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Aging in America
Climbing the Ladder Toward Recovery: The North Carolina Mobile Medication Program Winner

o O u r S ponsors!
Thank You T

Premier Sponsorships

The Roe Foundation

Distinguished Sponsorships

Anchor Capital Jane and Steve Akin Tish and Steve

Advisors, LLC Mead
Holly and
C. Bruce Johnstone Polly and Peter

Individual Sponsorships

Jean and John Kingston

Susan and Preston

Kelly and Gary Blank McSwain

Barbara and Fred Clifford Lynne and Mark

Ellen and Bruce
Herzfelder Roger D. Scoville

Teak and Chuck Hewitt Eileen and John Sivolella

Lucile and Bill Hicks Anngenette

and Bill Tyler
Pat and Al Houston

Better Government Competition 2017 3


Winner 8
R3: Right Care,
Right Place, Right Time:
Effectively Integrating
Senior Care and Housing
Kim Brooks
Chief Operating Officer, Senior Living
Hebrew SeniorLife

Competition Judges

Charles Baker, Sr. Robin Lipson

Professor Emeritus Chief of Staff/Chief Strategy Officer,
Northeastern University Executive Office of Elder Affairs
College of Business Administration
James F. Seagle, Jr.
President, Rogerson Communities
Nick Dougherty
Program Director, PULSE@MassChallenge
Joanna Weiss
Freelance journalist
Gary P. Kearney M.D., F.A.C.S.
and former Boston Globe columnist
Pioneer Institute Board of Directors

Advisory Committee

Cornelius J. Chapman, Jr. Bruce Herzfelder Paul S. Russell, M.D.

Burns & Levinson 1-Group, LLC Massachusetts General Hospital
Charlie Chieppo Tom Keane Brian Wheelan
Chieppo Strategies Pat McGovern Beacon Health Strategies
Katherine Craven Beth Israel Deaconess
Babson College Medical Center

4 Better Government Competition 2017

Runners Up

Early Detection and Treatment Mobilizing the Talent of

of Alzheimers Disease________ 13 Older Adults to Support
Professor David L. Weimer Critical Government Services____ 19
& Dr. Mark Sager Doug Dickson

Jewish Community Housing Return to

for The Elderly and Jewish Community Initiative_________ 22
Family & Childrens Service_____ 16 Loren Colman
Amy Schectman & Krista Boston
& Rimma Zelfand
Ride-Share Pilot Program______ 25
Ben Schutzman

Special Recognition

Boston Medical Center nesterly___________________ 30

Elders Living at Rachel Goor & Noelle Marcus
Home Program______________ 28
Eileen OBrien Wisconsin Coalition for
& Samantha J. Morton Collaborative Excellence
in Assisted Living____________ 32
Kevin Coughlin

Pioneer Institute Board of Directors

Stephen Fantone C. Bruce Johnstone Jim Stergios
Chairman Vice-Chair Executive Director
Lucile Hicks James Joslin Mary Z. Connaughton
Vice-Chair Treasurer Clerk & Assistant Treasurer

Nancy Anthony Alfred Houston Amir Nashat
David Boit Keith Hylton Diane Schmalensee
Frederic Clifford Gary Kearney Kristin Servison
Andrew Davis John Kingston Chairman Emeritus
Ellen Roy Herzfelder Nicole Manseau William B. Tyler
Charles C. Hewitt, III Preston McSwain

Better Government Competition 2017 5



ood policy goes slow on ideology mographics, our burgeoning aging population
and accelerates big impact. If that presents challengesbut also ample economic

is true, the Better Government and social opportunities.

Competition is a case study in how to use In defining the playing field for 2017, Pioneer
the wisdom of crowds to advance good posed two questions:

policy. Now in its 27th year, the trajecto- How do we establish the care and support sys-
ry of the Competition has provided highly tems that our older populations need?

practical solutions to real-life challeng- How do we unlock the enormous social capital
es. Often the problems we were trying to of our healthier aging population?
solve were deeply human; certainly that Given those parameters, the specific goals
is the case of previous years when we fo- of this years Competition are clear: We want
cused on issues like social services for aging to be a meaningful and productive time of

the indigent, effective care for those with lifeand that includes engaging older Amer-
icans in the workplace. We want to highlight
mental health issues, or ways to lower re-
new, successful ideas in housing, transporta-
cidivism rates or reintegrate people with
tion, custodial care and assistance options that
criminal backgrounds. make an independent and fulfilling life for
aging Americans possible. We want to enhance
training for medical and geriatric professionals
In 2017, Pioneer set a fundamentally different and identify policies to better coordinate care
task for the Competition. Our focus this year for older Americans. We want to leverage new
is to improve the quality of life for the aging. technologies to improve the lives of seniors.
Whereas the themes of the Competition in And, if you have thoughts on how to ensure the
previous years affected limited populations, future viability of retirement systems, we want
there is no other with aging. There is no pol- those ideas, too!
icy solution to or escape from this universal
In defining our objectives, Pioneer sought the
and inevitable part of the human experience.
counsel of an outstanding line-up of local,
The aging problem is truly a new phenome- state and national experts. They include: John
non; and it is, in fact, the positive outcome of N. Morris, Director of Social and Health Policy
a society that is working. We have more people Research and Alfred A. & Gilda Slifka Chair in
who are living longer because we, like many Social Gerontological Research at the Institute
other developed societies worldwide, have for Aging Research; Elissa Sherman, Presi-
achieved new levels of prosperity. With pros- dent of LeadingAge Massachusetts; Kevin Ca-
perity comes greater attention to health and hill, Research Economist at Boston Colleges
to the demand for improved medical processes Sloan Center on Aging & Work; Mark Mather,
and techniques to extend lifeand to main- Associate Vice President of U.S.Programs at
tain a high quality of life. From 1930 to 2010, the Population Reference Bureau; and Bron-
life expectancy in the United States rose from wyn Keefe, Research Assistant Professor at the
60 to 79 years. Most often, the additional years Boston University School of Social Work. These
have come hand in hand with the ability to are a few of the experts and policymakers who
lead a more fulfilling lifestyle. Given the Com- helped Pioneer refine and disseminate the
monwealths and the countrys changing de- 2017 Competitions problem statement.

6 Better Government Competition 2017


The Institutes gratitude goes to the dozens Our 2017 first-place winner is an initiative with
of state legislators, executive branch officials, demonstrated success in supportive housing
and media outlets whose advice and outreach for older adults. The Right Care, Right Place,
expanded the number and quality of entries Right Time: Effectively Integrating Senior Care
received. and Housing initiative from Hebrew Senior-
Life makes use of wellness teams designed for
We also thank the highly respected panel of
specific housing sites, marrying housing with
external judges who evaluated the 2017 BGC
health care in a way that reduces the transfer
submissions: Charles Baker, Sr., Professor
of seniors from homes to hospitals and emer-
Emeritus at Northeastern Universitys College
gency rooms. As existing programs in Brook-
of Business Administration; Nick Dougherty,
line and Vermont have illustrated, this model
Program Director at PULSE@MassChallenge;
for senior housing generates significant sav-
Gary P. Kearney, M.D., F.A.C.S., Pioneer In-
ings in reduced medical costs while ensuring
stitute Board Director; Robin Lipson, Chief of
seniors are able to live independently.
Staff and Chief Strategy Officer at the Execu-
tive Office of Elder Affairs, Commonwealth of This work is the product of an exceptional team.
Massachusetts; James F. Seagle, Jr., President My sincere thanks go to Shawni Littlehale, who
at Rogerson Communities; and Joanna Weiss, leads this Pioneer program and has built the
freelance journalist and former Boston Globe Competition into a national reference point for
columnist. innovative public policy. Id also like to thank
Matthew Blackbourn, who has demonstrated
The 2017 Competition recognized proposals in
keen research, management, and social media
a number of areas, including ways to augment
skills, and has helped grow the Competitions
state efforts to improve the early detection of
reach and quality. Shawni and Matt were ably
Alzheimers disease, and two local instances of
assisted by talented staff members (Mary Con-
public agencies employing innovative models
naughton and Greg Sullivan), fellows (Michael
to give elders cheaper and more reliable trans-
Weiner and Alexander Carlin), and interns, in-
portation and keep them engaged in the work-
cluding Benjamin Margolin and Mariella Ruti-
gliano. All have my gratitude.
We received a number of standout submissions
My final thank you is the most important, and
focusing on housing solutions for older adults.
it is to you. Without your support, this conver-
One awardee calls for a unique collaboration
sation about aging policy would be stuck in its
among existing senior service groups to create
various silos, and there would be little hope of
a replicable housing model specifically for se-
developing a forward-looking set of solutions.
niors with lifelong developmental disabilities.
The Institute and the Commonwealth of Mas-
Another winning idea came from graduate stu-
sachusetts are greatly in your debt.
dents that have created a digital platform to
connect millions of renters to older adults with Sincerely,
spare bedrooms, in an effort to address both
affordable housing concerns and the social iso-
lation and declining income among adults 55
and older. Other awardees focused on ensuring
internal quality in assisted living communities James Stergios, Executive Director
and programming to protect poor seniors from
homelessness and establish a stable channel to
permanent housing.

