Aging in Place

by HUD USER

Ag i N g i N Pl A c e
Vo l u m e 12, Nu m b e r 2 • 2010

U.S. Department of Housing and Urban Development
Office of Policy Development and Research
U.S. Department of Housing
and Urban Development
A Journal of Policy
Development and Research

Managing Editor: Mark D. Shroder
Associate Editor: Michelle P. Matuga

Advisory Board
Peter Dreier
Occidental College
Richard K. Green
University of Southern California
Keith R. Ihlanfeldt
Florida State University
Annette Kim
Massachusetts Institute of Technology
Carlos E. Martin
Abt Associates Inc.
Douglas S. Massey
Princeton University
Sandra J. Newman
John Hopkins University
Beth Shinn
Vanderbilt University
Raymond J. Struyk
National Opinion Research Center
Paul Waddell
University of California Berkeley
John C. Weicher
Hudson Institute, Inc.

A Journal of Policy
Development and Research
U.S. Department of Housing and Urban Development
Office of Policy Development and Research
Cityscape
Ag i n g i n Pl A c e
Vo l u m e 12, nu m b e r 2
•
2010

The goal of Cityscape is to bring high-quality original research on housing and community
development issues to scholars, government officials, and practitioners. Cityscape is open to
all relevant disciplines, including architecture, consumer research, demography, economics,
engineering, ethnography, finance, geography, law, planning, political science, public policy,
regional science, sociology, statistics, and urban studies.
Cityscape is published three times a year by the Office of Policy Development and Research
(PD&R) of the U.S. Department of Housing and Urban Development. Subscriptions are available
at no charge and single copies at a nominal fee. The journal is also available on line at http://www.
huduser.org/periodicals/cityscape.html.
PD&R welcomes submissions to the Refereed Papers section of the journal. Our referee process
is double blind and timely, and our referees are highly qualified. The managing editor will also
respond to authors who submit outlines of proposed papers regarding the suitability of those
proposals for inclusion in Cityscape. Send manuscripts or outlines to Cityscape@hud.gov.
Opinions expressed in the articles are those of the authors and do not necessarily reflect the
views and policies of HUD or the U.S. government.
Visit PD&R’s website, www.huduser.org, to find this publication and others sponsored by PD&R.
Other services of HUD USER, PD&R’s research information service, include listservs, special
interest and bimonthly publications (best practices and significant studies from other sources),
access to public use databases, and a hotline (800–245–2691) for help with accessing the
information you need.

iiiCityscape
Contents
Symposium
Aging in Place
Guest Editors: Cheryl A. Levine, Gavin Kennedy, and Emily Rosenoff
Guest Editors’ Introduction ........................................................................................................ 1
Assessing the Quality of Care Found in Affordable Clustered Housing-Care
Arrangements: Key To Informing Public Policy ......................................................................... 5
by Stephen M. Golant, Pamela Parsons, and Peter A. Boling
Integrating Community Services Within a NORC: The Park La Brea Experience ................. 29
by Susan Enguidanos, Jon Pynoos, Maria Siciliano, Laura Diepenbrock, and Susan Alexman
Health-Related Needs Assessment of Older Residents in Subsidized Housing ...................... 47
by Victoria Cotrell and Paula C. Carder
Health Indicators: A Proactive and Systematic Approach to Healthy Aging .......................... 67
by Fredda Vladeck, Rebecca Segel, Mia Oberlink, Michal D. Gursen, and Danylle Rudin
Aging in Place Partnerships: A Training Program for Family Caregivers of
Residents Living in Affordable Senior Housing ....................................................................... 85
by Alisha Sanders, Robyn Stone, Rhoda Meador, and Victoria Parker
Refereed Papers
Real Estate Brokers’ Duties to Their Clients: Why Some States Mandate Minimum
Service Requirements .............................................................................................................. 105
by Anupam Nanda and Katherine A. Pancak
Trailers and Trouble? An Examination of Crime in Mobile Home Communities ................ 127
by William P. McCarty
Departments
Graphic Detail
Recovery Act of 2009—Public Housing Capital Fund: Obligations and Number of Jobs
by ZIP Code .............................................................................................................................. 145
by Todd W. NcNeil
Data Shop
Using the Health and Retirement Study To Analyze Housing Decisions,
Housing Values, and Housing Prices ...................................................................................... 149
by Hugo Benítez-Silva, Selçuk Eren, Frank Heiland, and Sergi Jiménez-Martín
Referees 2009–10 ................................................................................................................ 159

iv Aging in Place

1Cityscape: A Journal of Policy Development and Research • Volume 12, Number 2 • 2010
U.S. Department of Housing and Urban Development • Office of Policy Development and Research
Cityscape
Guest Editors’ Introduction
Cheryl A. Levine
U.S. Department of Housing and Urban Development
Gavin Kennedy
Emily Rosenoff
U.S. Department of Health and Human Services
The Symposium, Aging in Place, in this issue of Cityscape explores the topic of affordable housing
plus supportive services. Through an ongoing collaboration of the U.S. Department of Housing
and Urban Development (HUD), Office of Policy Development and Research (PD&R), and the
U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and
Evaluation (ASPE), this issue represents the shared interest in aging in place. Previous collabora-
tion resulted in a synthesis of affordable housing plus services models in which “the relationship
between older age, chronic illness and disability, and higher use of long-term care services is well
established. In response to the rising demand for long-term care, consumer advocates, policy
makers, and service providers have encouraged the development of new models of organizing and
delivering health-related and supportive services that are attractive and affordable to older adults,
particularly those who are poor or of modest means.”
1

The focus on aging in place parallels the Obama Administration’s emphasis on targeting resources
to neighborhood needs. Considering that by 2030, we expect older adults (age 65 and older) to
make up 20 percent of the population, doubling from 35 to 70 million people, preparing commu-
nities to meet the needs of the aging population is timely.
There is no one way of organizing affordable housing and services; successful models may build on
existing resources in different ways. The purpose of this Symposium is not to catalog all models,
but to highlight current thinking on linking affordable housing and supportive services to facilitate
aging in place. Contributors to this issue are not selected as representative of the entire set of ex-
perts in this field; rather, our goal is simply to publish articles for this Symposium that would focus
on models that effectively link older residents of assisted housing to supportive services.
In “Assessing the Quality of Care Found in Affordable Clustered Housing-Care Arrangements: Key
To Informing Public Policy,” Stephen M. Golant, Pamela Parsons, and Peter A. Boling describe the
need for rigorous evaluation of aging in place models to provide an evidence base on which to build.
This article illustrates some complexities of evaluating the range of housing and services models that
1
See Harahan, Sanders, and Stone, (2006).

2
Levine, Kennedy, and Rosenoff
Aging in Place
encompass the multitude of federally subsidized housing settings (for example, HUD Section 202
and Public Housing or the U.S. Department of Agriculture’s Section 515 program). The authors
also identify implementation challenges for programs that bring supportive services (for example,
assisted living or PACE—Program of All-inclusive Care for the Elderly) to the residents of subsidized
housing. This article emphasizes that residents are part of the “structure” of the organization and
must be taken into consideration when designing changes to support their aging in place.
In “Integrating Community Services Within a NORC: The Park La Brea Experience,” Susan En-
guidanos, Jon Pynoos, Maria Siciliano, Laura Diepenbrock, and Susan Alexman explore expand-
ing a model that developed in New York City’s densely populated highrises, Naturally Occurring
Retirement Community (NORC), to Los Angeles. The authors describe the growing pains associ-
ated with adapting a model to a new location and the implementation costs involved. Research
conducted at Park La Brea highlights the critical importance of planning and implementing a
supportive-services model to facilitate aging in place and demonstrates the opportunity to include
resident volunteer opportunities.
In “Health-Related Needs Assessment of Older Residents in Subsidized Housing,” Victoria Cotrell
and Paula C. Carder also describe the lack of empirical research on the services needs of older
adults in subsidized housing. They highlight opportunities for partnerships between academics
and services providers. By conducting a needs assessment, social work students at Portland State
University gained valuable insight about the perceptions of health, well-being, and supportive
services needs among aging residents of a subsidized apartment building. The article highlights the
diversity of the aging population, including varying languages, cultural competency needs, and use
of alternative treatments.
In “Health Indicators: A Proactive and Systematic Approach to Healthy Aging,” Fredda Vladeck,
Mia Oberlink, Michal D. Gursen, Danylle Rudin, and Rebecca Segel remind us that, just by collect-
ing baseline data (for example, diabetes indicators), we can positively influence practice. The au-
thors also remind us of the fundamental importance of collecting assessment data to target services
effectively and to measure their effects. In addition, the authors describe a shift in clinical practice
from a reactive approach to a proactive approach that targets the right resources to the right people
at the right time.
In “Aging in Place Partnerships: A Training Program for Family Caregivers of Residents Living in
Affordable Senior Housing,” Alisha Sanders, Robyn Stone, Rhoda Meador, and Victoria Parker
explore aging in place in the community and find that informal care provided by family caregivers
is the critical link. In their study, most family members did not self-identify as caregivers. Out of
respect for residents’ privacy in an independent living setting, property staff may know little about
their residents’ supportive-services needs. Through building a partnership between property staff
and family members, residents’ ability to age in place can be reinforced. An unexpected benefit of
studying the role of family caregivers was the support they gave each other when they began meet-
ing with other caregivers whose family member lived in the same HUD-assisted property.

3Cityscape
Guest Editors’ Introduction
Articles included in this symposium of Cityscape are not peer reviewed. Rather, contributors repre-
sent scholars in the field of aging studies who have worked with PD&R and ASPE in recent years.
2

Contributors responded to a call for articles, circulated as an e-mail requesting articles to “explore
the topic of affordable housing plus services strategies that link older residents to supportive ser-
vices so that they can ‘age in place’.”
Affordable housing and supportive-services providers interested in models facilitating aging in
place, as well as researchers designing evaluations of new approaches to affordable housing and
services, will benefit from reading these articles.
References
Harahan, Mary F., Alisha Sanders, and Robyn Stone. 2006. A Synthesis of Findings from the Study
of Affordable Housing Plus Services for Low- and Modest-Income Older Adults. Washington, DC: U.S.
Department of Housing and Urban Development, Office of Policy Development and Research; U.S
Department of Health and Human Services, Assistant Secretary for Planning and Evaluation, Office
of Disability Aging and Long-Term Care Policy.
2
Contributors to this issue of Cityscape were solicited by e-mail sent to 12 researchers whom the co-editors knew to be
engaged in the discussion of affordable housing and services models. The April 1, 2009, e-mail solicited contributions
“featuring the integration of affordable housing and supportive services for older adults.”

4
Levine, Kennedy, and Rosenoff
Aging in Place

5Cityscape: A Journal of Policy Development and Research • Volume 12, Number 2 • 2010
U.S. Department of Housing and Urban Development • Office of Policy Development and Research
Cityscape
Assessing the Quality of Care
Found in Affordable Clustered
Housing-Care Arrangements:
Key To Informing Public Policy
Stephen M. Golant
University of Florida
Pamela Parsons
Peter A. Boling
Virginia Commonwealth University
Abstract
Purposively planned or adapted affordable community-based housing arrangements
are now available to accommodate low- and modest-income older people who have
functional limitations and chronic health illnesses. These housing arrangements
introduce various physical infrastructure and dwelling design changes and make
available supportive and health-related services that enable their vulnerable older
occupants to live independently and manage their health problems. They are known
by various names, but are referred to in this article as “affordable clustered housing-
care” or “housing-care.” Many of these housing arrangements are federally subsidized,
rent-assisted, multiunit apartment projects with low-income older occupants who have
aged in place or who have recently entered these properties. Despite support for these
options from many advocacy groups, research findings that demonstrate the benefits of
offering assistance and services in these housing arrangements are far from conclusive.
Such evaluations are essential to justify organizational and funding support from the
public and nonprofit sectors and to encourage the participation of housing and service
providers. Drawing on the work of Donabedian (1992, 1966), this article constructs
a theory-driven conceptual framework by which to organize and assess our current
knowledge regarding the quality of the assistance and care found in these housing-
care settings. To illustrate the practical applications of the framework, the article then
describes an ongoing research investigation that is assessing whether supportive services
offered in several federally assisted housing projects in Richmond, Virginia, have
reduced emergency room use of their elderly occupants.

