Executive Summary

This report outlines a Framework for the provision of an affordable Supportive Housing Program for seniors living on low or modest income in the City of Ottawa. The development of the Framework was guided by a working group of stakeholders convened by the United Way/Centraide Ottawa and led by the United Way/Centraide Ottawa’s Seniors Impact Council. The Impact Council’s goal was to develop strategies that would ultimately influence a significant investment of resources by the Champlain Local Health Integration Network (LHIN), the City of Ottawa and the Ministry of Health and Long Term Care (MOHLTC).

Stated simply, supportive housing in this Framework refers to any kind of housing and support arrangement that covers the gaps between housing for completely independent seniors and those living in long term care.

The Framework describes the key components of an affordable and effective Supportive Housing Program for seniors including appropriate housing, home support services, professional (health) services, the elements of a “senior friendly” community, the importance of technology and design, and strategies that will help sustain the program, protect the rights and address the needs of French language seniors, and recognize the growing diversity and overall cultural richness of Ottawa’s growing senior population. The Framework also provides figures on the needs of low income seniors in Ottawa that will help guide the Program’s implementation.

The report proposes the following five strategies to move the Supportive Housing Program for low and modest income seniors forward:

Strategy 1: Promote Supportive Housing to Stakeholders (seniors, caregivers, service providers, developers, politicians, funders etc.) by:

Developing a Vision for the Supportive Housing Program that incorporates some of the key themes heard at the May 15^th Affordable Supportive Housing Symposium, where local stakeholders came together with a common interest in seniors, housing and support services to help develop an action plan. For a more detailed description of the symposium see Appendix B, page 58. (affordable, accessible, inclusive, flexible, choice, integrated, promotes autonomy, responsive).
Developing a communication plan that recognizes the different target audiences (stakeholders) and strategies needed to raise awareness about supportive housing and promote the benefits of supportive housing and the proposed models.
Identifying Champions in the community with credibility and recognition to help spread the message through various public channels. An ideal champion will have comprehensive knowledge of the issues affecting seniors and be in a position to motivate and mobilize community, governments and businesses to action.

Strategy 2: Add 1,400-2,000 units of supportive housing to address the needs of seniors on low income (<$20,000) over the next five years by:

Building on existing components of Supportive Housing in Ottawa including the current “Aging in Place” Pilot Projects.

Targeting neighbourhoods with high concentrations of low income seniors such as Vanier and Centretown/Dalhousie.

Working with supportive housing providers such as Cornerstone/LePilier and other members of the Alliance to End Homelessness to meet the needs of homeless seniors and those at risk of homelessness.
Exploring new models of supportive housing such as Peel Senior Link’s coordinated and integrated 24/7 care model and Vancouver Coastal Health clustered care model of supportive housing.
Supporting the recommendations of the Ottawa Alternative Level of Care (ALC) Strategic Committee to help alleviate the pressures faced by the hospital and long term care sector.
Exploring with the Champlain Dementia Care Network the supportive housing model most needed in Ottawa to assist low and modest income seniors with dementia.

Strategy 3: Develop Partnerships and Alliances Within and Across Sectors to Implement Models of Supportive Housing by:

Setting up appropriate working groups including a Francophone working group to review, assess and develop one or more of the proposed models described in Strategy 2.
Setting up a strategic implementation committee that would cross sectors and be responsible for: lobbying for funds to set up Pilot projects; identifying ways to leverage existing resources; make final feasibility related decisions; develop a business plan for funders; help implement the model(s).

Strategy 4: Identify and target at-risk seniors in Ottawa who are in need of supportive housing by:

Developing a concise user-friendly screening tool for identification of at-risk seniors by front-line people including physicians, police, landlords, home support workers and others in the community.
Developing a communication and training mechanism for various sectors on the effective application of the screening tool, process and protocols for connecting senior at risk with help and a “train the trainer” workbook – all part of a toolkit.
Using GIS technology to map existing services for seniors and overlay where seniors on low income live across the City to identify high-risk neighbourhoods & gaps in services.

Strategy 5: Integrate Supportive Housing Initiatives into the Broader Continuum of Health and Social Care by:

Developing system-wide quality performance indicators.

Exploring the use of the Resident Assessment Instrument-Home Care assessment tool (RAI-HC) so that all service providers are using a standardized approach.

Inviting representation from key stakeholders within the broader system on the Supportive Housing Working Group to help establish respective roles and partnerships in providing supportive housing, monitoring the program, and advocating to all three levels of government (especially housing, health and social services) for long-term funding.

Ultimately, the goal of the Affordable Supportive Housing Framework is to provide a blueprint for the creation of a supportive housing program for seniors on low to modest incomes. This goal cannot be met by a singular sector. In order to assure success, the organizations within the Working Group must work collaboratively. A strong commitment from United Way/Centreaide Ottawa, the City of Ottawa, the Champlain Local Integrated Health Network as well as additional community representation and the participation of the private sector will incontestably guarantee the success of this endeavour.

May 15 Symposium Attendee List

Anne Aikens

North Renfrew Long Term Care Centre

Jane Alguire

Senior Wise

Services Inc.

Fara Aminzadeh

Community Research, Ottawa Hospital

Inika Anderson

Support Services, Parkinsons Society

Madeleine Anderson

Aging in Place

Ray Applebaum

Peels Senior Link

Linda Assad-Butcher

LHIN Board Member

Bev Bakka

UW/CO

Sheila Bauer

Ottawa CCAC

Donna Berger

CCAC, Cornwall

Marthe Bergevin

Association pour l’intégration sociale d’Ottawa

Lucille Berlinguette-Saumure

City of Ottawa

Christine Bidmead

Queensway Carleton Hospital

Ruth Boulianne

Résidence St-Louis

Robert Bourdeau

LHIN (Champlain)

Hélène Bourgeois

South-East

Ottawa CHC

Dora Brown

Interfaith Network

Carol Burrows

Council on Aging of Ottawa

Ron Campeau

CCAC, Cornwall

Jocelyne Contant

Champlain LHIN

Tony Cruickshank (represented by Sophie Mckeown)

Wabano Aboriginal Health Centre

Alex Cullen

City of Ottawa

Kathy Danbrook

Geriatric Assessment Centre

John Dickie

Eastern Ontario

Landlords Association

Christina DiTomaso

Western Ottawa Com. Res. Centre

Glenn Drover

ASHF Work Group

Paul Durber

First United Church

Marlynne Ferguson

City of Ottawa

Sue Garvey

Cornerstone Housing

for Women

Hinda Hassan

South-East Ottawa CHC

Kelly Hastings

Ottawa Community Housing

Dennis Jackson

Scotia Bank

Guirlène Jean-Baptiste

Association pour l’Intégration Sociale

Ipshita Kamal

UW/CO

Barbara Lajeunesse

Forge Com. Resource Centre

Johanne Levesque

Syposium Facilitator

Ambire SI Inc.

Al Loney

Council on Aging

of Ottawa

Rosemary Lowenger

Janet Lum

Canadian Research Network for Care in the Community

Vicki MacKinnon

Minto

Louise Martin

The Good Companions

Richard Mayer

Fédération des Aînés Francophones de l’Ontario

Lee McCarthy

Ottawa West Home Support/

Ottawa Community Support Coalition

Elaine McNaughten

Personal Choice Independent Living

Ann Norwak

RN,BN,MEd
Ottawa Public Health

Iris Newmann

Capital Care

Carmen Perron

Veteran Affairs

Implementation Project

Jocelyne Pion

CSEOCS

Oris Retallack

Champlain Dementia Network

Lise Richard

UW/CO Ottawa

Jean-Louis Schryburt

ASHF work group

Frank Sisson

Rideau Non-Profit Housing Inc

Jérémy Stevenson

Senior Planner, LHIN

Heather Tarnai-Feeley

Ottawa Hospital

Dennise Taylor-Gilhen

Ottawa Parkinsons Society

Lise Tessier
Ottawa Public Health

Shari Westman

Comfort Keepers

Janet Whillans

UW/CO

Paul Williams

University of Toronto

Jim Zamprelli

Canada Mortgage and Housing

Johanne Yelle- Weatherall

(represented by Larry Chambers)

Élisabeth Bruyère Research Institute

United Way Seniors Impact Council Members

Cal Martell – Council Chair Lise Richard

Director Devlopment Officer

Regional Geriatric Assessment Program Ottawa Community Support

Marion Balla Carol Burrows

President Volunteer

Adlerian Counselling & Consulting Group United Way Ottawa

Sheila Bauer Carol Halstead

Director, Client Services Executive Director

Champlain CCAC Township of Osgoode

Home Support

David Hole Jean-Louis Schryburt

Executive Director Teacher (retired)/Acting

South-East Ottawa centre Acting Executive Director

for a Healthy Community ACFO, Ottawa

Dennis Jackson Dr. Norman Tape

District Vice-President Governor, The Ottawa Hospital

Scotiabank-Ottawa Main Branch Federal Government Research

Richard Mayer Marlynne Ferguson

President Acting Director, Long Term Care

Federation des aines et des Branch

Retraites Francophones de l’Ontario Community and Protective Services

City of Ottawa

Diane Officer

Director, Long Term Care

City of Ottawa

Ben Franklin Place

United Way Staff

Bev Bakka

Director, Impact and Investment

United Way Ottawa

Affordable Supportive Housing Framework Working Group Members

Cal Martell Carol Burrows

Seniors Impact Council Chair Seniors Impact Council

UW/CO UW/CO

Jean-Louis Schryburt Elaine McNaughten

Seniors Impact Council Ontario Association of Not-for-Profit

UW/CO Homes and Services for Seniors

Russell Mawby Oris Retallack

Director of Housing Champlain Dementia Network City of Ottawa

Marlynne Ferguson Lucille Berlinguette-Saumure

Acting Director, Long Term Care Project Manager

City of Ottawa Seniors Agenda, City of Ottawa

Jim Zamprelli Eric Partington

Senior Policy Researcher Senior Consultant,

Canada Mortgage and Performance and Contracts

Housing Corporation Champlain District Local

Integration Health Network (LHIN)

Jeremy Stevenson Glenn Drover

Senior Planner President of Council on Aging

Champlain District Local

Integration Health Network (LHIN)

Lise Richard Vicki MacKinnon

Development Officer Vice President

Ottawa Community Support Coalition Special Projects, Minto

Sheila Bauer David Hole

Director, Client Services Executive Director

Ottawa Community Care Access Centre South-East Ottawa Centre

for a Healthy Community

United Way Staff

Bev Bakka

Director, Impact and Investment

UW/CO

Introduction

In early 2007, the United Way/Centraide Ottawa Seniors’ Impact Council convened a working group of stakeholders to develop an Affordable Supportive Housing for Seniors Framework and Action Plan to be considered by the City of Ottawa, Ministry of Health and Long Term Care (MOHLTC), not-for-profit housing providers and private developers. The goal of the United Way was to develop strategies that would ultimately influence a significant investment of resources by the Champlain Local Health Integration Network (LHIN), the City of Ottawa and the MOHLTC.

Approach

In developing the framework, the project team used the following approach:

Knowledge transfer from experienced consultants hired to assist in the development of the Framework and Action Plan;

Literature review to identify best practices and cost effective models of supportive housing (See Appendix A);
Review and further analysis of secondary data sources (e.g., 2004 Successful Aging Ottawa Seniors Survey; 2004 Ottawa Fact Book on Aging) to help identify seniors most in need;
Key informant interviews with other experts in supportive housing across Canada as well as local stakeholders to identify barriers and opportunities;
Symposium to showcase best practices across Canada, gather input, build consensus among local stakeholders, and explore next steps (Agenda attached in Appendix B); and
Meetings and ongoing discussions with members of the working group to ensure that the Framework and Action Plan meets community expectations.

The Need for Affordable Supportive Housing for Seniors in the City of Ottawa – Why Now?

Today the City of Ottawa is home to more than 90,000 seniors, representing about 12% of the total population. Second only to Calgary, Ottawa has the fastest growing senior population in Canada; one that is projected to increase even more rapidly over the next few decades. By 2031, the number of seniors living in Ottawa will be triple the number of today. Such rapid growth requires investment by governments in services for seniors. As such, it is important that the City of Ottawa be prepared with a realistic plan that addresses both immediate needs and considers the future.

A critical need for affordable supportive housing for seniors on low or modest income in Ottawa has been identified in a number of recent studies:

In August 2006 the Ottawa Alternative Level of Care (ALC) Strategic Committee released hospital bed occupancy figures[1] that showed the ALC occupancy rate in acute care beds in Ottawa hospitals is 19% and on the rise (well above other communities in Ontario). In 2004/05, Ottawa hospitals reported 46,553 ALC days, costing the system almost $25 million[2]. Today, there are more than 200 patients waiting in ALC, a figure that is expected to continue to rise dramatically. The majority of these patients are seniors on low income, waiting for placement in a basic Long Term Care room.
Currently in Ottawa 127 seniors are awaiting placement in long term care per 100 beds available. This situation is exacerbated by the fact that 20-25% of seniors currently placed in LTC could be more suitably placed in affordable supportive community-based housing. The basic cost for a LTC bed is $132.32*/day. This compares to $550 /day for a hospital bed and $33/day for supportive community-based care.

Note: this will increase by $1.43 as of Sept 1, 2007

Current planning through the Champlain LHIN predicts the need for more than 1,100 supportive housing units to be developed over the next five years.
A recent City of Ottawa report (Seniors Agenda: 2005 Stakeholder Consultation Report) identified affordable housing including assisting seniors to age in place as a top priority.
In the 2004 Successful Aging Ottawa (SAO) Seniors Survey, only 26% of respondents agreed that there were enough affordable housing options for seniors; 56% were concerned that there were not enough home support services for seniors staying in their own home. The survey also found that most Ottawa seniors (80%) intended to stay in their homes and had never seriously considered moving.
A recent Canada Mortgage and Housing Corporation (CMHC) study[3] on the profile of rooming house residents in Ottawa, Montreal and Vancouver found that “aging in place” with few supports and choices in terms of services and design aids was the norm for older tenants.[4]
Cornerstone/LePilier recently identified the need for supportive housing for older homeless women with complex needs.[5] (>100 women age 55+ stayed overnight in shelters according to the City’s most recent (2005) shelter count report).
There are currently >1000 seniors on the waiting list for affordable housing in Ottawa.[6]

Target Population

The target population for the City of Ottawa’s Affordable Supportive Housing for Seniors Framework is seniors on low (<$20,000) or modest (<$30,000) income. According to the 2004 Fact Book on Aging, 41% of seniors reported a personal income of less than $20,000 and 58% indicated incomes of less than $30,000 in 2000.[7] Women report lower personal income levels than men, as do Francophone seniors and those from other ethno-cultural populations.