Better Government Competition 2017 7


R3: Right Care,

Right Place, Right Time:
Effectively Integrating
Senior Care and Housing
Kim Brooks
Chief Operating Officer, Senior Living
Hebrew SeniorLife

8 Better Government Competition 2017

R3: Right Care, Right Place, Right Time: Effectively Integrating Senior Care and Housing Winner

Problem Statement

he needs of seniors in supportive hous- term services available through the Com-
ing span a range of physical, behavior- monwealth. There is significant potential for
al, and social issues. Many seniors are improved outcomes and savings if care from
designated as frail or at risk based on housing staff, payers, and community based
U.S. Department of Housing and Urban Devel- providers is better coordinated.
opment (HUD) definitions, and their physical
health issues decrease mobility, impede gross
and fine motor skills, and affect vision, mak- Proposed Solution
ing it difficult for seniors to shop, clean, bathe, Hebrew SeniorLife (HSL) has provided health
and cook, activities needed to maintain their care and housing for seniors, research into
independence. These seniors are at increased aging, and education for future geriatric pro-
risk of falling, a primary cause of emergency viders since 1903. HSL provides direct care for
transports to hospitals, and because of the 3,000 seniors every day.
social isolation often associated with their
HSLs Right Care, Right Place, Right Time: Effec-
decreased mobility, they are also at increased
tively Integrating Senior Care and Housing (R3)
risk of depression.
initiative provides coordinated, person-cen-
In addition, isolation can tered services to vulnera-
cause seniors to fall behind ble seniors with the aim of
on routine health care ap- Many seniors living in enabling them to live inde-
pointments, which then lead supportive housing meet pendently in the commu-
to the need for acute care the income guidelines for nity for as long as possible,
services. Lack of medication receiving the right care in
housing, but do not meet
adherence, in particular, is a the right place at the right
the income guidelines for
significant factor in seniors time. The long-term vision
no longer being able to live
MassHealth coverage. is to create a replicable,
independently. The lack of coordination scalable, and sustainable
between housing and model of housing with sup-
Further complicating the sit-
uation is that many seniors in
healthcare is a missed portive services.

supportive housing struggle opportunity. Enhanced wellness teams

financially, which impacts are embedded in specific
the decisions they make re- elderly housing complexes
garding prioritization of food, prescriptions, to serve as links between housing and health
co-pays, and other necessities. care, establishing relationships with residents
and collaborating on wellness and preven-
Many seniors living in supportive housing meet
tion efforts. These teams maximize the ef-
the income guidelines for housing, but do not
fectiveness of existing housing resources, and
meet the income guidelines for MassHealth
streamline communication and the exchange
coverage. The lack of coordination between
of information with emergency responders
housing and healthcare is a missed opportuni-
and payers. The teams are comprised of well-
ty. The result is frail, at-risk seniors trying to
ness coordinators, wellness nurses, care man-
live independently with little discretionary in-
agement staff from partner organizations and
come available for services and supports, and
health plans, and behavioral health providers.
no ability to be served by the coordinated long-

Better Government Competition 2017 9

Winner R3: Right Care, Right Place, Right Time: Effectively Integrating Senior Care and Housing

The primary aim

of R3 is to reduce
the incidence of
transfers of seniors
from their homes to
hospitals, emergen-
cy rooms, and long-
term care facilities,
as well as to reduce
associated costs.

Specifically, the wellness teams activities in- unnecessary calls and transports, and facil-
clude: itate communication/information flow.

Assessments of participating residents to Implementing effective communication

determine their needs and goals, and part- between housing and providers to relay
nering with housing staff to tailor pro- important information (e.g., changes in
gramming that meets those needs. condition, transitions between settings, or

Educating housing staff members, includ- changes in behavior/activity levels).

ing office, maintenance, housekeeping, Promoting self-care among residents
programming, and dietary staff, to identify through individualized coaching and im-
concerning changes in residents condition plementing and/or facilitating health and
and communicate those changes in a timely wellness programs, including strength and
and effective manner. balance work to prevent falls.

Using technology (such as reverse 911) to The primary aim of R3 is to reduce the inci-
conduct wellness checks and assist with dence of unnecessary transfers of seniors from
medication adherence. their homes to hospitals, emergency rooms,

Coordinating with primary care providers, and long-term care facilities, as well as to re-
mental health providers and hospitals. duce associated costs. Our focus throughout
will be on improving seniors quality of life and
Partnering with emergency responders to ability to live independently.
analyze call data to identify trends, reduce

10 Better Government Competition 2017

R3: Right Care, Right Place, Right Time: Effectively Integrating Senior Care and Housing Winner

R3 is adapted from the State of Vermonts Projected Outcomes

Support and Services at Home (SASH) model.1
R3s evaluation will track key performance in-
SASH is a care coordination program anchored
dicators for residents receiving services from
in affordable senior housing properties, serv-
the wellness teams, including falls, partici-
ing residents on the property as well as seniors
pation in wellness programming, medication
living in the surrounding communities. During
adherence, emergency room trips, transfers
the one-year testing phase, it was found that
to hospitals and rehospitalizations, and main-
SASH interventions helped reduce hospital ad-
tained or improved quality of life.
missions by 19%, no SASH participant who was
discharged from the hospital experienced a re- Based on the slower rate of growth in costs from
admission, and falls declined by 22%. In addi- the SASH model, we anticipate a slower rate of
tion, growth in annual total Medicare expendi- increase for seniors overall medical costs. As
tures was lower by an estimated $1,756-$2,197 mentioned, the SASH program showed a sav-
per SASH beneficiary (in well-established pan- ings due to slower growth of $1,756 - $2,197
els) compared to beneficiaries in two groups. per beneficiary per year. If we project a similar
amount for 600 residents, we would show po-
The R3 Project was also informed by the Care-
Oregon Housing with Services model2 which
was established to coordinate the delivery of
services from health, aging, and social ser-
vice providers to 11 properties. Data from this
model showed a 12% reduction in health care
costs for residents one year after moving into
an affordable housing site, as well as a 20% in-
crease in primary care usage and an 18% reduc-
tion in emergency department usage.

R3 incorporates key lessons learned from these

models, including the importance of direct en-
gagement with hospitals that have admitted
residents to ensure a smooth discharge pro-
cess, the involvement of a behavioral health
professional on the wellness team, and ade-
quate time budgeted for the wellness nurse.

[A]voiding just three

placements to long-
term care. . . would
equate to savings to the
Commonwealth of
$490,000 annually.

