Leading the Way in Innovative Affordable Housing for Older Adults

Until recently, Ruth Mariam, 95, of St. Louis, had to spend $50 each way on a cab ride to get from her apartment to her doctor. Otherwise, she’d have to ask one of her children to take off work to give her a lift. But in September, that changed when her home of 16 years, Covenant Place, opened its new community center. Today, she’s just an elevator ride away from a geriatrics practice.

Onsite primary care is now offered at Covenant Place, an affordable housing community that attracts older adults from the wider neighborhood with an array of wellness and medical services and cultural and social activities. Funded in part by Jewish philanthropy, Covenant Place is one of several affordable housing communities for older adults nationally — many of them nonprofit and faith-based — that set a high bar for quality of life by bringing services onsite and nurturing social connections.

Here's the backstory on Covenant Place.

In 2012, it was clear Covenant Place, located in a neighborhood with one of the highest concentrations of older adults in St. Louis County,  needed new buildings. “Quite honestly, the buildings were not aging as well as the people living in them,” says CEO Joan Denison.

“We have 16,000 seniors in close proximity and a quarter of those are income-eligible to live in affordable housing,” Denison says. “That was a surprise to learn.”

In addition to rebuilding the housing for its 420 residents, Covenant Place wanted to better serve their needs. All its residents have low incomes, 20% are 90 or older and many are immigrants from Russia and China. Rents are based on federal Section 8 affordable-housing guidelines, where residents pay an amount equal to 30% of income, minus medical expenses.

Before moving forward, Covenant Place partnered with David Carr, professor of geriatrics medicine in the Washington University Department of Medicine, and his team. They conducted surveys and a needs assessment of residents and older people in the neighborhood.

The researchers found that Covenant Place residents were high users of emergency medical services, making 255 ambulance calls annually, each costing Medicare hundreds of dollars. “The majority of respondents were using 911 as their primary care,” Denison says.

A survey of 500 Covenant Place residents and others nearby found that 70% would use a health care center if it were located in the community. From that emerged the idea to build onsite primary care practice, with some additional health services, as part of a $12 million, 19,000-square-foot community center. Today, this new Mirowitz Center has a geriatrics practice; physical, occupational and speech therapy; audiology and podiatry. It’s planning to add dental and optometry soon.

“We’ve created a hub where people can take care of their medical needs,” Denison says. “We purposely designed it to feel very modern and fresh and inviting. So many senior centers are in old gymnasiums.”

Having the doctor’s office in the middle of a community center, “has just been a destination built in heaven, with the goals of keeping people aging in place, keeping their quality of life up, reducing hospital and emergency room visits and use of resources, while we’re screening for frailty, dementia, falls, depression and managing those conditions," Carr says.

The practice sees 400 patients, both Covenant Place residents and those from the outside. Carr anticipates continued growth.

It will take a few years for his research team to learn if this model reduces ER visits, hospitalizations and medications and extends the time people can live independently.

In addition to the health services, Covenant Place has a goal to create a culture and environment that engages people and keeps them healthy.

The community center offers everything from chair ballet and martial arts to classes in painting and cooking, book clubs and movies, and reading old-time radio scripts. A challah bread-baking workshop drew people of all ages. Volunteer opportunities abound.

“We have socialization opportunities for people who need to find friends,” Denison says. “We have 'circle talk' facilitated by a social worker, where we say ‘Come as strangers, leave as friends.’ It worked!”

Mariam maintains a busy life. Always a “people person,” in her younger days, she and her late husband delivered newspapers. She was responsible for collecting money from subscribers, a job she enjoyed.

Now, she volunteers to help count money donated by residents to subsidize meals for others who need support. She enjoys dining at the center’s new HJ’s Café. She welcomes her neighbors from other countries and has even learned a couple of phrases in Russian and Chinese. Her favorite activity is singing with the Covenant Place chorale, practicing weekly.

Another example of a different kind of affordable housing for older adults can be found within New Holland, Pa., continuing care retirement community (CCRC) called Garden Spot Village. It’s a Mennonite-based complex that includes a group home offering family-style housing for five women.

Like most CCRCs, Garden Spot is too pricey for many people. “The concept of a co-living model originated out of our faith-based mission to enrich the lives of people who might not be able to [afford to] live in a retirement community,” says CEO Steve Lindsey.

Lindsey recalled a news story about an older woman in the Washington. D.C. area who converted her large home into a group house as a way to financially stay put and not become isolated. He thought, “What if we took that co-living model and ended up with a group of people living in a residential home that they could share and live on a sliding-scale fee and be able to have some support in living together?”

Garden Spot was creative about how to finance this vision. The $600,000 in construction costs for a new home were cut in half by recruiting volunteers.

Garden Spot residents, college students, Rotary Club members, local churches and contractors helped with everything from planning to construction, painting and moving in furniture.

“The way we tried to position it (is), as a larger community, we have a challenge,” Lindsey says. “We have an issue with providing affordable housing — let’s shape it as a community solution to a problem we’re all facing.”

