By Mark Olshaker, previously published in Tax Credit Advisor magazine, September 2020
Physical Retrofit and Operational Adjustments
“Once you’re home, you’re safe.”
That is the essence of Health Secure Housing as defined by Tax Credit Advisor columnist David Smith, founder and CEO of the Affordable Housing Institute (AHI) of Boston, MA. But, he adds, “This is an aspirational phrase to define a new standard: Everyone you regularly come in contact with is part of your health family, and we all have a stake in each other’s wellness.”
Smith enumerates the consequences of not achieving Health Secure Housing: rents go down, vacancy goes up, there is higher turnover, insurance expenses mount, financing is more difficult and selling the property is tougher.
So, the prime question becomes, how do we go about achieving that aspiration in the existing affordable housing stock, from both physical retrofit and operational perspectives?
Retrofitting and Forward Thinking
“Initially, we start off with the small stuff,” says Sharon Wilson Geno, executive vice president for national services and chief operating officer of Volunteers of America, headquartered in Alexandria, VA, a faith-based organization that operates nearly 20,000 affordable housing units. “How are the management offices organized? What construction changes do we need? Our service coordinators are an integral part of our senior buildings and we’re working to put the healthcare element into every aspect of our residences, so what do the service coordinators need? When we recapitalize, we build this into the design.”
For Wilson Geno, Health Secure Housing is about both physical and emotional elements, especially in the age of COVID-19. “Ventilation is a big issue. Negative air pressure to help [dissipate viral particles] is really key. Then there’s the whole issue of socialization through balconies, outdoor spaces, courtyards and opening windows. We should be thinking about all of that again. So, we really have to consider both the ‘hard’ and ‘soft’ stuff. For example, air conditioning in our senior buildings should not be thought of as an extra. The Department of Housing and Urban Development (HUD) has finally recognized it as vital as plumbing.”
The thinking around physical retrofitting has evolved as the demographic has changed. Wilson Geno observes, “We now have people much longer than we used to; people in their 80s and 90s with increasing frailties, people who are not going to want to go to skilled nursing homes or congregant care. We therefore have to look at American Disabilities Act compliance, better lighting, wider doors to accommodate walkers and wheelchairs, as well as COVID-related issues like proper ventilation and means of physical separation.”
“The first piece is easy,” says Pam Goodman, retired CEO of Beacon Communities of Boston, who still consults regularly for the organization and has been one of the thought leaders in affordable and subsidized housing. “We do a lot of renovation of existing buildings. We tend to focus on the envelope, making it as green as possible. And we focus on windows, ventilation, balconies; we reconfigure common space to better meet the programmatic needs of the people who live there, such as a wellness office, fitness and computer center and a single-chair hair salon. Sometimes we have the money to build onto existing structures.”
For several years now, Beacon has had a wellness program that includes: resident service coordinators; wellness offices; healthy meals and nutrition education; fitness centers; programming, education and community building; computer learning centers; transportation.
But, Goodman adds, “I really did drink the Kool-Aid about the importance of social interaction. This is a very interesting issue that we’ve been doing a lot of talking about. Contact is very important. We’re still wrestling with how much there should be post-COVID, but we think personal interaction is vital. Our common spaces are not open now. We took a very conservative line [when the pandemic hit]. Now we’re trying to figure out how to open safely and design things differently going forward. We’re doing as much as we can outside. We have no community meals at the moment; food is being delivered to each unit.”
Virtually everyone associated with the Health Secure Housing movement—by whatever name they call it or concept by which they define it—agrees that full capacity for virtual and noncontact communication is a critical step.
“In normalizing, Health Secure Housing, broadband communication is essential,” Smith comments.
“Broadband is the next thing everyone has to tackle and it’s absolutely vital,” Wilson Geno agrees. “We have been working with a coalition of other organizations on the connectivity piece. We keep asking, can we be doing more service coordination through video? What are the options for connecting?”
“Everyone has to have access to the Internet. But a lot of the older seniors can’t use our computer centers,” Goodman notes. “We’re really concentrating a lot on how to provide access and make it affordable. Tom Stokes has been focusing on how we change that paradigm.” Thomas Stokes is Beacon’s vice president for community engagement.
“Broadband is going to be like water in terms of necessary resources. In some of our communities, we’re buying Amazon Fire Tablets,” he explains. “We can arrange for people who don’t have digital access to borrow them. At Dominion Place in Richmond, VA we made the building wireless about a year ago and put an [Amazon] Alexa in each unit. Alexa becomes a means not only of communicating easily with residents, but also for things like telehealth appointments.”
“We Could Not Have Done This on Our Own”
Whether we are thinking about new construction or existing facilities, at the heart of Health Secure Housing is collaboration.
“What really needs to happen is we have to do a better job with aging in place,” states Geoffrey “Geoff” Brown, president and CEO of USA Properties Fund of Roseville, CA, which focuses on addressing social change through housing. He advocates introducing nursing programs into all age-restricted affordable communities. “Regular access to a support nursing program will save the system a lot of money. I think it’s very important to look at this from a taxpayer’s point of view and leverage services in the most efficient way. I’d like to have more resources available to help create assisted living conditions on-site, but one of the challenges is that every state is different, and some are more progressive than others.”
