g. GPS bracelets). Below is a description of the need levels targeted for residency, with additional details on the nature of residents categorized under Level 3. 2

3 Targeted Tenancy Levels Level # of Residents Type of Assistance Needed Level 1 13 Require no services or choose to use services. Level 2 25 Generally require assistance during the week with shopping, laundry and housekeeping. Program under which most residents at this level are funded requires needed assistance with two IADLs. Level 3 35 Need daily oversight and/or assistance with personal care needs. Level 3-3 Require daily oversight, but limited personal care (about one hour a day). Level 3 23 Require daily oversight and minimally get an hour of services. Do not have high medical needs, but are generally in maintenance mode. Level 3+ 8 Have high personal care needs that require several hours of care 24/7. May also have skilled nursing care needs. Example of Resident Independent, but may choose to participate in activities or wellness programming. Often no longer driving, physical tasks (carrying laundry, changing linens) have become too difficult, but can still handle personal care. Often younger disabled individuals with mental health or developmental disabilities that require regular monitoring and supervision, but limited personal care assistance. Aged, frail person who may have slight dementia, be at risk for falls and need monitoring while showering. Progressive muscular disease that requires assistance with all areas of personal care and frequent monitoring. When Sanborn Place first developed the tenant selection plan formula, they had about 45 Level 1 and five Level 3 residents. Over time, however, existing residents have aged in place and their needs have increased and frailer residents have moved into the building. Several service providers and residents in the community are aware that Sanborn Place can support a person with higher needs and often make referrals. After the property adopted a supportive living philosophy there was initially pushback from residents as the acuity level in the building began to creep up. Residents would often tell the CEO that certain residents did not belong at the property. She would tell them, Ok, we ll move him or her, but you re going to go with me to find an appropriate place for them because you may need that place in a year or two. With education and the strong sense of community at Sanborn Place, the CEO says she no longer hears comments like this. In fact, she hears just the opposite. When staff started serving one resident with Parkinson s disease dinner in his apartment rather than the community dining room because they feared his messiness would upset other residents, the residents pushed back and said he belonged in the dining room with them. When Sanborn Place holds disease education programs, they encourage all residents to attend so they can learn about the condition their neighbor may be suffering from and better understand and accept their behavior and circumstances. When Sanborn Placed refinanced in 2003, it used some of the proceeds to make accessibility updates in bathrooms, including installing walk-in showers, and kitchens in the units. In 2008, the property received 3

4 an assisted living conversion program grant from HUD. Twenty-six units were updated with full universal design features, allowing an individual with a wheelchair to have full accessibility and move around comfortably. The grant also supported installing a commercial kitchen and renovations to the dining room. Resident Services and Supports A range of services are available onsite at Sanborn Place. Most services are provided either directly by Sanborn Place or by Sanborn Home Care, although some are also provided through community partners. Services Available at Sanborn Place Service/Support Delivery Mechanism Provider Service coordination Property staff Sanborn Place 24-hr emergency response Property staff and sister corporation Sanborn Place, Sanborn Home Care Transportation Property staff and sister corporation Sanborn Place, Reading Senior Center Congregate meal Sister corporation Sanborn Home Care Recreation/socialization Property staff, volunteers, partnerships Sanborn Place, volunteers, community organizations Wellness and fitness Partnership YMCA, Town of Reading, Sanborn Home Care Homemaker and personal care Sister corporation Sanborn Home Care Service Coordination Sanborn Place refers to their service coordinators as quality of life coordinators. The property has two full-time positions, staffed by one full-time and two part-time individuals. This allows a coordinator to be available in the evenings and on the weekends, when families often visit the property and several events take place. The quality of life coordinators are funded through Sanborn Place s operating budget and are contracted from Sanborn Home Care. The quality of life coordinators do everything, assisting in areas such as identifying, applying and recertifying for benefits; assisting with problems with banks or utilities; helping read and understand mail; setting up transportation; plan activities; etc. As employees of Sanborn Home Care, the quality of life coordinators all go through home health aid training. With most trips taken off the property, a quality of life coordinator and home health aid accompany the residents. Sanborn Place feels the quality of life coordinator needs to have the proper safety training and be able to assist any resident when needed. 24-hr Emergency Response Sanborn Place originally had pull chords in each unit. In 1999 they replaced the pull chords with the HomeFree wireless monitoring system. Residents choose either a pendant or a watch, which sends a signal to a computer in the home care office and pagers carried by the nursing assistants when activated. If a nursing assistant does not answer the page within a predetermined time, a backup alert is sent to cell phones carried by other Sanborn Place and Sanborn Home Care staff. 4