Better Government Competition 2017 11

Winner R3: Right Care, Right Place, Right Time: Effectively Integrating Senior Care and Housing

tential savings in the form of slower growth in comes measures, communication strategies
costs of approximately $1,053,600 annually. and tools, resident assessments, satisfaction
surveys, and other related resources from the
If we calculate potential savings based on
R3 experience will be made available to other
our projected reductions in avoidable trans-
senior housing sites and interested stakehold-
fers, the potential medical expense savings
ers to develop an optimal approach in inno-
are consistent with the SASH savings. Using
vative healthcare delivery in affordable senior
baseline emergency response information
housing, replicable not only in Massachusetts,
for one of HSLs locations with 560 residents
butwith more than two million low-income
over a one year period, estimated medical
older adults currently living in affordable se-
expense savings would
nior housing across the country 4nationwide,
be $600,000 annually.
...related resources as well.
Additionally, avoiding
from the R3 expe-
just three placements to If successful, we expect the program will serve
rience will be made long-term care, assum- as a model for enhanced linkages between
available to other ing an average length of health care and housing across the U.S.
senior housing sites stay of two years and a
and interested stake- daily rate of $225 for the
long-term care facility, Endnotes
holders to develop
1. U.S. Department of Health and Human Services, Of-
would equate to savings
an optimal approach fice of Disability, Aging and Long-term Care Policy.
to the Commonwealth Support and Services at Home Evaluation: First Annual Re-
in innovative
of $490,000 annually. port, (
healthcare delivery vices-home-sash-evaluation-first-annual-report,

in affordable senior viewed 3/27/17)

housing, replicable Future Goals 2. h t t p : / / w w w . b i z j o u r n a l s . c o m / p o r t l a n d / b l o g /

not only in Massa- It is anticipated that
iment-rolls-out-to-1-400.html, viewed 3/13/2017
between 2000 and 2020
chusetts, butwith 3. Massachusetts Executive Office of Elder Affairs, Elder
there will be a 37% in-
more than two Populations Statistics.
crease in the number regs-stats/elder-population/, viewed 3/13/17)
million low-income of seniors 65 and older
4. LeadingAge, Affordable Senior Housing Plus Services
older adults currently residing in Massachu- Whats the Value? (
living in affordable setts.3 As such, the need default/files/Housing%20Services%20Value.pdf,
viewed 3/29/17)
senior housing across to ensure that hous-

the country... ing sites can effectively

serve frailer, aging se-
niors in a community Contact The Author
setting is of paramount importance.

HSL is already working with a number of hous- Kim Brooks

ing providers and health plans in the Boston Hebrew Senior Life
area to expand the work of R3 on a broader 1200 Centre Street
Boston, MA 02131
scale. We are also involved in a collaborative
effort with several local and national organi-
zations to create a model for sustainable hous- e:
ing with services. Education materials, out- p: 617-363-8000

12 Better Government Competition 2017

Runner Up

Early Detection and Treatment

of Alzheimers Disease
Professor David L. Weimer Dr. Mark Sager
Edwin E. Witte Professor Wisconsin Alzheimers Institute (retired)
of Political Economy
University of Wisconsin-Madison

munity longer. Although available therapies

are less than ideal, evidence indicates they
Problem Statement somewhat improve cognition, slow functional
Alzheimers disease (AD) increases in preva- decline,3 lower Medicare costs, and reduce the
lence with age, affecting up to 10% of the popu- rate of nursing home institutionalization.
lation aged 65 and older, but approximately 47%
There is also evidence that the rate of institu-
aged 85 and up. With an aging population40%
tionalization can be reduced through caregiver
of persons who turned 65 in 2000 will survive to
support. One study indicated that non-phar-
age 85the prevalence of AD will increase from
macologic interventions directed at caregivers
about 5 million today to 14 million by 2050.1
can delay nursing home placement by an aver-
An increase in the prevalence of AD will mean age of 1 years.4
higher long-term care costs. The most plausible
Early detection enables
estimates of total annual costs to the U.S. econ- With an aging popula-
treatment and caregiv-
omy attributable to AD surpass $200 billion. 2
tion... the prevalence of
er support when it can
All else being equal, AD patients impose costs
have the greatest im- AD will increase from
on Medicare about 60 percent higher than non-
pact on improving the about 5 million today to
AD patients. For states, AD patients impose a
quality of life for both 14 million by 2050. An
substantial cost on Medicaid programs through
nursing home use. Long-term care costs ac-
those with AD and their increase in the prevalence
caregivers, ultimately of AD will mean higher
count for 34.6% of state Medicaid spending na-
reducing nursing home
tionally. long-term care costs.
Unfortunately, studies
Proposed Solution suggest that between 40% and 80% of persons
with dementia go undiagnosed in primary care
One approach to reducing long-term care costs
and, as a result, are untreated.5
would be to lower demand for services by de-
laying the onset or slowing the progression of Several inexpensive but surprisingly effective
AD, or providing support to caregivers to enable initial screens for dementia are available. The
them to keep loved ones with AD in the com- animal naming screen, which asks respon-

13 Better Government Competition 2017 Better Government Competition 2017 13

Runner Up Early Detection and Treatment of Alzheimers Disease

Promoting early diagnosis so

that treatment and counseling
can be started early in the course
of AD to slow its progression and
enable caregivers to cope better
with the burdens of the disease
would delay later entry into ex-
pensive nursing homes.

dents to name as many animals

as they can in one minute, has
false positive and false neg-
ative rates of about 10%. The
test, which can be administered with minimal into account those identified as positive for
training, is inexpensive. A follow-up test, such AD by the first two screens who declined to
as the Cognistat exam, takes about 20 minutes proceed to the next stage in the process, AD
to be administered by a college graduate with patients can be identified at a cost of approxi-
one-day of training. A positive Cognistat would mately $3,200 per case, of which roughly $670
then be followed by physician diagnosis. would be covered by Medicare. However, long-

Promoting early diagnosis so that treatment term benefits would be substantial.

and counseling can be started early in the Under our proposed AD screening program,
course of AD to slow its progression and enable the state would have to spend approximately
caregivers to cope better with the burdens of $2,530 for each AD diagnosis. Drug treatment
the disease would delay later entry into expen- alone would likely delay nursing home insti-
sive nursing homes. We propose states create tutionalization by more than a year. In Wis-
incentives for early detection by reimbursing consin, the state Medicaid program pays on
primary care physicians and county health de- average 31 percent of the more than $46,000
partments for the costs of administering the annual reimbursement to nursing homes, or
animal naming and Cognistat tests. about $14,000. Even if this amount were re-

We estimate the costs of administering these alized years after diagnosis, its present value

tests to be $2.30 and $17.20, respectively. To would still be significantly higher than the cost

encourage participation, we propose setting per case diagnosed.

reimbursement rates at 150% of actual cost, or We analyzed the present value of net social
$3.50 and $26, respectively. and fiscal benefits from early detection and
treatment of AD.6 We took into account sev-
eral uncertainties: the mortality risks of the
Projected Outcomes AD patient and his or her spouse; the risk of
In the short-run, the AD screening program institutionalization at various stages of dis-
would add to state health-care costs. Based on ease progression; the effect of drug treatment
the experience of the Wisconsin Alzheimers on the rate of disease progression; the effect
Institutes use of the animal naming test and of caregiver intervention on the risk of insti-
Cognistat, followed by diagnosis, and taking tutionalization; the probability that patients

14 Better Government Competition 2017

Early Detection and Treatment of Alzheimers Disease Runner Up

would be diagnosed and treated at a later stage spent $1.85 billion on long term care while
of the disease when symptoms become more Massachusetts spent $4.63 billion, reflecting
apparent; and the relevant shadow prices a larger population and higher nursing home
needed to monetize all effects. costs.

