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1 Supporting Aging in Place in Subsidized Housing: An Evaluation of the WellElder Program Alisha Sanders, MPAff and Robyn Stone, DrPH January 2011

2 Funding for this project was provided by the SCAN Foundation. The views presented here are those of the authors and do not necessarily represent the official statements or views of the funders. The SCAN Foundation is an independent, not-for-profit charitable foundation dedicated to longterm services and supports that keep seniors self-sufficient, at home and in the community. As the only foundation with a mission focused exclusively on long-term care, The SCAN Foundation is taking action to develop and support programmatic and policy-oriented recommendations and solutions that address the needs of seniors and influence public policy to improve the current system. Supporting Aging in Place in Subsidized Housing: An Evaluation of the WellElder Program 2011, LeadingAge and the LeadingAge Center for Applied Research. All rights reserved. LeadingAge Center for Applied Research 2519 Connecticut Avenue, NW Washington, DC The LeadingAge Center for Applied Research, formerly IFAS, bridges practice, policy and research to advance high-quality 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 5,500 not-for-profit organizations dedicated to expanding the world of possibilities for aging.

3 Table of Contents Chapter 1 Introduction... 1 Statement of the Problem... 1 Rationale... 2 Study Overview... 3 Study Methodology... 3 Study Limitations and Challenges... 6 Chapter 2 Housing Communities and Resident Characteristics... 8 Housing Communities... 8 Resident Characteristics... 9 Resident Incidents Resident Move Outs Chapter 3 WellElder Program Implementation Program History Program Elements Chapter 4 Study Findings Program Benefits Differences between Members and Non-Members Program Participation Chapter 5: Conclusions and Recommendations WellElder Implementation Impact of the WellElder Program Potential for Replication Recommendations for Improvement Concluding Remarks References Appendix A: Group Education Sessions Appendix B: Resident Self-Administered Survey Results, by Membership... 63

4 List of Tables and Exhibits Table 2.1 Housing Property Characteristics... 8 Table 2.2: Resident Age, Gender and Residential Status Table 2.3: Resident Race and Ethnicity Table 2.4: Resident Place of Birth and Language Table 2.5: Resident Receiving MediCal Table 2.6: Self-Reported Health Status Table 2.7: Self-Reported Health Conditions Table 2.8: Percent of Residents Reporting Multiple Chronic Health Conditions Table 2.9: Percent of Residents Troubled by Pain Table 2.10: Percent of Residents Reporting ADLs and IADLs Table 2.11: Resident Reported Types of ADLs and IADLs Table 2.12: Resident Reported Falls Table 2.13: Resident Reported Emergency Room Visits, Hospital Stays and Outpatient Surgeries Table 2.14: Resident Reported Prescription Medications Table 2.15: Support from Family, Significant Others or Friends Table 2.16: Reported Level of Assistance Provided by Family, Significant Others or Friends Table 2.17: Resident Incidents Table 2.18: Resident Move Outs Table 3.1: Staffing Pattern Table 3.2: WellElder Program Membership Table 3.3: Non-Member Reasons for Not Joining WellElder Program* Table 3.4: Potential of Joining Program in Future Table 3.5: Number of Member Visits to WellElder Staff Table 3.6: Percent of Participants with At Least One Visit to WellElder Staff Table 3.7: Average Number of Visits to WellElder Staff per Member Table 3.8: Percent of Members with At Least Five Visits to WellElder Staff Table 3.9: Frequency of Services Provided by Service Coordinator Table 3.10: Frequency of Services Provided by Health Educator Exhibit 1: Examples of Residents Assisted through the WellElder Program Table 4.1: How the WellElder Program Helps Residents* Table 4.2: Differences between WellElder Program Member and Non-Member Characteristics Table 4.3: Differences between WellElder Program Member and Non-Member Service Use Table 4.4: Number of Resident Incidents Table 4.5: Percent of Residents Experiencing Incidents Table 4.6: Resident Move Outs and Destination... 48