Looking at Census household incomes for senior-led households presents a similar picture. The last available Census reported that 17,325 Ottawa seniors (about one third of all senior-led households) lived in senior-led households with less than $30,000 household income and 9,490 seniors (18% of all senior-led households) lived in senior-led households reporting a household income of less than $20,000.[8]

Seniors on low or modest income are most at risk of losing their independence and being inappropriately admitted to long term care. This is because income is related to many other factors that can result in the same outcome. According the 2004 Successful Aging Ottawa (SAO) Seniors Survey[9], compared to Ottawa seniors in general, seniors living in low to modest income households (% of seniors with a household income <$30,000 versus percent of seniors in general) are more likely to report:

Feeling in fair or poor health (30% versus 17%)

Being a patient overnight in a hospital, nursing home or convalescent centre in the past 12 months (17% [22% for seniors with income <$20,000] versus 12%)
Needing help with activities of daily living (32% versus 23%)
Not being able to get out as often as they would like (15% versus 9%)

According to the SAO survey, seniors on low or modest income were also less likely to report having their health or medical conditions diagnosed by a health professional than seniors in general (59% versus 66%). In terms of their profile, seniors in this income group were more likely to be women (74% versus 58%) who are living alone (57% versus 35%) in a home they rent (30% versus 12%). And as reported by the 2004 Fact Book, they are also more likely to speak French in their home (19% versus 13%) or another language other than English (17% versus 10%).

A Definition of Supportive Housing

The definition of supportive housing used in the Framework is a broad one that includes both traditional “aging in place” models and purpose-built or designed forms of supportive housing that also promote aging in place. As such the definition incorporates both CMHC’s definition of purpose-built supportive housing[10] and the definition put forth by the Ontario Ministry of Health and Long Term Care that links affordable housing and services[11]. Stated simply, supportive housing in this Framework refers to any kind of housing and support arrangement that covers the gaps between housing for completely independent seniors and those living in long term care.

Exhibit 1 below graphically illustrates the Affordable Supportive Housing for Seniors Framework. It begins with the premise that there are many ways in which supportive housing can be created.

What is paramount is the appropriate combination of supportive elements including suitably designed housing, accessible home support services, timely professional (health) services (including short term respite and convalescent care), and senior friendly safe neighbourhoods and amenities created through thoughtful and inclusive city planning policies. Underpinning the definition is the development of a supportive housing program that offers choice and is affordable[12], sustainable, responsive, recognizes both official languages and is also culturally sensitive to Ottawa’s diverse and multi-cultural senior population including Aboriginal seniors, recent immigrants and gay, lesbian, bisexual and transgendered seniors.

Supportive housing for seniors can have many different forms. It can be created in existing private homes through a combination of supportive services and design, or in income assisted social housing or market rent apartments with high concentrations of seniors such as the Aging in Place Model. Purpose-built examples of supportive housing for seniors include small group homes such as the Abbeyfield model (Abbeyfield Parkdale is an example in Ottawa), medium (up to 60 units) or larger congregate settings that can stand alone or be part of a “campus model” (such as Unitarian House in Ottawa). Assisted living facilities are included at the higher support level under the congregate housing model. In Ottawa, assisted living is available in some retirement homes; however, this option is currently not affordable for seniors on low or modest income.

Supportive housing can also be provided in mixed age communities such as mixed age market apartments, social housing or rooming houses, by introducing initiatives and programs that encourage neighbours and landlords to provide support. In some instances, intergenerational links can be created by virtue of location – for example, a seniors building located close to a high school provides the opportunity for exchange of support (seniors volunteering in schools and vice versa).

For a more detailed description of the different ways supportive housing can be created refer to the Literature Review in Appendix A.

The Number of Seniors in Ottawa who Need Supportive Housing

According to the 2004 SAO Seniors Survey, 23% of seniors in Ottawa need help with activities of daily living (such as preparing meals, shopping for groceries, everyday housework, heavy chores, personal care, and moving about). Most seniors report getting the help they need, however, 6% of those who need help with one or more activities of daily living say they are not receiving any help. This percentage increases to 15% for seniors living in households with less than $20,000 household income[13]. Using this percentage and projecting it to the population at large, it is estimated that about 1,400 low-income seniors in the City of Ottawa have unmet needs and could benefit from supportive housing (15% of 9,490 seniors living in senior-led low-income households <$20,000). Most of these seniors live in houses they rent. (6,235 seniors living in households with <$20,000 rent their home [66% of all low-income senior-led households])

According to further analysis of the 2004 SAO Seniors Survey, seniors most likely to report not having the help they need are women, over the age of 75, with little social support, and who speak a language other than English. Although only borderline significant[14], seniors living in a rural ward were also more likely to report not receiving any help.

The above figure (1,400) does not include homeless seniors, seniors at risk for homelessness and seniors living in rooming houses. This could add another 600-700 persons to the mix.[15]

Future Projections

Projecting into the future, the number of seniors 65+ in Ottawa (89,000 in 2001) is expected to grow to 270,000 by 2031 according to the 2004 Fact Book on Aging. This is an increase of 203%[16] over 30 years or roughly 7% each year – by 2010 the number of seniors will have already increased by 70% to over 150,000. These same projections can be applied to the numbers above.

Why Supportive Housing is Beneficial: the Evidence

Forms of supportive housing including aging in place models have long been proposed by experts in gerontology and health systems as viable options for seniors who need help with every day activities and who without this help are at risk for losing their independence and their choice in terms of place of residence. As well as improving the overall quality of life of seniors, there is evidence to show that even the most basic support service such as housekeeping can save the healthcare system money. The literature review in Appendix A provides references to the most recent studies in this area. As well, evidence presented by the key note speaker[17] and others at the Affordable Supportive Housing Symposium (www.teamgrant.ca) makes the case for a more balanced approach to health care that includes supportive housing as an important component of the overall health system.

The key arguments in favour of supportive housing are:

Targeted, managed home and community care within an integrated continuum consistently meet individual and system goals by maintaining the health, well-being and autonomy of individuals and their caregivers and by helping to solve key health system problems by lowering the incidence of inappropriate use of emergency care, acute care and long term care.
The targeted “Aging in Place” models of coordinated and managed on-site support for high risk seniors living in income-assisted seniors housing are cost- effective by allowing efficiencies in service delivery, and linking seniors to appropriate services when needed.
Lessons learned from evaluations of supportive housing for persons at-risk of homelessness show that appropriate forms of supportive housing are more cost- effective than the cost of no support and that overall cost are significantly higher for institutional responses versus community residentially based options.

A Supportive Housing Program for Ottawa

This section describes the proposed components of a Supportive Housing Program for low to modest income seniors in Ottawa based on the Framework depicted in Exhibit 1. The components and elements described throughout this section as well as the implementation strategies that follow focus on Ottawa. They could, however, be applied throughout the Champlain district.

Goal

The Affordable Supportive Housing Framework for Seniors will provide a blueprint for the creation of a supportive housing program for seniors living on low to modest income in the City of Ottawa that recognizes both official language groups and respects Ottawa’s diverse cultures.

Objectives

The Affordable Supportive Housing Framework for Seniors has five objectives:

To identify a range of different combinations of affordable housing and service supports required by seniors in Ottawa to enable them to live as independently and as fully as possible as health and vitality decrease;
To draw upon evidence-based and best practices research in the development of the Supportive Housing Program;
To help identify critical gaps in the current mix of housing and service supports essential to maintaining the independence and well-being of at-risk seniors in the community;
To help identify priorities and next steps in the short and longer-term that will address the identified gaps; and
To inform the Champlain Local Integrated Health Network in their allocation decisions related to affordable supportive housing for seniors.

Guiding Principles and Prerequisites

The following suggested guiding principles and prerequisites have been drawn from two sources: “best practices” described in the literature[18]; and a consensus of themes recorded during the small group discussions at the May 15^th Supportive Housing for Seniors Symposium – Making It Happen.

“Best Practices” Philosophy and Policies - Ottawa’s Affordable Supportive Housing for Seniors Framework will:

Target seniors most at-risk
Foster autonomy and support independent living
Be client-centred
Be inclusive
Include assessment and coordination of care and service
Give clients access to 24-hour support
Provide 24-hour emergency response
Be integrated into the broader continuum of health and social services
Be accountable
Be sustainable

“Best Practices” Service Delivery - Ottawa’s Affordable Supportive Housing for Seniors Framework will:

Be flexible and personalized in its delivery
Offer a variety of affordable housing and support service models
Employ ‘case management’ functions of case finding, care/service coordination, referrals and community development
Address multiple client needs (i.e., Alzheimer’s, addictions, mental health, cultural)
Offer flexible, consistent staffing
Be sensitive to linguistic, multicultural and other client diversities and needs in recruiting, hiring, training programs and education
Employ accessible communication tools for frontline staff (e.g., pager, cell phone)

“Best Practice” Administration and Management - Ottawa’s Affordable Supportive Housing Framework for seniors will:

Show leadership through common vision, commitment, and an understanding of at-risk seniors’ needs and informed decisions
Provide specialized environments for special needs (e.g., Alzheimer’s)
Create efficiencies through critical mass
Use the latest client information management software
Hire only “people focused” staff
Involve seniors in decisions that affect them
Understand and communicate with family members/caregivers
Establish realistic expectations about access and costs of support services
Support staff in their work
Establish policies on the rights and responsibilities of residents
Evaluate the effectiveness of services including client satisfaction

“Best Practices” Linkages and Relationships - Ottawa’s Affordable Supportive Housing Framework for seniors will:

Collaborate with all housing providers for assessment, admission, ongoing reviews, and other issues
Enhance access and linkages to a larger range of services, including health and long-term care
Link with hospitals and other formal health care service providers (e.g., physicians, clinics, outreach), other community service groups, volunteers, local business, cultural organizations and networks
Develop alliances with other health care agencies providing related services in the same building

Key Components of Supportive Housing

The circle diagram shown in Exhibit 1 is meant to illustrate a non-linear and dynamic approach to a comprehensive supportive housing program for low and modest income seniors. Each of the circles represents an important component of the program and each component contains elements that enhance the quality and effectiveness of the overall program. This section will briefly describe the major components and their key elements.

Seniors at Risk

In this proposed framework for Ottawa’s low income and modest-income seniors[19], at-risk seniors are positioned in the centre of the circle diagram. The different elements of an optimal supportive housing environment wrap around the senior as determined by their individual requirements, circumstances and resources available. The presence of case managers, needs assessment and coordination would facilitate the mobilization of the appropriate mix of resources and housing for the at-risk senior, wherever he/she may be residing in their home, in congregate or in hospital environments.

This circular framework also recognizes that intensity of need for supports does not always progress in a linear fashion towards increasingly more intensive types of supportive housing. For example, some at-risk seniors with relatively intensive support requirements can reside comfortably and safely in their own homes while other seniors with the same service support requirements but different circumstances may be more appropriately supported in a 24/7 on-site congregate model of supportive housing. By putting the senior at risk in the centre of this circular diagram, the different pathways that at-risk seniors often take based on their individual needs and circumstances at any given time are recognized. Flexibility and choice underpinning the overall framework will lead to responsive and cost-effective approaches for at-risk seniors.

Appropriate Housing

Central to the well-being of all seniors is appropriate housing. For seniors on low or modest income this is often a challenge in later life. CMHC has provided figures that show that 19% (>10,000) of Ottawa seniors live in households that are either not affordable (too expensive for their income), not suitable (too large or too small) or not acceptable (too run down).[20]

Many older people continue to reside in the home they raised their families and as they age, their activities, household composition and resources alter. Owners of older property face increasing maintenance or the need to make modifications to their homes while their own health and ability to cope with these issues is deteriorating. Older renters must deal with public and private landlords who are less willing to make adaptations to meet the needs of their older tenants. Increased rent can also become a problem. Inappropriate housing alone can sometimes be the reason why an older person on low income goes straight into a nursing home. There are simply not enough affordable options in between.

A supportive housing program can address the issue of inappropriate housing by linking seniors to affordable home help services in the community, government programs such as Residential Rehabilitation Assistance Program (RRAP), Home Adaptations for Seniors Independence Program (HASI), and information about alternative financing arrangements such as reverse mortgages.

Exhibit 1 shows that supportive housing can be provided in regular housing (as described earlier), seniors-only housing (Aging in Place Model) or by facilitating the development of affordable purpose-built supportive housing.

Linguistic and Cultural Inclusiveness

Ottawa is a bilingual city and as such access to services in both official languages is a basic right. For seniors on low or modest income, it is more significant. Seniors who speak French are more likely to report living in a low income household and, as it has been shown in the analysis detailed earlier, are also more likely to need supportive housing.

In addition to addressing the unmet needs of French language seniors, the supportive housing program must be sensitive to the needs of seniors from many different backgrounds including Aboriginal seniors, newcomers and seniors from the gay, lesbian, bisexual and transgendered community.

Elements that will foster inclusiveness include:

Programs and services being offered in both official languages
Access to cultural interpretation and translations services where needed
Cultural sensitivity workshops offered to staff
Working together with existing community alliances and collaborative groups to design appropriate programs (such as Fédération des aînés et des retraités francophones de l’Ontario, Ottawa-Carleton Immigration Services Organization, Native Friendship Centres, Odawa, Pink Triangle Association, Wabano Aboriginal Community Health Centre etc.)

Support Services

Ottawa offers a range of community support service to seniors through the Champlain Community Care Access Centre, the Ottawa Community Support Coalition, Community Resource Centres, and Community Health Centres etc. The types of supportive services that have been shown to most benefit seniors and foster independence include:

Help with activities of daily living such as shopping, housekeeping, banking, telephoning, meals
Transportation (volunteer drivers, specialized transportation)
Escort to appointments
Assessment and managed care
Help with personal care such as dressing, bathing and toileting (assisted living)
Help with medications (assisted living)
Palliative care (assisted living)

A number of studies (Lum et al, 2005; Hollander, 2006) have pointed to the importance of integrating the services around the needs of the client. It has also been found that the provision of lower cost services such as housekeeping can have a significant impact on the cost-effectiveness of a health care system.

Delivery Options and Service Arrangements

Currently services are arranged and delivered in several ways:

Residents can receive services in their home directly from community agencies on a pay as you go basis
In purpose-built supportive housing, services are typically offered as part of the resident’s monthly accommodation fee
Residents in some purpose built supportive housing can also use services on a pay as you go basis, at a monthly or yearly fee

Panel members at the Supportive Housing Symposium on May 15^th introduced some interesting delivery approaches including the Clustered Model in Vancouver where the delivery of services is clustered either in a building or neighbourhood to provide greater continuity of care and to achieve greater efficiencies (link to presentation on the web site). Peel Senior Link offers 24/7 on-site support to seniors in social housing through an integrated service model that targets residents most at risk (http://www.peelseniorlink.com/).

Whatever the arrangement of service delivery, the most critical gap for aging in place at home for low to modest income seniors is a publicly funded program that would provide housekeeping and homemaking services on a long-term basis – similar to the Integrated Homemaker Program that was discontinued in the mid-‘90s.

Professional Services

The framework recognizes the importance of linking the at-risk senior to responsive and knowledgeable (about seniors) professional services including:

General practitioners that are aware of what is available in the way of community supports for their older patients
Geriatric services
Timely access to specialists
Clinical nurse specialists
Allied health care workers
Sight and hearing specialists
Footcare clinics
Dentists

For those connected with the agencies that provide supports available in the community, referral to these professional resources likely occurs. However, research has indicated that the at-risk senior is more likely than not to be isolated, without family and friends to advocate on their behalf. Some at-risk seniors may only have contact with their family doctors, but unless doctors are aware of the resources available and help the senior to make the necessary connections, the at-risk senior is unlikely to access these vital professional services.