5 The nursing assistant assesses the situation and determines if 911 needs to be called. Sanborn s CEO notes that they have a number of people in wheelchairs who often slide out of their chair or get themselves in positions they cannot get out of. These people generally just need help getting back into their chair or resituated. In addition to being trained on properly lifting people, the nursing assistants also have an assistive device for helping larger individuals. Sanborn Place also does education sessions with residents aimed at teaching them how to fall safely. If a resident says they just got their walker stuck but were able to fall safely, the nursing assistant will help them up if they appear ok. Staff use an air lift cushion to help someone who has fallen get up safely. If staff does not know why a resident fell, they will call 911. Residents pay $20 per month for the pendant/watch. Individuals receiving services through some sort of home care program generally have the service paid for as part of their package. Others must pay out-ofpocket, although Sanborn Place assists those residents who may not be able to afford it. The success of the system depends on residents wearing the pendant/watch so that the device is within reach should they have an emergency. Sanborn staff does a great deal of education with residents to help them see why it is important for them to wear their pendant/watch at all times, otherwise they cannot alert anyone when they are having an emergency. The system can be upgraded from a pendent/watch to a GPS-enabled bracelet for those individuals suffering from dementia or Alzheimer s. The bracelet tracks individuals as they move so that home care staff can be aware if an individual has left their apartment or the building. The signal extends to the property perimeter. The system can also be upgraded to include chair and bed pads, which alert the home care staff if an individual has gotten up. A feature like this is useful for individuals who have come home from the hospital or rehab and are at-risk of falling should they get up on their own. Sanborn Place s maintenance staff go through part of the home health aid training focusing on safety awareness. They are trained on falls, choking and CPR. While the maintenance staff have been trained on fall safety, they would not lift a resident without having a nursing assistant present. Transportation Sanborn Place provides both individualized and group transportation. Individualized service is available Monday, Wednesday and Friday from 9am to 3pm. The mornings are set aside for doctors appointments and the afternoon for errands around town (grocery store, bank, etc.). Residents schedule trips, saying when they need to be dropped off and picked up. Tuesdays and Thursdays are reserved for group trips to places such as the shopping mall, WalMart, activities or out to lunch. The van was donated to Sanborn Place from the Rotary Club, and Sanborn Place pays for the operating expenses through fundraising and resident fees. For individualized trips, residents pay $5 per trip in town and $6 out of town. Group trips are generally free, but some may include a small fee (for example, a trip to view the fall foliage and have lunch). Sanborn Place shares the van with the Reading community. For example, when the senior center van is broke down they borrow the van and a local school uses the van one evening per week to take students home. 5

6 Congregate Meal Sanborn Place offers a daily congregate dinner meal. Residents who receive meal preparation as part of their service package through Sanborn Home Care participate daily in the meal program. 1 Other residents can choose to participate in the evening meal on a desired basis, and they are asked to reserve a spot the day before. All residents, including those receiving food preparation as part of a service package, pay $7 per meal and Sanborn Place subsidizes 40% of the full $13 cost. An average of 25 residents participate in the meal each night, about 22 of whom are regulars. The meal program began after the number of people receiving meal preparation as part of their service package grew to too large to efficiently produce individual meals. They began making group meals for about 10 residents. As the number of residents receiving meal preparation services grew they expanded it into a congregate program where individuals dined together and the overall resident population was invited to participate. Recreation/Socialization Sanborn Place offers an extensive range of regularly-scheduled and special-occasion activities, including events on the property and trips around the community. Each week or month the property hosts a reading club, a current events and coffee hour, puzzles and word games, yankee bingo, Wii competitions, crafts, movie nights, holiday celebrations, group birthday parties, family buffet night, etc. The property also takes residents on trips to participate in community celebrations, visit a museum, attend a performance, have lunch, see the Christmas lights, etc. All activities are free, except for trips like lunch at a restaurant or a theater