6 Aging in Place
Golant, Parsons, and Boling
Introduction
This article focuses on purposively planned or adapted community-based affordable housing that
is now available to low- and modest-income older people. The owners, sponsors, or building man-
agements of this housing have variously introduced physical infrastructure and design changes,
and they have made available supportive and health-related services to help their predominantly
older occupants cope with their physical or cognitive limitations and chronic illnesses. The goal is
to help them live independently longer and more securely and to better manage their health prob-
lems. More supportive housing environments are also expected to enable these vulnerable older
people to avoid or at least delay moves to institutions such as nursing homes, which critics argue
offer a more expensive and less satisfactory care environment (Mor et al., 2004).
Most of these housing arrangements consist of affordable multiunit rental buildings, but they also
can be single-family dwellings clustered in the same neighborhood. A considerable literature has
examined these housing arrangements and they are known by various labels, including service-
enriched housing, affordable supportive housing, affordable residential care (assisted living),
affordable congregate housing with services, affordable housing plus services, assisted living in
subsidized housing, residential supportive services program (SSP), and service-coordinated hous-
ing (Golant, 1999; Housing Assistance Council, 2006; Jenkens, Carder, and Maher, 2004; Milbank
Memorial Fund and Council of Large Public Housing Authorities, 2006; Pynoos, Feldman, and
Ahrens, 2004; Pynoos et al., 2004; Sheehan and Oakes, 2003; Stone, Harahan, and Sanders, 2008;
Washko et al., 2007; Wilden and Redfoot, 2002). I have earlier labeled these various housing
options as affordable clustered housing-care arrangements (sometimes abbreviated “housing-care”)
because they share several critically important core goals and features (Golant, 2008).
A substantial share of these housing arrangements are federally subsidized, rent-assisted apartment
projects funded under the Department of Housing and Urban Development’s (HUD’s) Section
202, 221, 236, Project-Based Section 8, and Public and Indian Housing programs and under the
Department of Agriculture’s Rural Rental Housing program (Section 515), or they are financed by
the Low-Income Housing Tax Credit (LIHTC) Program. This category also encompasses the unin-
tentional enclaves of older people found in Naturally Occurring Retirement Communities (NORC),
who receive SSPs. In addition, it includes those private-pay, licensed assisted-living facilities that
are occupied by a significant share of low-income, usually Medicaid-eligible older people, who
often have higher acuity care needs (Golant, 2008, 2004; Institute for the Future of Aging Services,
2009; Milbank Memorial Fund and Council of Large Public Housing Authorities, 2006; Pynoos
et al., 2004; Wilden and Redfoot, 2002).
Some of these housing arrangements were originally designed to accommodate their more vulner-
able older occupants, but most were originally expected to provide affordable housing. Only later
did their sponsors or managements variously introduce dwelling design features, such as common
area improvements to facilitate service delivery, home security technologies, medical monitoring,
preventative health and therapeutic care, household upkeep, and personal assistance solutions
(Golant, 2009). Some sponsors or owners of privately owned HUD projects or public housing
projects have undertaken far more substantial physical retrofitting to convert their properties to

7Cityscape
Assessing the Quality of Care Found in Affordable Clustered Housing-Care Arrangements:
Key To Informing Public Policy
state-licensed assisted-living facilities (HUD, 2005). Typically, the services offered by these housing
providers are made affordable with the funding support of public programs and the contributions
of nonprofit charitable organizations—usually different sources than those that made affordable
rents possible for these same older occupants (Institute for the Future of Aging Services, 2009).
Most elderly occupants in these housing-care settings are more than 70 years old and are more likely
to be women and living alone. They have typically aged in place, but larger numbers are also enter-
ing these properties at increasingly higher ages (Haley and Gray, 2008; Heumann, Winter-Nelson,
and Anderson, 2001). Many report that they do not have family members able to assist if they
become sick or disabled (Golant, 1999). Many properties have disproportionately high percentages
of minorities who are also eligible for Medicaid assistance (Redfoot and Kochera, 2004).
Advocates of these housing-care arrangements argue that their distinctive demographics make it
possible for housing providers and management companies, vendors, merchants, and care agencies
to target and serve sizable clusters—critical masses—of residents with similar supportive service
and health needs. These economies-of-scale advantages enable them to offer a coordinated and
comprehensive array of health-related or independence-supporting services more effectively and
less expensively (Golant, 2008, 1999). It becomes easier to justify expenses, such as physically
retrofitting the dwellings and common areas of their buildings, hiring a service coordinator or
case manager, offering onsite meals, or introducing a health clinic on the building’s premises. This
approach to providing support and assistance contrasts with that of service providers who must
incur substantial travel times and fuel costs in their efforts to reach out to elderly clients who are
geographically dispersed across a metropolitan or rural area (Evashwick and Holt, 2000; Medicare
Payment Advisory Commission, 2001).
Rationale and Goals of This Article
The availability of these affordable housing-plus-service arrangements depends much on the initia-
tives and capabilities of the housing sponsors, owners, or management companies. They must be
inclined toward serving less independent older people as part of their mission, willing and able to
secure funding for their operation from government programs or nonprofit charitable organiza-
tions, and able to establish partnerships with appropriate social service and healthcare providers
and organizations, such as academic medical centers. Moreover, they must be able to overcome a
variety of formidable financing, regulatory, insurance, and management obstacles (Golant, 2003a).
In light of these development and implementation challenges, it becomes especially important to
demonstrate the benefits and advantages of offering supportive services and health-related care
in these housing arrangements. Housing providers must have convincing evidence of the benefits
they stand to gain by offering this assistance. Policymakers at the federal, state, and local levels
who are charged with implementing and funding service- or health-related public programs must
have a clear understanding of the various pathways by which these housing-care arrangements can
positively influence the health and well-being of their lower income older occupants and of how
they can realize financial or political benefits. The public health community must have compel-
ling evidence that by helping older people cope more effectively with their chronic illnesses and

8 Aging in Place
Golant, Parsons, and Boling
responding earlier to their needs, it can realize overall lower healthcare expenditures, such as by
reducing the use of emergency assistance services.
Despite this need for information, the research findings to date are limited. There is no shortage of
anecdotal information, case studies, and descriptive empirical studies pointing to the benefits of
these affordable rental housing-care arrangements (Institute for the Future of Aging Services, 2009;
Pynoos et al., 2004; Wilden and Redfoot, 2002). Many fewer studies, however, have relied on
quasi-experimental research designs that would yield more rigorous and scientifically valid findings
(Stone, 2009). Although many advocacy groups believe in the importance of these options, we still
lack strong confirmatory research studies.
Drawing on the work of Donabedian (1966), this article constructs a theory-driven conceptual
framework by which to organize and assess our current knowledge regarding the quality of the
support and services now offered in these housing-care settings. Most experts agree that quality
of care “is a remarkably difficult notion to define” (Donabedian, 1966: 167). Which indicators
researchers decide to measure and the importance they assign to them will strongly influence their
findings and, in turn, will determine whether major stakeholders judge these supportive housing
arrangements as successful. Orderly and clear quality-of-care assessments are particularly impor-
tant for findings to be generalized from one setting to another (Mark, Hughes, and Jones, 2004). To
address these issues, this article identifies the extent that past studies have emphasized certain key
constructs and policy-relevant indicators over others, points to possible biases and gaps in these
assessments, highlights questions that deserve more investigative research, and suggests why past
research has sometimes fallen short of providing compelling findings (Golant, 2008). To illustrate
the practical applications of the conceptual framework, the article then describes an ongoing
research investigation that is assessing whether the extent of support services offered in several
federally assisted rental housing projects in Richmond, Virginia, reduces emergency room use by
their elderly occupants.
Framework To Assess Quality of Care in
Housing-Care Settings
Donabedian’s (1966) conceptual framework proposes that quality-of-care assessments must encompass
three components—structure, process, and outcomes. These three components dynamically interact,
with the result that the structure of a housing-care setting can potentially influence how much and
how well care is delivered (that is, process), and both these components (structure and process) can
influence the optimality of care outcomes. Distinguishing the independent and combined influences
of these components allows conclusions about whether the most needed services and best strategies
for delivering care are selected and whether they are implemented in the most effective and skillful
ways to achieve desired outcomes. Formulating these components to frame our review of quality-
of-care studies results in the following three evaluative inquiries (see exhibit 1 for further detail):
1. Evaluating structure. What is the capacity of the housing-care setting and its community
context to offer residents health-related and independence-supporting services?

9Cityscape
Assessing the Quality of Care Found in Affordable Clustered Housing-Care Arrangements:
Key To Informing Public Policy
2. Evaluating process. What is actually done and how well? How appropriately designed is
the property and its dwellings? Are the health-related and independence-supporting services
performed competently and effectively?
3. Evaluating outcomes. What resident behaviors or conditions are changed, maintained, and
optimized and what housing provider, management, staffing, community, or public policy goals
are achieved?
Structure, Process, and Outcome Indicators To Evaluate the Quality of Supports and
Services in Housing-Care Arrangements (1 of 2)
Evaluating Structure
What is the capacity of the housing-care setting and its community context to offer residents
health-related and independence-supporting services?
• Physical infrastructure of dwelling and building (size, condition, architectural design, common area space,
accessibility and safety standards, monitoring and information transmission technologies).
• Philosophy of care of housing provider regarding acceptable vulnerability levels of residents, allowed
health-related and independence-supporting services, and appropriate service delivery strategies.
• Number and mix of older tenants with physical and cognitive limitations, health problems, and
demographic risk factors.
• In-house paid and volunteer building and service staffing; worker-resident ratios; duties, education, and
training of staff.
• Outsourced/contracted paid and volunteer staffing; vendor and service provider partnerships (restaurants,
home health agencies, public health clinics, visiting nurses, hospitals, pharmacies, academic health centers,
adult daycare centers, nonprofit service organizations, Older Americans Act aging network).
• Affordability and accessibility of community-based, independence-supporting, and health-related services.
• Types and mix of health-related and independence-supporting services (housekeeping, homemaking,
meals, preventative health services, paratransit services, personal assistance, and home health).
• Types of social and recreational amenities.
• Types of service and healthcare delivery strategies.
• Funding sources to make dwelling and services affordable (rules, regulations, and spending guidelines).
• Regulatory or licensing oversight by governments.
Evaluating Process
What is actually done and how well? How appropriately designed is the property and its dwellings? Are
the health-related and independence-supporting services performed competently and effectively?
• Types, amount, regularity, and duration of performed services.
• Physical safety and accessibility records.
• Competence and effectiveness of performed duties, activities, and services.
• Service coordination and continuity patterns.
• Cooperation among housing management, service providers, and family members.
• Staff turnover rates.
• Extent of person-centered care approaches.
Exhibit 1

10 Aging in Place
Golant, Parsons, and Boling
Structure, Process, and Outcome Indicators To Evaluate the Quality of Supports and
Services in Housing-Care Arrangements (2 of 2)
Evaluating Outcomes
What resident behaviors or conditions are changed, maintained, and optimized and what housing
provider, management, staffing, community, or public policy goals are achieved?
• Resident outcomes:
• Objective indicators: morbidity/mortality rates, hospitalizations, emergency department visits, hospital-
housing transitions, physical and mental health, healthy behaviors, disability levels, duration of independent
living, departure rates, access to health and independence-supporting services, and social participation.
• Subjective indicators: individual assessments of residential quarters, health-related and independence-
supporting services, self-rated health, ability to live independently, information awareness and accuracy,
loneliness and security assessments, and respect for individual rights.
• Provider/management/staffing outcomes:
• Objective indicators: apartment turnover and vacancy rates, housekeeping and repair crises, building
maintenance demands, and tenant-management relations.
• Subjective indicators: service coordinator satisfaction, manager/staffing satisfaction, and
family satisfaction.
• Community/public health outcomes:
• Demand and costs for ambulance, emergency room visits, police visits, achievement of education and
training goals for students in academic health centers; jobs creation and other economic impacts.
• Public policy outcomes:
• Service delivery costs and savings—Medicaid or other government program expenditures.
• Demand and public costs for healthcare and emergency services.
• Rate of nursing home admissions.
• Funding agency satisfaction.
Evaluating the Structure of Housing-Care Settings
Structure refers to the stable physical, service-related, social, and organizational aspects of the
housing-care setting (Closs and Tierney, 1993; Donabedian, 1992; Lezzoni, 1994). Its contents
include the physical plant, staffing personnel, work assignments, monitoring, assessment, and
information procedures and technologies of a housing-care property and also the management
structure and administrative mechanisms that allow the organization to conduct, coordinate, and
control its work activities (Jackson, Morgan, and Paolillo, 1986). Structure also encompasses the
ambience of a setting; that is, whether its architectural design or layout makes it look and feel more
like a residential than a medical environment. A full portrayal of the structure will identify the
service resources offered by a housing provider and the different ways these are delivered to their
elderly tenants. It will inventory the funding sources that make its services affordable and the rules
and regulations that the housing-care management must follow to meet eligibility requirements. A
depiction of structure also extends outside the housing-care setting to include the resources of its
surrounding community. Housing providers often depend heavily on outside businesses, charitable
organizations, and service providers to secure their tenants’ care and assistance.