Neighbourhood and Community

Exhibit 1 acknowledges that family, friends and neighbours are an important source of support for many seniors. In fact, research has shown that supporting caregivers may also save the system money. Indeed, in the 2004 SAO Seniors Survey, 92% of respondents reported that they had someone to turn to when they needed help with things like meals, rides or chores. And just over 40% referred to family or friends when they needed medical advice.

A supportive community can also be created through thoughtful City planning, policies and programs[21]. Some key elements of a “senior-friendly” supportive community include:

Accessible public transportation in terms of design (easy step-up), routes, hours of operation, driver education (about seniors)
Policies and zoning flexibility that allows the creation of new supportive housing such as secondary suites, granny flats, purpose-built congregate housing
Emergency and safety support systems such as 911, personal emergency response systems linked to neighbourhood response centre, neighbourhood security check systems (i.e., Neighbourhood Watch), traffic safety programs and refresher courses
Universal community design that includes improved street lighting, additional benches, well-maintained streets and sidewalks (snow and ice clearing in the winter), flat curbs for scooters and walkers, increased signage, more time to cross the street etc.
Single access number/information line for seniors services
Affordable recreational and social activities
Affordable educational and cultural opportunities

Technology and Design

According to a recent report by Canada’s Public Health Agency, between 25% and 75% of falls by older people involve an environmental component including stairs and other factors in and around the home.[22] Almost 62% of injury-related hospitalizations for seniors are the results of falls. Reducing the incidence of falls among seniors would most certainly save healthcare costs. Home modifications should be an important component of a falls prevention program. According to the 2004 SAO Seniors Survey, only 38% of respondents reported having grab bars in their bathroom, considered a minimum basic home modification – other supportive design features were less common.

Advances in technology and good design can go a long way in the provision of a safe and supportive environment for seniors. Application of appropriate technology and design can:

Keep a home safe
Enable the senior to function independently; i.e., carry out activities of daily living (instrumental and self care)
Provide efficiencies in operations (e.g., zero entry shower allows the frail senior to bathe without assistance and minimizes risks such as falls)
Design can facilitate social interaction
Increase sense of safety and security
Promote independence and continued engagement in the community (e.g., walkers, canes and wheelchairs promote freedom of movement)
Facilitate communication (e.g., hearing aids, telephone handset with built-in volume, flashing signals for door bells, etc.)
Increase vision (sunglasses, large playing cards, touch tone phones, magnifying glasses etc.)
Increase coping skills (e.g., memory aides such as writing lists, using pictures to label contents, using pill organizers, talking clocks, and vibrating phones etc.)

Canada’s Public Health Agency has recently published a guide to home safety for seniors available at the following website: http://www.phac-aspc.gc.ca/seniors-aines/pubs/safelive/index.htm. CMHC offers a program, Home Adaptation for Seniors Independence (HASI) that assists seniors on low income to make small changes to their home to help them stay longer than would otherwise be possible. CMHC has produced a number of recent publications related to purpose-built supportive housing for seniors. In addition, CMHC’s Rental Residential Rehabilitation Program (Rental RRAP) offers financial assistance to landlords of affordable housing to pay for mandatory repairs to self-contained units occupied by low-income tenants. Mandatory repairs are those required to bring properties up to minimum levels of health and safety. More information on the enabling role of technology and design and available resources is contained in Appendix C.

Sustainability

Providing affordable supportive housing that is also sustainable over the long run is challenging and will require new resources as well as innovative approaches[23]. Strategies that will help include:

Developing strategic partnerships and alliances including private/public partnerships (e.g. Minto) to leverage resources, share market intelligence, coordinate efforts etc.
Linking to City of Ottawa Housing Strategy and City of Ottawa Rooming House Strategic Planning Framework to explore common goals and strategies (e.g. advocacy to different levels of government)
Managing revenue streams which are expected to come from multiple sources
Accessing CMHC programs and financial assistance such as Homeowner RRAP, Disabled RRAP, Secondary Suites RRAP and HASI described at www.cmhc-schl.gc.ca/en/co/prfinas/index.cfm
Being accountable by developing realistic performance indicators and benchmarks
Evaluation to demonstrate impact of model on clients and the system

The Action Plan

The following five strategies and associated actions are proposed to move the Supportive Housing Program for low and modest income seniors forward.

Strategy 1: Promote Supportive Housing for Seniors to Stakeholders (seniors, caregivers, service providers, developers, politicians, funders etc.) by:

Developing a Vision for the Supportive Housing Program for Seniors that incorporates some of the key themes heard at the Symposium (affordable, accessible, inclusive, flexible, choice, integrated, promotes autonomy, responsive etc.).
Developing a communication plan that recognizes the different target audiences (stakeholders) and strategies needed to raise awareness about supportive housing and promote the benefits of supportive housing and the proposed models.
Identifying Champions in the community with credibility and recognition to help spread the message through various public channels.

Strategy 2: Add 1400-2000 units of supportive housing to address the needs of seniors on low income (<$20,000) over the next five years by:

Building on existing components of Supportive Housing in Ottawa including the current “Aging in Place” Pilot Projects.

Targeting neighbourhoods with high concentrations of low income seniors including those living in rooming houses such as Vanier and Centretown/Dalhousie.

Working with supportive housing providers such as Cornerstone/LePilier and other members of the Alliance to End Homelessness to meet the needs of homeless seniors and those at risk of homelessness.
Exploring new models of supportive housing such as Peel Senior Link’s coordinated and integrated 24/7 care model, Vancouver Coastal Health clustered care model of supportive housing, and Deep River’s rural model of Long Term Care. (For a description of two other promising models see Appendix D)
Supporting the recommendations of the Ottawa Alternative Level of Care (ALC) Strategic Committee to help alleviate the pressures faced by the hospital and long term care sector.
Exploring with the Champlain Dementia Care Network the supportive housing model most needed in Ottawa to assist low and modest income seniors with dementia.

Strategy 3: Develop Partnerships and Alliances Within and Across Sectors to Implement Models of Supportive Housing by:

Setting up appropriate working groups including a Francophone working group to review, assess and develop one or more of the proposed models described in Strategy 2.
Setting up a strategic implementation committee that would cross sectors and be responsible for: lobbying for funds to set up Pilot projects; identifying ways to leverage existing resources; make final feasibility related decisions; develop a business plan for funders; help implement the model(s).

Strategy 4: Identify and target at-risk seniors in Ottawa who are in need of supportive housing by:

Developing a concise user-friendly screening tool for identification of at-risk seniors by front-line people including physicians, police, landlords, home support workers and others in the community.
Developing a communication and training mechanism for various sectors on the effective application of the screening tool, process and protocols for connecting senior at risk with help and a “train the trainer” workbook – all part of a toolkit.
Using GIS technology to map existing services for seniors and overlay where seniors on low income live across the City to identify high-risk neighbourhoods & gaps in services.

Strategy 5: Integrate Supportive Housing Initiatives into the Broader Continuum of Health and Social Care by:

Developing system-wide quality performance indicators.
Exploring the use of the Resident Assessment Instrument-Home Care assessment tool (RAI-HC) so that all service providers are using a standardized approach.
Inviting representation from key stakeholders within the broader system on the Supportive Housing Working Group to help establish respective roles and partnerships in providing supportive housing, monitoring the program, and advocating to all three levels of government (especially housing, health and social services) for long-term funding.

References

A. Paul Williams, Professor, University of Toronto, Supporting Seniors & Sustaining Medicare: Supportive Housing in the Balance of Care. Presentation, Ottawa Supportive Housing for Seniors Symposium: Making it Happen, May 15, 2007.

Alternative to Appropriate Levels of Care: Ottawa ALC Strategic Committee Report of Recommendations, August 2006.

Canada Mortgage and Housing Corporation, Profile of Rooming House Residents. Research Report Prepared by Social Data Research Ltd., May 2006.

Canada Mortgage and Housing Corporation, Life Lease Supportive Housing: Combining the Best of Housing and Complex Care. Prepared by The Capital Care Group, February 2005.

Canada Mortgage and Housing Corporation , Life Lease Housing in Canada: A Preliminary Exploration of Some Consumer Protection Issues. Prepared by Lumina Services Inc., June 2003.

Canada Mortgage and Housing Corporation, Supportive Housing for Seniors. Research Report Prepared by Social Data Research Ltd., 2000.

Connecticut Supportive Housing Demonstration Program. New Haven Corporation for Supportive Housing, www.csh.org.

Evaluation of the Aging in Place Pilot Project: Final Report. Prepared by The Flett Consulting Group Inc. & Social Data Research Ltd., 1996.

Flett, Darlene E., Last, John M., &Lynch, George: Evaluation of the Public Health Nurse As Primary Health-Care Provider For Elderly People. Aging in Canada – Social Perspectives, edited by Victor W. Marshal, Fitzhenry & Whiteside, 1980.

Hollander Analytical Services Ltd. Literature Review on the Cost-Effectiveness of Continuing Care Services. Veteran Affairs Canada and the Government of Ontario, July 2006, www.hollanderanalytical.com

Lum, Janet M., Simonne Ruff & A. Paul Williams, When Home is Community: Community Support Services and the Well-Being of Seniors in Supportive and Social Housing. United Way of Greater Toronto, April 2005.

Mancer, Kate and Carole Holmes, 70 Ways to Reduce the Cost of Developing and Operating Supportive Housing for Seniors. Funded by the Real Estate Foundation of BC for the BC NON-Profit Housing Association, October 2004.

National Advisory Council on Aging, The NACA Position on Supportive Housing for Seniors: No. 22, October 2002.

Ontario Seniors Participation in Health & Housing Policy: Summary of Main Issues. Prepared by the Ontario Coalition of Senior Citizens Organizations for Health Canada, January, 2003.

Pomeroy, S., Focus Consulting, Proactive Versus Reactive Responses to Homelessness: A Costing Analysis. Paper Presented to the Alliance to End Homelessness Community Forum on Homelessness. November 22, 2006.

Social Data Research Ltd., Searchable Database of Supportive Housing for Seniors in Canada. Prepared for Health Canada, April 2005. http://www.hc-sc.gc.ca/hcs-sss/pubs/care-soins/2005-seniors-aines/index_e.html

The Council on Aging of Ottawa, 2004 Fact Book on Aging: Seniors in the New Ottawa.

Vancouver Coastal Health, Outcome Evaluation: Changes in Hospital Utilization by Individuals One Year Post Access to Supported and Non-Supported Affordable Housing. Vancouver, British Columbia, October, 2006 (For more information contact Linda Thomas, Director, Housing Services, Linda.Thomas@vch.ca)

Introduction

The purpose of this literature review is to provide relevant and recent background information about supportive housing for seniors including:

A definition of supportive housing including the major elements
The relationship between supportive housing, aging in place and healthy aging
A profile of seniors who could benefit from supportive housing
The different types of models of supportive housing and cost effectiveness
Best practices and innovative initiatives

An internet scan, keyword search of the academic literature and correspondence with experts in aging was used to identify relevant articles and reports referred to in this review. The review was international in scope.

Definition of Supportive Housing

To date there is no consistent definition of supportive housing in Canada. In fact, the definition of supportive housing varies across jurisdictions, both within Canada, and internationally. Although there may still be no accepted "official" definition, a good "working" definition of supportive housing in Canada has been provided by Canada Mortgage and Housing Corporation (CMHC):

“Supportive housing is a term used to describe a range of housing options designed to accommodate the needs of seniorsthrough design features, housing management, and access to support services. At one end of the range, supportive housing refers to congregate housing with supportive features and services such as monitoring and emergency response, meals, housekeeping, laundry and recreational activities. At the other end of the range (referred to in most North American jurisdictions as “assisted living”) personal care services are also provided for frailer seniors with more significant support needs. Professional services may be provided on a home-care basis in a supportive housing setting as they would be if the resident were living in a different kind of (non-supportive) residential setting. Supportive housing may be provided by either the public or the private sector, for profit or not for profit. In some cases, one provider will be responsible for delivering the whole supportive housing package (services plus housing). In other cases services and housing components will be delivered separately, by different sectors. Supportive housing can be rented, purchased as a condominium in fee simple, or obtained through a life lease.”[24]

According to CMHC, “supportive housing is currently being developed to provide Canadian seniors with an intermediate housing alternative, between living alone without supports (staying at home) and the heavily regulated environment of institutional care”. [25] For simplicity, supportive housing is “housing with services for seniors regardless of government involvement and independent of any specific government program referring to “supportive housing” in its title or description.

Key Components of Supportive Housing

According to CMHC’s definition, for housing to be supportive it must have the following five key components:[26] First, supportive housing should have a home-like, residential character – in other words not be institutional. Second, supportive housing should be physically supportive – an environment in which residents and visitors can move about freely and have access to common areas for active living and socializing both indoors and outdoors. Third, supportive housing should facilitate access to necessary support services for assistance with activities of daily living. Fourth, supportive housing and service providers should have a progressive management philosophy that is “people focused” and allows for good communication between providers and residents. And fifth, seniors should have access to supportive housing that is affordable and offers choice in terms of services offered, tenure and types of residents.

Profile of Supportive Housing Providers in Canada

In 2005, Social Data Research Ltd. (SDR) collected information from 244 supportive housing providers across Canada as part of a two year pilot project to develop an inventory of seniors supportive housing and a searchable database. [27] CMHC’s definition of supportive housing was used to help define the survey parameters. The survey was restricted to projects that had been purpose built or converted to supportive housing in the last fifteen years.

The survey presented a snapshot of projects that currently exit in Canada and the residents who live in these projects. Most projects were located in Quebec, Alberta, Ontario and British Columbia. About half the projects opened in the last ten years. About one third of the operators defined their projects as assisted living. The survey identified projects from all sectors: public, private non-profit and private for-profit. They ranged in size from as small as less than ten units to as large as 400 units. One-bedroom suites appear to be the most prevalent although many projects offer more than one size of unit.

Almost all (99%) of projects offer some services on site through their own organization. The majority of projects offer: 24-hour security; unit repairs/maintenance; meals served in a common dining room; recreational activities; hospitality services such as personal laundry and housekeeping; help with medications; and assistance with activities of daily living. Some projects also offer: transportation assistance (such as a facility-dedicated van); escorts to appointments; doctor visits; social services (such as counseling and referrals); mental health services; meals on wheels or wheels to meals; and palliative care.

The majority of projects have an on-site service coordinator who helps residents to access services. Most projects also involve residents in management decisions that affect them. About half the projects have on-site staff. In some projects residents and front-line staff are asked to sit on advisory boards or are involved in some other capacity related to management.

Projects were asked to provide information on the minimum and maximum monthly cost of housing and support services to their residents. About 70% of respondents provided information on costs. The average minimum cost to residents reported was $866 per month, and the average maximum cost was $1,264. However, reported rates for some projects were as high as $4,200 per month. Almost all projects offered a subsidy to residents who could not afford the full costs.