performance. Wellness and Fitness Sanborn Place purchases all residents a membership to the YMCA, which they receive at a reduced rate. The YMCA also sends a trainer to the property three days a week to offer a fitness program, such as chair yoga. The property pays $35, half the normal fee, for a one-and-one-half hour session. About 10% of the population, generally the healthier residents, go to the YMCA and about 20 residents faithfully participate in the in-house fitness programs. The town of Reading sends a nurse to the property twice a month to hold a blood pressure clinic. When the town s nurse is on leave, Sanborn Home Care volunteers their nurse for the clinic. Residents can also have their blood pressure, as well as their blood glucose, pulse or blood oxygen level, checked anytime by just stopping into the home care office. The property usually hosts a hearing clinic twice a year, which is provided for free by a private audiologist. Homemaker and Personal Care When a resident is in need of a greater level of support, Sanborn staff will assess the situation with the resident and their family to identify possible programs for which they may be eligible and direct the resident to the appropriate agency to apply for services. Generally, this is Mystic Valley Elder Services, the state-designated entry point for the Reading area through which individuals can access a variety of programs, services and supports (see text box below). They might also refer residents to the Veteran s Administration or the Visiting Nurse Association (often for hospice care). If a resident is not eligible for any publicly-funded programs, they can purchase services privately from Sanborn Home Care, either out-of-pocket or through long-term care insurance. 1 Meal preparation includes the act of preparing the food, but not the food itself. 6

7 Sanborn staff will call Mystic Valley and alert them that the resident will be applying for services. Mystic Valley assesses the individual to determine their functional and financial eligibility for an appropriate service program. Once deemed eligible, Mystic Valley determines the amount of service hours the person will be allotted each month and assigns a case manager within the agency. Mystic Valley designates one case manager to oversee all their clients residing in Sanborn Place. The agency then assigns the individual to a community provider to deliver the services. Sanborn Home Care is the designated clustered vendor for Sanborn Place, meaning Sanborn Home Care is the assigned service Aging Services Access Points (ASAPs) and Programs for the Elderly and Persons with Disabilities ASAPs are the state-designated entities responsible for the coordination and delivery of community-based long-term care services to elders who meet state need and income eligibility requirements. There are 27 ASAPs statewide in exclusive geographic areas. ASAPs are private, non-profit agencies. Some also serve as the local area agency on aging. ASAPs provide the following services: information and referral; interdisciplinary case management (intake, assessment, development and implementation of service plans; monitoring of service plans; and reassessment of needs) and protective services (investigations of abuse and neglect of elders). Individuals can access a number of state- and federally-funded service programs through the ASAPs, including: Home Care Program - A state-funded support services program designed to help seniors live independently in their own homes. The program is for seniors with low to moderate needs, who do not need daily nursing care. To qualify, seniors must meet income limits and show a need for support services. Depending on income, there may be a monthly co-payment for services. Enhanced Community Options Program (ECOP) - A state-funded home care program for frail seniors who are medically eligible for nursing facility care but want to live at home. ECOP offers a higher level of services than the Home Care Program. To be medically eligible for nursing facility care an individual must need: 1) at least one skilled nursing or therapist service daily (for example, an IV, feeding tube, oxygen, sterile dressings, catheters, skilled-nursing evaluation, physical therapy, speech therapy, occupational therapy) or 2) a nursing service at least 3 times per week, plus two other services. Other services can be assistance with activities of daily living or additional nursing services. Frail Elder Home and Community-Based Services Waiver - A Medicaid program that provides low-income individuals who require nursing home level care with health care and support services in their home or community living residence. To be eligible you must be certified as medically eligible for nursing home care (see ECOP description above) and meet the income and asset. Available services, may include personal care services, housekeeping and chore services, laundry, home health aide, skilled nursing, companion services, supportive day program, home delivered meals, grocery shopping, transportation, wander response system, respite care, environmental accessibility adaptation, and transitional assistance. Community Choices Program - A program for frail elder waiver members who are at risk of entering a nursing facility very soon unless they get extra help at home. Elders currently in a nursing facility who want to return home are also eligible. Community Choices gives more hours of services than other home care programs. To qualify for Community Choices, you must be enrolled in (or eligible for) the Home and Community-Based Services Waiver program. You must meet other requirements that show you are at risk for immediate nursing home placement unless you get additional services. For example, you might be at risk and need extra services if you recently had a major medical problem. Group Adult Foster Care (GAFC) - A Medicaid program that pays for personal care services for eligible seniors and adults with disabilities who live in GAFC-approved housing. To qualify, residents must need help with at least one daily personal care task such as bathing or dressing. 7

