There’s a Nurse in the House

9 min read

USA Properties’ staff and residents coordinate care

USA Properties discovered that 25 percent of the residents in its senior communities moved out due to health issues. With two-thirds of its portfolio involving seniors, President and CEO Geoff Brown wondered what else he could do in the senior space.

The result is a pilot program, now in its third year, that provides nurses to three USA senior communities in the greater Sacramento area: Creekside Village in the city itself, Sierra Sunrise in Carmichael, and Vintage Oaks in Citrus Heights. Each location has an office for a specially trained, part-time nurse who works with social workers, service coordinators, property managers, maintenance staff and the residents themselves. This partnership between USA Properties Fund, Inc., the Roseville, CA-based affordable, senior and market-rate housing developer, and LifeSTEPS, the social services organization headquartered in Sacramento, dedicated to providing effective educational and supportive services to maximize the strengths of individuals and build resilient community, is an impressive and replicable model for affordable senior housing management.

“All of it goes under the heading of care coordination,” says Meredith Chillemi, LifeSTEPS’ director of aging and education services.

“When we started out, we watched seniors age in place but there was no connection with health services,” LifeSTEPS executive director Beth Southorn observes.

“LifeSTEPS is the largest senior services provider in the state of California. And we’ve been working with them for 22 years,” states Brown. “Beth has been very involved working with seniors on all sorts of social service programs. We will do anything we can to help our residents, so we created a 501(c)(3) to focus on senior services in affordable housing and help the residents age in place.”

Though they come from different sectors and disciplines, Brown says of Southorn, “Philosophically, we have the same goals. We’re both passionate and try to be innovative about affordable housing.” Together, they planned the pilot program and from the start, they were insistent on a rigorous, methodical, needs-based approach and measurable, evidence-based calculi.

“The only way we were going to get to where we needed to be was to prove it with the numbers,” Southorn adds. “I approached Geoff and said we have to prove this is cost-effective. We each agreed to pay half.”

The pilot program covers about 675 residential units.

“In the affordable housing industry, we rely on a lot of government and outside money,” Brown says. “It was very important to me that we use whatever resources we have as efficiently as possible. We knew there was plenty of need, but I didn’t want to go out and ask other people for funding until we could show lots of metrics and outcomes. We didn’t want to sell an idea, but an actual program that was up and ready and working. I wanted to be confident to say, ‘This is a cost-effective model.’ We decided to start this thing and put up our own money as an R&D expense, paid for out of the operations of each community.”

Effectuating Efficiencies
From the start, it was axiomatic that if an on-site program could keep seniors in their homes and out of nursing homes and extended care facilities, and if they experienced fewer necessary hospital visits, significant cost savings and efficiencies could be achieved.

The first step was a needs assessment, tailored to each community. “We spent several months interviewing residents and seeing what their needs were,” Southorn says. “We asked ourselves, ‘What is the purpose of healthcare in our community-based approach?’”

“There are a number of important social determinants of health,” Chillemi continues, “including age, gender, sexual orientation, education level, social and cultural considerations and, of course, access to healthcare.” Some of these relate closely to acknowledged barriers to optimum outcomes, such as lack of health understanding and information, red tape with medical insurance and government bureaucracies, literacy and language skills, and not receiving timely preventive services that then lead to hospitalization.

Chillemi explains, “Our health management focusses on what we found to be the top ten chronic diseases of seniors: high blood pressure, high cholesterol, arthritis, heart disease, heart failure, diabetes, depression, Alzheimer’s disease and other forms of dementia, and chronic obstructive pulmonary disease (COPD). One of the nurse’s responsibilities is to provide education to residents on signs and symptoms. And for those diagnosed, we provide further education into management with the final outcome goal defined as management in the ‘good range.’” The nurse connects residents directly to healthcare providers.

As the pilot program began, a range of challenges surfaced. “We found there was definitely a disconnect between housing and healthcare people,” Southorn says. “It took time for each group to learn how to work with each other. It wasn’t always easy getting the right fit. Also, we found that there are different skillsets for an in-hospital nurse and a community-engaging nurse. The community nurse has to be able to engage effectively with social workers and property managers on-site, as well as others, such as the maintenance people.”

