Supporting People as They Age in Community: Housing

For many people, “aging in community” is a better way to grow old.¹ It can offer greater independence and more opportunities for social interaction, without the limitations and expense of round-the-clock care in an institutional environment. Older adults get to stay in homes that are familiar and neighborhoods where they have connections. They contribute to the community as consumers, volunteers, caretakers, workers, and citizens.² The state saves on the cost of long-term institutional care, most of which is covered through Medicaid, a joint federal-state program.^(a) The costs for home- and community-based care, on the other hand, are typically covered by Medicaid waivers (for those who meet the eligibility requirements)^(b) or by seniors themselves, since it is significantly cheaper than nursing home care.⁴

Across the country, public and private programs are making housing more affordable and accessible for older adults. Innovative communities are offering senior-only or intergenerational housing that incorporates services and supports for older people. This report explores how housing programs and policies can afford people the opportunity to age well in the homes and communities they know and love, rather than seeing nursing homes as their only option.

Where Do Rhode Island’s Older Adults Live?

The majority of Rhode Islanders grow old in the community. Only 5% of residents (7,451 people) age 65 and over live in nursing homes, slightly above the national average of 3.1%.⁸ Among older adults living in the community in Rhode Island, more than two-thirds own their own homes, while the remainder live in rental units. Most of these households are small – less than two people on average – and many seniors live alone or with a spouse. While it is difficult to measure exactly how many people live in assisted living facilities, a recent inventory identified at least 4,089 residents of these facilities in Rhode Island (their age is unknown, but most are probably seniors).⁹ The level of care in assisted living facilities ranges widely, and people in these environments are generally considered to be aging in community.

Affordable housing is a significant concern for older people living on restricted incomes. Even those who own their homes outright face expenses for property upkeep, utilities, taxes, and adaptations to make their homes accessible as they age. In Rhode Island, a third of homeowners and half of renters over age 65 are considered “cost burdened” with respect to housing, meaning that 30% or more of their household income goes to housing costs. The percentage of seniors who are cost burdened by housing has increased significantly over the past decade.⁷

What Barriers Do Older People Face to Aging in Community?

In focus groups convened by the Aging in Community Legislative Subcommittee of Rhode Island’s Long-Term Care Coordinating Council, local seniors expressed many of the same concerns about affordability, age-friendly living environments, and access to services and supports.¹² They also articulated challenges related to safety, household responsibilities, and home-based care services. 

For some homeowners in the focus groups, it was a struggle to maintain their homes, pay for repairs, and take care of yard work and snow removal. Renters living in public or subsidized housing raised complaints about sanitation, safety, and security, since 24-hour monitoring is not mandated in these facilities. Some residents disliked the intergenerational composition of their housing complexes, fearing rowdy, noisy parties and alcohol and drug use among younger residents. 

For focus group participants needing long-term care supports in the home, many indicated that home-based service providers were unreliable, inconsistent, and incompetent, providing unsatisfactory care. Others mentioned that they could not afford or qualify for community support services.

A Housing Works Rhode Island study commissioned by Rhode Island Housing on the state’s housing needs produced similar findings.¹³ It documented the struggle of older homeowners to pay property taxes, utilities, upkeep, and insurance on limited incomes. The study also found that many older adults were resistant to moving into public or subsidized housing for the elderly, because of its reputation and lack of amenities. Older adults complained about disruptions caused by younger tenants, a lack of in-unit access to laundry, and the inconvenience of carrying groceries from parking lots to their homes.

Seniors have a range of needs when it comes to housing, but most of them fall into the three main categories identified by the Bipartisan Policy Center: They want housing that is affordable, in homes that are age-friendly, and in communities that offer relevant services and supports. Below we examine programs and policies that can help meet these needs.

How Can We Make Senior Housing More Affordable?