8 provider for all individuals in the building receiving state or Medicaid-funded home care services. Residents can choose an alternative provider, but this seldom happens. Mystic Valley informs Sanborn Home Care of the amount of hours allotted to the resident and Sanborn Home Care develops a care plan within the guidelines of the program in which the resident is participating. Sanborn Home Care provides a range of services based on the program the individual is being served under and the specifics of his or her care plan. Services can include case management, homemaker services, meal preparation, shopping, transportation, money management, medication management, monitoring and oversight, and personal care. Sanborn Home Care is not licensed to provide skilled nursing care. When assigned a resident through Mystic Valley who requires this type of care, they subcontract with the Middlesex Visiting Nurse Association (VNA) for the nursing services. Similarly, when the VNA is selected to provide a Sanborn Place resident Medicare skilled nursing care following a hospital or rehab facility stay, they subcontract with Sanborn Home Care to provide any personal care services. Sanborn Place has built relationships with the hospitals in their area and encourages the hospitals to select the VNA as the home health care provider for Sanborn Place residents because they have established relationships with the property and many of the residents. Residents, of course, always have their choice of provider. Mystic Valley s case manager reviews each of his or her clients annually and whenever they have a hospital stay or other change in condition. In these instances, Sanborn Home Care would alert the case manager and submit a request for a reassessment. If the resident is in the hospital, the case manager will let the hospital know Mystic Valley is involved with the client so the discharge planners will be aware of the supports they are receiving. The hospital generally alerts the case manager when they are sending the client home. If the client is in a nursing facility, Mystic Valley and Sanborn Home Care often go to the discharge meetings together so they can brainstorm about what the client needs in place to be able to safely return home Services delivered through Sanborn Home Care are paid for by the individual resident, either through their participation in a publicly-funded program or privately (insurance or out-of-pocket). Sanborn Home Care either bills the program the resident is participating in, the resident (or their family member) or the insurance program. Eligible residents could be supported through one of a variety of publicly-funded programs, including the Massachusetts s Home Care program, Medicaid home and community-based waiver programs, group adult foster care program, or the Veteran s Administration (see description of programs in box above describing ASAPs). The Mystic Valley case manager who works with Sanborn Place believes there are several advantages of having an onsite vendor, particularly one that has a 24-hour presence. With Sanborn Home Care, services will get started immediately once the client s eligibility is approved. Generally, she says, there is a delay in getting care initiated because the client has to worked into the agency s schedule. Being onsite, however, allows Sanborn Home Care to be more nimble. The continual presence, she believes, allows Sanborn staff to become very familiar with residents. They are able to constantly assess them, even something as simple as watching them walk down the hall, and are able to notice changes in condition. A 24-hour presence allows Sanborn Home Care to monitor clients throughout the day. Mystic Valley is often concerned about clients being discharged from the hospital and their ability to care for themselves. With their clients in Sanborn Place, they do not have these same worries because Sanborn staff will check on them frequently, including during the night, to ensure they are stable. Sanborn Home Care also helps the Mystic Valley case manager stay updated on her clients situation. They always have a list of the client s medications because of the relationship Sanborn Home Care has with a pharmacy to package and deliver medications. When a client is discharged from the hospital with 8

