Case Study: Hebrew SeniorLife Integrates Housing, Health, and Supportive Care Solutions

Hebrew SeniorLife illustrates both a housing-health care integration model and robust collaborations with local aging services providers and community organizations.

Hebrew SeniorLife, a nonprofit, operates and manages four affordable housing campuses in New England. In addition to moderate-income units, the properties have units funded through tax credits, while other buildings have project-based vouchers funded by the U.S. Department of Housing and Urban Development (HUD). Hebrew SeniorLife’s website describes each affordable housing community as providing “a complete and integrated spectrum of health care, housing, and services for older adults.” 

Recognizing that many older adults living in affordable housing need care coordination and additional wellness services to safely and independently age in place, Hebrew SeniorLife developed a demonstration program called Right Care, Right Place, Right Time (R3). To improve health and prevent avoidable hospitalizations, R3 embeds a nurse and wellness coordinator to work on-site with the housing team—including the service coordinator—to provide supportive services. The team also partners with a wide variety of regional community organizations to bring on-site programs and services to older adults on its campuses. Together, R3 and the community partnerships help older adults manage chronic conditions, eat nutritious food, have social engagement, and remain as independent as possible. 

An external evaluation of R3 determined that R3 met 90% of participants’ identified service needs, including nutrition and other whole-person health needs. This evaluation also reported:

• Reductions in emergency department trips (19%) and revisits (24%).
• Lower inpatient hospitalization rates (16%), reduced hospital admission days per beneficiary (25%), and hospital admission payments per Medicare beneficiary (22%).

Because of these evaluation results, Hebrew SeniorLife has received national recognition awards for R3. The nonprofit continues to provide R3 resources to its own properties and has expanded activities by partnering with other housing operators and health plans to provide R3 in other locations. 

Keys to Success

• Leverage congregate housing settings for economies of scale where a small on-site wellness team can efficiently serve a large group of people. 
• Serve as a "place-based" partner to health plans by providing efficient, on-site care coordination.
• Identify changes in older adults’ well-being and needs (through assessments, direct observation, and daily interactions) for early intervention and prevention.
• Effectively engage program participants in accessing needed supports through in-person one-to-one interactions and trusting relationships.
• Establish a wide range of collaborative partnerships with aging services and community-based organizations to bring supportive services on campuses.
• Reduce social isolation and strengthen social relationships between residents by facilitating regular activities and programming. Conduct strategic outreach to identify and engage residents who are most isolated and high-risk.
• Use a braided funding approach to create a sustainable model

Service Coordination Model

The nonprofit’s R3 program goes beyond traditional service coordination because it brings a nurse and wellness coordinator on-site (the “right place”) who actively engage older adults in managing their own health. The team first develops a trusting relationship with each person living in the community and invites them to participate in R3. Participants receive individual health needs assessments, discuss goals for wellness, and create person-centered care plans.

R3’s assessment tool ensures wellness teams have a holistic picture of each older adult. Specific questions gather information on existing services as well as potential risk areas, such as food insecurity, nutrition, memory health, and behavioral health. The team uses this information to determine risk and the need for additional supports. Based on the individual’s choices and preferences (“right care”), team members offer to:

• Coordinate care with primary care teams, specialists, insurance providers, in-home caregivers, and other health providers.
• Support transitions back home after a hospitalization or rehabilitation stay.
• Assist with connections to preventive services (“right time”) in the community to support well-being and independence and reduce emergency care and hospitalizations.
• Provide health guidance, education, and nutrition counseling to ensure continued appropriate self-management of chronic conditions.

The R3 wellness team works in an integrated manner with the service coordinator and other housing team members, such as facilities, programming, front desk, and food service staff. Each team member strives to build positive relationships with each individual. Together, they have a regular schedule for outreach to ensure all older adults living on their campuses have connections to the team. Teams also follow up with participants on their individual goals and areas of concern. 

