CONGREGATE HOUSING

The term congregate housing has both generic and specific meanings. Generically, it refers to multiplex-unit, usually planned, supportive housing for older people (and younger people with disabilities) who need or want assistance with daily activities. Seen as a more independent option than an assisted living or skilled nursing facility, congregate housing typically provides services such as housekeeping, meal preparation, and personal care, and frequently offers the opportunity for a congregate meal. Settings vary, however. For example, the site may have few or many units. It may be freestanding or part of a larger complex. Units may be fully equipped apartments or single rooms. Property management may be separate from or linked to services management. Services may be available to all residents or to a subset. Costs for housing or services, or both, may be publicly subsidized or require a fee.

In its more specific form, the term refers to certain federal- and state-funded programs for people with low incomes and significant needs for assistance with daily activities. These programs are typically located in rent-subsidized housing, follow specific procedures for assessing residents' needs and delivering or arranging services, and limit residents' costs (usually capped at 30 percent of income for rent and 20 percent for services).

This entry discusses supportive housing generally, then highlights the federal Congregate Housing Services Program (CHSP). The entry focuses on residential options for people with low incomes—because their needs are greatest and their options most limited. However, it should be noted that middle-income older people have few supportive housing options. They have too many resources to qualify for publicly subsidized programs, and too few to afford the $2500-plus per month costs of the more upscale supportive housing options (many of which could be described as assisted living facilities or retirement communities). Some private-pay retirement homes, often owned and operated by municipalities or nonprofit organizations, are relatively affordable, with monthly costs averaging $900 to $1500 for rent and a supportive services package that usually includes meals and housekeeping. Since nearly three-quarters of older people have incomes under $32,000 per year, even these "affordable" options are too expensive for many.

Why supportive housing?

Supportive housing for people with low incomes is one reasonable response to the following intertwined factors (among others):

• The number of people who need assistance with daily activities is increasing. The population is aging and younger people with disabilities are living to older ages. In addition, long hospital stays are increasingly discouraged.
• People strongly prefer to live in community rather than institutional settings.
• Policymakers and individuals are interested in cost-effectiveness and flexibility. Settings with large numbers of older residents, such as senior housing, offer unique service delivery opportunities through service "clustering." Clustering can reduce service costs, improve efficiency, and increase flexibility by reducing the number of workers on-site and the minimum hours workers must spend with one person.

Stephen Golant, in his excellent report The Casera Project: Creating Affordable and Supportive Elder Renter Accommodations, put it this way: "Not considering the elder-occupied rent-subsidized facility as a major service delivery target is a badly missed opportunity" (p. 37).

At its best, supportive housing offers accessible environments, well-functioning communities, social support, choices, control, access to flexible, cost-effective health care and supportive services, and social activities. Many observers believe that the setting, with its flexibility and balance between support and challenge, promotes health and functional independence, prevents or slows the progress of disability, prevents or tempers accidents, helps residents adhere to medical regimens, and responds creatively and effectively to diversity (the older population is, on almost any measure, more diverse than any other age group).

Although most older Americans live in single-family housing, about 12 percent—nearly four million—live in multiple-unit housing developments. About twenty thousand of these developments are federally subsidized and built specifically for older people. Many thousands more have been built with federal and state assistance. As residents age in place, these developments and community-based service providers have increasingly responded to residents' service needs. Often residents, families, professionals, and property managers arrange services as best they can (a "patchwork" approach). A more organized and effective strategy is on-site service coordination (also known as "resident service coordination" or "resource coordination").

The goal of service coordinators is to improve residents' quality of life and delay or avoid institutionalization by helping residents to obtain services they need and want. Coordinators play multiple roles, including service broker, community builder, educator, advocate, quality monitor, mediator, investigator, and counselor. Before 1990 the Department of Housing and Urban Development (HUD) and others in the housing realm prohibited service-related activity. Today, thousands of managers and residents depend on coordinators, who are often considered the key to successful supportive housing. The American Association of Service Coordinators was founded in 1999. Many states have active coordinators' associations.

The Federal Congregate Housing Services Program

HUD administers the Congregate Housing Services Program (CHSP). Designed to assist older people and younger people with disabilities to live independently in their own apartments, the CHSP provides housing combined with professional service coordination and supportive services, such as housekeeping, personal care, congregate meals, and transportation. It aims to encourage maximum resident independence in a home environment, improve management's ability to assess eligible residents' service needs, and ensure delivery of needed services.