11Cityscape
Assessing the Quality of Care Found in Affordable Clustered Housing-Care Arrangements:
Key To Informing Public Policy
Altogether, the components and attributes of the structural environment define the housing-care
setting’s capacity to offer different types, levels, and amounts of care and assistance to their older
occupants. Delineating these elements is critical therefore to better understanding the extent to
which housing providers can potentially achieve specified service- or assistance-related goals or
outcomes. Housing providers that offer their residents a preventative health program to improve
their health monitoring behaviors can hope to achieve a reduction in the incidence of emergency
medical episodes. They cannot, however, realistically claim to help residents cope with their physi-
cal limitations so that they can better satisfy their everyday household needs.
We also designate as part of the structural environment the demographic and vulnerability profiles
of the older residents. Resident composition is at once a product of the structural environment
and an influence on it. For example, older people with more demanding needs for supportive and
healthcare services will likely select those housing-care settings that enable them to cope with their
physical and cognitive disabilities and unmet social needs (Closs and Tierney, 1993). As they incur
more demanding needs for assistance and services, housing-care operators may respond by modi-
fying their physical infrastructure or adding more services.
Studies have offered far more information about the structural environments of housing-care
settings than about either their process aspects or care outcomes. Two different explanations ac-
count for this bias. First, methodologically, it is far more straightforward to describe and assess
the structural environment of a housing-care setting than it is to evaluate how well or effectively
it is delivering care or assistance to its tenants, and it is certainly far easier than assessing its care
outcomes. Second, housing-care settings consist of a very diverse array of properties and organiza-
tions. The emphasis on describing and assessing their structural environments is an acknowledg-
ment that they differ substantially in their capacity to accommodate the service and care needs of
their older residents.
Many analyses have focused on the physical infrastructure of housing-care settings. Most find that
they usually do not have the physical design features (for example, nurses stations, wide corridors,
medication carts) or staffing attributes (for example, workers in nursing uniforms as opposed to
street clothes) that resemble a nursing home and its medical model of care. Still, some properties
have more institutional-like physical features than others (Wilden and Redfoot, 2002).
Other generalizations are more difficult. These settings differ regarding how well their dwelling
units address the safety and accessibility needs of their vulnerable older occupants and whether
they contain common areas, such as commercial kitchens, dining areas, and spaces to perform
health assessments and therapeutic activities. Haley and Gray (2008) argue that these variations
influence the ability of older tenants to age in place in these properties.
Typically, housing-care settings that are licensed and regulated as assisted-living communities have
the most extensive physical infrastructures, and they usually must offer additional design and
security features if their residents suffer from dementias such as Alzheimer’s disease (Redfoot and
Kochera, 2004). Government-assisted rental properties that want to be licensed under their state’s
assisted-living programs have sometimes received funding from the Assisted Living Conversion
Program. Since 2001, this HUD program has funded the costs of physically renovating and retrofit-

12 Aging in Place
Golant, Parsons, and Boling
ting the apartment units and common spaces of its government-assisted rental properties (except
public housing) (HUD, 2005). Public housing facilities have used their Section 9 Capital Fund
Formula Grants and funding from the HOPE VI program to accomplish similar conversions (Milbank
Memorial Fund and Council of Large Public Housing Authorities, 2006).
The HUD Section 202 Supportive Housing for the Elderly Program is often identified as an affordable
rental property program that has produced exemplary housing-care settings. But much variation
exists in the physical infrastructure of the properties produced under this program, often depend-
ing on when the properties were built. Those constructed more recently tend to be smaller and
have fewer amenities than those built in the program’s earliest phase (1959 to 1974). These smaller
housing-care settings often lack the scale to justify the expenses required to introduce physical
infrastructure improvements or do not have the physical space to set aside as common areas (Redfoot
and Kochera, 2004). Those constructed during the mid-1980s, when government cost-containment
measures influenced the design of the projects, are particularly unlikely to have common spaces for
service delivery.
The physical layout of the property may also be influential. Efficiency units accommodating the more
frail residents in a property may be concentrated in one section of the senior housing building to
facilitate more efficient service delivery. But, as one report concluded (Milbank Memorial Fund
and Council of Large Public Housing Authorities, 2006: 10), “When services are in one location, it
may be difficult to increase or decrease program size as demand changes, which may lead to vacant
units or people not receiving services.”
Variations in the care and assistance capacity of housing-care settings can often be attributed to the
service delivery philosophies of their owners or sponsors. They can hold very different beliefs re-
garding whether their properties should cater to older people who require help to arrange for their
own assistance (Golant, 1999; Harahan, Sanders, and Stone, 2006; Levine and Robinson Johns, 2008).
Housing providers can also be influenced by the preferences of their healthier tenants. Older people
in some properties often do not welcome a more enriched service environment to help their frail
neighbors because they fear that their property will begin to look like a nursing home and they will
be continually reminded about the prospects of their own frailty (Golant, 1999).
Together these influences result in housing-care settings with very different care environments.
Some owners or managers will assist only their most vulnerable tenants with their housekeeping
and transportation needs, or help them find their own services. At the other end of the spectrum
are providers who offer their tenants a comprehensive array of supportive services: housekeeping,
communal meals, case management, health and wellness services, personal care services, and
health-related services. A study of three senior housing communities in the Denver metropolitan
area emphasized how housing providers can have very different care goals. Management companies
ranged from being proactive to laissez faire in linking their needy residents with supportive services,
although tenant participation in each of their service programs was voluntary (Washko et al., 2007).
Studies rarely address whether the capacity of a housing-care setting’s supportive environment is
appropriate in light of the needs of its older occupants and whether it can reasonably accommodate
the vulnerabilities of its occupants.

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Assessing the Quality of Care Found in Affordable Clustered Housing-Care Arrangements:
Key To Informing Public Policy
Housing providers also depend on different strategies to provide health-related and supportive
services to their more vulnerable tenants (Sheehan and Oakes, 2006). Typically, the approaches fall
along a continuum, ranging from providers who use their own in-house staff to offer services to
those who contract or partner with their state’s or local planning district’s aging and health agen-
cies, community-based home care and healthcare agencies, businesses, health professional schools,
or hospitals.
Housing-care settings sometimes arrange for their tenants to use the supportive and health-related
services offered by co-located or nearby PACE (Program of All-Inclusive Care for the Elderly) centers.
A PACE center enrolls older people who meet the criteria for nursing home care and who are eligible
for Medicare and Medicaid. It offers both acute and long-term care. Based on age, sex, and medical
morbidity criteria, the program receives capitation funding from both Medicare and Medicaid and
operates under global risk for all healthcare costs. PACE organizes and coordinates care and social
support at a community day health center where participants gather every day; participants’ dwell-
ings are also used as gathering points. PACE relies on intensive case and care management of its
older participants to control costs. A survey of PACE programs found that nearly all served tenants
in multifamily senior housing, both nonprofit-sponsored facilities and public housing. Most were
located within a 5 to 10 mile radius and nearly one-third of PACE programs co-located at least one
of their day health centers with senior housing (National PACE Association, 2003).
The following list shows the diverse service delivery approaches that housing providers use
(Institute for the Future of Aging Services, 2009: 4):
Paid service coordinators who provide information and referral to community health •
providers.
Use of resident volunteers and other lay people trained by health educators to assist •
residents with the management of chronic illnesses.
Direct employment of health providers, such as nurses or nurse practitioners, by the •
housing sponsor to serve residents in one or more of its properties.
Onsite health clinics operated at regularly scheduled times by community health •
providers such as a nurse, nurse practitioner or geriatrician.
Formal collaborations with community health providers (for example, health •
systems, hospitals, managed care companies, physician practices, public health
clinics, federally qualified health centers, pharmacies, etc.) to bring selected health
and medical services, health promotion, and preventive care to residents.
Collaboration with academic health centers to provide clinical learning experiences •
for medical, nursing or other health professional students.
Co-location of health providers in or adjacent to the housing community, such as a •
physician office, a senior center, an adult day health center, or a PACE site.
Networking one or more residential components co-located within the same campus, •
such as an assisted living facility and/or a nursing home, with the independent living

14 Aging in Place
Golant, Parsons, and Boling
property so that residents have access to additional health programs and services
(for example, nighttime and weekend emergency assistance, health education and
preventive care offerings, personal care, etc.).
Operation of a licensed home health agency, owned/managed by the housing •
provider on behalf of residents and the broader community.
Partnering with a local home health agency to bring personal care services to •
residents at a more affordable rate.
When deciding on their service delivery strategies, housing-care administrators inevitably must make
difficult tradeoffs. For example, contracting for personal care services from an experienced outside
vendor may make it easier for a housing provider to initiate a supportive services program and make
it unnecessary for the property to be licensed as an assisted-living community. It also reduces expo-
sure to liability, simplifies staff payrolls, and allows the housing provider to offer a more complex
menu of services (Milbank Memorial Fund and Council of Large Public Housing Authorities, 2006).
In return, however, the housing provider must give up some control over the qualifications and expe-
rience of the staff and the frequency, regularity, and continuity of delivered services. There is a dearth
of research that has investigated how housing providers decide to offer their services, the strengths
and weaknesses of their approaches, and how these decisions influence outcomes.
Most experts agree that service coordinators are key front-line staff in the housing-care setting,
because they have the following key responsibilities (Levine and Robinson Johns, 2008: 2):
Determining the service needs of eligible residents. •
Identifying appropriate services available in the community. •
Linking residents with the needed services. •
Monitoring and evaluating the effectiveness of the supporting services. •
Performing other functions to enable frail and at-risk low-income elderly and •
nonelderly people with disabilities to live with dignity and independence.
Service coordinators, however, have a very uneven presence in housing-care settings. For ex-
ample, even in the most lauded HUD Section 202 Supportive Housing for the Elderly Program,
only 46 percent of the properties had HUD-funded service coordination and 8 percent had
non-HUD-funded service coordination (Levine and Robinson Johns, 2008). Service coordination
availability also differs by location. In rural areas and in the South, Section 202 properties were
much less likely to have this staff person (Haley and Gray, 2008; Robinson Johns, 2008)—partly
because of the smaller buildings in that area of the country. Service coordinators were even less
likely to be found in other publicly assisted housing properties, such as those financed by the
LIHTC Program (Redfoot and Kochera, 2004).
Generalizing about the job assignments of service coordinators is also not straightforward. Some
coordinators are charged only with offering information to their tenants and referring them to ap-
propriate providers. Others act more proactively on any signs of tenants’ difficulties, initiating an
evaluation of functional limitations, health status, and service needs; referring them to appropriate

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Assessing the Quality of Care Found in Affordable Clustered Housing-Care Arrangements:
Key To Informing Public Policy
services; and then monitoring the effectiveness of their care and assistance (Sheehan and Guzzardo,
2008b; Stone, Harahan, and Sanders, 2008). Along with differences in their job descriptions,
the coordinators vary in their ability to carry out their responsibilities, which fundamentally is
influenced by how many hours a week they work and the number of older tenants they work with,
both of which also vary widely (Levine and Robinson Johns, 2008). The different job responsibili-
ties of service coordinators—and their potential effect on resident outcomes—is a good example
of why it is so important for studies to carefully describe and evaluate the variations in the service
delivery strategies that housing-care settings use.
Housing-care settings will differ considerably regarding their ability to secure the community-
based assistance and care that their tenants need (Golant, 2006). At one end of the continuum will
be communities that have earned labels such as “healthy,” “friendly,” “livable,” or “life-long” places
to age (Lawler and Berger, 2009), because they have local governments and nonprofit charitable or-
ganizations that are committed to creating living environments that enable their lower income and
vulnerable seniors to age in place (Alley et al., 2007). In urban centers with large academic medical
centers and an extensive network of nonprofit community service organizations, for example, there
is a greater possibility that housing-care settings may offer onsite care clinics and the full spectrum
of supportive and health services for their tenants (Yaggy et al., 2006). At the other end of the con-
tinuum are resource-poor, remotely located rural communities that have difficulty delivering most
services (Golant, 2003b).
Even though HUD-administered programs make the dwellings of housing-care settings affordable,
they infrequently fund the supportive services. Two notable exceptions exist. First, beginning in
1978, the Congregate Housing Services Program offered funding to privately owned, HUD-subsidized
rental projects of up to 40 percent of the costs of nonmedical supportive services, such as trans-
portation, personal assistance, housekeeping, meals, and the support of a service coordinator.
Since the mid-1990s, the program has no longer accepted new applicants, but privately owned,
HUD-subsidized rental projects currently operate 60 previously awarded programs. Second, since
the 1992 Housing and Community Development Act, the hiring of service coordinators has been
an eligible expense for all HUD-assisted, multifamily developments designed or designated for the
low-income elderly (HUD, 1996). Public housing projects also receive service coordinator funding
through the Resident Opportunities and Self Sufficiency (ROSS) grant program.
More commonly, the owners or sponsors of HUD-assisted, multifamily properties and public
housing projects secure funding from multiple sources, such as private foundations, resident
contributions, nonprofit charitable (often faith-based) social agencies, Older Americans Act, the
Community Development Block Grant, and state development and service agencies. Funding
their supportive service and healthcare programs is one of the biggest challenges housing provid-
ers face. When they consider financing alternatives, they must decide whether they are willing to
abide by the inevitable rules and regulations that can restrict the incomes and care needs of those
they serve. These standards can influence whether they can offer their older tenants light care
(for example, help with housekeeping) or heavy care (for example, assistance with more serious
mobility limitations). As one example, housing-care settings relying on Medicaid waivers to fund
their services must restrict eligible applicants to those with extremely low incomes and limited