The Low Income Housing Tax Credit Program (LIHTC) is one of the country’s most extensive affordable housing programs and can be used to promote more affordable rental housing for seniors. Under the LIHTC, states use federal funds to provide tax credits to developers who agree to set aside a certain proportion of units in new developments to be rented at reduced rates.^(c) Pennsylvania has used some of its LIHTC funding specifically to support affordable, age-friendly housing for seniors.⁶ The state allocates a certain portion of its tax credits to developments for older adults featuring age-friendly design and services to help them live independently.^(d)

Federal LIHTC credits are based on a state’s population; in 2016, Rhode Island received $2,690,000 in funding. Rhode Island Housing data shows that, since 1987, 77 elderly housing complexes in the state have received LIHTC tax credits, resulting in the creation of 588 new affordable rental units, as well as extended affordability periods and building renovations.¹⁴ LIHTC tax credits are available for assisted living developments if they can secure long-term funding for essential services.¹⁵ To promote the development of affordable assisted living and provide long term funding for essential support services in these facilities, in 1997 Rhode Island obtained a Home and Community-based Services Medicaid waiver to fund support services for up to 200 people residing in assisted living facilities certified and financed by Rhode Island Housing. Subsequently, the LIHTC program was used to help finance three assisted living facilities that include 151 units for low-income residents on Medicaid.¹⁴

Other federal programs that support affordable housing for the elderly and were used to develop many of Rhode Island’s elderly housing units have been underfunded in recent years.¹⁶ The U.S. Department of Housing and Urban Development’s (HUD) Section 202 program subsidizing supportive housing for low-income seniors has received no Congressional support for capital advances to fund new units in the past four years.⁶ HUD’s well-known Section 8 housing voucher program, in which eligible individuals pay no more than 30% of their income in rent, accepted applications in a lottery system for prospective tenants during only one week in the past 20 years.¹⁷

According to a 2015 inventory, Rhode Island has 19,601 subsidized housing units available for low-income seniors.¹⁹ These units are subsidized under a variety of federal programs, including the 202 and Section 8 programs mentioned above. Despite the availability of these subsidized units, wait lists for available apartments in some communities are long and nearly 16,000 senior households in Rhode Island spend 30% or more of their income on rent.¹⁰

While many of the federal subsidized housing programs described above benefit renters, targeted tax relief can help older homeowners. Circuit breaker property tax relief programs are designed to prevent low-income residents from paying too much of their incomes in property taxes. Rhode Island has a circuit breaker program in place for low-income senior and disabled homeowners and renters.^(e) It provides state-funded tax credits of up to $320 to those whose property taxes are between 3% and 6% of their household income. Legislation was introduced in 2017 to increase the credit to $750. Massachusetts has a similar program with credits available up to $1,000.

The increasing interest in smaller homes may also create affordable housing opportunities for seniors. Tiny homes, micro-units, and accessory dwelling units (small backyard, garage, or basement units on the same grounds as single-family homes) offer low-cost housing and closer proximity to family and neighbors. Portland, Oregon’s Residential Infill Project is an effort to encourage smaller, less expensive units such as ADUs, triplexes, and cottage clusters to be developed on narrower lots. In 2017, Rhode Island law changed to allow owners of single-family homes to build an accessory dwelling unit for a family member over age 62 without having to obtain a special permit.

How Can We Make Senior Housing More Accessible?

As seniors age, they face a number of health challenges, from limited mobility to vision problems to arthritis. Their home environments need to be adapted accordingly. Age-friendly housing addresses seniors’ physical limitations with features like handrails, bright lighting, non-slip floors, and wide entryways. Some older adults require wheel-chair ramps or stair lifts or need all their living areas to be on the main floor.

A number of government agencies and private organizations have developed guidelines and best practices for adapting homes to encourage safe, healthy aging and promote independence.²⁰ The non-profit Enterprise Community Partners, for example, created toolkits for affordable housing providers and property managers in New York City.²¹ They offer guidance on how to hire and train staff, make age-friendly building modifications and prevent falls, conduct assessments of seniors’ service needs, engage residents in activities, and leverage community-based assets and private partnerships to fund building enhancements.  

Because many older people live in the same homes they have been in for decades, they may have to make major modifications to adapt their houses as they age. While some age-friendly modifications are simple and inexpensive, others can be costly. Georgia, Virginia, the District of Columbia, and Allegheny County, Pennsylvania offer tax credits toward the cost of new accessible housing units or the modification of existing ones.⁶ The Lifespan Friendly Homes Program in New River Valley, Virginia assists older adults with home modifications and energy assessments through a collaboration among multiple public and philanthropic organizations.