In 2018, the new five-bedroom, five and one-half-bath home, christened Thistledown, opened across the street from the Garden Spot campus. Today, five women, all in their 70s, live there.

Ruth Dunlap was one of the first occupants. When she heard about the concept, she was hesitant about “living with a bunch of old ladies.” But Dunlap realized she could no longer keep up her home, financially or physically, and decided to apply.

She’s glad she made the move. The women there have carved out a way to be close friends and yet still have privacy and independence. Each has her own bedroom and bath, with ample common spaces. They buy and store their groceries separately, and generally eat meals on their own. Four have their own cars and they take turns using the two-car garage.

As for chores, they informally share housekeeping. In a conversation with housemate Esther Courtney, Dunlap gives her friend credit for doing “more than her share of the dusting. It’s not my thing.”

Courtney says her first reaction to the group house was, “Wow, this is a beautiful home, but I’m not sure how cooperative living would be,” she says. “But when I looked at it again and I thought about my townhouse, I thought, ‘I’m really tired of being alone, so this is a good thing.’ It’s doable, and I’m enjoying it and it’s home.”

One thing that makes it doable is the low rent. Like Covenant Place, Garden Spot charges 30% of income for rent. According to Lindsey, the combined rentals cover all operating costs, without a federal subsidy.

The women also have access to the Garden Spot campus, including the fitness room, pool, library and dining areas.

Garden Spot is planning to build more homes like Thistledown and may plant some in other neighborhoods rather than near its campus. Lindsey says having a case manager assigned to housemates is a key part of the model, to help them work through interpersonal difficulties and manage medical issues.

Lindsey has heard from developers and state agencies from Georgia to Australia who are interested in replicating the model. He thinks a few churches or civic organizations could team up with a local office on aging to build such housing and provide case management.

Both Dunlap and Courtney say they hope this affordable-housing model for older adults spreads.

“It’s a huge advantage for seniors to have affordable rent, where you can still live in a decent home and be around other people,” Dunlap says. “You grow and change when you’re living with people. One of the biggest things I’ve learned is that if you have respect for other people and their beliefs and their own way of doing things, then you can learn to live together, even if you don’t always agree with them.”

A model that does not require a capital investment is being developed by Hebrew SeniorLife in Boston, along with public and private partners. Dubbed R3 (Right Care, Right Place, Right Time), the program pairs a nurse and a wellness coordinator with residents of senior housing communities, most of them affordable housing.

Hebrew SeniorLife's research partner, the LeadingAge Long-Term Services and Supports Center at the University of Massachusetts in Boston, is studying the model for replicability and sustainability. In an ongoing demonstration program, researchers are following some 400 participants among 1,100 total residents at seven independent living sites.

So far, they have found an 18% reduction in ambulance calls after the intervention was put in place, with three of the communities having a more than 20% reduction. They are also seeing reduced hospitalizations and ER visits, although the data results are not final.

“This whole model is based on a shift to a proactive health care focus and integration with housing,” says Kim Brooks, Hebrew SeniorLife's Chief Operating Officer of Senior Living. “The [wellness] teams are proactively doing outreach to the seniors who are living there. They are doing in-depth assessment and connecting people with resources they need, to make sure they’re achieving their personal goals. We believe that is contributing to the results.”

The hope is that health plans will be willing to invest in programs like R3 as they see the cost benefits. Housing providers will also benefit, through reduced occupancy turnover if residents can remain independent longer.

Mimi Lewis, a social worker and wellness coordinator, and Anya Gorodetskaya, a wellness nurse, team up to serve three R3 housing communities in the Boston area. “Our goal is to make sure that we help people to live independently for as long as possible, and to make sure they have a good quality of living,” Gorodetskaya says.

Their salaries are paid through a private-public partnership and their services are free. They help residents stay on top of medical conditions and be healthier and happier.

Lewis and Gorodetskaya pay special attention to those who frequently visit the ER. They also offer classes on common conditions, such as diabetes or falling. They lined up mental health services with a therapist who is able to do house calls by visiting multiple patients in a single housing complex.

Earl Johnson, 70, has lived at Winter Valley, an affordable housing community in Milton, Mass., for five years. For the first four years, he was depressed and felt stuck, not even unpacking many of his belongings. A year ago, he heard about the R3 wellness team and sought them out.

“Mimi helped me get the care to monitor my diabetes,” he says. “I got a chance to talk with social workers and psychiatrists to get my head in shape, and they sent an occupational therapist over to help me get my apartment in order. Now I’m seeing something positive. I am deeply grateful for that.”

The team connected him with the PACE (Program of All-Inconclusive Care for the Elderly) program of Medicare and Medicaid, a one-stop shop for medical and therapy services.

“The personalities of the people who are involved are tantamount to how things are going to work out,” Johnson says. “Mimi and Anya are nice and understanding, and patient and very, very kind. That goes a lot towards forming a relationship and getting your health care. This way, you see sunshine and you look forward to your day. If you go off the rails, you have someone help you get back on.”