5 Chapter 1 Introduction The goal of this study is to evaluate the WellElder Program, a program developed and implemented in four low-income senior housing properties in the San Francisco bay area operated by Northern California Presbyterian Homes and Services (NCPHS) and Bethany Center Senior Housing. The program pairs a nurse health educator and resident service coordinator to help elderly residents maintain independent living by offering wellness and health education, health monitoring and individualized service coordination. The study is intended to add to the evidence base of the potential benefits of integrating health and supportive services into subsidized housing for older adults. Statement of the Problem Advanced age and low income place older adults at greater risk for chronic illness and disability, and consequently in greater need of health and long-term care services (Redford and Cook, 2001). For example, individuals age 85 and older are seven times more likely to need help with basic personal tasks like getting around the house, dressing, bathing, eating and going to the toilet than individuals age 65 to 75 (National Center for Health Statistics, 2007). Four out of five older adults age 65 and older have one or more chronic health conditions such as hypertension, heart disease or arthritis that may contribute to disability, while half experience at least two (Centers for Disease Control and Prevention, 2007). Multiple chronic diseases, along with poor health status and functional limitations, are more prevalent among the lower-income elderly. Individuals with multiple chronic conditions are particularly vulnerable to suboptimal care (Vogeli, 2007). They tend to use services more frequently and a greater array of services, which makes coordination of care more difficult. The number of different physicians seen annually by the average Medicare patient with a chronic condition ranges from four for persons with one condition up to 14 for persons with five or more conditions. As the number of providers involved in patients care increases, patients are likely to find it increasingly challenging to understand, remember and reconcile the instructions of those providers. Because persons with multiple chronic conditions take more medications on average, they are more likely to suffer adverse drug events. Having multiple chronic conditions also makes it more challenging for patients to participate effectively in their own care. Many people 65 and older have significant difficulty reading and comprehending medical information that is pertinent to their health. In one study of enrollees in a Medicare managed care plan, more than one-third of study participants had inadequate or marginal health literacy and the prevalence was found to increase steadily with age (Gazmararian et al., 1999). 1 Individuals with 1 Health literacy is not limited to the ability to read, but also includes the ability to understand instructions on prescription drug bottles, appointment slips, medical education brochures, doctor's directions and consent forms, and the ability to negotiate complex health care systems. It requires a complex group of reading, listening, analytical, and decision-making skills, and the ability to apply these skills to health situations (National Library of Medicine, 2010). Evaluation of the WellElder Program 1

6 lower incomes are also more likely to have limited health literacy (Office of Disease Prevention and Promotion). Health literacy affects people s ability to navigate the healthcare system, including filling out complex forms and locating providers and services, share personal information such as health history with providers and engage in self-care and chronic-disease management (Office of Disease Prevention and Health Promotion). Low health literacy has been linked to lower use of preventative services (Scott, Gazmararian, Williams and Baker, 2002). It has also been found to be linked to lower self-rated health status and higher rates of hospitalization and emergency room use (Cho, Lee, Arozullah and Crittenden, 2008). An older adult s inability to manage their health and functional needs not only potentially endangers their ability to remain safely independent in their own home, but the high utilization of health care services increases the cost burden on both the individual and the Medicare and Medicaid systems. For several years, policymakers, service providers and aging advocates have sought new ways of organizing long-term care supports in a manner that is both desirable and affordable. The emphasis has been on shifting away from institutional services and expanding opportunities for older adults to receive the assistance they need in the community. More recently, there has also been greater focus on strengthening care delivery options to help older adults with chronic conditions better manage their diseases and their transitions across settings, with the goal of improving their health outcomes and quality of life while lowering costs. One promising option for helping meet these goals is subsidized senior housing communities. With their economies of scale, the properties provide a potentially efficient platform to reach a concentrated number of individuals who could benefit from better self-care knowledge, monitoring and referral to appropriate community services. Interventions that link health and supportive services to low-income senior housing may assist elderly residents to better manage their health, decrease their use of emergency room and hospital services and maintain independence in their apartments for a longer period of time thus delaying or preventing transfers to a higher level of care. Rationale About two million low-income older adults, mostly single women in their mid 70s to early 80s, live in independent, largely multi-unit federally subsidized housing more than the number who live in nursing homes (Wilden and Redfoot, 2002). Findings from a range of studies indicate that significant numbers of these residents are aging and experiencing chronic illnesses and/or disabilities. According to the U.S. Department of Housing and Urban Development, the median age of Section 202 residents in 2006 was 74 years old and almost one-third of residents were 80 or older (Haley and Gray, 2008). In an analysis of the AHEAD Wave 2 survey (Asset and Health Dynamics Among the Oldest Old), Gibler (2003) found that older subsidized housing residents reported being in poorer health than unsubsidized renters and experienced more chronic health conditions. Gibler s study also indicated that subsidized housing residents have a significantly Evaluation of the WellElder Program 2

