By Alisha Sanders
The interim report focuses on the first 18 months HUD’s Integrated Wellness in Supportive Housing Demonstration.
The U.S. Department of Housing and Urban Development (HUD) released its first interim report on the Integrated Wellness in Supportive Housing (IWISH) Demonstration last week. Through the demonstration, HUD is testing an enhanced service model in 40 HUD-assisted senior housing communities across the country.
The IWISH model is centered around an onsite team that consists of a full-time enhanced service coordinator, called a Resident Wellness Director (RWD), and a part-time wellness nurse (WN) for roughly every 100 residents at the site. The RWD and WN conduct a comprehensive assessment of consenting residents to help them proactively address residents’ needs and interests through one-on-one supports and community programming.
The IWISH demonstration was initially established for a 3-year period, which ended in September. A provision to extend the demonstration for an additional 2 years is currently pending in the FY2021 federal budget.
The LeadingAge LTSS Center @UMass Boston was part of the demonstration’s implementation team, along with The Lewin Group and the WellHome Network. The implementation team helped refine the IWISH model and supported the 40 sites with training and technical assistance during the 3-year demonstration. Abt Associates is evaluating how IWISH was implemented and whether the model impacted residents’ healthcare utilization and housing stability, including transfers to higher levels of care.
The interim report focuses on IWISH’s first 18 months. It examines participating resident and property characteristics and provides extensive information about the early rollout of the demonstration. Here are a few initial key learnings that might be important to providers implementing an IWISH-like or other enhanced service model.
STAFFING
Abt’s evaluation found that most IWISH sites were able to hire/maintain the targeted number of RWDs for the studied period. Staffing the WN position, however, was challenging for some properties. Sites had trouble filling the nurse position, and more WNs left their positions than did RWDs. Contributing factors included property owner inexperience with contracting for healthcare services, a lack of urgency in identifying candidates by third-parties staffing the nurse positions, and the nationwide shortage of nurses, which has led to competition with higher-paying clinical settings.
Some sites also experienced challenges finding nurses who were fluent in languages spoken by housing community residents. Twenty-six of the 40 IWISH sites estimated that at least 10% of their residents had limited English proficiency, while a quarter estimated the level to be at least 50%.
Of those IWISH participants taking part in assessments during the evaluation period, 30% preferred to communicate in a language other than English. RWDs, who were more likely to be bilingual, could assist the nurses with translations. However, added translation responsibilities created workflow challenges for RWDs who were pulled away from other tasks. An inability to speak languages other than English also hindered the WNs in their role to help educate and coach residents on managing their health conditions.
Despite the challenges, members of the implementation team working directly with the sites believed that many of the nurses enjoyed their role at the IWISH sites because of the continuity of working with the same residents over time and the ability to build relationships with those residents.
RESIDENT ENGAGEMENT
Due to the research component of the demonstration, residents were required to enroll in IWISH. Abt found that the 40 IWISH sites had collectively enrolled 71% of their residents in the program one year after officially launching IWISH. Enrollment levels varied across properties: a small handful of sites saw enrollment rates below 50% while enrollment at one-third of sites was 80% or above.
Some staff reported difficulties getting residents to enroll in the demonstration. Some challenges were staffing-related, including unfilled RWD or WN positions and increased workloads due to the proactive elements of the model. Other challenges were resident-related, including perceived lack of need for the program, misinformation about the program, and concerns about disclosing personal information.
The implementation team helped address these challenges in several ways. It held small-group and one-on-one discussions with IWISH staff around time management and teamwork to help the team manage multiple IWISH components while also responding to residents’ daily needs. The implementation team also developed educational materials and talking points to help the IWISH staff address resident concerns. Talking points included messages that IWISH wasn’t just for frail residents, but was intended to help all residents stay healthy; that residents’ information would not be shared with anyone; and that participating in IWISH would not impact any other benefits residents may be receiving.
Most housing sites offering services do not “enroll” residents as IWISH did. However, these housing sites do need to encourage residents to engage with staff and in programming. Understanding why residents might be hesitant to participate, and developing targeted messaging, may help overcome residents’ concerns.
ASSESSING RESIDENTS
The assessment process used in IWISH consists of:
- A Person Centered Interview (PCI) that takes the form of an informal conversation to learn more about a resident’s background, interests, and motivations.
- A structured assessment examining physical and mental health, and functional and social factors.
As with all IWISH activities, participation in the assessment is voluntary. At the end of the first year of implementation, about three-quarters of enrolled residents had participated in a PCI and almost 70% in an assessment.
While several sites had been conducting some form of assessment prior to the demonstration, the 2-part IWISH assessment was more extensive than the assessments most sites had been using. Just over half of the RWDs told Abt that conducting the PCI and getting to know residents was one of the most rewarding aspects of their job.
Several of the RWDs were existing service coordinators who had been working at the IWISH sites before the demonstration. However, RWDs told the implementation team that they learned things about residents from the IWISH process that helped them better understand resident actions and behaviors. At the same time, some staff reported that they didn’t feel prepared to respond to some of the information they learned about residents. The implementation team attempted to address this need by providing a training around trauma-informed care.
Information from the PCIs and assessments helped staff work with residents to identify individual health and wellness needs and goals, and to develop community programs based on key issues experienced by the resident population as a whole. However, staff encountered challenges motivating residents to develop and complete their individual goals.
IMPORTANT CONSIDERATIONS
While this interim report only covers the early rollout of the IWISH demonstration, it identifies some important considerations for implementing an enhanced service program:
- Language ability can be a key implementation issue, depending on the housing community. Properties need to consider how they will address this issue, either by hiring bilingual staff or adopting other translation mechanisms.
- Staff may need training and support as they adapt to a new and expanded workload. This training could offer guidance on prioritizing resident requests and other elements of the onsite team’s work, and help team members understand how to leverage each other and not work in silos.
- Staff may need help working with residents in a more proactive and comprehensive way. Training could include such topics as motivational interviewing to encourage resident engagement and follow-through, or subjects such as trauma-informed care, cultural competency, or working with persons with mental health issues to guide understanding and response to resident needs.
Alisha Sanders is director of housing and services policy research in the Washington, DC office of the LeadingAge LTSS Center @UMass Boston. Her work focuses on identifying, evaluating, and advancing strategies and policies that link affordable housing settings with health and supportive services.