by Geralyn Magan
©2012, LeadingAge Magazine, May/June Edition.
Reprinted with permission.

How many prescription medications do you take?



Do you have family or friends in the area who can assist you when needed?



During the past 12 months, have you gone to a hospital emergency room (ER) about your own health?



The answers to these and 32 other questions are giving housing providers around the country valuable insight into the needs and preferences of the older residents living in their communities.

The questions are part of a new Resident Assessment Tool designed by the LeadingAge Center for Applied Research and available, along with a users’ guide and data calculation instrument, on the center’s website. The free tool comes in two parts:

• A 26-question assessment explores residents’ health and functional status. In addition to answering questions about medications and ER visits, residents are asked to identify their health conditions and indicate what conditions interfere with activities of daily living.
• A separate, nine-question assessment quizzes residents about social, educational, wellness and volunteer activities in which they would like to participate.

The Enterprise Connection

The LeadingAge Center for Applied Research developed the Resident Assessment Tool in partnership with Enterprise Community Partners, a national organization that has invested approximately $1.7 billion in more than 30,000 affordable senior housing units since 1982. Enterprise plans to distribute the tool, and the user guide that accompanies it, to its network of housing providers as a way to build their capacity to understand and create programs to address resident needs.

“We began working with LeadingAge on this tool because we wanted to be more intentional about helping our partners provide services in their housing,” says Cheryl Gladstone, Enterprise’s program director for senior housing. “We firmly believe in the benefit of connecting independent housing with services so that seniors, particularly low-income seniors, can age in place in their homes and communities.”

Using the Assessment

Housing communities can use the Resident Assessment Tool to identify particular residents who need assistance to remain healthy and independent. But most housing providers will also use the tool to create an overall picture of their resident population and to plan community-wide interventions that address identified needs.

“Most of the questions come from large national surveys and have already been tested for reliability and validity,” says Alisha Sanders, senior policy research associate with the Center for Applied Research. “We know that these questions produce accurate information. Our goal in developing this tool was to select questions that would yield the most useful information for affordable housing settings.”

Why Assess?

Housing properties with a service coordinator might wonder why they need to make a special assessment of residents’ needs. Doesn’t the service coordinator already have a handle on that?

Not necessarily, says Diane Burfeindt, vice president of operations for housing with services at Presbyterian Senior Living (PSL), a LeadingAge member based in Dillsburg, PA. Two years ago, PSL helped LeadingAge and Enterprise test the Resident Assessment Tool at two of its properties: Schartner House at Carroll Village, an affordable housing community in Dillsburg; and Presbyterian Apartments, an affordable housing community in Harrisburg. The assessment provided insight into PSL’s resident population that service coordinators did not have, despite their extensive knowledge of many residents, says Burfeindt.

“The assessment showed us that we didn’t know it all,” she says. “You may think you know what services your residents want and need. But this assessment will give you valuable nuggets of information that you didn't anticipate.”

Burfeindt was most surprised by the wide range of needs PSL residents reported on their assessment forms. Many were living with a variety of chronic conditions including diabetes and hypertension, she says. As a group, they were also at high risk for poor nutrition, had higher rates of incontinence than expected and reported frequent falls.

Using Data to Forge a Partnership

Because many of the identified health issues were equally prevalent among PSL residents, Burfeindt and her team weren’t quite sure where to begin the process of addressing those issues. Instead of going it alone, they decided to ask for help from PinnacleHealth, a hospital and health care system with which PSL wanted to develop a partnership.

“Working together to evaluate the assessment data actually helped form the partnership,” says Burfeindt. “We were able to show Pinnacle concrete data about the issues we were dealing with. That data gave some depth to what we wanted to do and the reason why we wanted to do it. It was a lot better than just telling them, ‘A lot of people have diabetes.’”

Initially, Pinnacle and PSL collaborated on a pilot diabetes management program, which features Pinnacle-sponsored education classes at both campuses, followed by one-on-one meetings between PSL residents and service coordinators to develop service plans focused on diabetes management. The program seemed a natural first response to the assessment data because Pinnacle was already operating a similar initiative in eastern Pennsylvania.

“We tried to identify activities that could give us an early win and demonstrate that we could bring about health improvement,” says Burfeindt. “We felt if we tried to tackle too much at once then we were just going to set ourselves up for failure.”

New Opportunities for PSL

The partnership between PSL and PinnacleHealth has grown by leaps and bounds since the two organizations first examined the resident assessment data from Schartner House and Presbyterian Apartments. While an evaluation of the joint diabetes management program continues, the partners are already gearing up to test new protocols for improving health and reducing hospital usage among residents of Presbyterian Apartments. The pilot project will be funded by a $50,000 Vulnerable Populations Grant from Enterprise Community Partners. If the results are positive, both organizations plan to replicate the model in other housing communities.

PSL is also moving ahead with other assessment-related initiatives and partnerships. To promote good nutrition, a new café located on the Carroll Village campus is adding healthy foods to its menu and providing health tips aimed at encouraging residents to choose those foods. PSL is also exploring ways to match one of its service-rich continuing care retirement communities with an affordable housing development managed by a local housing authority. The first step in that new partnership will involve administering the Resident Assessment Tool to identify residents’ service and support needs.

New Opportunities for LeadingAge

Significantly, the Resident Assessment Tool has also expanded the partnership between LeadingAge and Enterprise, according to Gladstone.

“Enterprise knows that we’re not the experts in everything,” she says. “But we’re really good at recognizing the people who are doing really good work and figuring out how to partner with them. LeadingAge is the expert in the field of housing with services. It’s been tremendous that we’ve been able to leverage LeadingAge’s work and bring it to our partners. We’re looking forward to doing much bigger and bolder things together in the future.”

Visit the LeadingAge Center for Applied Research website to find out more about the Resident Assessment Tool.