7 higher number of difficulties carrying out basic activities of daily living (ADLs) and instrumental activities of daily living (IADLs) than unsubsidized renters. 2 Using data from the 2002 American Community Survey, Redfoot and Kochera (2004) found that older renters receiving subsidies were twice as likely to experience activity limitations as home owners. Over half reported limitations in activities such as walking and climbing stairs, compared to one quarter of older homeowners. A third reported difficulty with shopping or going to the doctor, twice that of older homeowners. Estimates prepared for the U.S. Commission on Seniors and Affordable Housing (2002) show that one third of subsidized renters have some difficulty with ADLs and 12 percent have a mental or cognitive disability that interferes with everyday activities. A 2006 survey of managers for Section 202 and Low Income Housing Tax Credit (LIHTC) properties indicated that a significant portion of Section 202 residents (36 percent) and LIHTC residents (38 percent) are frail (have difficulty walking or performing everyday tasks) or disabled (Kochera, 2006). Together, the above studies suggest significant numbers of older adults with chronic illness and disability live in subsidized housing settings, many of whom are highly likely to have difficulty managing their health care needs and have unmet needs for assistance with basic activities. Interventions that link health and supportive services to low-income senior housing may assist elderly residents in remaining healthier and more independent in their apartments for a longer period of time, minimize ER and hospital visits and delay or prevent nursing home transfers. Study Overview The study was conducted by the LeadingAge Center for Applied Research. Funding for the project was provided by The SCAN Foundation. The study had three objectives: Objective 1: Describe the components of the WellElder Program and understand its implementation, including how consistently the program is implemented across the 4 sites. Objective 2: Understand program users and non-users and the factors associated with the decision to enroll. Objective 3: Understand the perceived benefits of the program to the residents, their families, the staff and the properties. Study Methodology The formative evaluation employed a multifaceted, qualitative and quantitative methodology. Data collection strategies included: a self-administered resident survey focus groups structured interviews 2 ADLs refer to basic activities of daily living such as bathing, dressing, eating, going to the toilet and getting around the house. IADLS refer to instrumental activities of daily living such as shopping, housekeeping, taking medications, using the phone etc. Evaluation of the WellElder Program 3

8 services provided, resident incident and resident move out tracking system The evaluation was conducted over a one-year period between July 2009 and June 2010, with service use, incident and move out data tracked for an eight-month period from October 2009 through May The study was reviewed by an Institutional Review Board to ensure all data collection activities met guidelines for human subject protection and was granted an exempt status. Each data collection component is described in more detail below. Resident Survey A self-administered survey was distributed to all residents in the four participating properties. Two survey versions were created, one for WellElder program members and another for nonmembers. Each survey contained two sections. The first section was identical in both surveys and asked residents about their health and functional status, their health service use, the support network and their service use. The second section differed in each survey, asking program members about their use of and benefits from the program and asking non-members why they chose not to participate in the program. Membership status was identified by the WellElder staff and any mention of the term WellElder in the survey was clarified as the program in your building where you receive assistance from the service coordinator and nurse. The appropriate survey was distributed to each resident s mail box and residents returned completed surveys to a secure box in a common location in the property. The surveys were anonymous and confidential and contained no personal identifiers. Surveys were translated into five languages, including Russian, Chinese, Korean, Vietnamese and Spanish. Assistance completing the survey was provided to residents requesting help. To help encourage a higher response rate, residents in each property were entered in a drawing for a gift card upon completing the survey. Response rates for the survey were as follows: Surveys Completed Total Residents Response Rate Property % Property % Property % Property % TOTAL % Interviews Structured, one-on-one interviews were conducted with the service coordinators, health educators, property managers and the NCPHS Director of Resident Services. These formal interviews were supplemented with several informal conversations to gain additional information and clarity about the WellElder program. Two rounds of interviews were completed with the service coordinators and health educators in each of the four housing properties. The first set of interviews focused on understanding how the program operates. The second round focused on the perceived benefits of the program to the residents, the housing property and others. The property manager of each housing site was also interviewed about the perceived benefits of the program to residents and the housing property. The NCPHS Director of Resident Services was interviewed about the history and development of the program, program operations and perceived benefits of the program. Evaluation of the WellElder Program 4