The analysis shows that benefits are larger for

detection at younger ages (younger patients Endnotes
having more exposure to risk of nursing home 1. CDC, Alzheimer's Disease (
care), earlier disease progressions (opportuni- aginginfo/alzheimers.htm).
ties for slowing the progression being greater), 2. Michale D. Hurd, Paco Martorell, Adeline Delavande,
married patients (who are more likely to have Kathleen J. Mullen, and Kenneth M. Langa, "Mone-
a caregiver), and women (who on average live tary Costs of Dementia in the United States," New En-
gland Journal of Medicine 2013:368 (2013), 13261334.
longer). For a married 70 year-old woman at
an early, but symptomatic, stage of AD, de- 3. Oscar L. Lopez, James T. Becker, Judith Saxton, Rob-
ert A. Sweet, William Klunk, and Steven T. DeKosky,
tection and treatment with currently available "Alteration of a Clinically Meaningful Outcome in the
drugs would yield a present value of expected Natural History of Alzheimer's Disease by Cholines-
net social benefits of $69,000, a present value terase Inhibition," Journal of the American Geriatrics
Society 53:1 (2005), 8387.
of expected net fiscal savings to Wisconsin
of $4,000, and a present value of expected 4. Mary S. Mittelman, William E. Haley, Olivio J. Clay,
and David L. Roth, "Improving Caregiver Well-be-
net fiscal savings to the federal government,
ing Delays Nursing Home Placement of Patients with
which pays a larger share of Medicaid nursing Alzheimer Disease," Neurology 67:9 (2006), 1592
home costs than the state, of $6,000. Combin- 1599.

ing drug treatment with caregiver intervention 5. Louise Robinson, Alan Gemski, Clare Abley, John
would increase net social benefits to $93,000, Bond, John Keady, Sarah Campbell, Kritika Samsi,
and Jill Manthorpe, "The Transition to Dementia
state savings to $15,000, and federal savings to
Individual and Family Experiences of Receiving a Di-
$29,000. Drug treatment alone provides fiscal agnosis: A Review." International Psychogeriatrics 23:7
benefits to Wisconsin in excess of the expect- (2011), 10261043.
ed costs per diagnosed case of $2,530. It should 6. David L. Weimer and Mark A. Sager, Early Identi-
also be noted that, because screening offers fication and Treatment of Alzheimers Disease: So-
cial and Fiscal Outcomes, Alzheimers & Dementia 5:3
potential savings to the federal government,
(2009), 215226.
one would expect states to be able to get Med-
icaid waivers to help pay for the program.
Contact The Authors

Future Goals Professor

In response to our cost-benefit analysis and David L. Weimer
the involvement of the Wisconsin Alzheimers 1225 Observatory Drive
Madison WI 53706
Institute, the state of Wisconsin has devel-
oped a state-wide cognitive screening program
( e:
ICAD2010_hawaii.pdf). As Baby Boomers age, p: 608-263-2325
states face the prospect of increasing Medic-
aid expenditures for long-term care. Analysis Dr. Mark Sager
showing positive net social and fiscal benefits e: masager@
for Wisconsin from AD screening would likely
show even larger benefits for Massachusetts.
In FY 2015 Wisconsins Medicaid program

Better Government Competition 2017 15

Runner Up

Jewish Community Housing

for The Elderly and Jewish Family
& Childrens Service
Amy Schectman Rimma Zelfand
President and CEO CEO of Jewish Family & Childrens
Jewish Community Housing Service of Greater Boston
for the Elderly

with intellectual disabilities are living with

family caregivers, not in supported or even
Problem Statement handicapped-accessible settings, and 25% of
The challenges of growing old can humble even these individuals are living with caregivers
the hardiest among us. Many older adults face over age 60 (University of Missouri-Institute
cognitive and physical changes, along with de- for Human Development). As family caregiv-
creased income and increased social isolation. ers age, they are unable to adequately (and in-
At the same time, the United States is experi- definitely) care for their loved ones. There is an
encing a dramatic and unprecedented demo- urgent and growing need for affordable, sup-
graphic shift. Americans over 65 will make up portive housing that meets the needs of this
20% of the U.S. population by 2029. population.

Individuals aging with intellec- However, there are few such

tual and developmental disabil- options for individuals with ID/
ities (ID/DD) face even greater [T]here is currently DD. Their needs are rarely met
challenges, and they too are liv- little collaboration by traditional housing develop-
ing longer. The number of adults ments for older adults. As a re-
between providers
with ID/DD aged 60 and older is sult, aging individuals with ID/
projected to nearly double from
of services for older DD often live with family mem-
641,860 in 2000 to 1.2 million adults and services bers or in small group homes,
by 2030. Further, individuals for people with dis- and experience increased isola-
with developmental disabilities abilities. tion as they age due to a lack of
demonstrate signs of aging in access to transportation, com-
their 40s and 50s that the gener- munity programs, and their
al population traditionally may not experience peers. As they experience declining mobility
until 20 to 30 years later. These individuals are and health due to age-related issues, they also
at a much higher, much earlier risk for age-re- find it difficult to participate in traditional day
lated health conditions. and social programming for younger adults
with ID/DD, further exacerbating their isola-
In Massachusetts, the majority (71%) of adults

16 Better
Better Government
Government Competition
Competition 2017
Jewish Community Housing For The Elderly And Jewish Family & Childrens Service Runner Up

132 Chestnut Hill
Land Sq. Feet
13,847 sq ft
Building Size
56,172 sq ft
Residential Units
Compounding the challenges experienced by have 3,000 square 61
older adults with ID/DD is the fact that there feet of ground floor
has been little collaboration between providers commercial space
serving older adults and those serving indi- for tenants and
viduals with ID/DD. If older adults with ID/DD neighbors, and a connecter bridge that will
are to have access to housing and services that provide seamless indoor passage between the
support positive aging in community, provid- new building and JCHEs existing 700-unit
ers serving each of these populations will need Brighton Campus. All residents will benefit
to combine their resources and expertise to de- from full access to JCHEs on-site services,
velop creative solutions. amenities, and programs, including a fitness
center, computer center, art studio, library,
performances, classes, and clubs.
Proposed Solution
From JF&CS, the residents with ID/DD will re-
Jewish Family & Childrens Service (JF&CS) and
ceive intensive individual 24/7 live-in support,
Jewish Community Housing for the Elderly (JCHE)
plus case management and personal care from
are embarking on a collaboration designed to
JF&CSs highly trained team.
better serve individuals with disabilities who
are aging. Working together, they are creat-
ing a replicable housing model that will enable Positive or Projected
individuals with lifelong developmental dis-
abilities to age in communities where they are
respected, supported, and positively engaged. By allowing residents with ID/DD to engage in
their community, we expect this model to pre-
The home of this collaborative project will be at vent or decrease social isolation. Plus, aging
JCHEs all-new, all-affordable 57,400 square caregivers will hopefully experience signifi-
foot supportive senior housing building at 132 cant relief knowing that their loved ones are
Chestnut Hill Avenue in Brighton (scheduled housed, cared for, and socially and intellectu-
to open fall 2018). The 61-unit, fully-accessi- ally engaged.
ble building will showcase a five-unit suite (5
bedrooms with private bathrooms and com- A broad body of research shows that support-

mon living and kitchen area, plus space for ive housing effectively helps people with dis-

overnight staff) designed specifically for older abilities maintain stable housing. People liv-

adults with ID/DD. The new structure will also ing in supportive housing less frequently use

Better Government Competition 2017 17

Runner Up Jewish Community Housing For The Elderly And Jewish Family & Childrens Service


are working to-
gether to create a
replicable housing
model that will
enable individu-
als with lifelong
disabilities to age
in communities
where they are
respected, support-
ed, and positively

costly systems like emergency health services. identify future implementation opportunities
Supportive housing can also aid people with at other JCHE buildings; 2) promote adoption
disabilities in receiving better health care of the collaborative model by creating and dis-
especially preventative care which ultimately seminating a best practices handbook; and 3)
reduces Medicare/Medicaid expenditures. provide technical assistance to other organiza-
tions looking to replicate our model. Ultimate-
ly, it is the shared goal of JCHE and JF&CS to
Future Goals develop permanent, inclusive, and supportive
JCHE and JF&CS anticipate that this pioneering housing where individuals aging with disabil-
model to house older adults with ID/DD with- ities can do so successfully and live out the re-
in a supportive senior housing framework will mainder of their lives.
be replicated in Massachusetts and beyond by
those who are interested in better meeting the
needs of this growing population. By integrat-
Contact The Authors
ing aging individuals with ID/DD into a senior
housing facility that includes robust support
services designed to meet the needs of older
adults, while also providing targeted supports
that will allow them to thrive in this setting,
JF&CS and JCHE hope to serve as a model for
similar projects. The model could be adapted
Amy Rimma
for housing facilities that are being developed Schectman Zelfand
in the future, or with slight modifications to
existing facilities. 30 Wallingford Road
Brighton, MA 02135-4753
JCHE and JF&CSs goals for the future are to: 1) p: 617-912-8400