Profile of Supportive Housing Residents

According to the 2005 SDR survey of supportive housing projects for seniors across Canada, the average age of residents living in supportive housing ranges from 63 to as old as 93. Most are women, and almost all are living alone. Residents of supportive housing come from many different cultural backgrounds, and some projects are sponsored by a particular ethnic or religious organization.

About 70% of the projects in the survey reported they have been designed to support “aging in place”. As a result some residents are quite frail and need help with most activities of daily living. However, on average, about half the residents require little or no assistance and function quite independently. Many supportive housing projects have some residents with dementia; however, very few have been purposely designed to serve the needs of persons with dementia.

Issues Related to Quality

The 2005 SDR survey also included a literature review and interviews with experts in supportive housing across Canada. One of the themes that arose in the review centered on the issue of where supportive housing fits in the continuum of housing and care for seniors with greater health needs. For persons who do not require 24-hour nursing care, experts agree that most forms of supportive housing make it possible for residents to safely “age in place”. However, for seniors with severe dementia or other chronic diseases that result in significant loss of abilities over time, supportive housing may not be able to sustain these individuals over the longer term. [28] Although most projects in the survey reported that they have features that support aging in place, only 16% indicated that they have been designed to serve the needs of persons with dementia. As well, 54% restrict tenure for persons with mental health issues such as dementia.

The standards of care (or lack of standards) and how this relates to the quality of life for residents in supportive housing are still hotly debated. To help maintain a high level of quality of life in supportive housing, some experts hold the view that clear provincial policy guidelines related to standards and quality of services are needed. However, at the same time, concern is expressed about setting standards that are too restrictive.

At the time of the SDR study (still true today), BC was the only province with any legislation in place related to supportive housing. Current legislation in BC restricts assisted living facilities in BC to providing mainly hospitality type services and only one or two of the prescribed higher forms of more intensive services.[29] To be eligible for assisted living in BC, all persons must be assessed by the regional health authority as needing the level of care provided by assisted living facilities. The BC legislation specifically excludes people “who are unable to make decisions on their own behalf” from private and public assisted living unless they reside with a spouse who is able to make those decisions for them.”[30]

The lack of national standards for supportive housing and differing access criteria for home support services across the country are seen as barriers to the development of good quality supportive housing for seniors. Since the SDR report, CMHC released a report that outlines a legal framework for supportive housing for seniors that could help policy makers explore regulatory options. (Described under Best Practices in this Report).[31]

Seniors’ Perspective on the Quality of Supportive Housing

A few years ago CMHC conducted a fairly comprehensive study of resident satisfaction in supportive housing.[32] To date, it still remains the only study of its kind. The researchers conducted 24 case studies of supportive housing options for seniors across Canada and interviewed more than 500 residents. They examined resident satisfaction in detail across several major areas: housing features (private and common spaces), tenure arrangements, social involvement and interaction, management and operational approaches, support services, amenities and overall satisfaction.

Overall, the User Satisfaction study found a high level of resident satisfaction with most aspects of supportive housing, however, some projects were rated more highly than others. It was difficult to discern which factors distinguished those providers who received a high rating and those who did not because the study was presented in a descriptive manner and did not draw any conclusions. The research did seem to show that the provision of a range of responsive support services was important to residents. Projects that were successful in this regard were rated more highly.

Staffing and family support are important issues related to the quality of supportive housing and ultimately resident satisfaction and quality of life. A recent study compared three different types of settings in Alberta – adult family living, assisted living, and dementia care residential settings.[33] Recall and stylized time-use methods were used to assess the types of tasks and amounts of service provided by family and staff caregivers in the three settings. The study found that family members provide about 30% of on-site services to residents. Family members spend most time in enhancing well-being, while staff spends most time in housework. Patterns of care differed across the three settings. Family members of residents in assisted living residences tended to spend more time providing care than those in the other two settings. Given the major involvement of family members in service provision, the researchers recommended that future program policies and practices recognize this involvement and its impact on family caregivers.

Common Models of Supportive Housing and Those Who Benefit From Each Model

Outside of the CMHC definition which restricts supportive housing to purpose built or modified congregate housing, others provide a broader range of different supportive housing models. The list below describes this broader range and the types of seniors that would most benefit from each of these models. [34]

Existing private homes that are adapted to produce a more supportive environment in an individual's own home through a combination of physical design changes, bringing companionship by sharing the home with another person (or persons) and accessing community support services. This type of supportive housing is ideal for a “house poor” senior living alone (or with their spouse) in a larger home that is owned who needs some security and companionship, extra income from rent, and a little help with home maintenance. “The golden girls” model is a form of home sharing where two or more seniors (typically women) decide to share a home – sharing costs and providing mutual support.
Supportive housing can also be created in an existing home by adding on an accessory apartment, secondary suite or a garden suite/granny flat – a small separate home that is built on the property of the "host" home. This type of supportive housing works well for those adult children and their parents (typically a widowed mother) who get along and are able to negotiate an arrangement openly and realistically. Children must be prepared to provide support and to help facilitate access to community support services when needed.

· Abbeyfield houses are small group homes that were initially designed in Great Britain for elderly, unattached people and those who are socially isolated and at risk of self-neglect. There is usually a housekeeper onsite who prepares meals, carries out housework and shopping. This type of supportive housing is for seniors who need more supervision and support than those relying on family and tenants for assistance. It is not suitable for seniors who need extensive personal care or whose behaviours are socially unacceptable.

· Congregate housing is a purpose built or modified form of supportive housing typically offered by the private sector. This type of supportive housing can range from a smaller development of forty units or less to larger ones of 100 units or more. Most developments offer one or more meals per day, emergency assistance (though medical staff are typically not on-site) and some level of support services, sometimes with options. “Assisted living” facilities are included at the higher support level under this category. Imported from the US, assisted level facilities (more common in Alberta and British Columbia) offer 24 hour staffing, personal care, meals and snacks, housekeeping, laundry and maintenance services. In congregate housing seniors live in private, self-contained suites which are lockable. Suites vary in size from bachelor suites to one or two bedroom apartments. This type of supportive housing is suitable for a wide range of seniors since it usually provides a mix of privately and publicly funded support services. A large enough complex can accommodate more diverse personalities and needs than a small place like an Abbeyfield house. At the assisted living end of the continuum, seniors with mild or medium dementia can often be accommodated although there is some debate in the literature about this issue.[35] Most assisted living facilities have been developed by the private sector and target a more affluent senior.

· The campus model of supportive housing provides a multi-level of care for residents so that they can “age in place” as their health needs change. The campus model typically has a combination of independent apartments for seniors, congregate supportive housing for frail elderly persons, and nursing care, on-site (i.e. assisted living) so that a continuum of care can be provided to residents. This model can accommodate seniors with no need for assistance, to those who just need to be provided with meals, to those who need nursing care. In addition to individuals being able to age in place, another advantage is that spouses with different levels of care needs can live in the same complex.

· Other creative models include cohousing/collaborative housing (mixed generational housing) and satellite homes. In a cohousing development residents usually own their individual homes, which are clustered around a "common house" with shared amenities. These amenities may include a kitchen and dining room, children's playroom, workshops, guest rooms, home office support, arts and crafts area, laundry and more. Each home is self-sufficient with a complete kitchen, but resident-cooked dinners are often available at the common house for those who wish to participate. Satellite homes are group homes or “cottages” designed for seniors who can live in a group situation who need personal or intermediate care. The “host” organization which can be a long term care facility, church, or seniors support services organization provides the staffing and necessary care.

There are a variety of tenure arrangements in supportive housing including: subsidized rental, market rental, condominium, equity co-ops and life leases. Each of these forms of tenure impact affordability in different ways and lack of awareness about a particular type of tenure form can become a barrier to the development process. Life Lease for example, is a form of tenure that has had mixed successes depending on the sponsor and yet has a great deal of potential in terms of facilitating aging in place.[36]

An interesting supportive housing model has been developed in Edmonton, Alberta but can be found in other provinces. This model has been described as a “careaminium”. It is a setting in which people purchase a condominium on a life lease. The home can be a one or two bedroom unit. The condominium developer, a long term care facility operator, provides all needed services. This model allows couples to live together in the same unit even when one partner needs a higher level of care than the other (unlike in the campus model or continuum of care model where spouses become separated).[37]

The Ontario Model of Supportive Housing

Ontario’s supportive housing program was born out of research conducted during the eighties that showed a need for support services for low-income seniors and families living in social housing. A provincial supportive housing program was introduced that provided additional funding for support programs in selected communities across the province that were considered “under-serviced” in this area. Today, supportive housing buildings are owned and operated by municipal governments or not-for-profit groups. Accommodations, on-site services, costs and the availability of subsidies vary with each building. The housing portion of supportive housing is rental accommodation covered by the Tenant Protection Act, 1997. The Ministry of Health and Long-Term Care funds personal care and support services costs.

In the City of Toronto a range of supportive housing models is described[38] along a continuum of independence ranging from:

· Low Support High Rise Model where residents live in self-contained units in an apartment building with or without on-site support services (greatest independence) and may have access to services offered by a nearby congregate housing facility.

· Low Support Congregate Model where residents have access to the same support services as above but do not live in totally self-contained units but rather share common dining facilities and other services. This model can successfully house vulnerable seniors who also have significant mental health problems. (e.g., LOFT/John Gibson House)

· Medium Support Multi-Service Model where residents live in a housing complex that is very close or attached to a multi-service agency and has easy access to other services that are operated on the larger site (e.g., elderly person’s centre, medical clinics, restaurants etc.). This model minimizes social isolation because of the proximity to support staff. Some seniors may be able to age in place longer than in less supportive models.

· Medium+Support Horizontal and Vertical Campus Models where seniors live in a congregate setting that is either nearby (horizontal) or part of (vertical) a long term care centre. In both cases residents have access to the full range of personal and nursing services needed for more complex care. The Baycrest Centre is a good example of this model and also includes a geriatric hospital.

· High Support Specialized Model where residents live in a closely monitored, specially designed physical environment for seniors with special needs. (least independence):

The Assisted Living Model

Assisted living facilities (ALFs) are a residential model of care that have received considerable attention in the US as a potentially less expensive and more appealing alternative to nursing homes. ALFs are now commonly found in Canada mainly in Alberta and British Columbia but also elsewhere. The Assisted Living Quality Coalition has defined assisted living as a congregate residential setting that provides or coordinates personal services, 24 hour supervision and assistance (scheduled and unscheduled), activities and health related services and is designed to minimize the need to move; to accommodate individual residents’ changing needs and preferences; to maximize residents’ dignity, autonomy, privacy, independence, and safety; and to encourage family and community involvement.[39]

Services and staffing can be arranged in a number of ways and are typically provided through partnerships between housing and service providers. Hollander, in his recent literature review[40] described three types of assisted living partnership models:

· The Informal Model – in this model the assisted living provider hires its own staff for private-pay health monitoring. The home care agency simply provides one-to-one care for clients who live in the assisted living building. There are no written agreements or partnerships between the assisted living provider and home care. This is the common model.

· The Preferred Provider Model – In this model the assisted living provider still hires its own staff but enters into a letter of agreement with one or more home care agencies to serve as “preferred providers” of home care services.

· The Comprehensive Model – In this model there is a formal contract between the assisted living provider and the home care provider to have the home care agency provide the full range of private-pay personal care and health monitoring for all residents, and government subsidized home care services.

Supportive Housing and “Aging in Place”

Supportive housing is often used in parallel with the concept “Aging in place”. In reality, the latter can actually be an outcome of the former. Aging in place, commonly means not having to move from one’s present residence in order to secure necessary support services in response to changing needs. It also assumes that most seniors prefer to remain in their home and indeed consumer research suggests that this true. The 2004 Successful Aging Ottawa Survey found that only 20% of seniors had seriously considered moving from their current home in the past year in spite of factors such as the home being too large and difficult to maintain, cost/financial reasons or health reasons. In fact, according to Statistics Canada, seniors made up only a small fraction of movers between the years of 1999 and 2001 in contrast to people under the age of 65. Seniors who rent are more likely to have moved than seniors who own their home. [41]

Aging in place may not be a positive experience for all seniors. A recent British paper [42] questions this notion for vulnerable seniors. The author contends that factors such as house disrepair, homelessness and thoughtless or unresponsive landlords can undermine a persons “quiet enjoyment” of home. In drawing conclusions, the author considered international perspectives on aging in place and found many similarities and common trends. The author reported that the policy focus in most countries is shifting away from institutional care towards supporting frail older people in their homes through the provision of health and social care services. However, many seniors fall through the cracks particularly those living in unstable housing situations including the homeless and persons with dementia.

As such the bottom line for many older people is not that they are vulnerable per se but that they live in vulnerable housing situations. The British paper concludes that there is a need for policy makers to respond to the diversity of circumstances in later life and that this response needs to address housing issues explicitly. “Aging in place” and “staying put” are viewed as slogans that could be turned into reality by denying access to more specialist and probably more expensive forms of accommodation with care. Quality of life needs to be thrown into the equation by improving mainstream housing circumstances for all older people and especially those on lower income and by investing in a wider range of housing options including residential care.[43]

Many Canadian seniors are indeed aging in place. Most are doing so out of choice. However, in some instances seniors are staying put for other reasons including a lack of affordable alternative housing options in their community. Statistics Canada recently reported that housing affordability problems have actually increased for lower income seniors between 1981 and 2001.[44] This is contrary to the notion that seniors are getting wealthier with each cohort. The high proportions of seniors staying in their homes and their neighbourhoods opens possibilities for creative ways to make sure affordable supports are there when needed.

Linking aging in place to the concept of home versus neighbourhood, the Australian Housing and Urban Research Institute (www.ahuri.edu) posted some interesting findings from a recent study[45] that examined the current housing tenure and future housing intentions of older Australians. Drawing on a national survey of nearly 7,000 older Australians, in-depth qualitative research using focus groups and internet chat lines, the study found there is a significant shift in the values and priorities of older Australians that is transforming the patterns of future housing tenure, lifestyle and family relationships. One of the main points made by the study is that independence, flexibility, consumer and lifestyle choices are now key values and priorities for Older Australians. The study also found that aging in place depends more upon attachment to location rather than the family home. Older people are now accepting of change with the baby boomers particularly comfortable with moving house. Problems of household and garden maintenance, divorce, death of a spouse, downsizing, and lifestyle preferences precipitate decisions to move.

Along the same line, a recent report from the Joint Center for Housing of Harvard University questioned whether tomorrow’s seniors, the aging baby boomers, will have different needs, preferences and priorities in terms of their housing than seniors of today.[46] While today’s American seniors overwhelmingly choose to remain in their own homes and neighbourhoods, according to research cited in the report, aging baby boomers are expected to be more mobile given their higher levels of education, greater wealth, better health and broader travel experiences. However, just as is the case in Canada, there is a widening gap between the most and least wealthy seniors in the US spurring the need for more affordable housing options. The report also predicts a revolution in the delivery of elderly support services (such as increases private sector in-home help services and new assistive devises and equipment) to satisfy a generation used to making their mark on the US economy and society.

