Post-Acute and Long-Term Care in Senior Housing

Post-acute care focuses on providing medical and rehabilitation services to older adults or those who are chronically ill or disabled after an acute event or hospitalization. Long-term care focuses on management of chronic illnesses or disability when individuals are unable to provide that level of care independently and safely for themselves. Long-term care can occur in nursing facilities, assisted living facilities, or in the home setting, which includes senior housing, group homes, or apartments. Post-acute and long-term care potentially involves the input of all members of the health care team including but not limited to therapists (physical, occupational, and speech), medical management, nursing care, social work, and pharmacy. The goal of PALTC, whatever the physical setting, is to optimize function and quality of life and to help individuals stay in the least restrictive setting. Increasingly there is recognition that PALTC is needed in low-income senior housing communities (J Aging Soc Policy 2018;30:227–243; J Urban Health 2010;87:827–838). These settings are federally subsidized housing buildings that receive support from the Housing and Urban Development (HUD) Section 202 program (“Connecting Public Housing and Health: A Health Impact Assessment of HUD’s Designated Housing Rule,” Pew Charitable Trusts, 2015, bit.ly/45okjfF). The majority of individuals living in these communities are from historically underrepresented minority groups; they live with multiple chronic illnesses (physical and mental), and they have limited access to health care, internet use, healthy food options, opportunities for physical activity, and safe indoor and outdoor physical environments (Lewin Group, “Picture of Housing and Health: Medicare and Medicaid Use Among Older Adults in HUD-Assisted Housing,” Department of Health and Human Services/ASPE/DALTCP, 2014, https://bit.ly/3YDmPfU; J Health Care Poor Underserved 2021;32:1415–1432; Can J Aging 2023;42:69–79). To provide PALTC in low-income senior housing, we developed the University of Maryland Interdisciplinary Wellness Program. We partnered with a subsidized housing organization to provide clinics in four of their communities. The purpose of the clinics is to augment primary health care and make wellness services more accessible for residents. Onsite services were developed based on the needs of the communities, which included immunizations (i.e., shingles, influenza, COVID-19), foot care with regard to skin and nail care, hearing screenings and cerumen removal, comprehensive medication reviews and monthly set up of medications, blood pressure assessment and management, completion of advance directives, annual wellness visits during individuals’ birthday month, and assessment and management of acute illnesses and acute clinical problems (e.g., skin infections, neuropathy, musculoskeletal pain, urinary tract infections, or dehydration). An intake assessment was done for every resident who came to the clinic, which included demographic information and reviews of their comorbidities, their perceptions of their health, the screenings and immunizations they had obtained, and their recent hospitalizations and current medications. We also addressed any acute medical or social problems the residents were experiencing, such as a fungal rash, swelling of the feet, or acute pain. We asked whether they needed help with access to services such as Meals on Wheels or obtaining medications. The four communities are in the Baltimore metro area, and they cumulatively include 375 residents who are 55 years of age and older. Each community has a property manager or resident services coordinator who serves as the contact person for the Interdisciplinary Wellness Program team. We held the clinics once a month for half a day in each of the four communities. The Interdisciplinary Wellness Program team included an advanced practice registered nurse, a pharmacist, a social worker, and a registered nurse, all of whom had expertise in the care of older adults in community-based settings. Before implementation, the team met with the property managers at each of the subsidized housing communities to coordinate the timing of the clinics and discuss ways to engage with the residents. We announced the opening of the clinics at a resident meeting and posted flyers weekly at each community for residents to sign up for services. The clinics were held just once a week from 1:00 p.m. to 4:00 p.m. and rotated such that each community had one clinic a month. In the first six months of starting the clinics, we provided 50 wellness clinics. Care was provided to 191 residents (51% of all residents living in the communities). The mean age of those who attended the clinic was 77 (± 9 SD) years old, and the majority were women (81%), non-Hispanic (87%), and Black (65%). The mean number of comorbidities reported was 4 (± 3 SD). The clinic services provided to these individuals are shown in Table 1. The interdisciplinary team member best suited to the care intervention provided the intervention. For example, the nurse practitioner provided services that involved hearing evaluations and cerumen removal, foot and nail care, and management of acute medical problems. The pharmacist provided in-depth medication reviews and coordinated adherence interventions with nursing and facilitated the immunizations of residents. The nurse, among other team members, monitored blood pressure and provided health education. Lastly, the social worker helped with access to care and related issues. All team members participated in obtaining intake information from the residents and with completing the Annual Wellness Visit during a resident’s birthday month. We checked 343 blood pressures over the six-month period and found a very high rate of hypertension among the residents in these communities. This stimulated medication reviews and resulted in improving adherence to medication management in many of the residents. Over the first six months of the clinics there was a significant decrease in blood pressures from 149 to 136 systolic (P = 0.002) and 74 to 68 diastolic (P = 0.05). Partnering with a local pharmacy, we made immunizations for COVID-19, influenza, and shingles available to the residents, and we gave 62 immunizations. Foot and nail care (e.g., cutting nails and addressing skin issues and hygiene) and ear and hearing evaluations with cerumen removal were popular requests, and we provided these services to 63 and 44 residents, respectively. We also diagnosed and managed 10 acute medical problems such as fungal infections, venous insufficiency, and gastrointestinal bleeding. Beyond just obtaining a list of medication, which was part of the intake health assessment, we conducted comprehensive medication reviews with 20 residents. During these more in-depth evaluations, we reviewed all medications (the pill bottles including over-the-counter medications), addressed inappropriate drug use, and eliminated medications when it was appropriate. We helped the residents access needed medications and facilitated adherence (e.g., setting up pill boxes).Table 1Services Provided to ResidentsServiceNumberImmunizations62Foot/nail care63Ear evaluations: cerumen removal and hearing evaluation44Blood pressure checks343Comprehensive medication reviews and setting up adherence systems20Home visits for acute issues4Diagnosis and treatment of acute problems10Completion of state-based end-of-life care directives12Comprehensive health assessments191Annual wellness visits58 Open table in a new tab Table 2Number of Visits per ResidentVisitsResidents179 (41.4%)250 (26.2%)323 (12%)414 (7.3%)513 (6.8%)69 (4.7%)73 (1.6%) Open table in a new tab The residents have greatly appreciated being able to access the health care services provided. Over half of the 191 residents (59%) visited the clinics multiple times, and a few have attended the clinic every month (Table 2). Currently we are not billing for these services because the clinician support was provided through a small grant obtained by the housing provider organization. However, these services are potentially billable, which could help cover the time of those providing the care. As individuals age in place in senior housing, it is important to consider providing the residents with accessible PALTC services. This type of accessible care can help prevent use of the emergency department for preventable problems such as strokes, hypertensive crises, sepsis from infections, or infectious diseases. These clinics are a wonderful way for academic practices or community practices to reach out to their local communities and facilitate aging in place.