To provide a foundation for the workshop’s discussions, two keynote speakers discussed the health consequences that inadequate housing can have for vulnerable older adults and individuals with disabilities and addressed some of the barriers that constrain the supply of such housing in the face of rising demand. Lisa Marsh Ryerson, president of AARP Foundation, described housing as the linchpin of well-being and discussed some of the programs her organization has supported in several communities. Erika Poethig, a fellow and the director of urban policy initiatives at the Urban Institute, then described the five dimensions of housing policy along with potential areas for changing housing policy to better support the needs of older adults and individuals with disabilities. A brief discussion moderated by Teresa Lee of the Alliance for Home Health Quality and Innovation followed the two keynote presentations.
Lisa Marsh Ryerson
The definition of a linchpin is a person or thing that holds something together, said Lisa Ryerson of AARP Foundation. At AARP Foundation, Ryerson said, she and her colleagues view housing as the linchpin of well-being both for individuals in a community and for the community
itself. With affordable, livable, and healthy housing, people of all ages and abilities have the opportunity to thrive, she said. Housing and the location of housing are social determinants of health that affect whether an individual has access to sustaining and critical services, to transportation to those services, and to important social connections. Those who struggle to pay their rent or mortgage face critical decisions on a daily basis about what other essentials they will not be able to pay for, such as food, medicine, health care, and transportation. In addition, Ryerson said, people whose housing circumstances contribute to falls, who live in unsafe conditions, or who experience social isolation often find that their health is impaired in the short and long term.
Currently, Ryerson said, approximately 1 percent of the nation’s housing stock is adequately equipped to meet the needs of older adults, having such essential elements as no-step entryways or grab bars (Baker et al., 2014). “That calls us to find long-term solutions to improve homes and communities and to provide health services so that older adults do not have to leave their homes or leave their communities when their health status or health needs begin to change,” Ryerson said. “When housing is at risk, overall well-being is then threatened.” Seeking to play a role in developing and implementing those solutions, AARP Foundation works to help ensure that vulnerable older adults with low incomes have access to healthy and nutritious food and to safe and affordable housing, that they are able to maintain critical social connections, and that they have opportunities to generate income.
Collaboration is essential to AARP Foundation’s work, Ryerson said. “It fuels the collective impact that makes a real difference in people’s lives.” In order to have a positive collective impact, institutional egos must be put aside, with all partners understanding that no single policy, program, or group can solve a complex social problem by itself. “It gets us out of our silos—the comfortable compartments that can restrict our thinking and limit our capacity—to join with others to solve these problems,” she said. Collaboration is essential to tackling persistent, stubborn, and complex social problems such as the availability of affordable and accessible housing that can enable older adults and those with disabilities to continue living in their communities. “Collective impact and a commitment to it allow us to bring a wide range of actors, each with a different lens, background, and expertise, but each sharing a commitment to a common goal,” Ryerson said. “This is how we can meet the needs of all people, including communities of color, the LGBTQ1 community, and people with disabilities.”
To put the issue concerning older adults in context, Ryerson explained
1 Lesbian, gay, bisexual, transgender, and queer or questioning.
that some 10,000 people in the United States reach age 65 every day. The question for many of these Americans is whether their expected quality of life will match their hopes for their future health and well-being. With more than 19 million older adults living in unaffordable or inadequate housing, and given the projections of a dramatic increase in the older adult population in the coming decades, solving this problem becomes even more urgent. For example, falls are the leading cause of injury and injury-related death among adults 65 and older, and according to the National Institute on Aging, 6 of every 10 falls happen at home (NIA, 2013).
The question, Ryerson said, is whether the nation is meeting the housing needs for older adults, and according to a study on older adults and housing conducted by Harvard University, the answer is clearly “No” (Baker et al., 2014). “This disturbing reality drives us to invest in innovative solutions to help people age in place, as almost 90 percent of older adults want to do,” she said. “For older adults to thrive and to live with independence and dignity in the least restrictive setting, we need new ways to provide health services in the most conducive settings, and this means looking beyond the doctor’s office.” It is important, she added, to embrace innovation through a more integrated, person-centered model of health care delivery that broadens the concept of health care so that it is not restricted to a hierarchy headed solely by physicians and so that care can be delivered in more places.