The CHSP has about one hundred sites across the United States. Some are from the original CHSP, authorized in 1978; the rest have been funded since a new version was authorized in 1990. (The new version mainly increases the amount of financial support required from the housing sponsor and community.) No new CHSP sites have been funded since 1995. CHSP participants pay 30 percent of their (adjusted) income in rent and up to 20 percent for services. HUD, state home- and community-based services programs, Medicaid, and donations cover the remaining costs.

Several studies have documented the original CHSP's overall effectiveness. The following description of the Portland, Oregon, CHSP may help illustrate the model. Four Housing Authority of Portland (HAP) apartment complexes have thirty CHSP slots each, representing about 30 percent of their total population. Each complex has an on-site service's coordinator who works with participants, CHSP staff, and local service providers to arrange and monitor services, recruit and oversee volunteers, and help participants strengthen informal supports. CHSP also employs homemakers and meal service staff. The Professional Assessment Committee, including health and social service professionals, consults with the coordinator on assessment, care planning, and troubleshooting.

Portland CHSP participants are encouraged and assisted to take an active role in advocating and caring for themselves. The program is voluntary, and participants decide what services they will use. Available services include on-site daily meals in a group setting, assistance with housekeeping and personal care, transportation, health and wellness promotion, Senior Companions, affordable foot care clinics, and daytime check-ins by CHSP staff. Trained HAP staff, contracted home health agencies, a nearby nursing school, and many volunteers provide services. Since service coordinators assign service providers to an entire site, workers often shop and do laundry for more than one person at a time, thus keeping costs low.

The Portland CHSP serves five main types of residents: frail older people who live in the CHSP building, at-risk older people from outside the CHSP complexes, deinstitutionalized people, younger people with disabilities, and people with temporary disabilities. Participants generally must be able to be on their own at night and for much of the day, and to be independent in transferring (moving from one position to another [e.g., from wheelchair to bed]) and toileting. The CHSP can often support a person who can transfer but is unstable for some tasks, or who has a temporarily higher level of need.

Looking to the future

Although there has been an increase in supportive housing innovations and initiatives since the late 1980s, supportive housing is still not readily available, and many complexes have long waiting lists. Golant, in The Casera Project, recommends several strategies to expand the availability and quality of supportive housing (pages 33–36), including the following:

• Increased funding for service coordinators
• Incentives for complexes to provide services
• Strengthened partnerships among state agencies, service providers, housing complexes, and others
• Assistance to property managers
• Continued research.

Other strategies include the following:

• Applying the lessons learned from planned supportive housing—especially in terms of service coordination, service delivery, and balancing support and challenge—to buildings or neighborhoods with disproportionate numbers of older people (sometimes known as naturally occurring retirement communities.
• Developing more options for middle-income older people, such as supportive cooperative housing.

Susan C. Lanspery

See also Continuing Care Retirement Communities; Government Assisted Housing; Housing.

BIBLIOGRAPHY

Golant, S. M. Housing America's Elderly: Many Possibilities, Few Choices. Newbury Park, Calif.: Sage, 1992.

Golant, S. M. The Casera Project: Creating Affordable and Supportive Elder Renter Accommodations. Gainesville: University of Florida, 1999.

Heumann, L. F. "A Cost Comparison of Congregate Housing and Long-Term Care Facilities for Elderly Residents with Comparable Support Needs in 1985 and 1990." In Congregate Housing for the Elderly: Theoretical, Policy, and Programmatic Perspectives. Edited by Lenard W. Kaye and Abraham Monk. Binghamton N.Y.: Haworth Press, 1991. Pages 75–98.

Holland, J.; Ganz, L.; Higgins, P.; and Antonelli, K. "Service Coordinators in Senior Housing: An Exploration of an Emerging Role in Long-Term Care." Journal of Case Management 4, no. 3, (Fall 1995): 25–29.

Milbank Memorial Fund, in cooperation with the American Association of Homes and Services for the Aging. Linking Housing and Health Services for Older Persons. New York: MMF, 1997.

Pynoos, J. "Supportive Housing for the Elderly: Past, Present, and Future." The Public Policy and Aging Report 8, no. 2 (Spring 1997): 14–15.

Schulman, A. "Service Coordination: Program Development and Initial Findings." Journal of Long-Term Home Health Care 15, no. 2, (Spring 1996): 5–12.

U.S. Department of Housing and Urban Development. Evaluation of the Service Coordinator Program. 2 vols. HUD-1614-PDC. Washington, D.C.: Office of Policy Development and Research, HUD, 1996.