9 home health care, Sanborn Home Care generally receive a three-page referral with details of the resident s situation because of their partnership with the VNA. Mystic Valley normally would not receive this information, which is very helpful to them in reassessing the resident s situation and determining whether their care plan needs adjusting. The Mystic Valley case manager also sees the fact that Sanborn Place s emergency alert system notifies the onsite staff rather than an offsite vendor as a benefit. This way staff can promptly respond to a resident rather than having to wait from someone to arrive from the community. She also sees it as an advantage that the nurse (when they are onsite) can assess the situation and determines if the individual needs to go to the hospital. In her judgment, a hospital stay can be very difficult on an elderly person and should be avoided if it is unnecessary. The Sanborn Home Care nurse has knowledge of the resident to help in their assessment of the situation. Even outside of emergency situations, the aids are available to help the residents throughout the day as needed. She sees the arrangement as being like assisted living, but an affordable version. Mystic Valley s case manager is convinced clients in Sanborn Place are able to stay in the community longer. She has two clients she believes would be in a nursing home if they lived elsewhere. One has severe COPD, total incontinence and requires oxygen 24 hours/day. She was not always getting all the services she needed because she would refuse them and would end up in the nursing home. Now living in Sanborn Place, she receives services about 6 hours/day, which they break out incrementally throughout the day to take her to bathroom and assist with whatever else she needs. She is now stable and has stayed out of the nursing home. Another client has severe Parkinson s disease. He now requires two feedings during the night, all medications must be given though a tube and he has constant uncontrollable body movement. Another client had a progressive muscular disease and they were able to keep her at home until she passed away. The key, the nurse believes, is the 24-hour presence. A physical therapist with the VNA also believes there are several advantages to her agency s relationship with Sanborn Place that makes her job easier and results in better outcomes for her clients. She believes she can get a more accurate history on residents. Sanborn staff have a history with the residents, they see their daily lives and they often have medical records. When the therapist gets a new client at Sanborn Place she will meet with the resident and then talk with the home care director or the aids. (The contract the VNA signs with the client allows them to discuss the client with Sanborn Home Care staff.) She will tell the director what she has learned about the resident and they often offer additional insight, such as she didn t tell you she fell last night. While working with a client, she generally stops in and talks with the director about once a week to get any pertinent updates on the resident. She also believes that working with Sanborn Home Care s aids provides better continuity of care because the aid often already has a relationship with and knowledge of the resident, as opposed to a new temporary VNA aid that might come in. The aid will also continue working with the resident after the therapist s course of care ends. The therapist will often teach the aid the exercise program she is working on with the resident or give them direction on other areas of their care. Like the Mystic Valley nurse, the VNA physical therapist also believes that clients who failed in the community would have been more successful at Sanborn Place. One former client, a 90-year old woman who lived alone, was unable to take her medications correctly. Although the VNA filled her pill boxes, they were not there to monitor that she took them properly. She went to the hospital twice for medication-related issues and is now in a nursing home. If she had lived in Sanborn Place, the physical therapist believes, someone would have been able to monitor her and ensure she was taking her medications correctly. She has several clients who cannot afford assisted living and she gets them on the waiting list for Sanborn Place. The other disadvantage she sees of assisted living is that once a person 9

10 needs a lot of support, they are discharged. That does not happen at Sanborn Place, she says. For example, one resident was fairly independent when she moved in. In two years, her neurological disease has reduced her to being tube-fed, but she remains in her apartment with the support of Sanborn Home Care. She does not believe an assisted living facility would allow her to remain. Sanborn Home Care believes there are several advantages to being a clustered vendor for the property and being co-located with the housing property. Sanborn Place provides office space and some infrastructure to Sanborn Home Care free of charge, which helps minimize overhead expenses. Being colocated in the property also allows staff to breakout the time allocated to an individual in a more flexible manner. Staff feels this is significant in supporting more frail residents to remain safely in their apartments. In a traditional home care model, an aid visits an individual for a set block of time on a set day. Some individuals, however, benefit from shorter intervals of time throughout the day. For example, some people need someone to ensure they are taking their medications regularly and correctly, which means they need someone to check on them three times a day. Others just need more frequent monitoring and oversight to ensure they are safe. This type of scheduling is not economically feasible in a traditional home care model where an aid is traveling around the community to individual homes. It is likely that residents get more care than the particular service program they participate in allots them. Because Sanborn Home Care staff are located on site, they are generally able to respond whenever a resident requests their assistance. Unless it becomes excessive, they are generally going to assist a resident and not charge for the additional care because they are available and the culture is