As an example of innovative thinking, Ryerson described a program called Care Angel—winner of AARP Foundation’s Aging in Place challenge—which is using an artificial intelligence-driven assistant that calls older individuals daily to check on their well-being. This assistant records how the older adults are doing and whether or not they have taken their medication. It also asks about their appetite, sleep quality, blood pressure, glucose levels, and other health-related questions. “Care Angel is a compelling example of how we can bring seemingly incongruent sectors together to achieve a common goal, enabling an older person to stay at home, and connecting them potentially to vital health services,” Ryerson said.
Although technology can provide new solutions with great potential to link housing and health, technology cannot be the only answer because human connection is also vital to well-being and quality of life, Ryerson said. The Community Aging in Place—Advancing Better Living for Elders (CAPABLE) program2 developed at the Johns Hopkins School of Nursing, for example, is using teams of occupational therapists, registered nurses,
2 See http://nursing.jhu.edu/faculty_research/research/projects/capable (accessed February 8, 2017).
and licensed contractors to go into homes and work with older adults to make crucial adjustments in their homes and in their daily routines to reduce the likelihood of hospitalization and the need for nursing home care (see Chapter 5). The Green House Project3 (Miller et al., 2016; Sharkey et al., 2011) is another program that links housing and health by providing skilled, individualized nursing care in an environment that looks and feels like home. This latter project is one of several that receives funding from Age Strong, an impact investment initiative of AARP, AARP Foundation, the Calvert Foundation, and Capital Impact Partners that leverages private capital investment for social good.
Simply knowing that affordable and accessible housing is central to both health and well-being—and to achieving the Triple Aim of better quality of care, better outcomes, and lower costs4—is not the same as doing something about affordable and accessible housing, Ryerson said. Despite growing interest in collaborations to bring housing and health together, she said, these types of partnerships have been slow to take off, slow to be replicated, and slow to be taken to a larger scale. During a meeting held by AARP Foundation and LeadingAge, four key elements were identified as critical for collaborations between affordable housing and health care to take hold:
- Identify the specific population to be served.
- Develop a partnership model for coordinating and integrating services.
- Share information between housing and health care partners.
- Create a sustainable business model for housing and health programs.
The focus of AARP Foundation’s work, Ryerson said, is human-centered design. “We look at both traditional and nontraditional models to lift up efforts that address social determinants of health, and regardless of the model, the common goal is to help strengthen the community and to help older adults thrive.” To carry out this effort, AARP Foundation looks for individuals and community-based organizations and professions across sectors that are primed to help and ready to channel their energy for good in new and perhaps unexpected directions. These partners could be organizations that are nonprofit, for-profit, public, private, or academic. For example, Ryerson said, the ShopRite supermarket chain
4 For more information about the Triple Aim, see http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx (accessed February 27, 2017).
found an opportunity to help low-income communities in Philadelphia that went beyond providing healthy food at affordable prices. Ryerson explained that the company provides access to health services, benefits programs, and nutrition services, including dietitians and nutritionists, within its stores. The nutritionists and dietitians conduct cooking demonstrations and workshops and provide one-on-one advice. They also take biometric readings for care-managed patients and track prescribed diet adherence and health changes. Furthermore, the stores provide transportation to and from the home and free food delivery for homebound individuals because the company recognized that these additional services would only be valuable if people could access them. “The need to secure, maintain, and sustain social bonds in order to generate good health over time is equally important,” Ryerson said. Perhaps not surprisingly, these stores have become community centers. These stores, she added, are not only transforming “food deserts into wellsprings of good nutrition, but they’re also building stronger communities by acting as a critical connector to services and to benefits.”
Going forward, it will be important that the health care policy debate in Washington, DC, and in communities around the nation is informed by the lessons learned from promising models for creating partnerships between affordable housing and health care to serve older adults, Ryerson said. “Why not seize this moment in time to find the nexus between seemingly unrelated issues, and for us, as a learning community, to bring those to the fore?” she asked. “It is time for groups that have had little experience working with each other to move from merely sharing an interest to coming forward in true collaboration.” She called on the philanthropic community, the research community, and the government to hasten this movement by supporting and analyzing promising partnerships in the field. “Let us use the skills, experience, empathy, and proximity of people who are well positioned to make a positive impact in a . . . place that falls outside the norm, and let us identify and deploy what I call agents of opportunity, such as Care Angel and other innovators, to help seniors age independently at home and in community.”