18 Better Government Competition 2017

Runner Up

Five Keys Charter
the Talent
to Reduce
Older Adults
to Support Critical
Authors Name Services
Company Name
Doug Dickson
Board Chair
Encore Boston Network

time with children and families in need of pro-

tective services. Duties identified include tran-
Problem Statement scription, data entry, filing, printing, record
management, and redaction of files.
Older adults watch more TV than any other age
group, almost as much as they once spent work-
ing each day. And they enjoy it less (Deppe, et Proposed Solution
al.). The results are boredom, less social inter-
Encore Boston Network (encorebostonnetwork.
action, lower life satisfaction, and higher risks
org), in conjunction with DCF and the Execu-
of obesity, depression, dementia, and heart,
tive Office of Elder Affairs, will develop, test
bone and diabetic disease. Too many older
and then expand effective
adults have lost purpose, which research shows
strategies for engaging
can shorten life by 7.5 years (Levy, et al.). Encore Boston
older adults as volun-
Network will
As older adults leave the workforce in Massa- teers for DCF, and create
chusetts, we face two challenges: a) how to keep a model that can be rep- develop, test
individuals active, healthy and engaged, and b) licated by other govern- and then expand
how to retain the benefit of their skills and ex- ment agencies. effective strategies
Drawing on relationships for engaging
At the same time, following the high profile developed through its older adults as
deaths of children involved with the Massa- Generation to Generation volunteers for DCF.
chusetts Department of Children and Families, Boston campaign (gener-
DCF, the Executive Office of Health and Human,
Services, and the Governors office sought ways which engages the talents of adults 50 and over
to strengthen department operations. One step as a human capital resource for the benefit of
was to identify duties being handled by social youth, Encore Boston Network will, as a pilot,
workers that could be handled by clerical staff refer older adults to fill 25 volunteer positions
instead, to free up social workers to spend more in 4 DCF offices (Dorchester, Roxbury, Hyde

19 Better Government Competition 2017 Better Government Competition 2017 19

Runner Up Mobilizing the Talent of Older Adults to Support Critical Government Services

Older adults bring

knowledge, skill and
experience that add
capacity to govern-
ment agencies.
Adding capacity
at DCF will benefit
vulnerable children
and youth.

One current program that connects older

adults to government service is ReServe, which
has filled a range of local government roles in
New York City over the last decade. It pays a
stipend to volunteers and charges an admin-
istrative fee to agencies. Relevant models from
the nonprofit sector include Generations In-
corporated, Executive Service Corps, Jump-
start Community Corps, and Boomers Leading

Findings from these initiatives point to pos-

sible approaches to challenges DCF may face
in recruiting, managing and retaining older
volunteers, which include: a) alerting them to
opportunities, b) making the experience desir-
able and fulfilling, and c) overcoming logistical
Park, and Chelsea). As they learn from this ex- obstacles such as lack of transportation. First,
perience, they will expand the initiative to the older adults respond best to volunteer oppor-
other 25 DCF Area Offices across the state. tunities when introduced to them by friends
or people they respect. Second, many prefer a
Studies show that engaging older adults in
setting in which they feel their skills and tal-
purposeful paid and volunteer work creates
ents are being used effectively and which con-
multiple benefits (Hoffman and Andrew).
nects them to likeminded individuals. Third,
Older adults bring knowledge, skill and experi-
they prefer to work near their homes.
ence that add capacity to government agencies.
Adding capacity at DCF will benefit vulnerable Specifically, Encore Boston Network will pilot
children and youth. Additionally, volunteers the following activities:
gain measurable improvements in health, life 1. Developing a targeted recruitment cam-
satisfaction, and longevity. paign to identify sources of and methods for

20 Better Government Competition 2017

Mobilizing the Talent of Older Adults to Support Critical Government Services Runner Up

engaging older adults who have the neces- munities in which they serve. At least 75
sary skills and experience, and developing percent of older volunteers will recommit
ways to connect them to DCF staff. to work beyond the initial year because
2. Insuring a quality work experience by de- their needs are being met and they under-
signing opportunities that can be done by stand the critical nature of their contribu-
teams of volunteers; by recognizing vol- tion to DCFs mission.
unteer contributions in ways that include a 4. Creation of a guide, to be shared with other
social component; and by designing activ- DCF offices and government agencies, of
ities that extend relationships beyond the best practices based on lessons gleaned
workplace. from the pilot.
3. Testing transportation options for volun-
teers that include stipends to cover costs, Future Goals
carpools, or directly provided group trans-
1. Based on the success Encore Boston Net-
portation. Virtual opportunities that elimi-
work achieves in filling volunteer positions
nate the need for transportation altogether
in 4 Boston offices, they will look to expand
will also be explored.
the program to the other 25 DCF offices in
the state.
Projected Outcomes 2. Leverage the DCF prototype to encourage
The lessons learned in the DCF pilot will be other government agencies and municipal-
migrated to other agencies at the state and ities to adopt similar approaches.
municipal levels. In that sense, Encore Boston
Networks primary measure of success will be
whether every older adult who wants to remain
Colin Deppe, et al., Age, affective experience, and tele-
actively engaged will have an opportunity to do vision use, American Journal of Preventive Medicine,
so. More specifically, Encore Boston Networks 2010

projected outcomes are: Becca Levy, et al., Longevity increased by positive

self-perceptions of aging, Journal of Personality and
1. The identification and placement of 25 vol- Social Psychology, 2002
unteers in the initial year, learning from
Linda Hoffman and Erin Andrew, Maximizing the po-
their experience how to shape the volunteer tential of older adults: benefits to state economies and
positions in the future so as to expand the individual well-being, NGA Center for Best Practices,
program to additional offices. 2010

2. The efficiency gained by having administra-

tive duties performed by volunteers to en-
able social workers to be in the field more of Contact The Author
the time. Having field professionals spend
more time working cases and responding Doug Dickson
to reports will lead to better outcomes for 176 Federal Street
vulnerable children and families across the Suite 501
state. Boston, MA 02110

3. 80 percent of participating volunteers will

report satisfaction with their work experi- e:
ence. They will feel connected to the DCF p: 617-755-7715
mission, their co-workers, and the com-

Better Government Competition 2017 21

Runner Up

Return to Community Initiative

Loren Colman Krista Boston J.D.
Assistant Commissioner Director of Consumer Assistance Programs
of Continuing Care The state of Minnesota Board on Aging
Minnesota Department
of Human Services

dents return to the community early in their

Problem Statement stays. Its goals are to increase the value of
long-term care from the standpoint of both
From 2017 to 2025, the costs of nursing home
residents and public programs, rebalance re-
and continuing care retirement facilities are
sources from nursing home to the commu-
projected to rise in the United States from $170
nity, employ long-term care resources more
billion to $260 billion.1 Although nursing fa-
efficiently, improve individual health and
cilities are increasingly a source of post-acute
functional outcomes, and enhance consumer
care in the US, it is the long-stay resident who
choice and quality of life.
accounts for the largest number of nursing
home (NH) days and the li- The initiative began with re-
ons share of Medicaid and search by Dr. Robert Kane and
out-of-pocket costs.
From 2017 to 2025, the Dr. Greg Arling that examined
cost of nursing home and the potential for develop-
The first 90 days after ad-
continuing care retire- ing target criteria to promote
mission is critical for deci-
sions about returning to the
ment facilities is project- greater numbers of transitions

ed to rise in the United from nursing homes. The state

community or becoming a
then developed a service using
long-stay resident.2 The de- States from $170 billion
the criteria, coupled with sup-
cision to become a perma- to $260 billion. port provided through the Se-
nent resident is of consid-
nior LinkAge Line, to transi-
erable importance. Private
tion residents who meet the
paying residents face large future out of pocket
criteria from nursing homes and long-term
costs; for the government, these individuals
care facilities back into their communities.
are at risk of exhausting their assets and con-
verting to Medicaid. On a weekly basis, target lists of residents who
may meet the criteria for transition back into
the community are developed in collaboration
Proposed Solution with the Minnesota Department of Health,
Minnesotas Return to Community Initiative Board on Aging, and Department of Human
(RTCI) helps private pay nursing home resi- Services. Lists are created based on residents

