Ruggles

Affordable

Assisted

Living

Boston,       Massachusetts

Introduction

The Developers New Communities Services New Atlantic Development Committee to End Elder Homelessness

The Residents

The Member

Audio Tour

The Numbers

Committe to End Elder Homelessness

Elisabeth Babcock is president and CEO of the Committee to End Elder Homelessness.

We are part owner, manager, and service provider at Ruggles Assisted Living. We got involved with the development because we had a previous working relationship with both Peter Roth (of New Atlantic Development Corporation) and Pam Shea (of New Communities Services) at another facility on Huntington Avenue. They had developed and owned the property, and we had been a contracted service provider.

Peter Touborg, site director for the Committee to End Elder Homelessness, at Ruggles Affordable Assisted Living.

They realized they wanted to do an assisted-living facility, but neither of their organizations had experience running supportive housing for elders at the assisted-living level. So they asked us to come in because of that.

We were a certified Group Adult Foster Care provider, which was key to being able to run an assisted-living facility in Massachusetts for the poor.

The original expectation was that we would just have a service contract to provide the services for the project. But as the project moved along, all of the financing partners really wanted to have us in the relationship in a more secure fashion because you couldn't really run an assisted-living facility without a service provider.

I think their concern was that if we decided that we didn't want to do the services any longer it wasn't going to be that easy to find another provider that could come in and serve this particular low-income population.

The Committee to End Elder Homelessness was founded 10 years ago to provide permanent housing for high-risk elders who had been homeless or were at a high risk of homelessness and had complex medical and behavioral health problems. We only operate permanent, supported housing. We're the only organization of this kind in the country.

Ruggles Assisted Living is only the second facility in the state that is entirely affordable and the first one in Boston. There are many mixed-use, mixed-income buildings, but I believe this is a really rare bird. We're allowed to serve a population that's earning up to 50 percent of median income, but the residents have turned out to be all earning under 30 percent of median income.

The residents are all Medicaid/Medicare recipients. Medicaid pays through its Group Adult Foster Care program for services for most of the residents. The residents receive three meals a day, a minimum of one hour of individual support for bathing or other activities of daily living. They also receive laundry support, and their apartments are cleaned for them.

The Executive Office of Elder Affairs told us that the population we're serving in this facility has a higher medical acuteness and frailty than that of the average assisted-living facility in the state.

I think we have targeted and focused our efforts on a very complex, very high-risk population — people with multifaceted health-care and mental-health-care needs. We have many residents who have mental-health issues as well as medical issues. All of them have medical frailties; they have to have them in order to qualify for the program.

Many of them have mental-health or substance-abuse problems. We consciously target that population because that's our mission as a nonprofit organization. And although we had originally set aside 18 units of the building for elders who were homeless, we expect the vast majority of the people who will occupy the building to have been homeless.

Originally, we expected 18 apartments to be furnished, believing that those homeless individuals would not be coming with their own furniture. But since we opened the building, staff has consistently asked us to add more furnished apartments. By the time we're done with our ramp-up, we expect that almost the entire building will have furnished apartments because the elders are coming from situations where they have no furniture of their own.

Assisted Living Versus Nursing Homes
Assisted-living facilities and nursing homes are financed entirely differently. Nursing homes — or long-term-care facilities as the industry refers to them — are licensed through the Department of Public Health rather than through the Executive Office of Elder Affairs. They're licensed as health-care facilities.

They bill Medicare and Medicaid as health-care facilities and are required to have on staff services that would allow a resident to be provided with intravenous medications, physical therapy, occupational therapy, and X-rays. They're required to provide emergency treatment and medication injections. Nursing homes are required to be able to do all of these things even though the residents won't necessarily need them. They must provide staff to meet the expectations of a very, very sick population that really cannot function independently at all.

What's most interesting about this is that we're now more than three-quarters filled and already 48 percent of our residents have come out of nursing homes. So they were in nursing homes and were eligible for nursing homes under the Medicaid requirements for nursing homes, but they didn't want to be in a nursing home and weren't appropriate for a nursing home.