“Above all,” said Ryerson in closing, “let us stop tackling the issues of housing and health on parallel tracks that do not intersect. Instead of talking about health and housing separately, let us do what we are doing today and advance the conversation about housing and health together, a conversation that includes practical ideas for addressing inadequate housing stock and quality as well as disparities based on age, race, ethnicity, gender identity, sexual orientation, and disability.”
Fellow and Director of Urban Policy Initiatives
Erika Poethig of the Urban Institute began her remarks by agreeing with Ryerson that breaking down silos is essential if the nation is going to provide affordable and accessible housing for those who need it. Poethig said that during her career focused on busting silos she has learned to “never assume that your framework is the framework that the other person across the table shares.”
Poethig said that she and her colleagues generally frame housing policy using five dimensions: quality, affordability, tenure (i.e., the difference between renting and owning a home), stability, and location. “Each of these, I would argue, has a differential impact on health outcomes, especially for older adults and people with disabilities,” she said.
Housing quality, Poethig said, first became an impetus for policy change early in the 20th century. Although quality drew less attention later in the 20th century, more recently it has re-emerged as an area of policy focus because of elements that can especially affect older adults and people with disabilities. For example, homes that have not been retrofitted, that have poor lighting, or that do not have a bathroom on the first floor are the types of quality conditions that can lead to falls. Not only are falls in the home a major cause of morbidity and mortality in older adults, but in 2015 falls were estimated to account for $31 billion in direct medical costs to Medicare.
The affordability of housing can have implications for an individual’s health. If housing is unaffordable, it compromises an individual’s ability to afford food, medication, and services that are important for maintaining health. This is especially true for many older adults and people with disabilities who support themselves on fixed incomes.
Housing tenure refers to renting versus owning a home. Not having the financial freedom to choose between renting or owning, or not having sufficient rental or purchasing options that are suitable for older adults or people with disabilities, can be another constraint on the ability to access needed services in some communities, Poethig said.
Housing stability refers to how often an individual has to move between homes. Moving can be stressful for anyone, Poethig said, even when an individual is moving to a more positive or better setting. Forced and frequent moves that disrupt care access can be particularly damaging to health. The recent foreclosure crisis, she said, had a negative effect on
housing stability, affecting not only those who owned their homes but also those who were renting a home that was foreclosed on.
Housing location, Poethig continued, is often characterized as being a construct designed to support opportunities for families and young children. Poethig said that supporting opportunity in terms of location for older adults and individuals with disabilities is also important and often not discussed in conversations about housing location.
Interplay Among the Dimensions of Housing Policy
The five dimensions of housing are interrelated, Poethig said, and they can sometimes be in tension with one another. Housing affordability, an area in which the federal government plays a central role, became a major emphasis of federal housing policy in the late 1960s, she said. Today, 83 percent of the U.S. Department of Housing and Urban Development’s (HUD’s) budget is dedicated to programs that provide federal rental assistance. Nonetheless, Poethig said, some 11.2 million households face severe rent burdens, as defined by paying more than half of household income on rent, and 91 percent of these severe-rent-burden households are of extremely low income, meaning they earn less than 30 percent of the area median income. Some 16 percent of the households facing both severe rent burdens and extremely low income are older adults, and 26 percent include at least one adult with a disability. Contrary to popular belief, the problem of severe cost burden is not confined to big cities, Poethig said—housing affordability is an issue that touches suburban, urban, and rural communities.
Federal housing assistance is distributed by a lottery system, Poethig explained. This means that only approximately one in four households that is eligible for assistance receives it. “That is a major challenge in our policy framework,” she said, adding that the aging baby boomer population is going to put even more pressure on rents over time. The Urban Institute has projected that over the next 15 years there will be 13 million new renter households and the number of older adult renter households will more than double, from 5.8 million to 12.2 million. A study conducted by HUD and published in 2015 estimated that only approximately 3–4 percent of households with at least one person with a disability received a housing unit with features designed for individuals with mobility disabilities, even though some 20 percent of the U.S. adult population has at least one disability. Thus, not only is there a constraint in terms of affordability, Poethig said, but there is also a constraint in terms of the supply of housing that is of a quality that is suitable for people with mobility disabilities.
One might ask, Poethig said, why the market is not responding to this
demand by building more homes. The answer, she said, lies partly in the fact that the nation’s housing supply overall is already falling short of the demand. However, she added, the construction of affordable housing will continue to lag because development costs—e.g., construction, labor, and land—are too expensive to produce affordable housing for those living on a fixed income. Therefore, subsidies will always be needed to fill the gap between what it costs to build housing and what many individuals can afford to pay.