22 Better
Better Government
Government Competition
Competition 2017
Return to Community Initiative Runner Up

RTCI helps
private pay
MDS (Minimum Data Set) admission assess- Once assistance has nursing home
ment. Certain criteria are pulled from the MDS been agreed to, an
to determine if the resident meets the target interview is con-
return to the
profile. Residents appear on the list if they: ducted with the res-
Have resided in a nursing facility for at least ident and primary
early in
45 days, caregiver to deter-
mine the residents their stays.
Have a goal of returning to a community needs, both physi-
setting, and
cally and mentally.
Have a 70% or higher probability rate of The CLS may rec-
being successful in the community, based ommend the resi-
on their health and functional characteris- dent apply for state assistance through Med-
tics as recorded upon admission. icaid or a home and community-based services
Community Living Specialists conduct visits (HCBS) waiver. Veterans are referred to the
to residents on the target list to provide un- County Veteran Service Officer to determine
biased information regarding the residents benefit eligibility. If the resident faces barriers
options for residing in the community and to to discharge, referral to the Ombudsman for
make them aware that they have the right to Long-term Care may be necessary.
live in the least restrictive environment. The Community Living Support Plans, which sug-
CLS explains the free service that is available gest the services that will be provided when
for being discharged back to the community. If residents leave a facility, are developed based
the resident agrees to the assistance, release of on the physical, social and emotional needs of
information is obtained that gives the CLS ac- the individual. Because not all individuals will
cess to the medical chart, ability to speak with be able to live in a home setting, options such
nursing facility staff and other health care pro- as adult foster care, group homes and assisted
viders, and to collect private information for living are explored.
data analysis and evaluation.

Better Government Competition 2017 23

Runner Up Return to Community Initiative

Once the resident is discharged, a second visit Future Goals

is conducted within 10 days. If the patient
On May 30th, the Governor signed into law an
needs more immediate follow-up, the CLS will
expansion of Return to Community. The initia-
visit within 72 hours. During the visit the CLS
tive will target new populations, including pa-
tients being discharged from a hospital, those
Verify the patients understanding of med- who contact the Senior LinkAge Line because
ications, they want to move to assisted living, or those
Review emergency plans, for whom Medicare Home Care has ended.

Ensure prescribed medications are filled, Minnesota has consulted with other states. As
Conduct medication reconciliation, other states think about replicating the model,

Ensure an appointment with a primary care they will need to consider: 1) strategic engage-
ment with the provider community to ensure
physician is scheduled, and
it will buy into the model; 2) a single point of
Make additional caregiver and consumer
entry for initial referrals combined with local-
referrals, if needed.
ly accessible staff that can meet with residents
Ongoing follow-up occurs 30, 60 and 90 days in almost real time. Having referrals come into
after discharge, with further follow-up offered a single web portal or toll free line allows for
for five years. quality monitoring to ensure intake is correct
and appropriately handled.

Since its inception in 2010, the RTCI has as- Endnotes
1. Keehan, S. P., Poisal, J. A., Cuckler, G. A., Sisko, A. M.,
sisted in the transition of 4,500 residents, 95%
Smith, S. D., Madison, A. J., . . . Lizonitz, J. M. (2016).
of whom received formally provided services National Health Expenditure Projections, 2015-
upon discharge from a facility. 85% received 25: Economy, Prices, And Aging Expected To Shape
care from a nurse or home health aide. Small- Spending And Enrollment. Health Aff (Millwood),
35(8), 1522-1531. doi:10.1377/hlthaff.2016.0459
er percentages had alarms or other technol-
ogy (55%), in-home or home delivered meals 2. Arling, G., Kane, R. L., Cooke, V., & Lewis, T. (2010).
Targeting residents for transitions from nursing
(34%), other in-home services (33%), or trans- home to community. Health Serv Res, 45(3), 691-711.
portation (21%). doi:10.1111/j.1475-6773.2010.01105.x

The results are both a higher quality of life 3. ibid

for consumers and recognized savings, both

for consumers and their families, and for the Contact The Authors
state. Estimated savings were $9.6 million over

the first four years of the initiative, calculat-
ed using a fiscal model that assumes savings
if (1) residents moved out of a nursing home
and remained off of or delayed enrollment into
a Medicaid long-term care waiver or (2) tran-
sitioned to a Medicaid long-term care waiver Loren Krista
for less costly services instead of remaining Colman Boston
in a nursing facility. The service was expanded
in 2014 with estimated savings of $18 million Minnesota Department of Human Services
since the expansion. P.O. Box 64976
St. Paul, MN, 55164-0976
p: 651-431-2605

24 Better Government Competition 2017

Runner Up

Ride-Share Pilot Program

Ben Schutzman
Director of Transportation Innovation
Massachusetts Bay Transportation Authority

FY2017, the RIDEs budget reached $109M, a

118% increase over just the last decade. Per-
trip costs to the MBTA in FY2017 are $59 ($35 in
Problem Statement variable cost and $24 in fixed cost). Expenses
The RIDE, Massachusetts Bay Transit Author- are expected to continue rising.
itys (MBTA) paratransit service, is a safety
net for people whose disabilities prevent them
from using public transit. In its current form, Proposed Solution
the RIDE provides door-to door, shared-ride The MBTAs solution was to launch a pilot with
transportation to eligible people who cannot Uber and Lyft to provide paratransit services
use fixed-route transit (bus, subway, trolley) in lieu of the shared-ride model. The idea was
all or some of the time because of a physical, conceived through partnership with disability
cognitive or mental disability. The RIDE runs advocates whose goal was to identify ways to
365 days a year, generally from 5 AM 1 AM, in reduce costs for The RIDE without cutting ser-
58 cities and towns. Accessi- vice.
ble vehicles serve persons
The pilot was set up to test if the following
Costs per trip with disabilities, including
could be achieved:
have averaged those who use wheelchairs
$9 vs. the and scooters. The fare, when Increased customer mobility,
traditional booked in advance, is $3.15. Equal or better service at lower cost,
RIDE per-trip Many customers rely on The Full-accessible service (including access to
RIDE as a lifeline, but its wheelchair accessible vehicles (WAV) and
cost of $59.
shared rides can be long. A options for individuals who do not have
customer might get picked smartphones and/or are un-banked),
up over an hour before they need to get to an Reduced travel and wait times.
appointment, even when the trip might only
Customers sign up directly with Uber or Lyft
take 20 minutes by car. There is also not much
and are provided a set number of trips every
flexibility to change ones schedule.
month, proportional to their trips taken on
Moreover, The RIDEs costs are increasing. the traditional RIDE service prior to joining the
In FY2007, the RIDEs budget was $50M. By pilot. For every trip, customers pay the first $2,

25 Better Government Competition 2017 Better Government Competition 2017 25

Runner Up Ride-Share Pilot Program

the MBTA pays up to the next $13, with cus- least equal or better service for no additional
tomers responsible for any additional costs. cost. Pilot enrollment was initially limited to
Customers can book directly via smartphone the first 400 individuals to enroll so as to en-
or via Lyfts call-in service. sure that the solution could be
Uber and Lyft provide access to tested at a smaller scale until it
wheelchair accessible vehicles Customers save began to generate savings and
(WAVs). money as well: a improvements both for custom-