In Rhode Island, the state-funded Access Independence program provides low-interest loans and grants for home modifications for individuals with disabilities. Some municipalities offer funding for home repairs and improvements from their Community Development Block Grant (CDBG) funds. For example, the Johnston-North Providence Home Repair program provides no-interest loans of up to $15,000 to assist needy seniors and families in both towns using CDBG funds. The no-interest loan is paid when the house is sold or transferred, so there is no monthly payment.

Some localities are working to ensure that new housing developments have age-friendly “universal design” features built in from the beginning.^(f) Cities have implemented regulations (e.g. Pima County, AZ), incentives (e.g. Austin, TX), and voluntary models (e.g., Irvine, CA) for encouraging the incorporation of age-friendly design elements into planning and zoning decisions.²²

Age-friendly housing extends beyond the physical environment to technologies and services that can help seniors stay healthy. Telehealth systems help monitor seniors’ health in the home, connect them with providers, and provide information about self-care.²³ For example, a project at the University of New Mexico called ECHO (Extension for Community Healthcare Outcomes) assists individuals in managing their chronic conditions at home. Minnesota’s “Live Well at Home” grants have funded technology such as Mobile-Mate, a mobile safety device that can detect falls, to empower older adults to remain active. 

Telehealth programs can extend provider capacity, reduce hospital admissions, and alert patients and doctors to the need for preventative interventions.²³ The Veterans Administration offers remote health monitoring in locations across the country. Some retirement companies are being created with built-in health monitoring technology. The University of Missouri and private company Americare partnered to develop Tiger Place retirement community, where residents can choose to be monitored by sensors that offer early detection of heart disease, infection, neurological disorders, and other conditions.²⁴

In Rhode Island several home care organizations, including VNA of Care New England and VNA of Rhode Island, provide telehealth services to monitor clients’ status between visits and assist with disease self-management. Local company Nalari Health works with community partners to offer telehealth services that link patients, providers, and caregivers through technology. Patient monitoring and care coordination are done remotely and clinical encounters occur online.

How Can New Models of Community Provide Seniors with Services & Support?

The level of services available in these communities ranges widely. Retirement villages for more independent seniors may limit their services to meal packages and social activities. Congregate housing and assisted living facilities typically provide more services, including on-site health care and housekeeping. Rhode Island’s St. Germain Manor, operated by the Woonsocket Housing Authority with supportive services provided by United Methodist Elder Care, is an example of a public-private partnership that offers affordable housing with assisted living features. More than a third of assisted living residences in Rhode Island report having waiting lists, averaging 24 to 30 weeks, suggesting that assisted living needs in the state are not being fully met.⁹

Services can also be layered onto seniors’ existing living situations. In Vermont, SASH (Support and Services at Home) offers social services and healthcare to Medicare recipients living in congregate housing or in the community. Each individual’s care is managed by a wellness nurse and a care coordinator. Funding is provided by the Center for Medicare and Medicaid Services, the state, housing and social service agencies, and private organizations. In Rhode Island, the Saint Elizabeth Community has received a grant to implement the SASH model at Saint Elizabeth Place, a 149-unit subsidized apartment complex for elderly people and persons with disabilities in Providence. The goal of the program is to make the home the center of healthcare coordination and allow people to remain living in the community as long as possible. 

Seniors-only communities aren’t the only option. Across the country, there are an increasing number of innovative intergenerational housing models that can provide seniors with the supports they need at an affordable price. Bridge Meadows is a multigenerational affordable housing community in Portland, Oregon bringing together older residents, adoptive families, and children in foster care. In exchange for 100 hours of tenant volunteer service per quarter, rent rates are kept low. Other cohousing developments and intentional communities combine private homes with shared community spaces and enhanced opportunities for community engagement.

Sandywoods Farm in Tiverton, Rhode Island is an intentional community funded with assistance from LIHTC tax credits and dedicated to supporting the arts, sustainable agriculture, responsible land use, and affordable housing. It has 50 affordable rental units for low- and moderate-income households, 16 single-family homes, 20 house lots for sale, a community garden, activities, and a Center for the Arts.