16 Aging in Place
Golant, Parsons, and Boling
assets. Prospective tenants must also have the same level of care needs as those residents admitted
to their state’s nursing homes. These requirements were met by the Coming Home program that
the National Cooperation Development Corporation developed and the Robert Wood Johnson
Foundation funded in the early 2000s. It achieved an impressive record of developing affordable
assisted-living communities in rural areas, but it required that 25 percent or more of a housing-
care property’s units and services be made &ldquo;available to persons using Medicaid to pay for services
and SSI (Supplemental Security Income) level incomes to pay for rent and meals” and excluded
“providers who offer only ‘light care’ programs intended as a pre-nursing home service” (Jenkens,
Carder, and Maher, 2004: 181).
Evaluating the Process of Housing-Care Settings
Process evaluations focus on the extent that the occupants of a housing-care setting take advantage
of its design changes and services and whether these are competently and effectively introduced
or implemented. This layer of inquiry goes beyond examining a property’s business plans, pay-
rolls, contracts, service plans, and mission statements that indicate how things are supposed to
perform. Evaluating the process of care reveals whether housing-care settings “are doing the right
things, which ones are not, and where we need to improve” (Wenger, 2008: 7). It would reveal, for
example, whether management and staff are treating their older tenants more as residents than as
clients and how well their supportive services and delivery strategies are actually helping tenants
live independently.
An example is helpful. If management of a housing-care setting contracts a nurse to perform well-
ness services twice a week—6 hours each visit—this service strategy would describe an aspect
of its structure—the “capacity” of the housing-care setting to deliver services. An evaluation of
process, however, would focus on the actual count of service episodes or visits that the nurse con-
ducted (over some period), along with how well he or she performed these duties.
The research literature offers very little information about how well these housing-care arrange-
ments provide care and whether errors, omissions, inconsistencies, or other failings occur. We
know little about whether hired staff members have sufficient training or experience, whether they
receive clearly specified job descriptions, and whether they competently attend to the needs or
problems of the elder residents. We lack evidence regarding whether housing-care settings imple-
ment services using the person-centered approach recommended by many advocates of a social
model of care, which emphasizes the importance of management and staff respecting the individu-
ality, privacy, and autonomy of residents (Calkins and Keane, 2008).
What we do know comes mainly from studies of the performance of service coordinators and
their relationships with their housing-care setting’s management. Sometimes, the job description
is at odds with the demands of the position. Service coordinators have complained that they have
too many residents in their properties to effectively do their job and report that they are “totally
overwhelmed” (Sheehan and Guzzardo, 2008b: 240). The management of the housing-care ar-
rangement may expect coordinators to assess the competence of all applicants, even though they
presumably only assist residents who voluntarily accept their services.

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Assessing the Quality of Care Found in Affordable Clustered Housing-Care Arrangements:
Key To Informing Public Policy
Coordinators may also interpret their job descriptions differently than their property managers do,
sometimes resulting in “a lack of clear distinctions between the manager’s and service coordinator’s
responsibilities and lines of decision-making authority” (Sheehan and Guzzardo, 2008b: 242). One
concern is that if older residents see the service coordinator as simply a representative of manage-
ment, “they may be less inclined to share personal problems with her” (Sheehan and Guzzardo,
2008b: 240). Guidelines may also be unclear regarding whether service coordinators can share
personal information about residents with management—and thus possibly violate their confi-
dentiality rights. Another source of disagreement is the extent to which housing managers assume
service coordinators’ responsibilities—such as learning about a health problem or resolving resi-
dents’ complaints and then acting without having carefully consulted with the service coordinator.
This practice is potentially troublesome, because managers and coordinators often have divergent
interests. The manager is often more inclined to evict rather than help a troubled resident, and the
coordinator is more inclined to advocate for the tenant.
Sometimes, how service coordinators interpret their position may not be in the best interests of
their older residents. They often “view their responsibility to care for the elder as an emotional
obligation and express personal concern for their client” (Sheehan and Guzzardo, 2008a: 260).
They describe their relationships with older residents as “family-like” and “feel a strong sense of
obligation or duty to care for familyless or isolated elders” (Sheehan and Guzzardo, 2008a: 267). A
possible danger is that service coordinators may abuse their influence because of their close, trust-
ing relationships with the older residents. This situation can result in their “disregarding residents’
decisions or coaxing residents into changing their mind.” Residents may fear retribution if they
refuse help. Thus, rather than “empowering residents, these actions may make them more vulner-
able” (Sheehan and Guzzardo, 2008a: 276).
An examination of the research literature strongly suggests that the process of care is the most
understudied of the three Donabedian assessment components. Ultimately, to evaluate process
in these settings, researchers must collect data on numerous key variables, such as the skills and
actions of any direct-care providers or the effectiveness of supportive services that outside service
agencies, vendors (for example, pharmacies), partnered organizations, and contracted management
programs offer. Researchers must measure how physical infrastructure and design changes translate
into greater resident safety and accessibility. Reliably measuring these variables is significantly more
difficult in housing-care settings than in more regulated environments such as nursing homes and
hospitals, where mandated data collection and reporting are routine, most staff have a common
employer, and parameters are more clearly defined.
Evaluating the Outcomes of Housing-Care Settings
The range of outcome categories (see exhibit 1) draws attention to the multiple stakeholders who
can benefit from the supportive and health-related services offered in housing-care settings. It also
emphasizes that judgments regarding the success or failure of these housing-care settings depends
largely on who is doing the evaluating—residents, providers, community leaders, or those with
public policy agendas. The typology also distinguishes research assessments by whether they
rely more on objective ratings than on the subjective appraisals or assessments of individuals—

18 Aging in Place
Golant, Parsons, and Boling
residents, housing managers, or service coordinators. Past housing-care evaluations have focused
on only a limited number of these indicators and some more than others. This failing is potentially
important because these indicators will measure very different housing-care setting consequences
and thus potentially result in very different judgments of success or failure.
When comparing two or more housing-care settings and attributing outcomes to their property and
service environments or contexts, research investigations have not always carefully controlled for the
effects of their tenants’ demographic and vulnerability profiles (Oakes, 2004). Research investiga-
tions have paid even less attention to the complex and reciprocal pathways by which the housing-
care arrangement’s structural environment and process behaviors have influenced its outcomes.
Federal agencies such as HUD and state government agencies charged with conducting long-term
care programs have most frequently judged these housing-care arrangements by whether, in delaying
or preventing their tenants from occupying nursing homes, they result in lower long-term care costs
(Black, Rabins, and German, 1999; Weinberger et al., 1986).
This evaluation protocol was emphasized early in studies of HUD’s Congregate Housing Services
Housing Program and the HOPE IV Program. Both programs were designed to link low-income,
rent-assisted older residents with a broad range of supportive services. A HUD-contracted report
found that these services did not consistently lower nursing home use, hospital admission rates,
costs, or mortality rates, nor did they produce gains in individual physical functioning (Ficke and
Berkowitz, 2000; Monk and Kaye, 1991).
On the other hand—
…receipt of services was significantly related to a range of positive outcomes…Service
recipients scored significantly higher in four major mental health dimensions (anxiety,
depression, loss of behavioral/emotional control, and psychological well-being), social
functioning (quantity and quality of social activities), vitality (energy level and fatigue),
and other measures of social well-being. (Ficke and Berkowitz, 2000: 3)
Thus, these same authors concluded—
These findings are consistent with the assumptions in the research designs and the results
of prior studies that show the impacts of similar programs address quality of life and care,
rather than changing such overt outcomes as institutionalization or otherwise having to
leave one’s home due to frailty. (Ficke and Berkowitz, 2000: 3)
As four decades of research testify, showing that affordable housing-care settings or, for that
matter, any home- and community-based service program can produce cost savings or delay the
entry of older people into nursing homes is notoriously difficult (Grabowski, 2006; Muramatsu
et al., 2007; Wiener and Brown, 2004). Moreover, the validity of reported outcomes is sometimes
unclear, because studies have not consistently implemented careful, randomized treatment control
designs that take into account the vulnerabilities of their tenants or the variations in the capacity
of housing-care settings to address tenant needs. Regarding the “evaluating the process” section
discussed previously, these studies have also not typically evaluated whether the services were

19Cityscape
Assessing the Quality of Care Found in Affordable Clustered Housing-Care Arrangements:
Key To Informing Public Policy
delivered competently and effectively. At least one expert has argued that focusing on overall cost
savings or reducing nursing home use “creates an especially lofty and difficult-to-meet standard of
success” and runs a greater risk of “unfavorable program assessments that weaken arguments for
initiating or continuing a supportive service program” (Golant, 2003a: 40).
In contrast, studies that have measured success by relying on less ambitious goals have more posi-
tively evaluated the quality of care offered in these settings. These studies have measured the extent
to which the tenants report successfully accessing and benefiting from the physical amenities and
service resources of the housing-care setting, or the extent to which they have experienced measur-
able health and well-being outcomes (Harahan, Sanders, and Stone, 2006).
A study of the Massachusetts Supportive Housing Program reported many favorable outcomes. De-
veloped in 1999, the program was designed to create “an assisted living like environment in state
funded, public elderly housing” (Mollica and Morris, 2005: i). It offered “service coordination and
case management, 24-hour personal care, on-call response, homemaker services, laundry, medica-
tion reminders, social activities and at least one meal a day” (Mollica and Morris, 2005: 2). Among
the reported findings: earlier recognition of tenant needs; tenant and family members’ greater sense
of safety, security, and support; avoidance of tenant crisis situations; the benefits of relieving prop-
erty managers of tenant “supportive service” responsibilities; reduced tenant turnover; and more
effective intervention strategies.
Researchers studying nutrition and human services interventions that targeted older and younger
people with disabilities living in the Seattle Housing Authority’s Low Income Public Housing
program reported similarly favorable outcomes (Siu, 2009). HUD’s ROSS Resident Service Delivery
Models—Elderly and Persons with Disabilities grant program funded the study. Using a quasi-
experimental research design, researchers reported greater social interaction with other residents,
fewer residents with chronic conditions, lower eviction rates, improved grocery delivery service,
and more frequent preventative health procedures.
A clinic operated by student nurses, which provided health screening, education, and outreach
and referral services 2 days a week in the community rooms of several public housing properties,
also reported favorable results: better access of older residents to needed care, better identification
and management of hypertension, improved diabetes disease outcomes, and better preparation
for emergency medical situations (Ellenbecker, Byrne, O’Brien, and Rogosta, 2002). Comparable
healthcare use outcomes were tracked in a case study of clients using an academic nursing clinic
located in a highrise apartment building for low-income seniors. Hospitalizations and emergency
room use were reduced over a 1-year period (Badger and McArthur, 2003).
Assessment and intervention programs specifically designed for elderly people in public housing
have tended to prudently focus on the most demanding health issues, such as psychiatric illness.
Evaluation of the PATCH (Psychogeriatric Assessment and Treatment in City Housing) Program
adds to the evidence base regarding mental illness and elderly people in public housing. This
randomized clinical trial compared usual care with a specific intervention: training case-manager
personnel to provide onsite referrals coupled with mobile onsite nurse assessment for psychiatric
illness. Positive outcomes included reduced symptom severity, but, when comparing the treatment