9 Focus Groups Focus groups were conducted with WellElder program members and non-members. Membership status was identified by the WellElder staff in each property. Groups were conducted in English, Russian and Chinese to ensure that the experiences and opinions of non-english speakers were captured. The purpose of the focus group with program members was to understand what type of assistance they receive from the WellElder program, what they think are the benefits of the program, what difference they believe it would make if the program were not available and any ways they would change the program. The focus group with non-members attempted to understand why they do not participate in the program, if they perceive there are any benefits of the program, where they currently get assistance with their health and wellness needs and whether they ever foresee participating in the program. A total of 11 focus groups were held, six with program members (two in English, two in Chinese, and two in Russian) and five with nonmembers (three in English, one in Chinese and one in Russian). Residents were compensated $20 for their participation. Services Provided, Incident and Move Out Tracking Data was tracked over an eight-month period from October 2009 to May 2009 in the three areas described below. This information was partially collected by the WellElder staff and the study team worked with the WellElder staff to develop formal data collection forms that added additional elements to the data already collected by the staff. The study team provided training and an instruction guide on the data collection processes. At the beginning of the study, the WellElder staff assigned each member and non-member an ID number. All data was tracked by those ID numbers so that no personal identifiable information was shared with the study team. All data was provided to the study team on a monthly basis. 1) Services provided by the service coordinator and health educator - The service coordinator and health educator in each building tracked the type of assistance they provided to WellElder program participants. The tracking form used was based on a prior form used by the WellElder staff. This was done to help enhance the consistency of the data since it was a form and method they were already familiar with. WellElder staff tracked the date the participant was seen, the amount of time spent directly with the resident, the amount of collateral time spent doing follow-up or other activities related to that visit and the types of assistance provided during the visit. The types of services that were tracked can be seen in Table 3.9 (service coordinator) and Table 3.10 (health educator). Only services related to the WellElder program, i.e. health and wellness, were tracked by the service coordinator. For example, if the service coordinator helped a resident receive a rebate from an energy assistance program for low-income seniors, that service would not be captured for this study. 2) Resident incidents The WellElder staff tracked significant incidents, including falls, 911 calls, emergency room visits, hospital stays and nursing home stays. This data was tracked for both WellElder members and non-members. WellElder staff identified the incidents through incident reports provided by the property management, security logs, or through direct knowledge of resident events. 3) Resident move outs The WellElder staff tracked resident move outs and the reason for move out. Reasons included moving to another senior subsidized apartment community, Evaluation of the WellElder Program 5

10 to another apartment property, in with family, to a residential care for the elderly/assisted living facility, to a nursing home or death. WellElder staff identified move outs and their reason from property management. Data Analysis Study data was analyzed through a combination of qualitative and quantitative methods. Findings from both the quantitative and qualitative techniques were interwoven to provide a comprehensive analysis. Qualitative data came from the resident focus groups and structured and informal interviews. A deliberate, inductive process was employed to analyze the data moving from individual interview and focus group write-ups to site level and group summaries and, ultimately, to a synthesized set of findings across the properties. For the focus groups, the note taker and moderator debriefed shortly after each group and took notes to record key themes. When all focus groups were completed, the study team identified key themes across all the groups and across each housing property. The same process was used with the structured interviews. Quantitative data were collected from the resident self-administered survey and the services provided, resident incident and resident move out tracking process. All data were entered into Excel and imported into SAS for data analysis. For the resident survey, various statistical tests were run, including basic descriptive statistics establishing means, medians, and frequency distributions by individual housing properties and program members and non-members. Fisher s exact tests were used to compare members versus non-members in categorical variables and T- tests were used for numeric variables. Descriptive statistics were calculated to describe the frequency of service and time spent on services for the various types by property and by race/ethnicity. Event rates and incidence of various health events were calculated by property and membership status. Study Limitations and Challenges Every research study faces limitations and challenges. In this study, limitations are defined as issues that are inherent in the type of research being conducted. Challenges are defined as issues that arose during the course of conducting the study that are barriers to achieving study objectives and which were (or were not) overcome. Two major limitations are noted. Although the study compared users with non-users, a control group was not available, which prevented examining the impact of the program on resident outcomes. The study should be viewed as descriptive and providing information on possible relationships that could be explored with additional resources to support a more rigorous design. In addition, focus group participants who provided an evaluative perspective on the WellElder program were told beforehand about the general topic area that would be discussed. The residents who agreed to participate were self-selecting or recommended by the WellElder staff as is true of many focus group efforts. Although the results from the focus groups were analyzed in conjunction with other data sources, the possible introduction of bias based on focus group makeup must be acknowledged. Evaluation of the WellElder Program 6