Elder Friendly Communities that Promote “Aging in Place”

A nation-wide US study[47] found only about half of American communities had begun to plan to address the needs of the exploding population of aging baby boomers. In response to this statistic, the National Association of Area Agencies on Aging[48] produced a work plan to help communities develop an elder friendly environment. A number of broad solutions to the aging in place challenges were outlined including: how to promote new housing options; transportation issues such as accommodating suburban lifestyles and what to do when driving is no longer an option; providing appropriate recreational opportunities; social, cultural and educational enhancement; viewing seniors as economic generators; providing access to health and social services; public safety issues and services; and promoting universal design in the context of fostering a universal community.

According to the National Association of Area Agencies on Aging,[49] the ten key components of an elder-friendly community are:

1. Preventative health care, such as health and lifestyle education, immunizations and screenings, to reduce injuries and the onset of chronic diseases, as well as a range of in-home health assistance to help people stay in their homes longer.

2. Nutrition education to promote healthy eating throughout a person’s lifespan, as well as nutritious community-sponsored programs such as home-delivered meals for those who have difficulty or are unable to prepare their own meals.

3. Age-appropriate fitness programs and recreational facilities that offer walking trails, benches, fitness equipment etc…

4. Larger, easier-to-read road signage, grooved lane dividers, reflective road markings and dedicated left hand turn lanes. Driver assessment and training to promote safe driving for all ages, especially after strokes or other health incidences. Transportation options for people who cannot or do not want to drive.

5. Special planning and training to help public safety personnel and other first responders locate and assist older adults during emergencies and disasters.

6. Home modification programs that make necessary adjustments for people with special needs. Zoning and subdivision plans that promote a variety of affordable, accessible housing located near medical, commercial and other desired services, as well as shared housing options for older adults and their caregivers.

7. Tax assistance and property-tax relief for those in financial need and programs to protect older adults against fraud and abuse.

8. Job training, re-training and lifelong learning opportunities, as well as flexible employment options to attract and retain older workers.

9. Opportunities to engage older adults in community boards and commissions as well as purposeful volunteer activities in local government and non-profit organizations.

10. Single point of entry for information and access to ALL aging information and services in the community, and strategic expansion of necessary services to support the older adults to age with dignity and independence in their home and community.

Along a similar line, another recent report provided an international perspective on policies for aging in place. [50] Based on research conducted in Japan, Finland and Australia, the report argues that well-designed housing and transportation that links seniors to amenities and services are the most critical components for positive aging in place.

Australian researchers[51] recently added the viewpoint of seniors into the aging in place discussion. In addition to outlining the elements (similar to above) of what would make a community senior friendly, researchers had seniors rate which elements were most important for them. Rated top priority was “personal/home safety”. Other important elements for seniors were transportation, attitudes towards seniors, physical attitudes and home support.

Seniors in Ottawa were asked to rate this city’s quality of life in the 2004 Successful Aging Ottawa’s Senior Survey. Issues of most concern according to the rating scale were the lack of affordable housing options for seniors, streets and sidewalks not being adequately cleared of snow in the winter, concern that there are not enough home support services to allow seniors to stay in their own home, and the level of responsiveness by local government to the needs of older people in Ottawa.[52]

Making the Case for Supportive Housing

Impact of Supportive Housing on Healthy Aging and Quality of Life

Advocacy groups for seniors have tried to make the case for supportive housing by linking housing to healthy aging. For example, the Seniors Health Promotion Network in Atlantic Canada recently made the following sweeping statement, “housing is the major variable in an older person’s life, physically, socially, financially, and psychologically.”[53] The report goes on to discuss the importance of a supportive environment for “Aging in place” and promotes more government involvement in stimulating affordable housing options for seniors. This theme is also echoed by an Ontario report on supportive housing by the Toronto District Health Council.[54]

A recent study[55] on the relationship between housing and the health of older seniors is worth noting. Drawing on data from an international survey of 1,918 people aged 75-89 years living alone in their own homes in Swedish, German, British, Hungarian and Latvian urban areas, the study found that participants living in better accessible homes, who perceive their home as meaningful and useful, and who think that external influences are not responsible for their housing situation (in other words they made their own decision on where to live) are more independent in daily activities and have a better sense of well-being. According to the authors, the findings suggest that older adults should play the central role in the negotiations around home modifications and relocation. Further, it is important that housing solutions be included within a multidisciplinary approach to assessment and care planning.

Another way to link housing for seniors and health is to examine the relative risk to health of different settings. The results of a research trial in New Zealand[56] to improve the outcomes of older people with high and complex needs found that the risk of mortality to seniors living in the community could be reduced through a coordinated service model. Three different pilot “Aging in place” programs were studied: the first was a needs assessment and service coordination initiative aiming to avoid duplication in service provision; the second was a case management program which guides a person’s pathway through the rehabilitation process; and the third was a Flexible Integrated Restorative Team that aimed to provide restorative home support for older people with high and complex needs. Some of the key findings of the research trial were:

Older people with high and complex needs who would otherwise be admitted to residential care can remain living at home with no apparent risk.
All three pilot programs reduced the risk of mortality compared with usual services.
Caregiver stress did not appear to increase in the intervention groups in comparison to usual care.
Predictive modeling showed a number of situations where older people were more likely to be hospitalized or enter residential care. These included functional decline, social isolation, negative moods, caregiver stress, inadequate meals, dehydration, delirium and a lack of medication review.

The bottom line conclusion was that older people assessed with high or complex needs can safely remain at home with provision of appropriate services.

In Canada, a number of studies have concluded that supportive housing not only improves the quality of life of at-risk older people but has the potential to prevent unnecessary institutionalization and decrease emergency room visits. Using a pre and post-program research design including a comparison sample, The Ottawa Aging in Place Pilot Project[57] found that the introduction of a part time on-site tenant support coordinator who linked residents to needed services along with a building dedicated home making team made a positive significant impact on the lives of seniors living in social housing. The study reconfirmed the results of earlier research in Ottawa, which also employed a rigorous longitudinal pre- and post-program research design. This model, however, evaluated the impact of a public health nurse as the primary health care provider on-site full-time five days per week, and examined impact on hospital admissions. Tenants residing in the buildings where the public health nurse was present showed significantly fewer hospital admissions than the controls in each year of the three years examined.[58]

A similar recent similar study[59] conducted by researchers at Ryerson and the University of Toronto in partnership with The Toronto Community Housing Corporation, Neighbourhood Link/Senior Link, Etobicoke Services for Seniors and St. Paul’s LAmeroux added further evidence to the field. The researchers concluded that judging by the relative risks of seniors in the study, supportive housing is a cost-effective alternative to institutionalization, preferable in terms of quality of life and independence even for the oldest old. In particular, the authors of the study stressed the critical role of intensive case managers in supportive housing in integrating services around the needs of the client, substituting lower cost services (such as vacuuming, laundry, cleaning and grocery shopping) for more expensive institutional supports, and reducing demand on emergency services through ongoing assessments. The study also found that contrary to common belief that given access to services people will maximize use and costs, under intensive client focused case management the incentive was the reverse – to use minimum level of services necessary to maintain the individual at the highest possible functional status.

In the same vein, the evaluation of a recent demonstration program in the US examined tenant outcomes for residents living in affordable, service-enriched rental housing for homeless and those at-risk of becoming homeless. [60] After monitoring the program for five years, the study found improvements in tenant’s level of functioning, independence, general health, level of satisfaction, and level of income.

Supportive housing in its more intensive form of assisted living has been put forth as an alternative to more traditional institutional care for seniors with dementia. The literature search uncovered one academic paper that addressed this issue in relation to quality of life. The study, based in Alberta, compared the effect of specialized services on the quality of life of residents with middle- to late-stage dementia living in assisted living facilities to those living in traditional institutional facilities.[61] The study used a prospective matched group design that involved 24 long-term care centers and four assisted living residences and 185 residents. The researchers found that the assisted living group of residents demonstrated less decline in activities of daily living, more sustained interest in the environment, and less negative affect than residents in the traditional institutional institutions. There were no differences between groups of residents in the two settings in concentration, memory, orientation, depression, or social withdrawal. The authors conclude that the quality of life for adults with middle to late-stage dementia is the same or better in a purpose built assisted living residence than in traditional settings.

Cost-Effectiveness and Relative Costs of Supportive Housing

A number of recent reports on supportive housing have cited studies (Canadian and International) that promote the cost-effectiveness of different models or elements of supportive housing. In addition, experts have tried to make the case that supportive housing and in particular assisted living can prevent or delay admittance to higher cost long term care and reduce hospitalization of seniors.[62] It has also been argued that targeted, managed home and community care within an integrated continuum consistently meet individual & system goals by maintaining the health, well-being and autonomy of individuals and their caregivers and by helping to solve key health system problems.

A frequently referenced program is On Lok/PACE (Program of All Inclusive Care for the Elderly)[63]. Initiated in the early 1970’s in San Fransisco’s Chinese community the program has since expanded to 36 PACE projects in the US (Canadian equivalent in Edmonton is called CHOICE). The service model, which targets seniors on low income & high risk, is organized around adult day care services & offers a continuum of services. Seniors are transported to the centre. Government funding for PACE clients average 95% of the costs of institutional care. Evaluations have shown that seniors enrolled in the program average fewer days in hospital than comparable groups of seniors and experience better health status & quality of health.

In terms of Canadian research, evidence-based studies are fairly short in supply. Leading the field is Vancouver Coastal Health (VCH).[64] VCH continues to examine ways to more cost effectively deliver health services. Through a series of initiatives that included targeting the highest needs groups (complex care seniors, adults with disabilities), linking community care funding to system outcomes (e.g. ALC bed reductions) and shifting the focus from LTC beds to assisted living (supportive housing) and residential care (care), VCH has reduced residential care beds (25%-30% of community clients met residential care thresholds), reduced ALC days from 12% to 6% and saved 17 in-patient beds by introducing geri-triage nurses in all emergency departments (nurses who were knowledgeable about available community support options).

A few other Canadian studies are worth noting. [65] Hollander cited his own earlier study (2001) of the cost-effectiveness of long-term home care that found over time, and for all levels of care needs, home care, on average, was significantly less costly than care in a long term care facility. Hollander also provided evidence on the relative costs of home support and professional home care (e.g., nurses, physiotherapist) in long term care. He found that approximately 90% of the expenditures for long term home care, for people with higher level care needs, were for home support services while 10% were for professional services. This means that any substitution effect of home care compared to facility care is, in large part, due to home support services and indicates that even basic home support services such as housekeeping can have a significant impact on the cost-effectiveness of a health care system.[66]

A recent report on the care of the elderly in Sweden[67] provided cost figures on the care of the elderly in regular housing and in special housing. Sweden provides an array of publicly funded coordinated services to seniors living in their own homes to assist aging in place including meals, home adaptations, transportation, personal safety alarms, home help, home medical services, short term housing, and day activities. Special housing exists for seniors who need help arranging care and need 24 hour support. In special housing seniors typically rent their suite which has been adapted for aging in place. On-site staff provides access to needed home medical services. More and more seniors in Sweden are able to live in regular housing with community support due to advances in health and medical care. The cost per care recipient in regular housing is approximately half that in special housing. As well the cost of providing special housing has increased more dramatically over the last 5 years than providing care in regular housing.

Hollander claims that there is now an emerging body of evidence on the cost effectiveness of assisted living/supportive housing. He refers to several studies (Swedish, British and American) that compare the costs, or costs and outcomes of assisted living/supportive housing services with long-term care facilities. Hollander cautions, however, that the evidence is still limited and somewhat mixed. Most of the studies discussed in the Hollander report were based on very small sample sizes, however, they do point in favour of supportive housing/assisted living in terms of cost-effectiveness particularly when adjustments are made for quality of life and client characteristics.[68]

The SDR literature review also uncovered some research on cost comparisons between different settings. A recent Quebec study compared the cost and resources associated with disabilities of elderly people living at home, in intermediate care (supportive housing) and in nursing care.[69] The study found that the cost of care was least at home and most in the nursing home setting, with intermediate care in between. While this suggests that it may be more cost effective to care for the elderly with disabilities at home or in intermediate settings such as supportive housing, the authors caution that the care was provided by less skilled people in the two less costly settings and thus the quality of care must also be taken into account. The study did not measure quality of care.

Lessons learned from evaluations of supportive housing for persons at-risk for homelessness are also applicable for seniors supportive housing. A recent outcome evaluation in Vancouver[70] examined changes in hospital utilization by individuals one-year post access to supported and non-supported housing. The study found that individuals with a mental illness who move into supportive housing experience a significant decrease in hospital use in the year post-housing. This decrease is assumed to be linked to fewer admissions for psychiatric reasons as has been shown by other studies.

The evaluation of a recent demonstration program in the US examined tenant outcomes for residents living in affordable, service-enriched rental housing for homeless and those at-risk of becoming homeless. [71] After monitoring the program for five years, the study found improvements in tenant’s level of functioning, independence, general health, level of satisfaction, and level of income.

A recent Canadian study by Pomeroy produced a costing analysis of different levels of supportive housing for persons at risk for homelessness. [72] Pomeroy’s study tests the hypothesis that “purposeful, well designed supportive housing is more cost effective than the cost of doing nothing which results in either institutional or emergency use”. Pomeroy collected data of actual costs across a range of existing facilities and housing options in four cities – Vancouver, Toronto, Montreal and Halifax. Pomeroy studied four levels of support and four building forms. The study found that overall costs were significantly higher for institutional responses versus community residentially based options (even when a fairly high level of support was provided in the latter). Emergency services also tend to involve higher costs than the community/residentially based options.

Best Practices

The following ideas and best practices represent the most current thinking and approaches related to supportive housing for seniors.

A Legal Framework for Supportive Housing for Seniors: Some Options

CMHC’s report on the regulation of supportive housing for seniors provides some interesting options. Responding to the study’s main finding that “all seniors participating in the consultations felt that special regulation was necessary” but not wanting to discourage developers from entering the field, the authors of the report provided a range of options that could be considered by housing policy makers.

Option 1 – Develop a comprehensive supportive housing statute that would include provisions related to:

Rights and responsibilities of residents
Issues relating to rental, purchase, and life lease tenure
Mandatory standards
Special standards in “assisted living”
Information to be provided to residents

· Option 2 – Establish a system of “elder ombudsmen” at the provincial level with responsibility for seniors housing issues and would serve as a “one stop shop” easy to access system for finding information, making complaints and resolving disputes and other kinds of problems.

· Option 3 – Establish a working group to create national best practice guidelines such as the guidelines in the US for assisted living facilities.

· Option 4 – Establish a supportive housing for seniors “centre of excellence” whose role would be to create a model “Code of Practice” for accreditation.

· Option 5 – Establish a (non-legislated) system for accreditation with input from consumer and providers as well as academics.

· Option 6 – Establish a central information database accessible through the internet and through a seniors housing “hotline” that would provide information on availability, costs, rules and conditions of residency.