Bringing the maintenance staff into the equation is an often-overlooked, but important, resource. They are the people most likely to be in resident’s dwellings on a regular basis and therefore can observe firsthand how they’re doing. “They have a relationship with the seniors,” Chillemi says. “They have known these residents for a long time and have a baseline about their health. If there is a problem, they can report it.”

In actually designing the pilot program with USA, Southorn says, “I drew on all my years in affordable housing.” It involved a schedule of progressive goals, and it is on track to meet them.

As Chillemi outlines: “In the first year, we focused on the social workers and the social determinants, so that the social workers and nurses would learn how to work together with the residents and property managers. In the second year, we knew the needs of the residents, so we built the program based on that knowledge. In the third year, we’ve been able to transition to less intervention and more of a maintenance position.”

Residents and Staff as Partners in Wellness
“Thriving in place” is a phrase LifeSTEPS uses in its communications with residents, outlining the services available to them and the goals of the program. The idea is to make the seniors active partners in their own health and wellbeing outcomes. Once they are onboard with the program, they start becoming proactive and they teach other residents. Many now come to the nurse on their own to have their blood pressures checked and other basic tests.

“We have a long history with the residents, which means they trust us,” Southorn says. “They see the nurse in the club house and socializing. She is a trusted member of the community.”

The ultimate success of the pilot program will be judged by numbers and other statistics. But the individual examples are what put a human face on the efforts. “We are literally saving lives,” Chillemi declares.

“A property manager might notice a resident with bruises,” she suggests, “and realizes that she had a fall. The nurse is going to look at her medication and see if that had anything to do with the accident and review her fall-risk assessment. The social worker will set up transportation to a fitness class, such as Tai Chi, to help with strength and balance. And the property manager might coordinate with the maintenance staff to install grab bars and other stability aids.” All of these are components of the new approach to care coordination. For example, if a nurse recommends a particular food need for a resident, the social worker will figure out the means to access the right food program.

Chillemi recalls a resident who had cancer of the jaw. “The nurse helped the gentleman pre-surgery. And during his hospitalization and convalescence the social worker arranged care for his wife with dementia. The nurse advocated for his rehabilitation and helped stabilize him by administering his IVs. A resident at Creekside came home from the hospital with respiratory distress. It turned out he didn’t know how to set up and clean his nebulizer, so the nurse came in and showed him how. Several days later, he called her and said he didn’t feel well. She looked into it and found he had been given the wrong medicine for the nebulizer. She was able to get him stabilized without rehospitalization.”

“When you’re released from the hospital, you just want to go home and go to bed,” Southorn says. “Often, seniors are given information on discharge that is not always easy to understand. Our nurse helps arrange aftercare and the social worker determines it to be safe and successful.” Overall, real-time case management is the goal. This has significant cost implications, since Medicare can penalize a hospital if a patient has to be readmitted for the same condition within 30 days.

“We’re involved with hospitals, state government, the lending community and foundations,” says Brown. “Our goal is to scale it up in a way where we’re recruiting more nurses.”

“We found there were not enough community nurses being trained, so we’re working with UC Davis, with eight masters-level students and their community instructor,” Southorn explains.

“We take a lot of pride in building projects that, if you drove by, you would not be able to tell it was an affordable housing community,” Brown says. He defines that as Goal 1.0. “Adding social services to our communities, including after-school programs, scholarships and other features is 2.0. The nurse and health maintenance programs are 3.0, through which I feel we are creating outstanding communities. And we couldn’t achieve that without the partnership with LifeSTEPS. We are really trying to be impactful on our residents’ lives.”

“We are very, very proud of this program,” says Southorn. “I feel elated that we’re at the point where we have enough to talk about that we can move the needle closer and closer to resident healthcare. We have created a database with advanced measurements that is a lens for Geoff and me to have the numbers to show the success. We want to show nationally what works. We’ve learned some important things and we don’t care who does them, as long as they get done!”

Story Contacts:
Geoffrey Brown,
Meredith Chillemi,
Beth Southorn,