A study conducted by Urban Institute found that older adults in the United States spend much more of their income on housing than on health, with housing accounting for approximately 25 percent of their income, Poethig said (Johnson, 2015). Due to property taxes and the costs associated with maintaining a home, this holds true even among those who own their home free and clear, she said. For the 7 million older adults whose incomes are 125 percent of the poverty level, housing costs account for 74 percent of their income. “So absent increased resources for federal rental assistance, America’s older adult population and people with disabilities will continue to face these particular housing instability challenges, and I would argue, poor health outcomes,” Poethig said. One policy barrier to addressing this problem is what Poethig called the “wrong pockets problem,” which refers to the inability of the housing sector to capture the savings to health care expenditures that could result from an investment in housing. “We are just going to see these costs land in another part of the ledger,” she said.
One concern regarding stability is the effect that foreclosures have had on people with disabilities living in group homes established after the 1999 Olmstead Decision ruling by the U.S. Supreme Court.5 Poethig said that HUD does not have any mechanism to address foreclosures or the displacement and housing instability that can result from them. Poethig suggested that the U.S. Department of Health and Human Services provide more clarity on what the technical details of the ruling require in order to identify other possible options for the delivery of services and for arranging housing in a community. This clarity is needed both for the people who work at HUD to develop programs to support the law and for those who work at the U.S. Department of Justice to enforce the law.
HUD does have resources through the Community Development Block Grant Entitlement Program6 to fund repairs, improvements, and retrofits that can benefit homeowners who are older or who have dis-
5Olmstead v. L.C., 527 U.S. 581 (1999). This ruling requires that community-based services be provided to individuals with disabilities when appropriate.
6 For more information, see https://www.hudexchange.info/programs/cdbg-entitlement (accessed February 14, 2017).
abilities, which can help them to remain in their homes. However, Poethig said, these resources are not sufficient to meet demand and are not dedicated solely for retrofitting homes. She noted that the Bipartisan Policy Center7 has been developing ideas for securing new sources of funding for retrofitting homes.
Identifying Policy Levers
Approximately half of the people receiving federal rental assistance are older adults and people with disabilities, but assistance for families with children is equally important, Poethig said. She said that she worries that advocates for these groups will be in tension with one another about the positive role that federal rental assistance can play in improving life outcomes. To avoid this, Poethig suggested that federal rental assistance be expanded to all who are eligible, although she admitted that this is unlikely to happen in the current political climate. Equally important, she added, is preserving the assets that are in place today. Private owners have opted out of their federal subsidy contracts in many communities across the United States. It is destabilizing to older adults and can force them into having to move into another community, she said. In some communities, she added, regulatory barriers can also reduce the supply of affordable and accessible housing.
A new model called “pay for success” is an evidence-based policy tool that could be useful for financing affordable and accessible housing and also for increasing the understanding of the connection between housing and health, Poethig said. This financing model is designed to relieve the government of the risk of investing in a new program. It combines private capital and private investors to provide a source of funds to support the scaling up of evidence-based social programs, and the government repays the investors if the program is successful. The concept of partnerships between different sectors is at the very heart of this program. Poethig said that evidence-based supportive housing8 models are getting attention as potential candidates for pay-for-success programs. This model is still new, with only 11 of the financing programs having begun at this point. One example is found in Denver, Colorado, which is using pay-for-success to pay for supportive housing services, with other programs subsidizing the housing itself. Poethig noted that the recently enacted Comprehensive
8 Supportive housing is non-time-limited affordable housing matched with voluntary ongoing supportive services appropriate to the tenant.
Addiction and Recovery Act9 had originally included $100 million to support the guarantees of pay-for-success programs, but this provision was pulled from the bill before it became law. Urban Institute, she added, has a pay-for-success initiative.10
Expanding the Evidence Base
Poethig concluded her presentation with a call to increase efforts to conduct research and collect data to better understand successful partnerships between housing and health. She cited CareOregon11 and the Support And Services at Home (SASH) program in Vermont12 as successful programs from which more can be learned through research and data collection in order to identify the benefits of connecting housing and health (see Chapter 5). “We need to continue to invest in the evidence to build our understanding of how these kinds of partnerships work, what costs they may be saving, and how we can actually cover those costs,” she said. “That will help us in communication with our partners in Congress.” Poethig also called for more work to disaggregate data or, in some cases, to match data from different agencies in order to increase understanding and further fine-tune available programs.