20 Aging in Place
Golant, Parsons, and Boling
group with the usual care group, no reduction in residential moves of the elderly people was
found, as measured by evictions or the frequency of shifts to other settings, including nursing
homes and board-and-care facilities (Rabins, et al., 2000; Robbins et al., 2000).
A very promising ongoing monitoring and evaluation system is being conducted at two NORC
sites within the Charles E. Smith Life Communities in Rockville, Maryland. Here, the residents are
receiving onsite social and health services from four service agencies. The evaluation is focusing
on service provision and utilization patterns, staff compliance, and client satisfaction. The study is
one of the first to recognize the importance of measuring the initial health status of a tenant sample
with the intention of measuring how health outcomes change over time (Cohen-Mansfield and
Frank, 2009). Worth noting, however, is that it would be difficult if not impossible to implement
this research design in HUD-assisted housing because laws related to the Fair Housing Act would
not allow for the mandatory collection of individual resident health data. Acknowledging individ-
ual privacy rights while increasing understanding of resident healthcare needs remains a challenge
(Fair Housing Act, 1968).
Studies have not specifically examined how PACE sites, which may have different care patterns,
influence the outcomes of senior housing occupants (Mukamel et al., 2007; Temkin-Greener,
Bajorska, and Mukamel, 2008). Hospital admission rates of the frail older population in PACE
centers, however, usually match the general Medicare population rate and are well below rates
experienced by nursing home residents (Wieland et al., 2000). In addition, the number of hospital
and nursing home days, in general, is also reduced (Hirth, Baskins, and Dever-Bumba, 2009; Sands
et al., 2006).
The most consistently reported outcome in housing-care settings is the high ratings of service coor-
dinators that both residents and managers give (Ficke and Berkowitz, 2000). Service coordinators
receive credit for increasing service awareness, better linking older people with needed services,
and finding solutions to their problems (Levine and Robinson Johns, 2008; Sheehan and Guzzardo,
2008b). Older residents emphasize they have a greater “sense of security and emotional support”
and stronger social supports (Sheehan and Guzzardo, 2008a: 263).
The operators of rent-assisted housing-care properties have consistently emphasized that they can
manage their buildings more easily and effectively because the service coordinators take respon-
sibility for addressing their residents’ assistance and health needs. The following bullet points list
some of the favorable outcomes (Commission on Affordable Housing and Health Facility Needs
for Seniors in the 21st Century, 2002; Golant, 2003a; Levine and Robinson Johns, 2008; Stone,
Harahan, and Sanders, 2008):
Lower apartment turnover and vacancy rates.•
Fewer housekeeping and repair crises.•
Decrease in legal fees/evictions/time in court.•
Greater marketability of units.•
Fewer unscheduled visits from human service professionals.•

21Cityscape
Assessing the Quality of Care Found in Affordable Clustered Housing-Care Arrangements:
Key To Informing Public Policy
Fewer crises, such as fires or accidents.•
Fewer off-hour emergency calls to management and local paramedics.•
Better bricks and mortar building management.•
Fewer failed unit inspections.•
Reduced time pressures on administrators.•
Better tenant-housing management relations.•
An Evidence-Based Research Investigation: Emergency
Room Use in Publicly Assisted Rental Housing in Richmond
A research project just under way applies this articles’ quality-of-care conceptual framework to
evaluate whether lower income older residents occupying more service-enriched affordable rental
complexes are less likely to use acute care health services—as indicated by their ambulance-related
emergency room usage (the outcome indicator).
Research Plan
The focus is on the federally funded rent-assisted housing buildings in the southeastern city of Rich-
mond, Virginia. Three major rental housing programs are included: (1) Section 202, (2) seniors-only
and mixed-age Public Housing Authority buildings, and (3) privately owned conventional apartment
buildings occupied by elderly residents who are recipients of Section 8 vouchers. Older recipients of
Section 8 vouchers are specifically included as a control or reference group, because their buildings
are less likely to offer any supportive services or health-related services. Emergency room use pat-
terns are treated as baseline measures that are compared with those of older residents in the other
two programs, which are more likely to offer services.
The settings will be structurally distinguished by their physical features, the demographics of their
older tenants, the types and delivery strategies of their supportive services, and, specifically, the
availability of onsite staffing, such as service coordinators or equivalent positions. We will distin-
guish several characteristics of the neighborhoods of these buildings, particularly the poverty status
of their populations.
Process indicators will include the roles played by service coordinators in the service delivery
process and the frequency and timeframe of the service delivery strategies by which tenants receive
different types of supportive and health-related services.
Research Methods
HUD administrative data for elderly people occupying the rent-assisted housing in Richmond,
Virginia, will be linked with individual-level ambulance records from the Richmond Ambulance
Authority database for a 2-year period (calendar years 2005 through 2006). U.S. census tract data
will be linked with tenant-level data from HUD’s Public Information Center (PIC) and Tenant

22 Aging in Place
Golant, Parsons, and Boling
Rental Assistance Certification System (TRACS), which HUD uses to manage its rental assistance
programs. PIC enables housing authorities to electronically submit tenant-level information to
HUD, including resident characteristics such as age, race, and gender. TRACS contains data fields
describing household characteristics, such as financial income and sources, rent and expense
allowances, unit characteristics, the presence or absence of disability, previous housing circum-
stances, and reasons for moving out.
A telephone survey will be administered to the managers of the rent-assisted and voucher-occupied
buildings to obtain measures of service availability (for example, presence of onsite social worker,
care coordinators, or nursing services). The interview schedule will be pretested within one public
housing, one Section 8, and one Section 202 building to assure content validity of interview
questions.
Planned multivariate statistical analyses will disentangle the effects of housing program type,
building-specific characteristics, community context features, service resource capacity, service
use, and resident characteristics on the tenants’ emergency room use. Of particular interest will
be emergency room use comparisons with buildings occupied by housing voucher recipients
who cannot avail themselves of onsite supportive services—representing a control group for this
analysis. Although this analysis does not provide direct resident-level health status information, it
does begin to evaluate the differences between and among program types and demonstrate how the
availability of support services influences one type of healthcare use, namely, emergency ambulance
transport. Higher rates of ambulance transport are likely to indicate that differences in the health
status of individuals exist within the housing programs, but they may also reflect the absence of
structured support programs.
More comprehensive and definitive future evaluations that also measure individual physical well-
being from healthcare records and resident assessments can build on the findings of this study.
The current missing link in studies evaluating the effectiveness of support services in housing
programs is the availability of resident-level health data that can be linked to health and cost
outcomes. A need exists to develop randomized studies that include the structure of the housing
setting (context) combined with resident health characteristics (including level of frailty), while
assessing the effect of the process of care delivery on health outcomes over time. Only then will
we be able to fully define and evaluate housing service outcomes that can support policy change.
Donabedian’s conceptualization provides an easy-to-apply framework to help guide the designing
of evaluation research focused on residents and their housing programs.
Summary
Affordable clustered housing-care arrangements have emerged as an important option that can
help frail low- and moderate-income older populations maintain their health and independence.
Despite the many descriptive studies of these housing arrangements, we still lack carefully con-
structed evidence-based assessments to justify their receiving stronger public policy commitments
and funding support or to gain the participation of most affordable-housing providers. Given the
economic constraints facing governmental programs for housing and health care, we must offer

23Cityscape
Assessing the Quality of Care Found in Affordable Clustered Housing-Care Arrangements:
Key To Informing Public Policy
more compelling evidence of the beneficial outcomes that result from linking affordable hous-
ing with independence-supporting and health-related services. We need more research on what
works, who benefits, and why. We have proposed an evaluative framework based on the work of
Donabedian to identify the range of quality-of-care assessment questions and issues, have reviewed
how the current literature now informs this assessment framework, and have outlined an ongoing
research study illustrating its applicability. Affordable clustered housing-care settings offer one im-
portant public policy solution that can respond to the aging-in-place demands of tomorrow’s older
baby boomer population and should be included in any discussions on how American society can
best cope with its age wave, which is building in strength and nearing the shore.
Acknowledgments
Stephen Golant thanks AcademyHealth and the Commonwealth Fund for their earlier support of
his research on affordable clustered housing-care.
Authors
Stephen M. Golant is professor of geography at the University of Florida, Gainesville.
Pamela Parsons is assistant professor of internal medicine in the Section of Geriatrics at Virginia
Commonwealth University.
Peter A. Boling is interim division chair, Division of General Medicine, and Director of Long-Term
Care and Geriatrics at Virginia Commonwealth University.
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29Cityscape: A Journal of Policy Development and Research • Volume 12, Number 2 • 2010
U.S. Department of Housing and Urban Development • Office of Policy Development and Research
Cityscape
Integrating Community
Services Within a NORC:
The Park La Brea Experience
Susan Enguidanos
Jon Pynoos
Maria Siciliano
University of Southern California
Laura Diepenbrock
Susan Alexman
Jewish Family Service of Los Angeles
Abstract
Naturally Occurring Retirement Communities (NORCs) are neighborhoods or buildings
in which older people represent a significant proportion of the population, but for whom
the communities were not planned to meet their needs. Bringing activities and services
to these communities provides a mechanism for increasing access to needed resources
and supports, enabling older adults to continue to reside within their community,
or age in place. In 2003, Jewish Family Service of Los Angeles (JFS-LA) received
funding to develop social services within Park La Brea, a 162-acre, private apartment
complex consisting of 4,200 apartment units located in eighteen 13-story towers with
approximately 1,500 senior residents. The program, termed LIFE (Living Independently
in a Friendly Environment), was designed to involve organizations that could offer
support, provide feedback, link the program to the wider community, and create
innovative approaches. The development of the program included formative evaluation,
program implementation, and outcome measurement. This article describes the process of
engaging the private owners of the apartment community; methods employed to involve
community residents on many levels, including conducting needs assessments, developing
volunteer roles, and creating a leadership training program and an advisory council; and
programs and services that were developed in response to these processes. The article also
discusses implications for sustainability.

30 Aging in Place
Enguidanos, Pynoos, Siciliano, Diepenbrock, and Alexman
Background
This case study examines the efforts of a social service agency to develop services and programs
in Park La Brea, a Naturally Occurring Retirement Community (NORC) in Los Angeles. Although
this residential community had a large population of older adults, it was not planned to meet their
needs and had no formal connections to services. A primary objective of the program was to iden-
tify and develop needed services to help maintain seniors in the community, create an opportunity
for older people to act as resources, enable different generations to interact, and take advantage
of the economies of scale to efficiently provide new services and activities. In many ways, the ap-
proach built on the NORC Supportive Services Program (NORC-SSP) model, pioneered by Fredda
Vladeck and her colleagues in New York (Vladeck, 2004).
The process included achieving buy-in from the property management company, conducting a
needs assessment of residents, and developing a range of services and activities, including opportu-
nities for volunteering.
Park La Brea NORC Program: LIFE
In 2003, the Administration on Aging (AoA) awarded Jewish Family Service of Los Angeles (JFS-LA)
a grant to develop services for NORCs. One site for the JFS NORC program, entitled LIFE (Living
Independently in a Friendly Environment), was Park La Brea. Park La Brea is a 162-acre private
development, managed by a for-profit company, consisting of 4,200 apartment units located in
eighteen 13-story towers, with garden apartments ranging from one to three bedrooms. The towers
resemble blocks of housing located around green spaces, inspired by the work of Le Corbusier, the
internationally renowned French architect and planner.
Sometimes referred to as a “minicity,” Park La Brea has its own security patrol and recreation cen-
ter. The apartments were initially planned and developed in the 1940s and 1950s as a residential
community for moderate-income people by Metropolitan Life Insurance Company, which also built
a “sister” complex with a similar street layout, Parkmerced in San Francisco, and other large com-
munities, such as Stuyvesant Town and Peter Cooper Village in New York. In many ways it appears
as an eastern model that has been transplanted to Southern California.
Park La Brea was partially gated in 1980. By 1995, to market the community as a more upscale
setting, the owners had updated it by adding a community center, health club, pool, and café.
Park La Brea also began to attract an increasing number of Korean Americans, partly drawn by its
close proximity to shopping and a highly regarded nearby grammar school.
JFS staff considered Park La Brea a community where older people who were aging in place needed
services, but from which very few residents sought assistance from its nearby Freda Mohr Senior
Center. The exception was for Meals on Wheels. Staff thought that older Park La Brea residents
either were unaware of the Freda Mohr Senior Center or perceived that it “was for poor people,
but not for them.” Nevertheless, JFS considered the older residents of Park La Brea an untapped
market whose lives would be improved considerably by the addition of services and activities.