Seniors Housing Information Program (SHIP), British Columbia

SHIP is an excellent one-stop information port for seniors housing in BC. The site includes information on all types of purpose built seniors housing and has a separate section on supportive housing and assisted living projects. SHIP has a searchable database available online at www.seniorshousing.bc.ca. SHIP could be a model for local municipalities, other provinces or as national database as described in Option 6 above. SDR conducted the pilot project for the establishment of a national database on supportive housing. At this point in time the pilot database contains information on over 300 projects.

70 Ways to Reduce the Cost of Developing and Operating Supportive Housing for Seniors [73]

This guide is an extremely useful tool for interested individuals and groups who wish to develop and operate affordable, supportive housing for seniors. It is intended to assist groups ranging from non-profit organizations that have never been involved in seniors housing before to operators of large assisted living facilities. The guide focuses on housing that provides hospitality services (meals, laundry, housekeeping, social and recreational activities) or personal care services (help with bathing, dressing, eating etc…) or both.

According to the authors, supportive housing is considered “affordable” if it does not require more than 70% of household income. For seniors living on a minimum pension income, 70% equates to about $700 per month. The authors maintain that it is virtually impossible to provide shelter and services for $700 per month without government subsidies. Through research into existing supportive housing projects and information gathered from a variety of other sources, the authors identify a number of opportunities for streamlining costs and improving efficiency. The guide provides guidelines, comparisons, and suggestions that will save money in the development, construction and operation of supportive housing projects for seniors.

Topics covered in the guide include: how to determine the need and demand for supportive housing in your community; the development process, partnerships and financing; board governance; operations: cost savings and creating efficiencies; cost effective design; adaptive reuse; and developing supportive housing for seniors in small communities and rural areas.

Aging in Place: A Toolkit for Local Governments

This useful resource was recently produced by the Atlanta Regional Commission jointly with the Community Housing Resource Centre of Atlanta. Aging in Place is a tool designed to help local governments in the US (but could easily be transferred to other countries) plan and prepare for their aging populations. The tool recommends techniques for coordinating housing development regulations and healthcare supports so older adults can stay in their homes. It also addresses specific quality growth practices so older adults can get out of their homes. It details examples of coordinated approaches to the provision of neighbourhood housing and supportive services that make it not only possible, but also cost effective for seniors to stay in their communities.

The heart of the Aging in Place toolkit is a set of local strategies organized into three critical issue areas: Healthcare (Integration of healthcare delivery with housing and planning initiatives); Environment (housing and urban design); Planning and zoning (housing stock and location).

American Association for Retired Persons’ (AARP) Checklist for Aging in Place Home Design

AARP provides a check list for Aging in Place Home Modifications on their website. Designed for use by elderly consumers, the site includes information on understanding universal home design, a bathroom checklist, guidelines for doors, floors and walkways, how to modify a kitchen, and information related to lighting and storage areas. The site also includes a special needs checklist which allows consumers to rate their own needs for home modifications based on a range of difficulties with daily activities. AARP studies have shown that medical costs of seniors living in a Universal Design home can be as little as half the cost of living in a traditionally designed home. For more information, visit www.aarp.org/families/home_design

Public Health Agency of Canada’s Report on Seniors’ Falls, Division of Aging and Seniors, 2005

Falling is a risk factor for seniors in terms of losing their independence and having to move to a nursing home. This report takes a comprehensive look at the issue of falls among seniors. The report includes a chapter on evidence-based best practices for the prevention of falls including appropriate practices according to setting. Practices include: how to assess risk factors; using multifactorial interventions that includes a combination of assessment and interventions such as exercise programs, behaviour change, medication review and modification, treatment of contributing health conditions, assistive and protective devices, environmental modifications, and education. For more information about this publication visit: www.phac-aspc.gc.ca/senior-aines/pubs/senior_falls/index.htm

A Recent Summary of Best Practices in Supportive Housing for Seniors

Hollander, in his 2006 review summarizes best practices for supportive housing within the Ontario context. The practices are organized under four major components and could be considered prerequisites for supportive housing:

Best practices related to philosophy and policy

Fostering independent living
Client-centred approach
Assessment and coordination of care and service
Community development
Client access to 24-hour support
Emergency response
Security checks
Integration within health care system
Responsiveness to health care system needs (e.g., in discharge capacity with hospitals)

Best practices related to service delivery

Flexibility in delivery in a variety of housing models
‘case management’ functions of case finding, care/service coordination, referrals and community development
Providing programs for all residents (e.g. congregate dining) to promote awareness and create community
Address multiple client needs (e.g. frail, Alzheimer’s, mental health, cultural)
Flexible, consistent staffing
Sensitivity to multicultural and other client diversities and needs in recruiting, hiring, training programs and education
Accessible communication tool for frontline staff (e.g., pager, cell phone)

Best practices related to administration

Leadership through common vision, commitment, and an understanding of seniors’ needs and informed decisions
Providing specialized environments for special needs (e.g., Alzheimer’s)
Funding for all residents under one envelope or buildings in close proximity to maximize flexibility
Creating efficiencies through critical mass
Use of client information management software
Using an internal waitlist for seniors in need of services

Best practices related to linkages and relationships

With all residents
With all housing providers for assessment, admission, ongoing reviews, and other issues
Access and linkages to a larger range of services, including health and long-term care
With hospitals and other formal health care service providers (e.g., physicians, clinics, outreach), other community service groups, volunteers, local business, cultural organizations and networks
Developing alliances with other health care agencies providing related services in the same building

2006 CMHC Report: Renovation and Repair Referral and Advisory Service for Seniors and Others Who Are Homeowners (Available fro CMHC’s Canadian Housing Information Centre, Order Number 65291)

This study focused on the development of a model for a renovation and repair referral and advisory service for seniors and others who are homeowners. The proposed model is intended to provide consumers with a method for finding honest and qualified renovation and repair contractors. By facilitating renovations, repairs and home adaptations, such an advisory service could provide seniors with a better opportunity to age-in-place (i.e., to continue to live independently in their homes for as long as possible).

2006 CMHC Report: Senior's Housing for Seniors: A Feasibility Study

Converting single-family detached houses, owned and occupied by seniors, to create secondary suites can have potential benefits for seniors and the neighbourhoods in which they live. The objectives of this study were to: estimate the interest of senior homeowners in converting their current homes to create secondary suites; outline the financial and renovation implications of conversion; and identify the regulations and zoning which affect conversion. Findings are based on interviews with senior households and group discussions with builders, real estate specialists and City officials. (Prepared by The Council on Aging of Ottawa, Available from CMHC’s Canadian Housing Information Centre, Order Number 65308)

Two CMHC Publications on Flex Housing (The Professional’s Guide, and Homes that Adapt to Life’s Changes)

These two publications are available in the Canadian Housing Information Centre (613-748-2003). They are an excellent resource for individuals and groups wishing to learn more about the concept of flex housing and practical advice and how to introduce flex design into home settings. Flex design is an example of the type of building technology available today that would assist aging in place.

CMHC Report: Planning Housing and Support Services for Seniors

This older (1998) publication is available in the Canadian Housing Information Centre (613-748-2003). It is still timely and provides a wealth of practical hands-on advice including examples of needs assessment tools to help communities plan for their aging population.

Upcoming CMHC Reports with Relevance for Supportive Housing

CMHC is soon to release a number of reports that should prove useful for individuals and groups planning to introduce supportive housing and aging in place solutions. These include:

· Supportive Housing for Homeless and Hard-to-House Seniors, will provide an in depth description of a successful housing project for homeless and hard-to-house seniors with a focus on outcomes, lessons learned and advice for other supportive housing projects.

· Determining the Implications of the Aging of the Canadian Population for Housing and Communities, will identify challenges and opportunities for planning, designing and managing communities (cities, small towns and suburbs) with increasing older populations. The research will gather practical information through case studies of communities that have already reached the proportion of seniors that Canada is expected to have in the next 30 years.

· Adapting Bungalows for Seniors’ Home Care, describes the results of a post-occupancy evaluation of suburban bungalows that were redesigned for seniors receiving health care services at home.

· Adapting the Home Environment for Alzheimer’s and Related Dementia, will develop a self-assessment tool that will function as a community resource guide to individuals experiencing Alzheimer’s Disease and related Dementia and their families through the process of adapting the home environment while reflecting their individual needs and concerns.

· Caring for Aging Parents, will provide research findings to help the housing industry learn the degree of commitment that exists for this type of personal family care for older parents and assess the implications for the housing market of this form of housing demand.

· Conversion of an Existing Institutional Building to 58 Affordable/Accessible Housing Apartments for Seniors and Disabled Adults, chronicles the Armitage Gardens Project which revitalized a vacant and under utilized portion of a building into 58 affordable rental apartments.

More information about these reports and how to obtain a copy can be found in CMHC’s Current Housing Research, Volume 13, Number 2, Winter 2006-2007 and by contacting the Canadian Housing Information Centre at 613-748-2003.

Innovative Initiatives

The following supportive housing initiatives have been referred to in the literature and by experts. Some are fairly new and some have stood the test of time.

Canadian Initiatives

WOODGREEN COMMUNITY CARE and WELLNESS FOR SENIORS (Toronto)

WoodGreen Community Services is a comprehensive neighbourhood service centre for vulnerable people including seniors, families, youth, new immigrants, and persons with special needs including the homeless. For seniors who need home support, WoodGreen offers: meals on wheels; friendly visiting; telephone assurance/security checks; transportation to and from medical appointments as well as group outings; personal support and housekeeping services 24 hours a day, 7 days a week within seniors homes that includes assistance with bathing, grooming, and taking medications; and supportive housing that provides a social environment and 24-hour on site support to assist seniors with their daily activities.

WoodGreen also offers social activities and wellness programs, adult day programs for seniors with dementia, case management and social work for seniors and their families, and caregiver support.

Recently, federal, provincial and municipal officials joined WoodGreen and its partners for a ground breaking ceremony to celebrate the construction of a first of its kind apartment complex (Wellesley Central Residences Inc.) that will provide supportive housing to seniors and people with HIV/AIDS.

For more information about Wood Green visit: www.woodgreen.org

Address:

835 Queen Street East

Toronto Ontario

Contact: Brian Smith, President, 416-572-0000, ext. 4001

LOFT (LEAP OF FAITH TOGETHER) JOHN GIBSON HOUSE SUPPORTIVE HOUSING PROGRAM (Toronto)

The John Gibson House Supportive Housing Program (J.G.H.) in the west end of Toronto helps some of the most vulnerable, at-risk and frail older adults in the community. Through a multi-service approach, the program offers 24-hour on-site access to services for seniors who have traditionally been under-served. JGH assists them with health and medical concerns, mental illness, and substance abuse problems and other related issues. The communal dining program at JGH provides affordable and nutritious meals to its residents, and to seniors in the broader community. The use of Personal Support Workers has provided practical assistance and care to residents, enabling them to remain in their homes.

John Gibson House provides supportive housing services for fifty seniors at its Crawford Street site, as well as for seniors living at LOFT's apartment buildings in downtown Toronto.

The success of the John Gibson House Program is based on collaboration between its service users, staff members, and the community. It has, for over 75 years, continued to be committed to serving the needs of those most in need in the community.

For more information about LOFT visit: www.loftcs.org

Contact: Maria Egervari 416-537-0001 or

(416) 537-3477; megervari.dunnav@loftcs.org

PEEL SENIOR LINK

Peel Senior Link, a non-profit charitable organization established in 1991, provides a comprehensive range of personal care & home-making services to seniors. Its mission is to make independent living possible for senior citizens who might otherwise be expected to enter more institutional settings, such as Long-Term Care facilities and hospitals.

Peel Senior Link services have a reputation of being client-directed, flexible and individualized. The organization coordinates personal care & home-making services, at no charge, for over 1,000 seniors in designated buildings in Mississauga and Brampton. These services include:

· 24/7 On-Site Services are for seniors who require daily and ongoing assistance and live at one of the designated service buildings managed by Peel Living and Wawel Villa. Having staff on-site lets seniors know that help is available, easing their fears about living alone.

· Personal care & home-making services make it possible to provide support to seniors without taking away their independence and dignity.

· Day Services are for seniors who require limited assistance on an as-needed basis and are available at all Peel Senior Link designated service buildings.

· Peel Senior Link strives to help improve the physical health of seniors by providing education about nutrition, helping seniors shop for healthier groceries, making referrals, and advocating with community agencies on behalf of clients.

For more information about Peel Senior Link visit: www.peelseniorlink.com

Contact: Ray Applebaum, Executive Director: 905-712-4413; ray@peelseniorlink.com

NORTH RENFREW LONG-TERM CARE CENTRE (Deep River)

The North Renfrew Long-Term Care Centre is a well known rural project that includes 21 long-term care suites and 10 self-contained apartments. Seniors are supported in their apartments by a range of community support services including an Adult Day Service – Drop-in Centre, Meals-on-Wheels-Wheels-to-Meals/Diner's Club, Respite services, and transportation services. The project is linked to other Deep River area health services including the Community Care Access Centre, North Renfrew Family Services, Canadian Red Cross Society Homemaker Services, and the Para-Med Health Services.

Address:

47 Ridge Road
P.O. Box 1988
Deep River, Ont.
K0J 1P0

Phone: 613-584-1900

LAURIER HOUSE and THE CAPITAL CARE GROUP (Edmonton)

The CAPITAL CARE Group has been caring for people since 1964. The Group has the reputation of being leaders in continuing care has grown into the largest publicly funded and operated continuing care organization in Canada. The CAPITAL CARE Group is a wholly owned subsidiary of Capital Health, the regional health authority.

The Laurier House model is an innovative approach that delivers, in a condominium-like setting, the level and type of health care and social services that are traditionally available only in long-term care institutions. Laurier House through design and service arrangements allows individuals and couples to age in place. One appealing feature is that elderly couples can remain living together in the same apartment even when one partner needs more complex care. This is possible because Laurier House is built on a health care campus that also includes a traditional long-term care centre, built in 1994, and a centre for Alzheimer’s disease built in 2001.

One of the unique features of the Laurier House model is that it utilizes life leases to “unbundle” the costs of various services that are provided, allocating them either to the client or the health care system. Housing costs, a private expense, are separated from the costs of both publicly funded personal support services and the housing-related support services. The costs of healthcare at Laurier House are funded by the health region and clients must go through the same screening process as they would to be admitted to a long-term care facility.

Laurier House is an attractive building with forty-two 1 and 2 bedroom suites. It is physically linked to the other two centres on the campus. On the outside it has the appearance of a residential development and inside it looks like a small hotel. At the front entrance, a reception desk at the side lobby serves visitors to Laurier House and the Alzheimer Care Centre. The Laurier House dining room occupies a central location on the main floor and its kitchen operates like a restaurant with limited hours.

The Laurier House model was recently (2005) the subject of a CMHC study[74]. This study examined the attitudes toward life lease housing of Laurier House clients, their families, and the professionals whom seniors consult when they require long-term care. The final report is available from the Canadian Housing Information Centre, 613-748-2003)

CHOICE (Edmonton)

The Capital Care Group also operates three CHOICE programs in Edmonton. In January 1996, Capital Health funded and introduced the Comprehensive Home Option of Integrated Care for the Elderly (CHOICE). CHOICE was modeled after the American PACE Program (Program of all Inclusive Care) which has been in existence since 1966 and was based on the On Lok Program in Chinatown in San Francisco.