11 Two primary challenges were encountered in the data collection process. First, service use data was tracked by the individual service coordinators and health educators in each of the four housing properties. WellElder staff visits with residents can address multiple issues and it is possible that all service coordinators and health educators did not categorize the types of assistance they provided similarly. Most areas of assistance are distinct but some are slightly more subjective. Although the study team provided guidance for all WellElder staff on the data collection process, there is still a possibility of some inconsistent tracking across properties. Additionally, service coordinators were asked to track only those services that were considered WellElder services and not all services they provide. WellElder services are ones that have a health and wellness-related element. Although guidance was given to service coordinators about the types of services to track and not track, they still individually decided what services to record. It is possible that there may be some inconsistencies across the service coordinators in what services they did or did not record. To maximize uniformity and ensure the quality of the data, the study team reviewed the data submitted monthly from the service coordinators and health education for potential recording discrepancies and had frequent conversations with them to help ensure consistency. Second, the data on resident incidents (falls, 911 calls, ER visits, hospitalizations and nursing facility stays) may be incomplete. Because the properties are independent housing communities, they do not track the coming and going of residents and residents are not required to check in with the property. All of the properties have 24-hour onsite security who see everyone coming and going into the building. In addition, all residents have emergency notification systems in their apartments to notify security when they have an emergency and need assistance. Most transfer in and out of the building due to one of the incidents being tracked would have been recorded by the security who then create incident reports. In addition, residents often alert the WellElder staff when they have had an incident, and neighbors often do the same. There is a chance, though, that an incident may have gone unknown to the property or WellElder staff. For example, a resident s doctor may send them directly to the ER from an appointment in their office. Evaluation of the WellElder Program 7

12 Chapter 2 Housing Communities and Resident Characteristics The WellElder program operates in four senior housing communities in the San Francisco Bay and San Jose areas. Three of the properties Eastern Park Apartments, Western Park Apartments and Town Park Towers are operated by Northern California Presbyterian Homes and Services for the Aging. The fourth Bethany Center Senior Housing is a free-standing community. Each is an affordable independent rental property designed for low-income seniors aged 62 and above. Each property has articulated a philosophy of helping to support their residents to meet their health and supportive service need and to safely age in place. Housing Communities The four properties were developed through funding mechanisms from the U.S.Department of Housing and Urban Development. One property was developed through the Section 202 program, which is the only federal financing source specifically for senior housing. A Section 202 property receives a construction loan plus project-based rental subsidies that limit the tenant s monthly rent payment to 30 percent of their income. Qualified tenants generally must be at least 62 years old and have incomes less than 50 percent of the area median income. The other three properties were developed through the Section 236 program. Section 236 is a mortgage interest subsidy program for all age levels, but properties can be designated for elderly households. Tenant eligibility is limited to households earning under 80 percent of the area median income. HUD sets a basic rent and tenants must pay either the basic rent or 30 percent of their income, whichever is higher. However, the property may also receive some form of rental assistance subsidy, such as Section 8, that limits the tenant s monthly rent payment to 30 percent of their income. These rental subsidies may cover all or a portion of the units in the property. Table 2.1 describes the type of subsidy mechanism through which each property was developed, the number of units and residents in each property and the median income of the resident population. Table 2.1 Housing Property Characteristics Property 1 Property 2 Property 3 Property 4 Subsidy Type Section 202 Section 236 Section 236 Section 236 Number of Units Units with Project-based Rent Subsidies* Number of Residents** Median Resident Income*** $9,772 $14,700 $15,312 $10,288 *Some residents in units that do not have an attached project-based rental subsidy may have a tenant-based Section 8 voucher from the City of San Francisco. **At start of data collection period. ***Information provided by each housing property from their tenant eligibility system. Evaluation of the WellElder Program 8