Every trip a customer takes as

same-day trip on ers and the MBTA. Due to its ini-

part of the pilot is paid out of the traditional RIDE tial success, the pilot has since
been opened to all customers
the budget for the traditional costs customers
of The RIDE, with over 1,000
RIDE vendors. Since costs are $5.25, but pilot costs
enrolled to date. Collective-
only billed on consumption and average only $4.52 ly, these customers have taken
the partnership can be stopped
a trip. more than 20,000 trips.
at any time, the potential finan-
cial downside is limited. Costs per trip have averaged $9
vs. the traditional RIDE per-trip cost of $59.
Customers save money as well: a same-day
Outcomes trip on the traditional RIDE costs customers
Prior to launch, the MBTA decided that, at a $5.25, but pilot costs average only $4.52 a trip.
minimum, the pilot would have to provide at
Customers have expressed satisfaction. The
pilots Net Promoter Score (a measure of cus-
tomer satisfaction) is 79%. For comparison, the
transit industry average is 12% and the MBTAs
fixed route average over the last 12 months was
11%. Customer satisfaction was linked to the
following improvements:

Real-time bookings. Being able to book

on-demand, customers experience in-
creased mobility, freedom, and sponta-
neity. For customers who would occasion-
ally miss their RIDE trip when a doctors

I cannot begin to describe, one

customer says, how thrilled I am
with this service. It has given me
back something I lost a couple of
years ago and thought I would
never have again a sense of in-

26 Better Government Competition 2017

Ride-Share Pilot Program Runner Up

appointment ran long, the pilot has been a because it is so time consuming and exhaust-
savior. ing due to my medical issues. For all intents

Lower wait and travel times. Customers and purposes, I have pretty much been house-
bound due to the constraints of The RIDE. The
save 34 minutes on average on their trips.
To date, more than 11,000 hours have been great thing about the [pilot] program is if I feel
saved by pilot customers. well enough to go out to a store on the spur of
the moment, I can go within minutes. I do not
Increased Trips. Because of the per-trip
have to plan ahead.
savings the pilot has achieved, the MBTA
can allow customers to take more trips and
still save money. Pilot user trips are up by Future Goals
over 25% compared to their baseline histo-
The MBTA has set an ambitious goal of deliv-
ry, but the MBTA still saves money.
ering 10% of the RIDEs estimated 1.9 million
Accessible Options. Both Uber and Lyft FY18 trips via Uber or Lyft. In addition, it will
provide options for those who may lack work to maintain accessibility for riders by
familiarity with technology or access to integrating Uber/Lyft bookings into the MB-
smartphones. For seniors and others who TAs call center, avoiding the need for smart-
do not have bank accounts, both companies phones, and increasing WAV supply as demand
allow payment via prepaid debit card and increases.
other non-credit solutions. For custom-
ers with mobility devices and wheelchairs,
Contact The Author
both companies have accessible vehicle op-
I cannot begin to describe, one customer Ben Schutzman
10 Park Plaza
says, how thrilled I am with this service. It
3rd Floor
has given me back something I lost a couple Boston, MA 02116
of years ago and thought I would never have
again a sense of independence. I have been
using The RIDE for a couple of years but have e:
p: 617-222-3200
only been going out for medical appointments

Better Government Competition 2017 27

Special Recognition

Boston Medical Center

Elders Living at Home Program
Eileen OBrien Samantha J. Morton
Director, Boston Medical Centers CEO, MLPB
Elders Living at Home
Program (ELAHP)

A recent Boston census estimated that 2,400

homeless individuals were over 51 years of
Aging Right in the Community, a joint program of age.
Boston Medical Centers Elders Living at Home
Older adults are especially vulnerable to high
Program (ELAHP) and MLPB (formerly Medi-
housing costs because so many are on fixed
cal-Legal Partnership | Boston), works to pre-
incomes. A report from Bostons Commission
vent homelessness among Greater Bostons
on Affairs of the Elderly and the Gerontology
most at-risk older residents. The Aging Right in
Institute at UMass Boston notes the average
the Community (ARC) project provides intensive
annual income of Boston residents ages 60-79
case management, supported by legal exper-
is $18,000, and for those over 80 is $13,100.
tise, to individuals age 55+ who are homeless
or at risk of homelessness to keep them safely Low-income, older adults in unstable hous-
housed and living with as much independence ing situations face barriers to health and so-
as possible. cial services. Many suffer from mental illness,
cognitive decline, substance abuse, undiag-
In 2016 an estimated 564,700 people in the
nosed health conditions,
U.S. were homeless; 50%
and poor nutrition. They
were over 50 years of age.
tend to be socially isolat-
ed and are often unable
A recent Boston to effectively access ex-
census estimated isting social services on
that 2,400 homeless their own. The best way
to address the complicat-
individuals were
ed needs of this popula-
over 51 years of age.
tion and prevent or end
elders homelessness is
with specialized, legally
informed, intensive case management.

The ARC team approaches the problem of older

adult homelessness from three angles:

28 Better
Better Government
Government Competition
Competition 2017
Boston Medical Center Elders Living at Home Program Special Recognition

1. Helping those already homeless to transi- ARCs goals include:

tion back into safe, affordable permanent 1. Program clients will be stable in housing,
housing; with long-term supports that make it pos-
2. Providing stabilization services to help sible for them to maintain housing and live
those who have been homeless but are now as independently as possible;
housed maintain that housing, increase 2. Clients will have successful resolution of all
their well-being, and maximize their inde- legal needs; and
pendence; and
3. Individual client needs and legal outcomes
3. Engaging in crisis intervention and home- will inform systemic solutions preventing
lessness prevention services for those at housing insecurity through: a) elimination
imminent risk of losing their housing and of practical, logistical, and bureaucratic
falling through the cracks. barriers to housing; b) outreach to
Older citizens in need are re- and education of housing-insecure
ferred to ELAHP by BMC phy- Since its inception, and at-risk older adults;c) devel-
sicians and other providers, ARC has main- opment of an effective screening
area shelters and outreach tained a homeless- and advocacy infrastructure that
can be exported to other organi-
programs, food pantries and ness prevention rate
meal sites, and community zations serving older adults; and
of 94%, and 98%
agencies. Eligible individu- d) addressing policies that may
of those stabilized be creating barriers to housing for
als meet with a case manager
for an assessment to identify
with project services vulnerable older adults.
immediate needs and barriers have remained in Since its inception, ARC has main-
to obtaining and/or keeping stable housing. tained a homelessness prevention
permanent housing, and to rate of 94%, and 98% of those sta-
discuss potential solutions. bilized with project services have
Case managers develop individualized service remained in stable housing. 148 clients have
plans (ISP). The programs Clinical Coordina- been served by the project over its first three
tor, an RN, provides consultation for the cli- years.
ents medical needs.

Those who are homeless work on a plan to Contact The Authors

secure housing (submitting applications, se-
curing necessary documentation, attending
screening appointments). For those at risk of
losing their housing, services include landlord
mediation, and support with court appearanc-
es and related activities.

All program clients suffer from at least one Eileen Samantha

chronic illness, and currently 65% suffer from OBrien J. Morton
two or more, presenting enormous challenges
75 Arlington Street
to their abilities to live safely and with some
Suite 500
degree of independence.
Boston, MA 02116
p: 617-336-7500

Better Government Competition 2017 29

Special Recognition

Rachel Goor Noelle Marcus
Graduate of MITs Masters Graduate of MITs Masters
in City Planning Program in City Planning Program

with extra rooms to those seeking affordable

On any given night, more than 50 million bed- rents. Guests will pay more affordable rent by
rooms sit empty across the U.S. Many of these helping around the house, and elderly home-
spare rooms belong to those aged 55+ who owners will gain economic stability, security,
hope to stay in their homes and communities social connection and support to stay in their
for as long as possible, but strug- homes as they age.
gle with social isolation, the daily
As graduate students, we are acute-
maintenance of their homes, and On any given
ly aware of how hard it can be to
declining incomes. At the same night, more find affordable housing. At the
time, millions of renters struggle than 50 million same time, we have watched peo-
to afford high rents in areas close
bedrooms sit ple around the world open their
to jobs.
empty across cars, homes, and hearts to complete
nesterly is a social enterprise fo- the U.S. strangers as the sharing economy
cused on alleviating housing in- has disrupted life as we know it. We
security in the U.S. by addressing wondered if it might be possible to
both of these problems. Through an online employ the sharing economy to better use ex-
marketplace nesterly connects households isting resources and increase the amount of af-
fordable housing.