The Edmonton CHOICE Program operated by a three way partnership between Edmonton Capital Health, the Capital Care Group and The Good Samaritan Society was the first of its kind in Canada. The program is designed to assist seniors to continue living independently and in their own homes longer, by managing all their health requirements. All participants of the program come to one of the CAPITAL CARE CHOICE day centres from one to five days where a full range of medical, psychological, social and supportive services are available by a dedicated interdisciplinary care team. More information about CAPITAL CARE COICE can be found at www.capitalcare.net/Programs/choice.htm

Address
The CAPITAL CARE Group

#500, 9925 - 109 Street

Edmonton, Alberta, Canada

T5K 2J8

Contact: Dr. Doris L. Milke, Research Coordinator

Phone
(780) 448-2400

Fax
(780) 496-7148

E-mail
info@capitalcare.net

Website Comments
info@capitalcare.net

Website
www.capitalcare.net

Initiatives Outside Canada

BEACON HILL VILLAGE (Boston)

Beacon Hill Village helps persons age 50 and older who live on Beacon Hill and in its adjacent neighborhoods enjoy safer, healthier and more independent lives in their own homes–well connected to a familiar and attentive community. Faced with the prospect of leaving the neighborhood they love in order to obtain the services of a retirement community, a group of long-time Beacon Hill residents decided to create a better alternative–Beacon Hill Village is designed to make remaining at home a safe, comfortable and cost-effective solution.

By partnering with proven providers of services, Beacon Hill Village is able to offer its members preferred access to social and cultural activities, exercise opportunities and household and home maintenance services, as well as medical care and assisted living at home. As a nonprofit, membership organization, it can provide these programs and services more cost-effectively than most conventional retirement communities.

Villagers can choose from an à la carte menu. Some services are included in the annual membership fee, with others provided at reduced rates. Services include: Information services; Household services (home repair, household cleaning, errands, organizing closets, computer problem solving, bill paying etc.); transportation (individual and group rides to anywhere – doctors, airport, friends, cultural events), meals and groceries (weekly shopping, home delivered meals – elegant or casual, dining groups), Volunteer programs (opportunities for members to help each and others in the community at large), concierge services (delivered exclusively by one in-home service provider and includes rides to anywhere, picking up prescriptions, dry cleaning, packing boxes, mailing packages, waiting for repair person, picking up theatre or concert tickets, taking in computer for repairs, watering plants and picking up mail during vacations).

Beacon Hill Village originated with a dozen civic-minded residents of this neighbourhood who all wanted to remain at home even after experiencing some difficulties with activities of daily living. Today the organization has 340 members aged 52-98, an annual budget of $300,000, an executive director and staff, a stable of established service providers and enough foundation support to subsidize moderate or low income members who number one fifth of the total. The annual fee for members is $550 for an individual and $780 for a household, plus the additional cost of discounted à la carte services.

The grassroots experiment has drawn praise in a recent AARP publication, has been written up in the New York Times, and has been hailed by an array of research institutes, including the AgeLab at M.I.T. and the North Carolina Centre for Creative Retirement. The organization has recently published a how-to manual to help guide other community groups wishing to start a similar organization through the complexity of creating a business plan and surveying community needs.

Beacon Hill Village
74 Joy Street
Boston, MA 02114

Phone: (617) 723-9713

www.beaconhillvillage.org

CERTIFIED AGING-IN-PLACE SPECIALIST (CAPS) PROGRAM

The Remodelors™ Council of the National Association of Home Builders (NAHB) in collaboration with the NAHB Research Center, NAHB Seniors Housing Council, and AARP developed the Certified Aging-In-Place Specialist (CAPS) program to address the growing number of consumers that will soon require these modifications. While most CAPS professionals are remodelers, an increasing number are general contractors, designers, architects, and health care consultants

The CAPS program goes beyond design to address the codes and standards, common remodeling expenditures and projects, product ideas, and resources needed to provide comprehensive and practical aging-in-place solutions. CAPS graduates pledge to uphold a code of ethics and are required to maintain their designation by attending continuing education programs and participating in community service.

A Certified Aging-in-Place Specialist (CAPS) has been trained in:

The unique needs of the older adult population
Aging-in-place home modifications
Common remodeling projects
Solutions to common barriers

More information about CAPS can be obtained from The Remodelors Council at 800-368-5242 x8216 or via e-mail at remodel@nahb.com

The Need for Supportive Housing in Ottawa

The 2004 Successful Aging Ottawa Survey and the 2004 Ottawa Fact Book on Aging along with the BC guide by Mancer & Holmes (70 Ways to Reduce the Cost of Developing and Operating Supportive Housing for Seniors[75]) provide the type of information that will help local housing and service planners determine the need for supportive housing in Ottawa. Using just two indicators from the SAO Seniors Survey – the number of respondents who could be considered frail (based on perceived poor health, number of poor health days in the last month, need help with 3+ ADLs or rely on Para Transpo) and the number of respondents on low income (<20K and no greater than 30K), it is estimated that somewhere between 1000 and 4000 Ottawa seniors could benefit from affordable supportive housing. For seniors with an annual income of $20,000 the most they could afford for housing and support services would be $1,170 per month. (Based on the affordability guidelines provided by Mancer & Holmes)

Previous research has identified unmet needs for older homeless women[76] and gay, lesbian, bisexual and transgendered seniors in Ottawa.[77]

Trends that Might Impact the Need for Supportive Housing in the Future

Next to Calgary, Ottawa has the fastest growing senior populations in Canada, a population that is projected to increase even more rapidly over the next few decades. The number of seniors 65+ in Ottawa (almost 90,000 now) is expected to grow to 267,000 in the next 30 years and the group 85 and over will more than triple and stand at nearly 34,000. Whereas today, seniors represent about 12% of the population by the year 2031, about one quarter of the population will be 65+. The reason for this surge in numbers is due largely to the aging of the “baby boom” generation born between 1946 and 1960. Increasing longevity and declining fertility rates among the child-bearing population are also factors.

There is much debate among experts[78] about the implications of an aging society in Canada. In particular, questions such as: “Will baby boomers be better or worse off financially during their old age than previous generations?”and “How well will baby boomers age in terms of their health?” are often posed. The answers to these questions will impact housing, health and social services over the next 10 to 20 years.

Some of the most recent projections and “thinking” from experts at Statistics Canada, National Advisory Council on Aging (Seniors in Canada, 2006 Report Card), National Council of Welfare, and universities across the country suggest the following trends:

· The percentage of seniors living on low income has decreased over time and it would appear that each cohort of seniors over the past 4 decades have had more disposable income. At the same time, an increasing number of people in the “boomer” generation are feeling uncertain about their financial future and do not know when they will be able to retire. Over thirty percent of recently surveyed baby boomers (General Social Survey, 2002) were not sure when they would retire.

· The percentage of seniors who are currently working has increased from 6% in 2001 to 8% in 2006, a trend that is predicted to continue for a number of reasons including declining high tech stock prices in pension plans, the mounting pressure on the labour force due to the early retirement of some baby boomers, coupled with a booming economy in many parts of Canada. In a recent Statistics Canada Labour Force Survey (2002), one fifth of Canadians reported that they had no plans for retirement and expected to continue working after age 65.

· There is a widening gap between families at the top of the income scale and those at the bottom with respect to pension contributions. Those at the top of the scale are better off than their 1986 counterparts than those at the bottom. This trend held true for two parent families as well as lone parents and singles.

· The increasing longevity of Canadians is putting pressure on pension funds, particularly the huge size of the Baby Boomer generation. Recent immigrants who are less likely to have a pension plan through employment and are more likely to be self-employed, as well as women living alone are most vulnerable to the experience of financial insecurity in retirement.

· Income is related to physical and mental health and overall quality of life (a relationship confirmed in the 2004 SAO Seniors Survey). While the average income for seniors has improved over time, the income gap between men and women continues. According to the National Advisory Council on Aging, senior women living alone, older seniors 75+ and recent immigrants are more likely to live on low income than other Canadian seniors (also confirmed in the 2004 SAO Seniors Survey).

· The percentage of seniors who own their own home has increased over the last 5 years with 86% of couples owning their own home in 2003. With more and more senior homeowners, the potential for needed home maintenance and other home support services increases.

· Seniors’ housing conditions in general are improving with fewer seniors living in core housing need (paying more than 25% of their income on housing) now than six years ago

· The number of seniors living alone is on the rise, particularly for women over the age of 85.

· As the baby boomers age, the number of people in the “sandwich” generation continues to rise – almost 3 in 10 Canadians aged 45-64 in 2004 reported that they were caring for a senior and also had at least one unmarried child living at home. Eighty percent of these Canadians, mainly women, also work outside the home causing 10% of these working Canadians to reduce hours and lose income. (According to the 2004 SAO Seniors survey, as many as 3000 seniors in Ottawa may be caring for an ill spouse as well as still supporting adult children.)

· The projected health of “baby boomer” seniors has been given a mixed grade. It is true that life expectancy continues to rise. More and more Canadians are embracing a healthy lifestyle (witnessed by an increase in the reported operating revenue of fitness and recreation centres) resulting in improved functional and mental health. As well, the introduction of cholesterol lowering drugs and other medical breakthroughs have seen a decrease in heart disease. At the same time, however, other indicators are not so positive. Baby boomers have a higher rate of obesity than previous generations (more for men than women). As a result, the rates of chronic diseases such as diabetes and arthritis are on the rise.

· Today’s seniors are embracing technology with a growing percentage (5% in 1997 to 25% in 2003) using the Internet. In the 2004 SAO Survey 40% of respondents reported using the internet for Email and other purposes. This percentage will continue to grow tremendously as baby boomers age. According to Statistics Canada, Ottawa has one of the highest Internet usages in Canada with 77% of the population (85% age 18-44) reporting use of the Internet in 2005.

References

Boldy, Duncan et al., Creating a Senior Friendly Community – A Local Government Consultation Case Study. Occasional paper presented in Aging in Place: Implications for Local Government, Australian Local Government Association, July 2006.

Canadian Centre for Elder Law Studies, A Legal Framework for Supportive Housing for seniors: Options for Canadian Policy Makers. Prepared for Canada Mortgage and Housing Corporation, March 2005.

Clark, Warren, What do Seniors Spend on Housing. Statistics Canada, Canadian Social Trends, Autumn 2005.

Connecticut Supportive Housing Demonstration Program. New Haven Corporation for Supportive Housing, www.csh.org.

Dalrymple, Elli, Liveable Communities & Aging in Place: Developing an Elder-Friendly Community. National Association of Area Agencies on Aging, Partners for Livable Communities, 2007.

Department of Health and Human Services; Office of Disability, Aging and Long-Term Care Policy; Office to the Assistant Secretary for Planning and Evaluation; and the U.S. Department of Housing and Urban Development, August 2006.

Gerontology Research Centre, Simon Fraser University, Housing Options for Older Canadians: User Satisfaction Study, Part 2: Resident Satisfaction Survey Results. Prepared for Canada Mortgage and Housing Corporation, 1999.

Gnaedinger, Nancy, Supportive Housing: An International Literature Review. Submitted to: The Steering Committee on Supportive Housing, British Columbia Ministry of Municipal Affairs, July 27, 1998.

Harahan, Mary, F. et al., Lessons from the Workshops on Affordable Housing Plus Services Strategies for Low- and Modest-Income Seniors. Prepared for the U.S.

Hawes, C. “A key piece of the integration puzzle: managing the chronic care needs of the frail elderly in residential care settings”. Generations, 23, 51-55, 1999

Hollander Analytical Services Ltd. Literature on the Cost-Effectiveness of Continuing Care Services. Prepared for Veterans Affairs Canada and the Government of Ontario, July 2006.

Hébert, Réjean, Dubuc, Nicole, Buteau, Martin, Desrosiers, Johanne, Bravo, Gina, Trottier, Lisa, St-Hilaire, Carole, and Chantale Roy, “Resources and costs associated with disabilities of elderly people living at home and in institutions”. Canadian Journal on Aging, Vol. 20 no. 1 2001, 1-21.

Keating, N.C., Fast, J. E., Connidis, I. A., Penning, M. & J. Keefe, “Bridging policy and research in eldercare”. Canadian Journal on Aging, 16, 22-41, 1997.

Keating, Norah, Fast, Janet, Dosman, Donna, and Jacquie Eales, “Services Provided by Informal and Formal Caregivers to Seniors in Residential Continuing Care”. Canadian Journal on Aging, Vol. 20 No. 1, 2001, 23-45.

Lilley, Susan, Policies for Aging Populations: An International Perspective. Prepared for Population and Public Health Branch, Atlantic Regional Office, Health Canada, November, 2002.

Lin, Jane, The Housing Transitions of Seniors. Statistics Canada, Canadian Social Trends, Winter 2005.

Lumina Services Inc., Life Lease Housing in Canada: A Preliminary Exploration of Some Consumer Protection Issues. Prepared for Canada Mortgage and Housing Corporation, June 2003.

Means, Robin, Safe as Houses? Ageing in Place and Vulnerable Older People in the UK. Social policy and Administration, Vol. 41, No. 1, February 2007, pp. 65-85.

Milke, Doris et al., Life Lease Supportive Housing: Combining the Best of Housing and Complex Care. Canada Mortgage and Housing Corporation, February 2005.

National Association of Area Agencies on Aging, The Maturing of America – Getting Communities on Track for an Aging Population. Produced in partnership with The MetLife Foundation, International City/County Management Association, National Association of Counties, National League of Cities, and Partners for Livable Communities, 2006.

New Zealand Ministry of Health, Media Release, September 26, 2006; Parson M. et al., ASPIRE Assessment of Services Promoting Independence and Recovery in Elders. http://www.moh.govt.nz/moh.nsf/by+unid/

Olsberg, Diana & Mark Winters, Ageing in Place: Intergenerational and Intrafamilial Housing Transfers and Shifts in Later Life. AHURI Research & Policy Bulletin, Issue 67 October 2005.

Oswald, Frank et al., Relationship Between Housing and Healthy Aging in Very Old Age. The Gerontologist, 47: 96-107, 2007.

Phillips, CD et al., Effects of facility characteristics on departures from assisted living. The Gerontologist, 43(5): 690-6, Oct. 2003.

Reimer, Marlene, A. Slaughter, Susan, Donaldson, Cam, Currie, Gillian, and Michael Eliasziw, “Special care facility compared with traditional environments for dementia care: A longitudinal study on the quality of life”. Journal of the American Geriatrics Society, July 2004, Vol. 52, NO. 7.

Schafer, Robert, Housing America’s Seniors. Joint Centre for Housing Studies of Harvard University, 2000.

Seniors Health Promotion Network, More Than Shelter: Housing Policy Kit for Seniors in Atlantic Canada, 2004.

Social Data Research Ltd., Supportive Housing for Seniors. Prepared for Canada Housing and Mortgage Corporation, 2000.

Spenser, Charmaine, Assisted Living in British Columbia’s ‘New Era’. Seniors Housing Update, Vol. 13, No. 1, 2004.