So almost half of them moved into Ruggles as a preference. Ruggles has licensed medical and clinical providers on staff, but is not focusing on a medical model as much as a supportive and wellness model. Before Ruggles, that option didn't exist for them.

Most of the residents have medical problems such as diabetes, congestive heart disease, pulmonary disease. Many of the residents have problems with breathing or need oxygen; they have problems with high blood pressure, hypertension; some have a history of substance abuse or other mental-health issues. So it's a real mixed bag.

The average age of a resident in the facility right now is 73 years old, which is younger than that of other assisted-living facilities in the state. For those, the average is about 81 to 83 years old.

So we're dealing with folks who are younger than the residents of the average assisted-living facility, but they also have more complex conditions than those residents; many of the residents are mobility-impaired and require wheelchairs or walkers. We have a pretty complex patient population.

There are certainly many, many assisted-living facilities in the state. In fact, if you talked to Mass-ALFA — the Massachusetts Assisted Living Facilities Association — they would tell you there is an over-saturation of assisted-living facilities in many areas of the state.

But these assisted-living facilities have been targeted toward people who have the means to pay privately. And the private-payment rates really range about $4,000 to $6,000 per resident per month. So you can see that Ruggles is drastically different, because the residents who come to Ruggles are able to live there on what they would normally live on in a Section 8 apartment.

They would pay one-third of their income and a small service fee, and in exchange for that receive three meals a day, all of their services, and housing. If a person, for example, had a social-security income of $600 a month, and that was all they had, they would keep $150 and live in the facility and receive all of the services and meals for $450 a month. The balance of their expenses would be paid through the various state programs that we bill. This is, of course, one-tenth of what they would pay under private assisted living. This is really interesting because Ruggles is a beautiful facility that looks like any other market-rate, assisted-living facility.

The Residents
We're finding that the folks who are moving in to the facility come largely from the greater Roxbury area. Most of them come from Roxbury, Jamaica Plain, the South End, and Dorchester. We had one lady who moved in from next door. Two of the residents went to the Lafayette School as children.

When they live here they're free to come and go. They can go out and do shopping; they can take the bus and do whatever activities they want to do as long as they are able. And if they're not physically able to get around on their own, there is a van service to transport them to different programs or medical appointments. Most of the residents sit outside during the day. There's a lot of grass and park benches around the building. They kibitz with the neighbors and are very much a part of the social scene of the neighborhood.

An Alternative to Nursing Homes
It's so expensive under Medicaid to be in a nursing home; it costs about $4,500 to $5,000 a month. But the cost for services at Ruggles is about half that. There's a net savings of about $2,500 per resident, per month.

The total savings that Ruggles will create for the state of Massachusetts this coming year by having those individuals move out of nursing homes and into this facility is almost $700,000. That's just for this one facility. That, of course, is a major item.

We're doing this very much as a pilot; for this kind of population it has never existed before in Massachusetts. And the savings is just extraordinary. Because of this we're really starting to talk with legislators and the administration about the possibility of replicating this because it represents such a significant win in Medicaid savings for the state.

I think Ruggles does serve as a model. There's no question about it. We were originally waiting to see what the residence would do in terms of preventing people from going into nursing homes. We expected the elders who moved here to be very frail and coming from home or other situations where they needed more support.

We thought that over time we would be able to demonstrate that this kind of care prevented people from going into the nursing home too soon. But what we're finding is that it's taking people out of nursing homes. This is what the people want; they would rather live here than in a nursing home. It's the model they choose when they have a choice.

In the health-care crisis in Massachusetts, we're usually dealing with people who want more of everything. They want to be able to go into the teaching hospitals. They want to be able to have any and all tests that they need. Everybody wants access to heavy-duty medical care.

But what this facility has shown is that if you give elders a chance, they will buck that trend and voluntarily opt for a situation where they're receiving less expensive care and are able to take care of themselves more and be more independent in the community.

The number-one issue driving the Medicaid budget right now is long-term care; nursing home costs are a big issue for Medicaid. So this seems to be a way for us to address that problem.

The Federal Home Loan Bank of Boston has helped to make this pilot — this model — possible. And it's already bearing fruit.