13 Resident Characteristics Residents in all four housing properties were asked to complete a self-administered survey that asked about their background, health and functional status, health services use and support network. The following description of residents is drawn from the survey responses. Summary of Resident Characteristics The median age of the housing residents is 78 years with the youngest age 38 and the oldest age 95. Sixty-three percent of the residents are female and three out of five live alone. The resident population is extremely diverse. Only one third of the residents are white, ranging from 14 percent to 58 percent across the four properties. The largest group 58 percent is Asian. A little less than one in 10 are Hispanic (ranging from four percent to 21 percent across the properties) and a little less than 3 percent are black or African American (ranging from one percent to six percent). Only 14 percent of the residents were born in the United States and only 16 percent report English as their first language. The majority of the resident population across the four properties is of Chinese or Russian origin. With respect to their health status, 71 percent of the residents indicated that their health was fair to poor. Over half (54 percent) reported having three or more chronic conditions with the three top illnesses identified as high blood pressure, arthritis and heart problems. A little over one third of the residents reported having a memory-related disease and 28 percent reported emotional or psychiatric problems. The latter two conditions are particularly likely to be underestimated given that they are self-reported and subject to concerns about stigma or lack of knowledge. Three out of four residents across all four properties reported that they are troubled with pain, with a little less than one in four indicating that they are in severe pain. On average, residents reported taking six prescription medications, ranging from none to 21. In terms of functional status, over one half (55 percent) of the residents report that they have limitations in one or more activities of daily living. More than one third (35 percent) have fallen at least once over the past 12 months. With respect to service use, almost one third of the residents reported using the emergency department over the past year. One in five had been hospitalized at least once and close to one in four had received out-patient surgery. The majority of residents reported the availability of some level of social support. Eighty-seven percent indicated that they had someone in the area to call if necessary. Almost one half indicated that they received calls from someone in their social network on a daily basis; one out of five reported having daily visits. On the other hand, 30 percent of the residents received visitors once a month or less. When asked about assistance from their social networks, 11 percent reported that they did not need any help. At the opposite extreme, almost one third reported receiving considerable assistance. Evaluation of the WellElder Program 9

14 It is possible that the survey results may overestimate residents health level and understate their functional status to some degree. Potentially some of the residents who did not participate were the frailer residents who might have more difficulty completing the survey. It is also possible residents may not have accurately disclosed their health status, health conditions or level of disability and need for assistance. This may reflect residents denial about their health status and functioning level or fear that revealing information about their needs will jeopardize their ability to remain in an independent living setting. Demographics As shown in Table 2.2, the median age of residents completing the questionnaire in the four properties is approximately 78 years old. Considering only residents age 62 and over, the median age is 79 years old. Between 58 and 69 percent of residents completing the survey are female. This proportion is slightly smaller than is generally seen in affordable senior housing properties, where an average 80 percent of residents are females. The survey also revealed fewer residents who live alone in comparison to the average affordable senior housing property. Table 2.2: Resident Age, Gender and Residential Status Property 1 Property 2 Property 3 Property 4 Total Median Age Age Range Gender 41.3% male 58.7% female 31.0% male 69.0% female 38.4% male 61.6% female 36.4% male 63.6% female 37.1% male 62.9% female Live alone 44.6% 60.7% 69.6% 61.4% 60.2% The four properties are racially and ethnically diverse, as reflected in Table 2.3. All four properties have a large immigrant population, with the dominant groups being Chinese and Russian. Table 2.4 shows that the majority of residents completing the survey were born outside of the United States and do not speak English as their first language. Table 2.3: Resident Race and Ethnicity Property 1 Property 2 Property 3 Property 4 Total Hispanic 5.8% 3.9% 7.3% 21.0% 9.1% White Black or African American Asian Native Hawaiian or other Pacific Islander American Indian or Alaska Native Other Evaluation of the WellElder Program 10

15 Table 2.4: Resident Place of Birth and Language Property 1 Property 2 Property 3 Property 4 Total Born in the U.S. 6.5% 26.2% 16.7% 6.9% 14.2% English is first language Table 2.5 shows the proportion of residents in the four properties who report receiving MediCal benefits. 3 Across all the properties, over three-quarters of residents are able to access assistance through the Medicaid program. The lower percentage of residents in Property 2 receiving MediCal in comparison to the other properties may be due to the larger number of units in the property that do not have attached rental subsidies resulting in some residents with higher incomes that make them ineligible for MediCal. Table 2.5: Resident Receiving MediCal Property 1 Property 2 Property 3 Property 4 Total Receive MediCal 82.7% 56.6% 84.9% 90.9% 79.7% Health and Functioning As shown in Table 2.6, between 62 and 85 percent of residents across the four properties reported their health as fair or poor, while 15 to 38 percent said they were in good to excellent health. According to the 2009 National Health Interview Survey, 23.9 percent of adults age 65 and over perceive their health as fair or poor. Among adults age 62 and older who receive both Medicare and Medicaid a population that may be comparable to the population in this study 52.8 percent rated their health as fair or poor (Center for Disease Control and Prevention, 2010). Table 2.6: Self-Reported Health Status Property 1 Property 2 Property 3 Property 4 Total Excellent 0% 2.4% 2.9% 1.2% 1.8% Very good Good Fair Poor The resident questionnaire also asked respondents to identify specific health conditions they were currently experiencing. Table 2.7 shows the most common health conditions reported were high blood pressure (67.2% of all residents), arthritis (66.8%) and heart problems (42.4%). Several residents also reported memory-related disease (35.4%), diabetes (30.4%) and emotional, nervous or psychiatric problems (27.8%). According to the 2009 National Health Interview Survey, 51.0 percent of persons age 65 and over report a doctor s diagnosis of arthritis, 56.2 percent experience hypertension, 30.8 percent 3 MediCal is the name of the Medicaid program in Calinfornia. Evaluation of the WellElder Program 11