31Cityscape
Integrating Community Services Within a NORC: The Park La Brea Experience
In 2000, Park La Brea had a sizeable older population that totaled about 1,500 people over the
age of 60, or 14 percent of its 11,000-resident population, many of whom were aging in place.
The median income of residents aged 65 to 74 was $34,926; for those aged 75 and older, it was
$30,167, with about 2.6 percent of people over the age of 65 living below the poverty level (U.S.
Census Bureau, 2000).
NORC Structure
Three initial partners on the project included the Jewish Federation of Greater Los Angeles, a local
medical center (Cedars-Sinai), and the Area Agencies on Aging (AAAs) of the city and county of
Los Angeles. JFS, the grant recipient, was responsible for overall planning and implementation
of the project. The medical center helped plan the initial needs assessment and provided health
screenings, and the AAAs were available to receive referrals for services.
LIFE formed a steering committee, a service-provider coalition, and an advisory council at Park
La Brea to guide and support the program. The steering committee, which consisted of more than
20 organizations, agencies, and political representatives, had the purpose of engaging community
leaders and organizations in actively participating in the NORC program. The service-provider
coalition was composed of local agencies and government departments that might provide services
to residents and refer clients to LIFE. The advisory council consisted of local community residents
charged with tasks such as helping to identify needs and recruiting members and volunteers.
Initially, LIFE owed its slow start to the relative newness of the program, the difficulty in recruit-
ing residents to participate in the needs assessment, the absence of an advisory council, and the
need to develop a trusting, positive relationship with property management and the existing tenant
organization. In addition, few existing onsite services or programs were offered specifically for
older people. The leaders (themselves older men) of the Park La Brea tenant organization, which
predated the NORC, had been individually trying to assist tenants, but they were stretched beyond
their capacity. Consequently, many residents in need were not receiving outside supportive services
or assistance from community-based organizations and agencies. LIFE therefore introduced a
unique set of programs and events into the community.
NORC Program Components
Management Buy-In
The relationship with the property’s management is considered key to the success of a NORC. The
greater the support and continued participation by management, the more successful the NORC
will be at responding to residents’ needs and concerns (MacLaren, Landsberg, and Schwartz,
2007). Because Park La Brea was relatively new territory for JFS and had a private owner with
whom JFS had had no previous relationship, the extent of management support and participation
was unknown. JFS assumed that older residents were not a priority for the management, because
marketing of the complex targeted younger people, and many older residents lived in rent-stabilized
units, keeping rents lower than they otherwise would have been. On the other hand, older people
were considered relatively stable tenants who paid their rent on time, stayed for long periods of

32 Aging in Place
Enguidanos, Pynoos, Siciliano, Diepenbrock, and Alexman
time, and caused few disturbances. The small number of older people who had difficulties were
those who needed help with social services or were isolated, both problems that the Park La Brea
management and its security patrol felt unqualified to address.
Park La Brea management staff felt overburdened by the problems brought to them by older
residents and dismayed about the prospect of having to evict older tenants who could no longer
care for themselves or their apartments. Management bought into the concept of being part of a
national demonstration project and the positive public relations this would provide as a senior-
friendly community. As it turned out, Park La Brea staff were relieved to have the burden taken off
them and pleased to have help in trying to meet older residents’ needs. The management agreed
to provide office space, offered priority use of their facilities for programming and activities, and
brought in their activity director to partner on activity planning, which made branding of the pro-
gram easier and facilitated access to program services.
Cooperation from the Park La Brea management staff was a key factor in the success of the project.
In addition to providing space, management staff helped to publicize and distribute the needs
assessment survey, introduced LIFE staff to key residents, and referred seniors to LIFE programs
and services. This support was critical to ensure the ability to provide an onsite presence by LIFE,
including designated office space, areas to run activities, and help from maintenance staff to set up
spaces for meetings and large events.
Needs Assessment
The first phase of LIFE consisted of a comprehensive needs assessment process. The needs assess-
ment process is critical to identifying the exact needs of communities, NORCs, and their residents.
An assessment can determine or verify gaps or duplications in service coordination, locate missing
linkages, determine the availability and accessibility of services, gauge resident awareness (or lack
thereof) of services, identify the ways in which residents prefer to access service information, and
can identify the most important needs of residents (Nolin et al., 2006). Programs can then be struc-
tured to respond to the identified needs.
The needs assessment conducted for LIFE included focus groups with older residents, a targeted
survey of Park La Brea senior residents, and an assessment of the residents’ perceived needs among
service providers. The needs assessment, which was intended to drive the program, also served as
an initial entrée into the community and a mechanism to involve seniors.
Before the formal needs assessment, JFS sent a survey asking older residents what types of activities
they currently engaged in and if they already volunteered themselves or would like to. Respon-
dents were recruited to participate in the formal needs assessment. Focus group data provided
qualitative feedback from participants, and the needs assessment survey provided quantitative
indication of needs and interests of these older community members. Data from the older residents
were triangulated with survey results from the service providers to determine whether the needs
existed because of gaps in service provision versus other possible barriers in accessing services (for
example, knowledge, service eligibility, transportation).

33Cityscape
Integrating Community Services Within a NORC: The Park La Brea Experience
Focus Groups
From June through July 2004, six focus group sessions were held with older adults residing in Park
La Brea, involving 41 individuals. LIFE social workers conducted the focus groups, which were
approximately 45 minutes long. The social workers, who conducted the focus groups in English,
asked the following questions:
What are the needs of older adults in your community?•
What would make it easier for you to participate in activities or access services?•
Identify one service you would create if you could select anything.•
Identify several features of your community that indicate that it is a good place to grow old.•
All focus groups identified safety as a primary concern, including issues such as physical ac-
cess (for example, wheelchair ramps, stairwell lighting), emergency preparedness (for example,
earthquake, fire), personal emergencies, and emergency response systems. In addition, across the
groups, participants identified needs such as transportation; emergency support and other services
for frail, isolated older residents living alone; a resource directory; and social activities. They often
cited both public and private transportation as needs, along with the availability of parking. They
listed a reliable means for daily transportation and a need for emergency transportation from the
hospital and other emergency care facilities. They identified daily telephone check-in programs
for isolated older residents to ensure these residents’ safety. Almost every group mentioned the
need for centralized, comprehensive information or resource handbooks listing activities, events,
and other services available to older adults. Participants used the focus groups as an information
exchange opportunity. The final question from the assessment asked what community features resi-
dents thought contributed to making Park La Brea a good place to grow old. In response, residents
consistently identified the safety and security of the complex, its convenient location, the beauty of
grounds, and easy access to security and maintenance personnel for assistance.
Needs Assessment Survey
The needs assessment survey was anonymous and lengthy, about five pages long. Locating seniors
to complete the needs assessment survey was challenging, despite the varied methods used to
distribute the form (for example, via mail, senior-service providers, and focus groups). This chal-
lenge may have resulted from the lack of existing social networks of older adults within the Park
La Brea community; hence, no existing groups or social structures existed for recruiting the older
residents. In addition, the lengthiness of the survey may have been viewed as overly taxing for frail
older adults. In fact, most (78 percent) of the needs assessment respondents were recruited from
the focus groups. As a result, the respondents may not necessarily be a representative sample of
the community at large and may represent an easier to access, healthier, more active segment of
the population and not the frail or homebound senior residents of Park La Brea. This hypothesis
was later confirmed as LIFE staff gradually became aware of the fairly large population of frail
homebound seniors living in Park La Brea, a reality that became apparent only after the LIFE
Program had an established and trusting relationship with both the community and the residents

34 Aging in Place
Enguidanos, Pynoos, Siciliano, Diepenbrock, and Alexman
association. No previous data described the activity limitations or disabilities of Park La Brea’s
older residents, so determining the representativeness of the respondents on these variables was
not possible. (A HUD regulation in the Fair Housing Amendments Act of 1988 prevents property
owners from collecting demographic characteristics of resident.
1
)
Of the 63 residents of Park La Brea who completed the survey, most were female (83 percent).
About one-half were widowed, and the mean age of respondents was 81 years, ranging in age
from 63 to 96 years. Of those sampled, 75 percent lived alone. Among the remaining 25 percent
of respondents living with another person, most (93 percent) lived with their spouse; 20 percent
indicated they were taking care of someone.
Developed to elicit detailed information about the health, wellness, and needs of seniors living in
the community, the needs assessment survey covered a variety of topics—current activities, activi-
ties interests, barriers to participation in activities, volunteer interests, supportive services currently
used, need for supportive services, physical and emotional health status, use of medical services,
fall prevention, transportation issues, exercise, and community perception.
Current Activities and Barriers to Participation
The survey included several questions regarding respondents’ current activities and their interest in
participating in those activities. Respondents reported current engagement in a number of activi-
ties, with more than one-half indicating that they watched TV and movies (64 percent) and read
(56 percent). About one-third of the respondents reported that they currently used a computer;
went to concerts, theater performances, and
museums; attended exercise classes; listened
to the radio; talked with family; or traveled.
Residents had significant levels of interest in
participating in many of the activities, with
the three top areas of interest being attending
concerts and theater performances, going on
field trips, or attending a lecture. In addition,
almost one-third of the respondents ex-
pressed interest in travel, learning about and using the computer, involvement in political activity,
and exercise. The primary barriers identified among the respondents in accessing activities were
economic constraints, lack of transportation, and lack of awareness of activities.
Volunteering Interest
Although a considerable proportion of the respondents reported volunteering, the responses
indicated a potential for much more involvement. An early version of the needs assessment survey
did not include questions on volunteer interests; therefore, only 33 (52 percent) individuals were
1
24 CFR 100.202 (c); also see the Fair Housing Act, as amended, at 42 U.S.C. 3601 – 3619, which states “It shall be
unlawful to make an inquiry to determine whether an applicant for a dwelling, a person intending to reside in that
dwelling after it is so sold, rented or made available, or any person associated with that person, has a handicap or to
make inquiry as to the nature or severity of a handicap of such a person.”
Park La Brea needs assessment respon-
dents reported interest in participating in
the following top three activities:
Concerts/theatre (57%)•
Field trips (46%)•
Lectures (43%)•

35Cityscape
Integrating Community Services Within a NORC: The Park La Brea Experience
surveyed regarding what type of volunteer work they were currently involved in or interested
in doing. About one-fourth of respondents reported that they currently assist other seniors with
information, referrals, and services. Nearly all (88 percent) expressed interest in volunteering in at
least one of the options listed. It appears that a core of respondents were interested in administra-
tive support activities, such as helping with mailings (39.4 percent) and planning activities (39.4
percent). More than one-half (55 percent) were interested in more direct service involvement, such
as providing information and referrals, checking on seniors, and counseling.
Supportive Service Needs
Among the respondents, only one-third reported needing some sort of supportive assistance.
Housework was the most frequently reported need for assistance in terms of daily living, followed
by going to appointments, laundry, and errands. This low level of in-home supportive needs may
represent a response bias to the survey, because healthier, more active seniors in the community
were more likely to participate in the needs assessment survey.
Service Provider Survey
In an effort to identify the needs of older adults and the potential barriers to service use as per-
ceived by service providers, the JFS LIFE program engaged a master’s level social work intern to
help conduct interviews and focus groups with local service providers. JFS LIFE asked Park La
Brea and the city of West Hollywood area organizations and private businesses to participate in a
phone interview, an in-person interview, or a small focus group at their site. The intern conducted
15 interviews and 7 focus groups over a 2-month period. A total of 76 individuals participated,
with 55 participating in focus groups and 17 participating in in-person or over-the-phone inter-
views. Participants represented myriad agencies, ranging from fire department and cab service to
medical facilities and community case management agencies.
Results of this assessment revealed several gaps and barriers in service provision, including trans-
portation; lack of coordinated and structured care; staff turnover and agency transition; social
isolation and lack of social activities; diversity of populations served; and lack of awareness, educa-
tion, and sensitivity about senior issues and available services.
Summary
Overall, triangulation of the three needs assessments revealed significant consistencies in identified
needs. Transportation, population diversity issues, social activities, and lack of awareness of avail-
able services were identified among all three assessment techniques. Interestingly, social isolation
was not identified through the senior populations surveyed; however, this response was clearly
a reflection of the response bias for both survey and focus groups, and, as the program began to
unfold and the frail populations began to be identified, the LIFE staff had concrete evidence of this
hidden population.