At Dominion Place, Beacon established a broad-based clinic with Virginia Commonwealth University (VCU) staffed with students from the various professional schools, including medical and law schools, who are guided by their professors. Services include informing residents about issues that might affect them, medication reminders, COVID-19 and other kinds of testing and services or assistance they might need.
“It’s been very successful,” says Stokes. “It has involved a lot of training with residents. The people in the clinic were very hands-on pre-COVID. We utilize Alexa Echo Show and Fire Tablets, and users get simplified printed instructions on how to perform different functions, using pictures as much as possible, like Ikea does.” The clinic has been supported by grants from the National institutes of Health and AARP.
“We can check usage data [for the digital devices] to see what the residents are using them for,” Stokes elaborates. “Then, we went to the highest users—about 75 to 80 people—and created videos for every single service the clinic provides; from pharmacy and medications, all the way to bedbug inspection and remediation.”
“We could not have done this on our own without VCU,” Goodman states. “Now, we’re trying to move it to other locations.”
“The idea is to learn as much as we can from this,” Stokes says. “VCU is working with us in Erie, PA, where we’ve purchased buildings and are doing rehabbing.”
Another innovative experiment is Beacon’s work with Connected Living, whose slogan is “Reinventing Senior Living for Today’s New Normal.” Together, they plan to introduce the Temi robot – a mobile device with an interactive screen that can be sent to each resident’s dwelling controlled remotely by an operator, into Beacon’s Highland Glen Apartments in Westwood, MA. Temi and devices like it are expected to become a staple of assisted living projects.
Who Pays? The Tyranny of the Silos
As logical and constructive as the Beacon-VCU collaboration sounds in working toward effective Health Secure Housing, it is far from the norm.
“The more you can do on-site, the simpler the solution will be. Unfortunately, that’s not how the reimbursement system works,” Goodman says. “This is my hot button. To get people to work together at a local property is as close to impossible as you can imagine. What VCU is doing in Richmond is fabulous. We have not been able to get another institution in Boston to replicate it. I have worked on this concept for more than five years. The system is just not set up for coordinating. Tom and I have sat in these meetings that had both housing and health people. I don’t want to participate in any more studies. We know how this works. We know that [on-site health security measures] reduce overall health issues and the need for emergency services.”
“So many of us have been chipping away at this with Health and Human Services (HHS) and HUD, with Medicare and Medicaid for so long,” Wilson Geno says. “Housing is healthcare! We have research on all of this, that by providing essential health services you can avoid spending a huge amount of money later on, but there’s still rigidity at HHS: ‘We’re not paying for real estate or housing.’ And Medicare and Medicaid don’t seem to get that housing is a highly effective intervention for preventative health. Prevention is always cheaper than treatment. Instead of doing this on a waiver basis, this should be national policy.”
“If you compare tax credit housing to market rate assisted living, the costs go up four to five times,” says Brown. “We need to figure out a way to allow residents to stay through creating a condition of more assisted living through tax credits. Operators like us can partner up with assisted living providers. That would really help in our space. The problem is, there are two silos and unfortunately, I don’t think that’s by accident. People have their own turfs they’re protecting and that’s not in the best interests of residents.”
“Some of this is a function of the appropriations process – that different committees are responsible. But an epic change is needed. I’m hoping COVID will accelerate it.”
The Legacy of COVID
COVID-19 is the greatest public health challenge the world has faced in a century. But has the experience provided any long-term lessons that would be useful in Health Secure Housing?
“We’ve learned that we have to be able to move so much faster than we ever did,” Wilson Geno declares. “We have to go back to buildings we’ve recently renovated and make sure they are adequate to handle social distancing, digital communications and other services internally. We may have to figure out how to refinance more efficiently.”
“On a specific level, we’ve developed protocols,” Stokes says. “Once we’ve been notified that a resident is infected, we have to notify other residents. We bring in expert third-party cleaners to disinfect all common areas. Then, if the resident is not going to the hospital, we determine how to meet his or her needs to stay quarantined, such as medicine or food. Sometimes we will suit up with personal protective equipment to remove trash from the apartment or whatever else has to be done.
“On a more general level, we’ve learned that we have to be really careful about spacing with smaller events, more shifts and a lot more virtual programming. We need more digital resources and technology training. So, one of our challenges now is how do we get our residents more comfortable with tech.”
“Tom’s folks contacted every single resident to make sure they had their meds and everything they needed,” Goodman says. “Now, we’re asking each one if they still want that kind of regular contact. I don’t know that we’re going to be designing much differently, although we’ll need more space and have to figure out how to pay for it,” she adds. “On the physical side, HVAC should be state of the art. We’re looking at things like movable walls and flexible spaces, but most of all, we’re looking to get back to human contact.”
Perhaps the greatest legacy of COVID-19 is that we’ve experienced it, and all of the emotional and economic pain has been made real in people’s minds, so the consequences no longer require creative imagination. Smith points out that few people are willing to pay for avoided costs until they have to start paying for the consequences. Then they start to understand and appreciate the value equation. “Financial catastrophe,” he observes, “is a precondition for fundamental reform.”