16 suffer from all types of heart disease and 19.5 percent report diabetes (Center for Disease Control and Prevention, 2010). Among persons age 65 and older who receive both Medicare and Medicaid, the incident of these health conditions is higher: 58.3 percent report a doctor s diagnosis of arthritis, 69.1 percent experience hypertension, 36.4 percent suffer from all types of heart disease and 29.9 percent report diabetes. These proportions are similar to those of the survey respondents in the four housing properties. High blood pressure or hypertension Table 2.7: Self-Reported Health Conditions Property 1 Property 2 Property 3 Property 4 Total 68.1% 61.5% 67.4% 71.3% 67.2% Arthritis or rheumatism % Heart problems % Memory-related disease % Diabetes or high blood sugar % Emotional, nervous, or psychiatric problems % Cancer or a malignant tumor % Chronic lung disease % Several residents in the four properties experienced multiple chronic health problems, which might indicate a significant need for services and supports. As shown in Table 2.8, between 44 and 70 percent of residents across the four properties reported having three or more of the conditions noted in Table 2.7. In 2006, 54.2 percent of non-institutionalized Medicare beneficiaries age 65 and older reported living with three or more chronic health conditions (Cubanksi et al, 2010). Table 2.8: Percent of Residents Reporting Multiple Chronic Health Conditions Property 1 Property 2 Property 3 Property 4 Total No Chronic conditions 3.3% 11.9% 12.2% 5.8% 8.7% 1+ Chronic conditions Chronic conditions Chronic conditions Residents were asked if they were often troubled by pain and, if so, how bad the pain is most of the time. Table 2.9 shows that 68 to 82 percent of respondents across the four properties reported being in frequent pain. Of those, a large proportion is experiencing moderate to severe levels of pain. Evaluation of the WellElder Program 12

17 Table 2.9: Percent of Residents Troubled by Pain Property 1 Property 2 Property 3 Property 4 Total Often troubled with pain 82.4% 67.9% 70.7% 78.2% 74.4% Level of Pain Mild Moderate Severe The self-administered survey also collected information on functional status to determine the level and types of disability experienced by residents. This information is useful in estimating the proportion of residents who might need assistance or services to help compensate for disability. Table 2.10 presents the percentage of residents reporting functional limitations. Functional limitations are classified into two categories limitations in Activities of Daily Living (ADLs) such as eating, bathing, dressing, getting in and out of bed or using the toilet and limitations in Instrumental Activities of Daily Living (IADLs) such as preparing meals, managing money, shopping, doing housework and using a telephone. Across the four properties, almost a quarter of respondents reported no limitations in ADLs or IADLs, while one-fifth said they need assistance with only IADLs and just over half reported needing assistance with one or more ADL. Table 2.10: Percent of Residents Reporting ADLs and IADLs Property 1 Property 2 Property 3 Property 4 Total No ADL/IADL limitations 18.6% 35.7% 26.7% 16.5% 24.6% IADL limitations only ADL limitations According to the 2007 Medicare Current Beneficiary Survey, 13.8 percent of older adults aged 65 and above reported needing assistance with IADLs only and 24.5 percent reported needing assistance with ADLs (Federal Interagency Forum on Aging Related Statistics, 2010). This comparison suggests that the level of disability among the residents in the four housing properties is higher than in the general population of older adults. Table 2.11 details the types of ADLs and IADLs residents reported in the self-administered surveys. Evaluation of the WellElder Program 13