36 Aging in Place
Enguidanos, Pynoos, Siciliano, Diepenbrock, and Alexman
Service Development
Providing and coordinating social services are key elements of NORCs; the social services include
transportation, social activities, service coordination, personal care services, and physical and
mental health services (Black, 2005). Most services, activities, and support that the LIFE program
provided were in direct response to the identified needs of the community. Although the LIFE
program did not directly address all the broader concerns identified in the needs assessment (for
example, the issue of affordable housing), the programs and services that LIFE provided were gen-
erally consistent with what older people said they wanted.
Since the goal of the LIFE program was to maintain older adults in their community, addressing
the concerns and interests expressed in the needs assessment process was critical. As a result of
this process, the Park La Brea LIFE program developed a basket of services that improved access
to information and referrals, including activities in the areas of health and wellness, social events,
concerts, and day trips. Promotion of health and wellness was accomplished through educational
lectures and workshops, health fairs conducted in partnership with a local medical center and
other health collaborators, and a peer-to-peer senior Talkline. Also, the LIFE program created a
drop-in center in Park La Brea, which held office hours to serve senior residents seeking assistance
or information.
In addition, partnerships with other service providers brought activities to the community, includ-
ing case management, transportation assistance, health monitoring, fitness, and disease preven-
tion. For example, in an effort to address the issue of transportation, LIFE staff used existing JFS
transportation services to provide rides to grocery stores and medical appointments. LIFE staff also
referred homebound clients to social workers at the JFS Multipurpose Center, a previously existing
JFS service at another location for ongoing case management services. They also created a resource
directory to assist volunteers who provided information and referrals to Park La Brea residents.
Safety and Home Modifications
Although safety issues and access to Park La Brea facilities were primary areas identified in focus
groups, access issues were not acted on because JFS considered it to be outside the agency’s
scope of expertise and too difficult to correct because of the age of the buildings, which had been
constructed before the Americans with Disabilities Act (ADA) and the Fair Housing Amendments
Act. Instead, JFS worked with residents and volunteers to overcome some of the access barriers by
providing volunteers to help residents in their homes and to help them get to activities and medi-
cal appointments. One internal collaborator, JFS Home Secure Program, worked with management
and residents to install grab bars, hand-held showers, and other small-scale equipment in apart-
ments to help older residents carry out activities such as bathing and to prevent falls and accidents.
Educational Lectures and Workshops
In collaborations with multiple community service provider partners, the LIFE staff conducted
numerous lectures and workshops on health topics, general interest and community information,
emergency preparedness, benefits, and transportation. Health lectures included informational
presentations on vision, depression, heart health, and physical activity. The program also provided

37Cityscape
Integrating Community Services Within a NORC: The Park La Brea Experience
flu shots. LIFE staff identified general interest lecture themes by conducting annual community
activity surveys and by gathering information from the constituent member activities committee.
Community members and outside experts presented lectures on a variety of topics (for example,
conservatorship, investments, and consumer fraud) and provided information on elections. The
two other partners (Cedars-Sinai and AAA Steering Committee) and members of the service pro-
vider coalition often participated in these activities. Over the course of 3 years, they presented ap-
proximately 63 lectures. More than 100 people got their flu shots through the program. Combined,
more than 760 individuals (duplicated) attended LIFE educational lectures and workshops during
the project. Multiple collaborations with community groups provided opportunities for intergen-
erational sharing to benefit older adults, such as Spring Chore Day, when college students helped
seniors turn their mattresses, and the Veterans History Project, in which local high school students
came to Park La Brea to receive firsthand accounts of war from veterans residing at Park La Brea.
Health and Information Fairs
The LIFE staff held a health fair and several senior outreach events in conjunction with other com-
munity service partners, focusing on activities, health, and disaster preparedness. They provided
health screenings, increased awareness of services and safety issues, and connected seniors with
services and programs. The health fair attracted 115 older residents.
Talkline
A primary mechanism for providing ongoing information, referrals, and support was Talkline. The
initial intent of Talkline was to (1) increase volunteer involvement and develop leadership capacity
among senior volunteers, (2) increase access to services and community activities, and (3) provide
ongoing support to seniors. Volunteers operated the Talkline phones. To advertise the availability
of Talkline, the LIFE staff ran ads in local newspapers and distributed flyers to local senior-based
service agencies. Between September 2005 and November 2006, the staff made 693 contacts, 48
percent of which were incoming calls to the Talkline. On average, Talkline volunteers spent 12
minutes (range: 2 to 90 minutes) per call. About one-half of the calls were outgoing to provide so-
cial support and specifics on upcoming activities and events and general information and referrals.
Working on the Talkline represented about 39 percent of all volunteer hours.
Initially, Park La Brea’s Talkline volunteers called older residents in response to messages that they
left on Talkline’s voice mail for information, referrals, and event RSVPs. The volunteers, however,
saw the additional need for friendly support calls to LIFE members who were homebound, socially
isolated, and frail. In addition to providing telephone support, volunteers also assessed the clients’
needs and made appropriate referrals. Talkline therefore evolved to meet the needs of frail and
homebound residents, serving as a bridge to LIFE social services, case management, and referrals.
Park La Brea Office Hours and Home Visits
The LIFE program established office hours in direct response to findings from focus groups that
indicated the need for a centralized information source; those established hours became an impor-
tant mechanism for increasing access to community resources. LIFE’s social work staff, consisting
of one full-time and one part-time social worker, kept regular office hours and provided services

38 Aging in Place
Enguidanos, Pynoos, Siciliano, Diepenbrock, and Alexman
such as information and referral, case management, and the development of care plans to help
residents age in place. They made referrals to services such as home-delivered meals, home health,
and home modification. They also assisted residents with a variety of other needs, such as crisis
intervention, case management, grief counseling, and advocacy with medical services (U.S. Social
Security Administration and government agencies that handled housing assistance). As the demand
for these services increased, Park La Brea’s social workers required additional support, which vol-
unteers, who acted as case aides, provided. These volunteers received training and weekly supervi-
sion from the LIFE staff. Combined, social work office visits, home visits, friendly visitors, and peer
counseling made more than 2,000 contacts and provided referrals and resources to Park La Brea
residents, many of which involved home visits.
Transportation
Transportation was a high priority on the needs assessments of Park La Brea residents. The LIFE
program established a JFS van service to provide local transportation to medical appointments,
shopping, and LIFE program-related activities. Between September 2005 and February 2007,
residents used transportation services for 2,628 one-way trips, 51 percent of which were for medi-
cal appointments, 45 percent for shopping, and 4 percent for LIFE-related activities. The program
provided transportation to the activities center to attend LIFE events only if three or more residents
requested services.
At the end of the grant period, funds were no
longer available to subsidize the transportation
service. JFS transportation services continued
to provide transportation for errands and
medical appointments at a cost of 50 cents
each way through its city of Los Angeles
AAAs funding. The addition of a charge for this service did not affect general ridership; residents
continued to use the van and did not complain about the cost. Transportation to LIFE events ceased,
however. As a result, many Park La Brea members who were unable to drive and could not physically
walk the distance from their apartment to the activities center found it difficult to attend activities.
Social Events and Day Trips
Throughout the course of the program, LIFE held a number of social events, ranging from picnics
and barbeques to regular meetings of groups such as the coffee klatch and the crafts group. These
groups increased social interaction among LIFE members and enhanced civic engagement as
participants were drawn into discussions of the wider community. Day trips were one of the top
identified desired activities in the needs assessment. In response, LIFE began organizing and offer-
ing day trips to residents for a nominal fee that ranged from $5 to $15 during the first year. As the
range of activities increased over subsequent years, so too did the cost for participants, with some
as high as $35 to events such as the musical Fiddler on the Roof. The staff made a special effort to
ensure that costs varied month to month so as not to exclude individuals unable to afford the more
expensive trips. LIFE offered day trips monthly, with attendance ranging from 10 to 45 participants
and with 24 day trips provided from November 2004 to February 2007.
LIFE arranged transportation to—
1,353 medical appointments•
1,176 shopping trips•
99 LIFE activities•

39Cityscape
Integrating Community Services Within a NORC: The Park La Brea Experience
NORC Membership
A core aspect of NORCs involves developing a membership of older people living in the commu-
nity (Vladek, 2004). LIFE membership was a concept based on NORC models on the east coast,
where members paid monthly or annual membership fees that entitled them to a basket of services.
It also was viewed as a way to build identification with the program, a sense of camaraderie, and
sustainability. Membership created a way to track participants in the program, create community
buy-in, and attract and retain seniors. By becoming a member, an older adult would have full ac-
cess to LIFE activities, lectures, transportation, and services.
The membership process evolved throughout the LIFE project, beginning informally and gradually
developing into a formalized application process in 2005. Although LIFE enrollment initially was
free, it was envisioned that, once seniors were engaged in LIFE services and programs, they would
be willing to pay a membership fee. A total of 467 members were enrolled in LIFE from May 2004
to June 2007. Although the members paid no membership charges or dues during the 3 years
of the LIFE program, at the end of the grant funding period, a group of residents at Park La Brea
instituted a membership fee to help sustain the program. The committee recommended an annual
membership fee of $25, which was approved by the LIFE Advisory Board. The fee went into effect
in July 2007. Since implementation, approximately 150 residents pay the $25 annual dues. In
addition, when day trip prices exceeded $15 per trip, attendance decreased dramatically, but an
increase in the price of the exercise class from $2 to $3 per session yielded no decline in participa-
tion. Thus, the implementation of dues had a somewhat negative effect on both membership and
day trip participation, although smaller increases in weekly group activities did not seem to affect
participation.
Volunteerism
Creating volunteer opportunities, building senior empowerment and ownership, and engaging
seniors in leadership and governance roles, core features of successful NORCs (Vladek, 2004), were
specific objectives of LIFE. Just as management’s buy-in is important, so is buy-in by residents.
Moreover, participation enables residents to take an active role in the decisionmaking process in
their community (MacLaren, Landsberg, and Schwartz, 2007), further ensuring that community
needs will be met. The importance of the role of volunteers, particularly in terms of program sus-
tainability, contributed to the decision to evaluate the role and contribution of the LIFE volunteers.
LIFE volunteer roles fell into four areas: governance, individual support service, programmatic
activities, and administrative and program development support. Volunteer governance roles in-
cluded participation on advisory councils and various program committees. In addition, volunteers
received leadership and advocacy training and helped to educate government officials on seniors’
issues in their city, at the state capital, and at the federal level. Volunteers also led activities, staffed
the office, helped with fundraising, and took on important roles in programmatic activities, such as
Talkline, peer counseling, friendly visiting, and CONNECT (a volunteer-led program helping frail,
older adults and adults with disabilities to access transportation). Total recorded volunteer hours
from August 2004 through June 2007 were 2,215 hours (see exhibit 1).

40 Aging in Place
Enguidanos, Pynoos, Siciliano, Diepenbrock, and Alexman
Overall, volunteer involvement proved to be a critical element in the operation of the LIFE program.
Not only did the number of volunteers increase over the course of the program, but the amount
of time spent volunteering was also significant. Between March 2005 and August 2006, volunteers
kept a log documenting the types of activities they conducted as volunteers and the time spent in
each activity, with 866 volunteer hours logged.
Exhibit 2 lists specific LIFE activities in which volunteers contributed their time.
Exhibit 1
Total hours spent volunteering
June 2007
February 2007
August 2006
February 2006
August 2005
February 2005
August 2004
0 100 200 300 400 500 600
355
520
514
320
299
175
32
Governance
Advisory council meetings
Activities committee meetings
Resource development committee
Individual Supportive Services
Senior Talkline
Peer counseling
Friendly visiting
Case aid
Program Activities
Educational lectures
Game time group
Coffee klatch
Walking group
Leading day trips
Play reading group
Administration and Program Development
Outreach
Transportation meetings
LIFE member needs assessment
Exhibit 2
LIFE activities for which senior residents volunteered

41Cityscape
Integrating Community Services Within a NORC: The Park La Brea Experience
Between February 2005 and September 2006, Park La Brea volunteer activities focused largely on
providing individual supportive services (see exhibit 3). Within this category, volunteers spent a
large segment of their time working on the Talkline, providing friendly visiting, conducting peer
counseling, and serving as case aides by providing information and referrals to people who con-
tacted the office. Leading activities was also a primary focus of volunteers. The highest number of
hours spent volunteering related to providing individual supportive services, followed by conduct-
ing program activities in Park La Brea.
Exhibit 3
Percentage of time spent in specific volunteer categories: February 2005–September 2006
12
Exhibit 3.