to support resident needs. In all circumstances they are available to respond to emergency needs, including those residents who are not home care clients. Sanborn Home Care is also a clustered vendor for the Reading Housing Authority. However, they are unable to support as complex a level of resident at the housing authority property as they can at Sanborn Place because they are not able to provide care and oversight on a 24-hour basis (and because of the physical structure). Services are provided daily from 7am to 7pm. To compensate for their more limited presence, however, Sanborn Home Care attempts to partner with other community entities to put the necessary supports in place for housing authority residents. For example, they recently worked with other groups to put adequate supports in place for a client who the housing authority director had concerns about. Working with the Meals on Wheels program, the community nurse advocate and a Massachusetts Supportive Housing Program Sanborn Place is not part of the Massachusetts Supportive Housing Program. However, the relation the ASAP has with Sanborn Place as a clustered vendor is similar to what occurs through this state-designed program. The Supportive Housing Program was developed by the Executive Office of Elder Affairs and the Department of Housing and Community Development to create an "assisted living like" environment in state-funded public elderly/disabled housing. The program, which currently operates in 22 locations, is a partnership between local housing authorities, the ASAP (see previous page) and a community service provider. The ASAP assigns a case manager to the housing property and designates one service agency (a clustered vendor ) to provide services in the building 24/7. Available services include service coordination and case management, personal care, homemaker services, laundry, medication reminders, social activities and at least one meal a day. Services are paid for by a range of funding sources based on the resident s eligibility and might include state-funded home care services; Medicaid HCBS services; Medicaid state plan services; Older Americans Act Title III-C nutrition services; Older Americans Act and Title III-B social services. 10

11 volunteer shopper, Sanborn Home Care was able to set up a schedule where the resident had someone checking in on her three times a day. Other Services The Sanborn group attempts to work closely with residents doctors. They have about four primary care physicians they work with who, according to Sanborn s CEO, allow, appreciate and respect our care management. They recommend these physicians to residents moving to the property who need a new doctor, although all residents are free to select whomever they want as a physician. Residents will also sometimes switch their doctor to one who coordinates with the property. These practices will communicate with Sanborn Home Care about residents medical care and will accept Sanborn s assessment of a resident situation, which will minimize care barriers for the resident. For example, if Sanborn Home Care s nurse calls to discuss a possible medication complication, they will make changes without requiring the resident to come for an office visit first. If the nurse believes a resident needs VNA care, they will not require the resident to go to the ER first. Clients of Sanborn Home Care sign an open release that allows staff to communicate with any other care entity, unless one is explicitly excluded. For residents who are not clients of Sanborn Home Care, they would request the resident sign a release, allowing them to communicate with their health care providers, if needed. Financing Services Sanborn Place funds services through multiple methods, including its operating budget, a services fund created when refinancing its Section 202 loan and fund raising. The property funds the quality of life coordinators through its operating budget. When Sanborn Place refinanced its Section 202 loan in 2003, it dedicated a portion of the excess proceeds towards resident services. The property receives $45,000 annually from this services fund. This fund helps to finance home care staffing, particularly the afterhours presence. Fundraising helps to cover the operating costs of the van, subsidize the meal program, purchase the YMCA memberships and trainer, and support resident activities. A former resident s family started a foundation in their father s honor and gives a large portion of their annual proceeds to Sanborn Place in recognition of the property s support of their father. The property also hosts an annual holiday raffle to which many community businesses donate items and conducts a fundraising appeal that goes out to families and community members. Community Partnerships The Sanborn Group s CEO states we pride ourselves in being a care management model. We work together with all the other providers. They have created strong alliances and working partnerships with several community organizations including Mystic Valley Elder Services, Middlesex Visiting Nurses Association, Reading Senior Center, the Town of Reading (including Elder Services community nurse advocate and social worker), the Reading Housing Authority, Department of Mental Health, area hospitals (Winchester Hospital, Hallmark Health), area assisted living and nursing and rehabilitation centers, the Rotary Club of Reading and others. The town of Reading shares a similar philosophy on collaboration, which encourages them to link services and work together with other organizations. The senior center director notes the town has a history of supporting seniors in the community and emphasizes working together to problem solve and create a comprehensive system. She observes that the various agencies and organizations in the 11