“At the core of our model is a focus on what matters most to each individual. We start by developing a relationship and learning from the older adult what are their priorities, what are their goals, and what do they want our support with.” —Stephanie Small, Executive Director, Simon C. Fireman Community (a Hebrew SeniorLife residence)

Extensive Community Partnerships for Services

The wellness team also cultivates partnerships with community organizations, including local food banks and schools, to enhance access to assistance and community connections. Table 1 provides some highlights of these partnerships. These partnerships directly serve or connect older adults with supports for whole-person health needs, functional needs, and improved social connectedness, whether on Hebrew SeniorLife campuses or by enhancing programming in other community sites in the region. The table also notes funding sources when that information is available.

Table 1. Select Hebrew SeniorLife Partnerships that Foster Community Connections

Health Care Integration

Integrated housing and health care is key to Hebrew SeniorLife’s efforts to preserve independence, quality of life, and dignity for all older adults. The nonprofit offers a robust continuum of services to older adults living in Hebrew SeniorLife residences, including in-home care, post-acute care, long-term chronic care, dementia care, palliative care, and hospice care. 

The R3 program also:

• Coordinates with regional hospitals to support older adults as they return to the community with a program model that has broader impact beyond many traditional care transition models.
• Supports behavioral health by collaborating with local mental health providers for on-site care. 
• Serves as a “place-based” partner to health plans by providing efficient, on-site care coordination to support individuals with that coverage. R3 staff can serve as extenders of plan staff, such as performing wellness checks as needed.

Table 2 provides an overview of some key health care partnerships that Hebrew SeniorLife developed to support integration.

Table 2. Select Hebrew SeniorLife Partnerships that Support Health Care Integration

Financing and Partnership Support for Service Coordination

Hebrew SeniorLife braids together a variety of funding to provide the R3 program. Hebrew SeniorLife originally used grant funding to pilot and evaluate their approach, then leveraged the demonstrated outcomes to establish ongoing contracts with Massachusetts health plans including Program of All-Inclusive Care for the Elderly programs, Medicare Advantage, and dual-eligible managed care. At Hebrew SeniorLife properties, their funding approach braids together these healthcare contracts with philanthropic support and building operations funds to reduce dependence on any single funding source while sustaining a model that promotes health and well-being. 

To scale the R3 program in other places, Hebrew SeniorLife works directly with housing operators that want to offer R3. In these partnerships, Hebrew SeniorLife provides the framework and expertise needed for implementation. Currently, R3 program operates in 15 sites across eight municipalities and serves more than 2,000 older adults. 

“Hebrew SeniorLife seeks to provide older adults with personalized care and services through the R3 program that is designed to preserve their independence and quality of life. By continuing to expand the R3 model, we can better equip more people with the resources they need related to health, wellness, and prevention to live their best lives possible.” Kim Brooks, Executive Director, R3 Program, Hebrew SeniorLife

Summary

Hebrew SeniorLife designed R3 to efficiently integrate care and housing for older adults in congregate settings, and an evaluation documented the program’s effectiveness in reducing emergency department use and revisits as well as hospitalizations. In addition, R3 pairs the wellness team with the existing housing team to create a coordinated effort across staff to meet individuals’ goals without duplication. The nonprofit’s extensive array of partnerships with local community-based organizations improve access to additional services or resources that address health, well-being, and functioning. Health care partnerships enable Hebrew SeniorLife to offer a continuum of care. 

Learn More

• Right Care, Right Place, Right Time, Hebrew SeniorLife
• Evaluation of R3 (executive summary) LeadingAge LTSS Center at UMass Boston 
• The Effect of the Right Care, Right Place, Right Time (R3) Initiative on Medicare Health Service Use Among Older Affordable Housing Residents, Health Services Research
• Housing and Community Partner Views on the Benefits of Housing with Services: The Right Care, Right Place, Right Time Program, The Gerontologist
• Integrating Health Care and Affordable Housing at Hebrew SeniorLife, YouTube