Some seniors are developing their own intentional communities and networks to support aging in place. Based on a grassroots, mutual-aid approach, the “Village” model offers members a menu of support services (transportation, home maintenance, wellness programs, etc.) organized by volunteers and a small paid staff.²⁵ Villages are not pre-planned residential developments, but rather self-organized systems created in existing neighborhoods and tailored to the needs of residents.

The Village model can be described as an intentional social network that advances social inclusion, social engagement, and practical support. A survey of operational villages found that over 85% provide assistance in at least six of the eight domains for age-friendly cities and communities identified by the World Health Organization.²⁶ Beacon Hill Village in Boston was one of the first Village programs in the country, and the Providence Village has successfully replicated the model in Rhode Island. Stay At Home in Little Compton also offers Village-type services to area residents. Village programs are grassroots initiatives that take some time to develop, but there is potential for expansion if older adults and community partners become interested and dedicated to building these communities. 

Naturally occurring retirement communities (NORCs) are similar to the “Village” model in that they expand the availability, accessibility, and affordability of supports for aging within an existing community.²⁷ Unlike Villages, however, NORCs typically arise in a single building, often a high-rise apartment with more functionally impaired and economically insecure residents. Villages, on the other hand, tend to be comprised of multiple dwellings within more advantaged and racially homogenous neighborhoods.

While Villages utilize diverse funding sources, including membership fees, and are mobilized by older adults in leadership and volunteer roles, NORCs tend to rely largely on government funding and paid professional staff. NORCs show more potential for reaching heterogeneous populations, including the most vulnerable seniors, but offer less opportunity for seniors to engage in the community’s creation and management. From 2002 to 2005, $21.4 million in federal grant funding was provided to support 41 NORC projects across 25 states.²⁸ One program was implemented in Rhode Island, by Shalom Apartments in Warwick in cooperation with URI. It focused on fall prevention by offering apartment safety inspections, fall risk screenings, and exercise opportunities.

A study of 69 Villages and Natural Occurring Retirement Communities found numerous benefits to members.²⁹ Residents indicated that they were more likely to stay in the community, more socially engaged, more likely to obtain outside assistance, and better able to take care of their own homes as a result of participation. They felt healthier and rated their quality of life as higher due to these programs.

Improving Housing for Rhode Island’s Older Adults

Affordability and accessibility are particularly important in Rhode Island, given the state’s high cost of living and older housing stock that requires more updating than in other parts of the country. There are a number of programs and policies already in place that could be expanded to make housing more affordable and accessible for seniors. These include the Low Income Housing Tax Credit Program, which incentivizes developers to build affordable housing, and Rhode Island’s Property Tax Relief Circuit Breaker program, which eases the tax burden for low-income elderly homeowners. The state could also consider creating or identifying funds to offer low-interest loans or tax credits to cover the costs of home modifications that allow seniors to remain in their own homes. Legislation submitted this year, the "Rhode Island Livable Home Tax Credit Act," would provide tax credits of up to $5,000 to cover 50% of the total amount spent to make a new residence meet accessibility criteria or to retrofit an existing home. 

The state might also evaluate ways to improve existing housing, such as addressing some of the concerns about intergenerational subsidized housing complexes that were expressed by Rhode Island seniors in focus groups. The “Housing for Older Persons” exemption of The Fair Housing Act allows certain public housing facilities to be designated specifically for seniors. Another option would be to require 24-hour security in subsidized house complexes with large numbers of seniors. In addition, funding and training could increase the ability of resident services coordinators to provide services and mediate tenant-to-tenant issues in mixed population housing facilities. 

Looking at more far-reaching innovations in senior housing, Rhode Island may want to consider promoting some of the alternative housing models discussed above. Intentional communities, cohousing, tiny homes, the Village model, NORCs, and other supportive housing options can help seniors save money, stay connected to family and neighbors, and access services and supports. Resident-driven projects like the Providence Village and public-private partnerships such as the St. Germain Residence could be expanded. The feasibility of developing a cohousing demonstration in the state could be discussed with developers and the home building industry. In addition, the 2016 voter-approved Housing Bond could help finance construction of new units, rehabilitation of existing properties, or repurposing of underused nursing home space into more innovative senior housing.