12 community frequently have mutual clients. We re all interacting because we all have a different piece. Usually our own piece flows smoothly, but sometimes that flows into another piece. We tap into each other. One example of a shared client is a woman who had severe adjustment issues after moving into Sanborn Place. Sanborn Place, the senior center and the town Elder Services social worker and nurse advocate set up a plan together to help her adapt. They set up transportation to help her continue to come to the senior center since she used to come regularly. The social worker continues to work with her and her family since they were already familiar and comfortable with her. When she had a fall and was resistant to care, the nurse advocate got involved because the client was willing to deal with her. They also set up a volunteer shopping escort for her safety due to her declining mobility. Senior center clients sometimes go to Sanborn Place for activities and Sanborn Place residents attend the senior center for meals and activities. The senior center and Sanborn Place each have a van, but share vans when needed. When the senior center director has someone she is concerned about she will call or refer the individual to the town s social worker or the nurse advocate. The social worker and nurse advocate will make referrals to Sanborn Place. In comparison to other municipalities she has worked in, the town s nurse advocate says she finds the level of cooperation and interaction to be much higher. It s something about the esprit de corp, she believes, It s not top down, no one has to give permission for things to happen, the city puts people in place that work as a team. The senior center director says it is abstract how we work together; it just comes from mutual respect for each other and trust in each other to make the right decision. Each has a piece of the services puzzle, and if there s something you can t do, you pick up the phone and call someone else. There s no concern about this is my client. Reading aging organizations, however, do not feel they see the same level of cooperation from physicians and hospitals. Staff say medical providers are slower to come to the idea of working as a team and care management system. While they make phone calls and send notes to health care providers about their clients to try to keep them in the loop, the physicians rarely communicate with them. Staff believes HIPAA laws, to some extent, are a barrier to freer communication. They find that if they are able to establish a relationship with discharge planners, they are a little more willing to work with them. Sanborn Place s CEO states, I think of Sanborn as a community resource. It s our responsibility to be available to the community. We have an assisted living facility in the community and I m probably their biggest marketer; it s not a competition. Sanborn Place also has an established relationship with the Reading Fire Department. When the department recently contracted with a new back-up ambulance service, they set up a time for the new service to visit Sanborn Place to learn about the property and meet the staff. Sanborn Place s CEO says, They would never send someone to the building without them knowing how we work and what we expect. Sanborn Place hosts meetings for the local Rotary Club, providing the space and refreshments. Several club members have parents who either currently live or have lived in Sanborn Place. The club purchased a van for Sanborn Place, which the property also shares with other community organizations. 12

13 When the mother of one Reading family passed away in 1999, the family discovered the true level of care she had been providing their dad who had Alzheimer s. While exploring their dad s living options, they received a visit from Sanborn Place s CEO. She had previously met their mother, knew she was their father s caregiver, and became aware she had passed away. She told them about Sanborn Place and that they might be able to help support their dad. She told them she knew there were other families in the community like them and that Sanborn Place was trying to create a model that could support them. Their dad moved in but ultimately needed more care than Sanborn Place could provide at that time. They started to offer 24-hour care in response to his needs, but were unable to staff up quickly enough to adequately support him. The Sanborn Place CEO helped the family find an assisted living residence, and when he become too advance for them to handle she helped them through a series of next steps. The family started an annual golf tournament in 2000 and because of the supportive experience they had with Sanborn Place, gave the bulk of the proceeds to them. The family ultimately created a foundation, called the DKG Foundation, and continues to give the bulk of their proceeds to Sanborn Place because they have seen how the organization gives to the community. Because of their outreach around the community, Sanborn Place is known by many Reading residents. When a town council member s father had a stroke and ended up in a nursing home, they knew that was not the right place for him. Others in the community told the son he needed to talk to the CEO at Sanborn Place. She visited his father at the nursing home and agreed he did not need to be