Hebrew SeniorLife will use $900,000 in funding to test a model of housing with supportive services that it says could improve quality of life and reduce medical costs for older adults living in affordable housing and potentially save the healthcare system billions of dollars every year if rolled out nationally.

The “Right Care, Right Place, Right Time: Effectively Integrating Senior Care and Housing” initiative, funded with a $420,000 grant from the Massachusetts Health Policy Commission through the Health Care Innovation Investment Program and $480,000 from other sources, will try to determine whether wellness teams embedded at supportive housing communities offer a more coordinated approach to anticipating and responding to resident needs.

“We expect that this project will translate into a 20% reduction in transfers to hospitals, emergency rooms and long-term care for seniors, resulting in substantial cost savings to the healthcare system and a slower rate of increase for seniors’ overall medical costs,” said Kim Brooks (pictured), vice president of senior living at the non-profit, non-sectarian organization, a Harvard Medical School affiliate. “Projected savings per person are estimated at $1,800 per year. If scaled up nationwide, the savings could exceed $3.6 billion.”

The program also could decrease isolation and loneliness among residents, Hebrew SeniorLife hopes.

The preparatory stage of the two-year pilot project began in December. The 18-month implementation period will begin June 1. Hebrew SeniorLife said that its initiative is based on components of Vermont’s SASH (Support and Services at Homes) model and CareOregon’s Housing with Services model.

More than 600 residents involved

Initially, 620 residents at four Boston-area Hebrew SeniorLife sites will be part of the test, which is expected to be expanded to include an additional site outside of the organization. The participating communities currently offer varying levels of supports for residents, Brooks told McKnight’s Senior Living, “ranging from limited resident services coordination to very supportive environments with social workers, fitness, dining and coordinated healthcare.”

The new, embedded wellness teams will enhance communities’ current offerings and focus on the connection between housing and healthcare, she said.

“For example, in an already-supportive environment, the team may utilize an existing technology to do med reminders for those at risk for medication nonadherence. They will coordinate with local emergency response teams to improve the flow of communication, response and support for seniors requiring services,” Brooks said. “They also will be very focused on conducting assessments, pre and post, and measuring outcomes. Close attention will be paid to key performance indicators such as falls, medication adherence, emergency room trips, hospitalizations and long-term care placements.”

The wellness teams also will work to enhance residents’ existing relationships with providers, she said. “Should a need for additional services be identified during the process, the team may make referrals to coordinated programs such as a Program of All-Inclusive Care for the Elderly or Senior Care Options, if appropriate,” Brooks said. “There will be an effort to coordinate closely with health plans covering seniors who reside in the communities.”

Assessments will determine the types of education that will be provided to residents, Brooks said. “We envision focusing on education around falls prevention, chronic disease management, balance, engagement and self-directed care, aligning care with what matters most, including end-of-life planning, and medication management and adherence,” she said.

Four new hires

Hebrew SeniorLife recently hired two wellness coordinators who will be part of the larger wellness teams that will direct relationships with healthcare providers, educate residents in self-directed care and enhance connections with mental health providers, emergency responders, health plans, aging services providers, physicians and hospitals. An additional two people will be hired to work on the initiative, Brooks said.

“We have a number of current staff — resident service coordinators, social workers — supporting this work in addition to their current responsibilities and have dedicated half of an executive position to this initiative as project director,” she added. Brooks also is dedicating much time as investment director.

Consistent payer involvement needed

By the end of 2018, researchers hope they will have created a sustainable, replicable model that will change the way services are funded and delivered to the more than 2 million low-income older adults who live in seniors housing across the country.

“The proposed model’s success depends on consistent involvement across all payers to ensure efficiency,” according to the grant proposal. “A payer-funded model would provide a long-term, sustainable system where each payer contributes a share of costs based on the number of covered lives in a congregate housing setting. The centrally provided, site-based wellness and care coordination would be distributed based on affordable housing unit counts in a region.”