Dara Baldwin of the National Disability Rights Network started the discussion by commenting that even though rental assistance programs are earmarked for various groups, older adults, people with disabilities, and families are all interconnected: families may have parents or children with disabilities, for example. Baldwin noted the need for data on whom the rental assistance is helping. Poethig agreed that this is an important nuance and an intersection where different communities can come together to advocate for more rental assistance.
Margaret Campbell of Campbell & Associates commented that in addition to quality, accessibility should also be considered a critical dimension of housing policy. She said that HUD does not have standards for accessibility and suggested that the agency develop standards for accessibility similar to those that it has for affordability. Poethig agreed that HUD should create standards for accessibility, adding that she would
9 Comprehensive Addiction and Recovery Act of 2016, Public Law 114-198, 114th Cong. (July 22, 2016).
also like to see the agency update its quality standards to include more considerations for accessibility because those are the standards by which it assesses housing units.
Daniel Davis of the Administration for Community Living asked the panelists if they have insights into why builders are not building housing to the accessibility standards that people need. Ryerson said that this problem confounds her, too, especially considering that accessibility increases livability for everyone across the age span living in an accessible home. Perceived cost is a factor, she acknowledged, which makes it important to look at the evidence that shows that meeting accessibility standards comes with overall cost savings. One aspect of the problem, Poethig said, is that the housing in many parts of the country was built before creation of the standards set by the Americans with Disabilities Act.13 Another issue, she added, is that 50 percent of the nation’s rental housing is in small buildings such as single-family detached units whose owners may not be aware of the rules and standards as they apply to the single-family housing market. Daniela Koci of Loveland Village said that her organization has developed an affordable housing apartment complex for individuals with developmental disabilities and their caregivers. A big hurdle the organization faced was that the standards for cost per unit set by state and federal funders such as HUD were lower than the thresholds for many universal design principles, which created challenges for procuring funding. “So if you are a private developer, it is not worth it on the profit side, and if you are a nonprofit it is hard to secure funding because the cost per unit is so high up front,” she said.
Caroline Blakely of Rebuilding Together asked the keynote speakers for suggestions on how to effectively communicate the importance of the connection between housing and health to leaders in the private capital and corporate sectors. Ryerson said that it is important to generate and disseminate data to show how safe, adequate housing benefits both individual health and community health. Lee agreed that building an evidence base is crucial for bringing new partners to the table, including those in the for-profit world. She added that some of the new health care delivery and payment models might provide an incentive for more activity in the housing realm. She pointed to recent work by Eric Fisher and colleagues at the Dartmouth Institute for Health Policy and Clinical Practice (Fraze et al., 2016), who found that leaders of accountable care organizations are starting to think about the connections between health and social determinants of health, such as housing, transportation, and food. “I think we might be getting close to a tipping point of connectedness, but we are not quite there yet,” Lee said. Poethig added that the
13 Americans with Disabilities Act of 1990, Public Law 101-336, 101st Cong. (July 26, 1990).
30-day hospital readmission metric for Medicare reimbursement could serve as a lever to convince health care systems to pay more attention to housing issues.
Sarah Triano of Centene Corp., a Medicaid managed care organization, asked the panelists if they knew of any innovative projects using telehealth. Lee replied that telehealth is used often in the home health context, in part because of the payment structure—i.e., providers are paid per episode, not per visit. Her organization’s website14 includes innovation profiles that it has developed involving telehealth. This technology, Lee said, may help a strained workforce meet the growing needs of older adults and individuals with disabilities who want to remain in their homes.
Karen Anderson of the National Academies of Sciences, Engineering, and Medicine asked the panelists to comment on how the issues and ideas they raised specifically affect minorities and low-income individuals. Poethig replied that HUD’s federal rental assistance program primarily serves people who are very poor and vulnerable, and minorities represent a disproportionate percentage of those receiving rental assistance. Therefore, she said, federal rental assistance presents an opportunity and a platform upon which to connect and address broader issues surrounding health disparities. Ryerson agreed and noted that it is important when forming solutions to be thoughtful about how different lenses of identity might intersect. “Communities cannot and will not be healthy unless we make that consideration at the forefront of all of our design thinking,” she said. “We have to stop this collective thinking that it is okay to subtract the talent and contributions of some members in communities.”