there. He was able to get an apartment in Sanborn Place and they set up a service plan for him, which includes personal care a couple times a weeks (showers), homemaker services, medication checks and dinner services (which he wanted for the socializations aspect). He has lived in Sanborn Place since 2007 and, according to his son, is thriving: The independence is what he likes. He s on his own and can do what he wants. He s had no health crises since moving to Sanborn Place; everything is stabilized. I attribute that to the fact that he s in an independent environment. It helps him mentally and pride wise. The Future The Sanborn group has plans to build additional units to accommodate the Reading community s interest in expanded affordable opportunities and a place where individuals can age in place. They are also exploring partnering with a community health organization that could bring additional healthrelated resources to the property. Sanborn Place has submitted a proposal to HUD s assisted living conversion program for a second grant to upgrade additional units with universal design features. They also have plans to build an additional 48 units, which would be built to be universally accessible. The new property, which will be joined with the existing property, will be mixed-income. Several people from the Reading community have expressed interest in Sanborn Place, and while moderate income, are still above the income eligibility guidelines. The hope was to finance the property through the Section 202 program combined with low income housing tax credits. The group did not receive a Section 202 award in the 2011 round, however, and will now work with MassHousing partnering with local banks to finance the property through tax credits. The Sanborn group is currently in discussions with the Commonwealth Care Alliance (CCA), a senior care options (SCO) program providing integrated health care and social support services, about ways they might work together. CCA serves older adults (65+) dually eligible for both Medicaid and Medicare and individuals with serious physical, cognitive, or chronic mental illness covered under Medicaid. A SCO is a partnership between Medicaid and Medicare that provides a complete package of health care and social services for low-income seniors. A team of health professionals develops a plan of total individualized care for each member. The SCO builds a network of medical and other professionals, either through 13

14 direct employ and/or through contract, including a primary care doctor, nurses, specialists, home care providers and a geriatric support coordinator. The Sanborn group is exploring becoming a contracted provider with CCA. Currently, clients of Sanborn Home Care receive their supportive services under a variety of state and/or federally funded home care programs. Sanborn Home Care separately bills each program their clients participate in. Each resident arranges their own health care providers, although Sanborn Home Care does attempt to coordinate with their physicians as much as possible. A relationship with CCA could lead to administrative efficiencies for Sanborn Home Care, an increased health presence at the property, and better integrated care for residents. If residents receiving services from Sanborn Home Care enrolled with CCA, Sanborn Home Care could bill one entity and program, rather than the multiple programs it currently bills. Through a relationship with Sanborn Place, CCA could send a nurse practitioner to the property to assess and check on residents, potentially avoiding an unnecessary trip to the ER or hospital. With the health providers working under the same umbrella as Sanborn Home Care, they may be able to better communicate with residents physicians and help coordinate care. All members of CCA are required to use their network of health providers. One challenge the Sanborn group and CCA are exploring is the physician and hospital that several residents utilize is not in CCA s network. Depending on what solutions they may be able to identify, residents may be required to change their doctor to participate in the SCO. The Sanborn group s CEO believes that residents may be willing to do this. Several residents are with their current doctor because they are a physician that collaborates with Sanborn Home Care, not because they have had a long-term relationship. If the Sanborn group decides to go forward with the partnership to CCA, they will introduce the program to residents and educate them about the benefits of the program and what it will mean to join it. It will be each resident s choice to join CCA or not. This research was funded by the U.S. Department of Health and Human Services and the Department of Housing and Urban Development under contract HHSP WC. The views expressed are those of the authors and are not those of the U.S. Department of Health and Human Services or the U.S. Department of Housing and Urban Development. The LeadingAge Center for Applied Research, bridges practice, policy and research to advance highquality health, housing and supportive services for America s aging population. The Center s three signature objectives are to advance quality of aging services, develop a high-performing workforce and enhance resident options through services and supports. Through applied research, the Center creates an evidence-base to improve policy and practice. LeadingAge is an association of 6,000 notfor-profit organizations dedicated to expanding the world of possibilities for aging. Visit to learn more about the Center s work. 14