Successful Aging Ottawa, 2004 Seniors Survey Report of Results. Prepared by Social Data Research Ltd. June 15, 2005.

Swedish Association of Local Authorities and Regions, Care of the Elderly in Sweden Today, Publication developed in SALAR’s Health and Social Care Division, Stockholm, 2006.

The Flett Consulting Group Inc. & Social Data Research Ltd., Evaluation of the Aging in Place Pilot Project: Final Report. 1996.

The NACA Position on Supportive Housing for Seniors. No. 22, October 2002.

Toronto District Health Council, Building on a Framework of Support and Supportive Housing in Toronto: Supportive Housing for Seniors. September, 2002.

[1] From Alternative to Appropriate Levels of Care: Ottawa ALC Strategic Committee Report of Recommendations, August 2006.

[2] Using a per diem cost for ALC care of $550.

³ CMHC, Life Lease Housing in Canada: A preliminary Exploration of Some Consumer Protection Issues. Prepared by Lumina Services Inc., June 2003

[4] Being conducted by Social Data Research Ltd. with L. Bonnie Dinning.

[5] Social Data Research Ltd/The Flett Consulting Group Inc. worked with Cornerstone/LePilier to develop the model.

[6] Statistics provided by the City of Ottawa Housing Department.

[7] 2004 Fact Book on Aging: Seniors in the New Ottawa. The Council on Aging of Ottawa.

[8] 2004 Fact Book on Aging: Seniors in the New Ottawa. The Council on Aging of Ottawa, figures for non-farm households.

[9] For more information about the survey and how it was conducted please go to www.coaottawa.ca

[10] Canada Mortgage and Housing Corporation, Supportive Housing for Seniors. Research Report Prepared by Social Data Research Ltd., 2000

[12] Defining “affordable” housing is challenging because “affordability” is interpreted differently by different people, depending on their perspective and circumstances. Canada Mortgage and Housing Corporation (CMHC) defines acceptable housing as housing that is adequate in condition, suitable in size, and affordable. When households live in housing that is below one or more of the adequacy, suitability, or affordability standards, and have incomes that are too low to allow them to rent alternative dwellings that meet acceptable standards for less than 30% of their before tax income, CMHC considers them to be in core housing need. In 2001, 19% of senior-led households in Ottawa were living in households considered to be in core housing need compared to 14% of non-senior led households. (Figures provided by CMHC)

[13] Based on further analysis of the 2004 SAO Seniors Survey data selecting seniors reporting low income.

[14] The SAO survey likely under-represented seniors in the more rural areas of Ottawa. Other studies as well as focus groups held in rural areas of Ottawa following the survey support the survey finding that rural areas are generally underserved.

[15] Based on estimates provided by the City of Ottawa Housing Department that show 642 older persons accessed shelters in 2005, and a reanalysis of the 2004 CMHC Study, Profile of Rooming House Residents that indicated 50-75 older rooming house tenants require help.

[16] The formula to calculate percentage increase is: new value-old value/old value *100 or in this case: 270,000-89,000/89,000*100%

[17] A. Paul Williams, Professor, University of Toronto, Supporting Seniors and Sustaining Medicare: Supportive Housing in the Balance of Care. Presentation, Ottawa Supportive Housing for Seniors Symposium, May 15, 2007

[18] Hollander Analytical Services Ltd., Literature on the Cost-Effectiveness of Continuing Care Services. Prepared for Veterans Affairs Canada and the Government of Ontario, July 2006

[19] This framework is applicable for at-risk seniors of all income groups.

[20] Figures on core housing need for senior-led households provided by CMHC for the purpose of this report.

[21] For a good check list and description of an elder-friendly community see for example: http://www.n4a.org/

[22] Report on Seniors falls in Canada. Division of Aging, Public Health Agency of Canada, 2005.

[23] A recent study funded by the Real Estate Foundation of BC for the BC Non-Profit Housing Association resulted in a practical guide that describes ways to reduce the cost of developing and operating supportive housing for seniors. This useful resource and others are available at http://www.seniorshousing.bc.ca/Research.asp

[24] Canadian Centre for Elder Law Studies, A Legal Framework for Supportive Housing for seniors: Options for Canadian Policy Makers. Prepared for Canada Mortgage and Housing Corporation, March 2005.

[25] Canadian Centre for Elder Law Studies, A Legal Framework for Supportive Housing for seniors: Options for Canadian Policy Makers. Prepared for Canada Mortgage and Housing Corporation, March 2005.

[26] For a description of each of these components, please refer to “Supportive Housing for Seniors” Prepared by Social Data Research ltd. for Canada Mortgage and Housing Corporation, 2000..

[27] For a complete description of the methodology and the detailed results please refer to the final report: Social Data Research Ltd., Searchable Database of Supportive Housing for Seniors in Canada. Prepared for Health Canada, April 2005. http://www.hc-sc.gc.ca/hcs-sss/pubs/care-soins/2005-seniors-aines/index_e.html

[28] For a good discussion of this issue see: Phillips, CD et al., Effects of facility characteristics on departures from assisted living. The Gerontologist, 43(5): 690-6, Oct. 2003.

[29]Spenser, Charmaine, Assisted Living in British Columbia’s ‘New Era’. Seniors Housing Update, Vol. 13, No. 1, 2004.

[31] Canadian Centre for Elder Law Studies, A Legal Framework for Supportive Housing For Seniors: Options for Canadian Policy Makers, Prepared for Canada Mortgage and Housing Corporation, March 2005

[32] CMHC, Housing Options for Older Canadians: User Satisfaction Study, Part 2: Resident Satisfaction Survey Results, prepared by The Gerontology Research Centre, Dr. Gloria Gutman and Mary Ann Clarke Scott, Simon Fraser University, Vancouver, BC, in collaboration with Nancy Gnaedinger, Danielle Maltais, Luba Serge and David Bruce, 1999.

[33] Keating, Norah, Fast, Janet, Dosman, Donna, and Jacquie Eales, “Services Provided by Informal and Formal Caregivers to Seniors in Residential Continuing Care”. Canadian Journal on Aging, Vol. 20 No. 1, 2001, 23-45.

[34] Social Data Research Ltd., Searchable Database of Supportive Housing for Seniors in Canada. Prepared for Health Canada, April 2005; Hollander Analytical Services Ltd. Literature on the Cost-Effectiveness of Continuing Care Services. Prepared for Veterans Affairs Canada and the Government of Ontario, July 2006; The NACA Position on Supportive Housing for Seniors. No. 22, October 2002.

[35] Social Data Research Ltd. Inventory of Supportive Housing and Searchable Database. (Literature Review) Prepared for Health Canada, July 2006

[36] Lumina Services Inc., Life Lease Housing in Canada: A Preliminary Exploration of Some Consumer Protection Issues. Prepared for Canada Mortgage and Housing Corporation, June 2003.

[37] Canada Mortgage and Housing Corporation, Life Lease Housing in Canada: A Preliminary Exploration of Some Consumer Protection Issues. Prepared by Lumina Services Inc. June, 2003; Life Lease Supportive Housing: Combining the Best Aspects of Housing and Complex Care. Prepared by The CAPITAL CARE Group, February, 2005.

[38] Cited in Hollander Analytical Services Ltd., Literature Review on the Cost-Effectiveness of Continuing Care Services. Veterans Affairs Canada and the Government of Ontario, July 2006.

[39] Harahan, Mary, F. et al., Lessons from the Workshops on Affordable Housing Plus Services Strategies for Low- and Modest-Income Seniors. Prepared for the U.S. Department of Health and Human Services; Office of Disability, Aging and Long-Term Care Policy; Office to the Assistant Secretary for Planning and Evaluation; and the U.S. Department of Housing and Urban Development, August 2006.

[40] Cited in Hollander Analytical Services Ltd., Literature Review on the Cost-Effectiveness of Continuing Care Services. Veterans Affairs Canada and the Government of Ontario, July 2006.

[41] Lin, Jane, The Housing Transitions of Seniors. Statistics Canada, Canadian Social Trends, Winter 2005.

[42] Means, Robin, Safe as Houses? Ageing in Place and Vulnerable Older People in the UK. Social policy and Administration, Vol. 41, No. 1, February 2007, pp. 65-85.

[44] Clark, Warren, What do Seniors Spend on Housing. Statistics Canada, Canadian Social Trends, Autumn 2005.

[45] Olsberg, Diana & Mark Winters, Ageing in Place: Intergenerational and Intrafamilial Housing Transfers and Shifts in Later Life. AHURI Research & Policy Bulletin, Issue 67 October 2005.

[46] Schafer, Robert, Housing America’s Seniors. Joint Centre for Housing Studies of Harvard University, 2000.

[47] National Association of Area Agencies on Aging, The Maturing of America – Getting Communities on Track for an Aging Population. Produced in partnership with The MetLife Foundation, International City/County Management Association, National Association of Counties, National League of Cities, and Partners for Livable Communities, 2006.

[48] Dalrymple, Elli, Liveable Communities & Aging in Place: Developing an Elder-Friendly Community. National Association of Area Agencies on Aging, Partners for Livable Communities, 2007.

[50] Lilley, Susan, Policies for Aging Populations: An International Perspective. Prepared for Population and Public Health Branch, Atlantic Regional Office, Health Canada, November, 2002.

[51] Boldy, Duncan et al., Creating a Senior Friendly Community – A Local Government Consultation Case Study. Occasional paper presented in Aging in Place: Implications for Local Government, Australian Local Government Association, July 2006.

[52] Successful Aging Ottawa, 2004 Seniors Survey Report of Results. Prepared by Social Data Research Ltd. June 15, 2005

[53] Seniors Health Promotion Network, More Than Shelter: Housing Policy Kit for Seniors in Atlantic Canada, 2004.

[54] Toronto District Health Council, Building on a Framework of Support and Supportive Housing in Toronto: Supportive Housing for Seniors. September, 2002.

[55] Oswald, Frank et al., Relationship Between Housing and Healthy Aging in Very Old Age. The Gerontologist, 47: 96-107, 2007.

[56] New Zealand Ministry of Health, Media Release, September 26, 2006; Parson M. et al., ASPIRE Assessment of Services Promoting Independence and Recovery in Elders. http://www.moh.govt.nz/moh.nsf/by+unid/

[57] Evaluation of the Aging in Place Pilot Project: Final Report. Prepared by The Flett Consulting Group Inc. & Social Data Research Ltd., 1996.

[58] Flett, Darlene E., Last, John M., &Lynch, George: Evaluation of the Public Health Nurse As Primary Health-Care Provider For Elderly People. Aging in Canada – Social Perspectives, edited by Victor W. Marshal, Fitzhenry & Whiteside, 1980.

[59] Lum, Janet M., Simonne Ruff & A. Paul Williams, When Home is Community: Community Support Services and the Well-Being of Seniors in Supportive and Social Housing. United Way of Greater Toronto, April 2005.

[60] Connecticut Supportive Housing Demonstration Program. New Haven Corporation for Supportive Housing, www.csh.org.

[61] Reimer, Marlene, A. Slaughter, Susan, Donaldson, Cam, Currie, Gillian, and Michael Eliasziw, “Special care facility compared with traditional environments for dementia care: A longitudinal study on the quality of life”. Journal of the American Geriatrics Society, July 2004, Vol. 52, NO. 7.

[62]Hollander Analytical Services Ltd. Literature Review on the Cost-Effectiveness of Continuing Care Services. Veteran Affairs Canada and the Government of Ontario, July 2006; Social Data Research Ltd., Searchable Database of Supportive Housing for Seniors in Canada. Prepared for Health Canada, July 2005.

[64] Referenced by A. Paul Williams, Professor, University of Toronto, Supporting Seniors & Sustaining Medicare: Supportive Housing in the Balance of Care. Presentation, Ottawa Supportive Housing for Seniors Symposium, May 15, 2007

[65] Keating, N.C., Fast, J. E., Connidis, I. A., Penning, M. & J. Keefe, “Bridging policy and research in eldercare”. Canadian Journal on Aging, 16, 22-41, 1997; Hawes, C. “A key piece of the integration puzzle: managing the chronic care needs of the frail elderly in residential care settings”. Generations, 23, 51-55, 1999; Gnaedinger, Nancy, Supportive Housing: An International Literature Review. Submitted to: The Steering Committee on Supportive Housing, British Columbia Ministry of Municipal Affairs, July 27, 1998.

[66] Hollander Analytical Services Ltd. Literature Review on the Cost-Effectiveness of Continuing Care Services. Veteran Affairs Canada and the Government of Ontario, July 2006

[67] Swedish Association of Local Authorities and Regions, Care of the Elderly in Sweden Today, Publication developed in SALAR’s Health and Social Care Division, Stockholm, 2006.

[69] Hébert, Réjean, Dubuc, Nicole, Buteau, Martin, Desrosiers, Johanne, Bravo, Gina, Trottier, Lisa, St-Hilaire, Carole, and Chantale Roy, “Resources and costs associated with disabilities of elderly people living at home and in institutions”. Canadian Journal on Aging, Vol. 20 no. 1 2001, 1-21.

[70] Vancouver Coastal Health, Outcome Evaluation: Changes in Hospital Utilization by Individuals One Year Post Access to Supported and Non-Supported Affordable Housing. Vancouver, British Columbia, October, 2006 (For more information contact Linda Thomas, Director, Housing Services, Linda.Thomas@vch.ca)

[71] Connecticut Supportive Housing Demonstration Program. New Haven Corporation for Supportive Housing, www.csh.org.

[72] Pomeroy, S., Focus Consulting, Proactive Versus Reactive Responses to Homelessness: A Costing Analysis. Paper Presented to the Alliance to End Homelessness Community Forum on Homelessness. November 22, 2006.

[73] Mancer, Kate and Carole Holmes, 70 Ways to Reduce the Cost of Developing and Operating Supportive Housing for Seniors. Funded by the Real Estate Foundation of BC for the BC NON-Profit Housing Association, October 2004.

[74] Milke, Doris et al., Life Lease Supportive Housing: Combining the Best of Housing and Complex Care. Canada Mortgage and Housing Corporation, February 2005.

[75] Mancer, Kate and Carole Holmes, 70 Ways to Reduce the Cost of Developing and Operating Supportive Housing for Seniors. Funded by the Real Estate Foundation of BC for the BC NON-Profit Housing Association, October 2004.

[76] Needs Assessment by Cornerstone/LePilier and subsequent research by Social Data Research Ltd., Senior Women’s Supportive Housing Residence. Final Report, June 2003.

[77] Social Data Research Ltd. & Anne Wright Associates, How Well Are We Doing? A Survey of the GLBT Population in Ottawa. Sponsored by Pink Triangle Services, July 2001.

[78] Two useful books on the subject often quoted are: Boom, Bust and Echo 2000: Profiting From the Demographic Shift in the New Millennium, by David K Foote (1996); and more recently, Baby Boomer Health Dynamics: How Are We Aging?, by Andrew W. Wister (2005)

[79] Canada Mortgage & Housing Corporation, Supportive Housing for Seniors: Research Report. Prepared by Social Data Research Ltd. 2000