18 ADLs IADLs Table 2.11: Resident Reported Types of ADLs and IADLs Property 1 Property 2 Property 3 Property 4 Total No ADLS 36.1% 51.2% 48.5% 44.7% 45.5% Bathing/Showering Dressing Transferring from bed/chair/car Using the toilet Incontinence Eating No IADLs 21.6% 39.8% 29.6% 17.6% 27.4% Using the telephone Shopping Preparing meals Housekeeping Doing laundry Traveling to places out of walking distance Taking medications Managing money or finances The self-administered survey asked residents if they had fallen down in the past 12 months and, if so, how many times. Table 2.12 shows that about one-third of residents across the four properties reported having a fall in the past year, with a median of 2 falls per resident reporting a fall. According to the Centers for Disease Control and Prevention, an estimated three out of ten persons age 65 and older experience a fall each year (CDC, 2006). Table 2.12: Resident Reported Falls Property 1 Property 2 Property 3 Property 4 Total Had a fall 33.7% 32.5% 35.9% 37.4% 35.1% Median # of falls Range Health Service Use Residents were asked if they had gone to a hospital emergency room, been a patient in a hospital overnight or had any outpatient surgeries in the past 12 months, and, if so, how many times. Table 2.13 shows that between 27 and 40 percent of residents across the four properties reported having a trip to the ER in the past year. A slightly smaller proportion, between 13 and 25 percent, reported having an overnight hospital stay. A number of residents across the four properties, from 20 to 30 percent, said they had an outpatient surgery over the past year. Evaluation of the WellElder Program 14

19 Table 2.13: Resident Reported Emergency Room Visits, Hospital Stays and Outpatient Surgeries Property 1 Property 2 Property 3 Property 4 Total Emergency Room Visit 39.8% 26.5% 29.8% 32.9% 31.7% Median # of visits Range Hospital Stay 25.0% 13.4% 20.5% 20.0% 19.9% Median # of stays Range Outpatient Surgery 30.1% 19.5% 30.4% 20.2% 25.7% Median # of surgeries Range In 2006, 30 percent of beneficiaries in traditional fee-for-service Medicare reported at least one visit to the ER. Among this same group, 21 percent reported at least one inpatient hospital stay, but hospitalization rates varied by characteristics such as health status, age and income. Hospitalization rates were higher among those in poor or fair health (38 percent and 30 percent, respectively), among those ages 85 and older (33 percent), and among those with incomes less than $20,000 (25 percent) (Cubanksi et al, 2010). As Table 2.14 shows, respondents reported taking between zero and 21 different prescription medications, with the median number of medications taken per person ranging between 4 and 7 across the four properties. According to the National Health and Nutritional Examination Survey, 37 percent of adults aged 60 and over used five or more prescription medications (Gu, Dillon and Burt, 2010). Table 2.14: Resident Reported Prescription Medications Property 1 Property 2 Property 3 Property 4 Total Median # of medications Range Support Network The self-administered questionnaire asked residents about their informal support network and the level of assistance they receive from this network. As shown in Table 2.15, an overwhelming majority of respondents across the four properties reported having persons in the area who can assist them when needed. Approximately 90 percent indicated they receive a call on a daily or weekly basis from a family member, significant other or friend, while roughly 70 percent receive a daily or weekly visit. It should be noted that a large, but unknown, number of residents in the four properties participate in the In Home Supportive Services (IHSS) program. IHSS is a Medicaid-funded program in California that provides individuals with domestic and personal care assistance to help them live safely in their homes. Services are provided by a personal aid and can range from assistance with household chores to personal care such as dressing and bathing. Participants can Evaluation of the WellElder Program 15

20 select a family member to serve as their aid, and some number of residents in the four properties utilize a family member as their paid aid. Table 2.15: Support from Family, Significant Others or Friends Property 1 Property 2 Property 3 Property 4 Total Persons in area who can assist 91.8% 84.8% 82.1% 92.7% (76) 87.1% Call Visit Daily 64.3% 46.1% 34.3% 60.2% 49.1% Weekly Monthly Less than monthly Never call Daily 28.9% 13.7% 12.9% 33.3% 21.3% Weekly Monthly Less than monthly Never call Table 2.16 shows that respondents reported receiving a range in level of assistance. While between six and 17 percent of respondents across the properties reported not needing any assistance, between 23 and 46 percent reported receiving considerable assistance from their family, significant others or friends. Table 2.16: Reported Level of Assistance Provided by Family, Significant Others or Friends Property 1 Property 2 Property 3 Property 4 Total Do not provide assistance 6.1% 3.9% 10.9% 3.6% 6.7% Limited assistance Moderate assistance Considerable assistance I do not need assistance Resident Incidents Over the course of the eight-month data collection period, each of the four properties tracked residents who experienced falls, 911 calls, emergency room visits, hospitalizations or nursing home stays. Table 2.17 shows the percentage of residents in each property who experienced each type of incident tracked as known to the property. It should be noted that a resident may experience multiple incidents in a single occurrence. For example, a resident may call 911, be taken to the emergency room and admitted to the hospital. Evaluation of the WellElder Program 16

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