The idea of intergenerational

homesharing is not new. In
fact, in the mid-to-late 19th
century, 1 of every 2 urban

We wondered if it might be
possible to employ the sharing
economy to better use existing
resources and increase the
amount of affordable housing.

30 Better
Better Government
Government Competition
Competition 2017
nesterly Special Recognition

dwellers at some point lived in a boarding nesterly plans to launch a pilot in Cambridge
house, a form of intergenerational co-housing. this summer, and expand to the Boston mar-
Today, there are a handful of small non-profits ket by fall, to serve the large local student and
making senior-youth housing matches in their aging populations in both of those cities. Our
local communities. However, to our knowl- goal is eventually to serve populations around
edge, no one has tried to leverage technology, the world.
and the sharing economy it has helped to cre-
While our product will start with students and
ate, to scale a homesharing model.
older households in the Boston area, we be-
The demand for such a program could not be lieve nesterly can positively affect the broader
more timely: community by increasing overall housing sup-

1 in 3 U.S. households will be headed by ply and thereby relieving pressure on the local
someone aged 65 or older by 2035. (Source: housing market.
Projection from the Joint Center for Hous- The shortage of affordable housing, the pres-
ing Studies). sure on the local housing market from growing
70% of adults over the age of 45 prefer to stay student populations, and a rapidly aging senior
in their homes and communities. (Source: population are all critical challenges that nest-
Survey conducted by AARP in 2014). erly will help communities face.

Most peoples incomes rapidly decline as

they enter retirement, making it harder to
make ends meet. Nearly 25% of older adults Contact The Authors

report difficulty paying monthly expenses
(Source: United States of Ageing Survey-

Cities are spending billions of public dollars

to subsidize affordable housing construc-
tion. In May 2013, New York City announced
an $8.2 billion, 10-year affordable housing Rachel Noelle
Goor Marcus


Better Government Competition 2017 31

Special Recognition

Wisconsin Coalition for Collaborative

Excellence in Assisted Living
Kevin Coughlin
Policy Initiative Advisor
Executive Division of Medicaid Services

cellence in Assisted Living addresses these

issues. It is a collaboration of Wisconsins De-
Assisted living communities (ALCs) have partment of Health Services Division of Qual-
emerged as an important component of ity Assurance and Division of Medicaid Ser-
long-term care. Consumer demand, con- vices, Wisconsins four assisted living provider
cerns regarding nursing home quality, and the associations, the states advocacy agency, The
availability of capital for construction and ren- Board on Aging and Long Term Care, and the
ovation of facilities have combined with states University of Wisconsin-Madison. The four
efforts to reduce long-term care costs. The re- provider associations represent roughly 40
sult has been dramatic growth in the assisted percent of the states licensed ALCs.
living industry. In some states, there are now
Using a data repository into which all four
more beds in ALCs than in nursing homes.
provider associations and their members feed
Initially, ALCs were a mar- data, the Coalition employs a
ket response to consumer comprehensive quality assur-
demand and demographic Preliminary data show ance and quality improvement
trends, without regard to reg- the early adopters (QA/QI) program that has been
ulatory considerations. More have better regulatory approved by DHS. First, ALC
recently, Medicaid developed compliance and fewer residents complete a standard-
payment policies and waiv- ized Resident Satisfaction Sur-
reports of complaints
er programs for the care of vey for Coalition members. The
from residents and
qualified individuals in ALCs. surveys are submitted for data
With no federal ALC regula-
their respective family processing and analysis. One
tory authority, states began members. standardized satisfaction sur-
to implement regulatory vey is used for all ALC members,
standards on their own, often in all four associations.
through licensing requirements. However, the
Next is a set of performance measures that
sheer size of the ALC market has taxed the ca-
cover structures, processes, and outcomes for
pacity of state regulators. In Wisconsin alone
Coalition members. These include staffing,
there are 3,679 licensed facilities.
quality improvement activities, norovirus and
The Wisconsin Coalition for Collaborative Ex- influenza infection rates, falls, and hospital-

32 Better
Better Government
Government Competition
Competition 2017
Wisconsin Coalition for Collaborative Excellence in Assisted Living Special Recognition

[T]he average number of falls with

injury per ALC has declined from
1.58 falls with injury/ALC to 1.35
falls with injury/ALC.

izations. Coalition member communities are

required to submit a report on these measure-
ments on a quarterly basis. Associations review
their member data and intervene to help them
improve when necessary, which can result in
fewer complaints and overall better regulato-
ry compliance, and better resident and family

The surveys and performance measures

demonstrate that Coalition ALC members have
made great strides in increasing resident sat-
isfaction while improving health outcomes. As
a collaborative for 2016, overall resident sat-
isfaction had the following composite scores
(based on a rating of 1-5):

Staff 4.41
Rights 4.43
Environment 4.51
Activities 4.26 member ALCs. Preliminary data show the early
Meals and Dining 4.15 adopters have better regulatory compliance
and fewer reports of complaints from residents
Health 4.46
and their respective family members. The data
Overall 4.44
also show a marked improvement in the early
Total 4.38 adopters quality measurements and resident
satisfaction over the duration of their Coalition
Comparing calendar year (CY) 2013 to CY 2016, membership.
the average number of falls with injury per ALC
has declined from 1.58 falls with injury/ALC to
Contact The Author
1.35 falls with injury/ALC. Re-hospitalizations

per ALC show a similar decline, from 1.57 to
1.34 re-hospitalization/ALC. Staff retention Kevin Coughlin
(68%) and staff immunization rates (67%) were 1 W. Wilson
high compared to national averages for ALCs. Room 550
Madison, WI 53703
One study analyzed the regulatory compliance
data of ALCs that have been members of the
Coalition for three years compared to non-
p: 608-266-6989

Better Government Competition 2017 33

History Better Government Competition

ioneer Institutes Better Government Competition, founded in 1991, is an
annual citizens idea contest that seeks out and rewards the most innovative
public policy proposals. The Competition grand prize winner receives $10,000; four
runners-up receive $1,000 each, and other proposals receive special recognition.
Recent winners have included proposals on pension reform, virtual schooling, job
training, housing, and many other pressing topics.


2017 Aging in America 2003 Innovative Ideas on Key Public Issues

2001 Law Enforcement, Education, Housing,
2016 Improving Care for Individuals Living
Family Preservation
with Mental Illness
2000 Ideas Into Action
2015 Fixing Our Troubled Justice System
1999 A Wise and Frugal Government
2014 Leveraging Technology to Improve
Government 1998 Streamlining Government

2013 Revving Up the Great American 1997 Bringing Competition to State and
Job Engine Local Government

2012 Restoring Federalism 1996 Public Safety and Fight Against Crime

2011 20 Anniversary - Budget Busters

th 1995 Local Solutions to Public Problems

2010 Governing in a Time of Crisis 1994 Welfare in Massachusetts

2009 Health Care Reform 1993 Improving Policies and Programs

Affecting Children
2008 Sustaining School Reform
1992 Improving Environmental Policies
2007 Improving Government at the State
and Programs
and Municipal Levels
1991 Restructuring/Privatizing State
2006 Better Government Competition
15th Anniversary
2005 Streamlining Government
2004 State and Local Focus

25th Annual

Improve the Quality & Access to Care for

Individuals Living
with Mental Illness

Fixing Our Troubled Justice System PIONEER INSTITUTE


34 Better Government Competition 2017

185 Devonshire Street, Suite 1101 Boston, MA 02110 | 617.723.2277 |

Pioneer Institute for Public Policy Research is an independent, non-profit organization that specializes in the support,
distribution, and promotion of research on market-oriented approaches to Massachusetts public policy issues. As
a tax-exempt 501(c)(3) organization, Pioneer Institute relies solely on donations from individuals, foundations, and
corporations, and does not solicit or accept government funding. All contributions are tax-deductible.

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