Percentage of Time Spend in Specific Volunteer
Categories:
Feb 2005 - Sept 2006

5%

Governance

10%

Admin/Program

Development

17%

Activities

68%

Individual

Supportive

Service

5%
Governance
10%
Administration and
Program Development
17%
Program Activities
68%
Individual Supportive
Services
One of the greatest challenges in the volunteer segment of the LIFE program was the ability to
recruit and retain LIFE volunteers. Most of the program’s volunteers were 80 years old or older.
Although the LIFE program provided an opportunity for older adults to remain active and involved
in the community, their volunteer commitment was a variable because of health problems, health-
care issues, and caregiving responsibilities. LIFE staff found that younger seniors, however, were
reluctant to commit to regular, ongoing volunteer assignments or to engage in a regular volunteer
job because of employment (many worked full time) or other commitments. Such barriers led
LIFE staff to design flexible roles such as friendly visitors and disaster specialists. These types of
assignments enabled volunteers to set their own schedules, often carrying out their responsibilities
in the evening or on weekends. LIFE continued to struggle, however, with recruiting and retaining
volunteers throughout the program period.
Sustainability
Securing funding for service provision and administrative staff has been a continuing chal-
lenge for NORC programs, many of which subsist on a combination of fundraising by resident
organizers, service fees, family contributions, and government and foundation grants. Studying
17 NORC organizations, Wilden and Redfoot (2002) found that 16 received substantial funding

42 Aging in Place
Enguidanos, Pynoos, Siciliano, Diepenbrock, and Alexman
from residents, 6 were principally funded by Medicaid, and 6 were subsidized by gifts and dona-
tions from private organizations and federal, state, and county governments. Among the Admin-
istration on Aging-funded NORC programs, only 3 out of 41 NORCs had fees for membership.
Some services were open only to members; others, to everyone.
Most of the long-running east coast NORC programs have sustained their programs and activities
through internal support rather than external funding. Although many NORC programs began
with an external funding base, as these funds began to diminish, they shifted to internal sources,
including resident fees, costs for activities, and building manager and co-op fees. Given the lack of
previous experience in developing of NORCs on the west coast, and the difference in culture and
populations, issues of sustainability were critical to the program.
Residents and management alike highly valued the LIFE program at Park La Brea. As noted previ-
ously, Park La Brea management provided in-kind support by contributing office and program
space. In addition to contributing their time, residents donated funds to the program and paid
a membership fee ($25 per year). These funding sources, however, were insufficient to pay for
LIFE’s core staff or service provision. The membership fee, for example, fell far below the $600 to
$800 that Beacon Hill Village, a program in Boston, and its approximately 50 replicated programs
charge. Created by residents aging in place in Boston’s Beacon Hill, the Village provides its resi-
dents with a variety of services, the total cost of which covers about 60 percent of its operations,
leaving it with the task of raising additional funds from private sources to fill the gap. Although the
management of Park LA Brea was willing to continue and increase its in-kind support, it was not
able to commit funds for staffing of the program nor was it willing to add a surcharge to resident
rents to support the program. Fortunately, an anonymous donor through the Jewish Federation of
Greater Los Angeles contributed $100,000 to JFS that supported the LIFE Program and that was
supplemented by the membership fee. In addition, in 2008, JFS was able to obtain another grant
from the AoA.
Discussion
Overall, the LIFE program accomplished a great deal even with its many challenges. It developed
a significant range of services and programs, and the number of members consistently grew each
year. Members reported that LIFE increased their knowledge of community services and provided
the appropriate amount of services in an effective manner. In addition, they believed that LIFE
had a positive effect on their community. Connecting seniors to their community and developing
a social network was a major success of LIFE. Recruiting and retaining volunteers, however, was a
constant struggle. Nevertheless, LIFE was able to involve a substantial number of volunteers who
themselves benefited from their participation and contributed to the well-being of others.
Initially, it was challenging to empower seniors. The strategy was to involve community residents
on many levels, including needs assessments, developing volunteer roles, and creating a leadership
training program and an advisory council. This approach was a radical shift in the service-delivery
paradigm, requiring seniors to see themselves as partners in service delivery rather than just
recipients. Gradually, resident participation and engagement increased. Residents gained an overall

43Cityscape
Integrating Community Services Within a NORC: The Park La Brea Experience
sense that the services that LIFE developed and provided were in direct response to the needs that
community members identified. Members identified strongly with LIFE and actually ran some of
the programs. Advisory council members felt a strong commitment to LIFE and took their roles as
representatives of other residents seriously.
Securing funding for service provision and administrative staff has been a continuing problem for
NORC programs––LIFE has been no exception. By the time federal funding for LIFE ended, there
was a concerted effort by both Park La Brea residents and LIFE staff to obtain funding to support
continuation of the program. Fortunately, as mentioned earlier, the Jewish Federation of Greater
Los Angeles was able to secure a donation to JFS that supported LIFE social work staff at the site,
which was supplemented by membership fees referred to earlier. The direct funding from property
management, however, for core staff support did not materialize as hoped.
Conclusion
JFS’s LIFE program in Park La Brea represents a NORC-SSP in a large private development oper-
ated by property management staff. NORCs have a number of challenges, including obtaining buy-
in from management, gaining residents’ support and participation, accurately assessing residents’
needs, creating breadth and flexibility of services, and securing long-term funding (Black, 2005).
The experience with Park La Brea indicates that, in spite of these challenges, such a program can
be successful in building a community, providing services to people in need, and engaging older
people in both activities and helping each other. It can take several years, however, to build up the
trust of both residents and management.
Bringing services directly to the community has enabled JFS to reach many older adults who were
previously underserved. The successful recruitment and training of volunteers has enabled the
program to serve many more seniors than traditional care management programs would, given the
small professional staff. Using volunteers is a relatively low-cost way to help enable older adults
to remain independent, a meaningful way to involve them in giving back to their community, and
an approach that ensures that residents have a say in the types of services that will enable them to
remain independent.
Despite the multiple benefits associated with NORC-SSPs, significant challenges remain in sustain-
ing these models following the expiration of grant funding. This experience clearly illustrates the
ongoing need for a trained professional social work presence and the need for continuity in leader-
ship with the program. Although community volunteers can administer and maintain significant
aspects of the NORC, the role of the professional paid program administrator is critical in main-
taining the volunteer base, securing ongoing funding support, and coordinating numerous activi-
ties that include interacting and coordinating with health and community service organizations.
Acknowledgments
The authors thank the many residents of Park La Brea who participated in the project and also
thank the management of the community.

44 Aging in Place
Enguidanos, Pynoos, Siciliano, Diepenbrock, and Alexman
Authors
Susan Enguidanos is the Hanson Family Assistant Professor of Gerontology at the Leonard Davis
School of Gerontology, University of Southern California.
Jon Pynoos is the UPS Foundation Professor of Gerontology, Policy, and Planning at the Andrus
Gerontology Center, University of Southern California, and Co-director of the Fall Prevention Cen-
ter of Excellence, Los Angeles, California.
Maria Siciliano is a doctoral student and research assistant at the Leonard Davis School of Geron-
tology, University of Southern California.
Laura Diepenbrock is the LIFE program manager at Jewish Family Service of Los Angeles.
Susan Alexman is the director of Older Adult Services at Jewish Family Service of Los Angeles.
References
Black, Kirsten J. 2005. “A Conceptual Model of the Evolution of NORCs and Their Associated
Supportive Services Program.” Annual Meeting of the Gerontological Society of America, Orlando,
Florida, November 22, 2005.
MacLaren, Catharine, Gerald Landsberg, and Harry Schwartz. 2007. “History, Accomplishments,
Issues, and Prospects of Supportive Service Programs in Naturally Occurring Retirement Com-
munities in New York State: Lessons Learned,” Housing for the Elderly: Policy and Practice Issues:
127–144.
Nolin, JoAnn, Sharon T. Wilburn, Kenneth T. Wilburn, and Dax Weaver. 2006. “Health and Social
Service Needs of Older Adults: Implementing a Community-Based Needs Assessment,” Evaluation
and Program Planning 29: 217–226.
U.S. Census Bureau. 2000. “Summary File 3, Table P56.” In: 2000 Decennial Census. http://factfinder.
census.gov (accessed August 31, 2009).
Vladeck, Fredda. 2004. A Good Place To Grow Old: New York’s Model for NORC Supportive Service
Programs. A special report from United Hospital Fund. New York: United Hospital Fund.
Wilden, Robert, and Donald L. Redfoot. 2002. Adding Assisted Living Services to Subsidized Housing:
Serving Frail Older Persons with Low Incomes. Washington, DC: AARP, Public Policy Institute.
Additional Reading
Carpenter, Brian D., Dorothy F. Edwards, Joseph G. Pickard, Janice L. Palmer, Susan Stark, Peggy S.
Neufeld, Nancy Morrow-Howell, Margaret A. Perkinson, and John C. Morris. 2007. “Anticipating
Relocation: Concerns About Moving Among NORC Residents,” Housing for the Elderly: Policy and
Practice Issues: 165–184.

45Cityscape
Integrating Community Services Within a NORC: The Park La Brea Experience
Centers for Disease Control and Prevention (CDC), National Center for Health Statistics. 2001.
National Health Interview Survey.
Hunt, Michael E., and Leonard Ross. 1990. “Naturally Occurring Retirement Communities: A
Multi-Attribute Examination of Desirability Factors,” The Gerontologist 30 (5): 667–673.
United Hospital Fund. N.d. “NORC Blueprint.” http://www.norcblueprint.org (accessed August 2009).

46 Aging in Place

47Cityscape: A Journal of Policy Development and Research • Volume 12, Number 2 • 2010
U.S. Department of Housing and Urban Development • Office of Policy Development and Research
Cityscape
Health-Related Needs
Assessment of Older Residents
in Subsidized Housing
Victoria Cotrell
Paula C. Carder
Portland State University
Abstract
When a nonprofit organization with nursing-home and assisted-living experience
purchased a 30-year-old highrise apartment building in downtown Portland, Oregon,
the new owners were faced with how to manage a building that provided housing to
more than 200 older residents whom they knew very little about. As long-term care
providers, they knew that older people were at risk for developing chronic illnesses, dis-
abilities, and other factors that could result in moves to nursing homes, hospitalizations,
and early death. They also knew that older adults in subsidized housing, such as this
Section 8 building, have higher levels of disability than their age cohorts in unsubsidized
housing and apartment rentals (Redfoot and Kochera, 2004). What they did not know
was whether and in what ways these residents’ independence and quality of life might be
jeopardized by unmet health and social service needs. In collaboration with the Portland
State University School of Social Work, a multidimensional needs assessment was
developed and conducted to identify the most important unmet needs of the residents as
a group so that targeted services could be planned. Findings based on interviews with
130 residents revealed a heterogeneous population of older adults whose health status
varied considerably, especially among the four different ethnic and language groups
living in the building. This article describes how the results of such an assessment can be
used to plan for enriching services to those most in need.

48 Aging in Place
Cotrell and Carder
Introduction
Housing sponsors have increasingly begun to address the questions of whether and how to
confront the health and supportive service needs of older tenants. Many older people move into
independent housing hoping that they will never leave. Whether planned or not, subsidized
housing for older adults serves individuals who are increasingly in need of assistance to maintain
the level of stability required to reside in independent housing. This article presents a case study
of how a housing sponsor, Cedar Sinai Park (CSP), and a university partner, the Portland State
University (PSU) School of Social Work (SSW), implemented a health-related needs assessment of
older tenants of a U.S. Department of Housing and Urban Development (HUD) Section 8 building.
The goal of the assessment was to collect empirical data that would result in accurate statistics on
the resident population that could be used to plan the most appropriate services to support aging
in place.
“Aging in place” is a goal that some licensed facilities (such as assisted-living facilities and board-
and-care homes) have espoused but not one that subsidized-housing providers have actively
adopted. Instead, housing sponsors have traditionally offered services specific to property manage-
ment, community-building activities, and information and referral regarding community programs
(Heumann, Winter-Nelson, and Anderson, 2001; Kochera, 2002). Reasons that housing sponsors
have not inquired about residents’ needs in the past include a respect for resident privacy, a com-
mitment to providing independent housing, and a lack of financial incentive to provide services.
Several forces have converged, however, to pressure sponsors to either offer or coordinate support-
ive services; those forces include an organizational desire to reduce costly and disruptive resident
turnover, an awareness that current residents of subsidized housing are older than in previous
decades (in part because they enter at older ages), and an increasing national interest in strategies
that support aging in place as a more sustainable way to deal with a swelling demographic of older
adults (Harahan, Sanders, and Stone, 2006).
What Services Should Be Provided?
Little is known about the health-related service needs of older adults who live in subsidized housing.
Such tenants might require supportive services because they may have some combination of age-
based chronic illnesses, disabilities, and limited social supports, in addition to having modest
incomes. In HUD Section 202 properties, the average age increased from 72 years in 1983 to
75 years in 1999; in the oldest buildings (those built before 1975), the average age of residents
was 78.2 years in 1999, and almost 39 percent were more than the age of 80 (Heumann, Winter-
Nelson, and Anderson, 2001). The aging of the population has widespread implications for housing
sponsors, as Heumann, Winter-Nelson, and Anderson (2001: 19) have explained:
The increase in average resident age, the increase in residents aged 85 and older, and the
fact that projects are admitting older applicants have far-reaching implications for the
management, staff training, and service orientation. Older tenants are likely to require
unique support and services as well as barrier-free and supportive physical design.

49Cityscape
Health-Related Needs Assessment of Older Residents in Subsidized Housing
The population of current older residents is more diverse than in previous years, with nearly
one-fourth of the residents identifying themselves as non-White. In addition to increasing age and
racial or ethnic diversity is an increased need for services. In 1999, HUD 202 managers indicated
that 22.3 percent of residents were frail and that residents more than 80 years old listed the com-
bination of support services, improved security, and increased social contacts as important reasons
for moving into a Section 202 building (Heumann, Winter-Nelson, and Anderson, 2001).
A 2001 survey of properties financed through the low-income housing tax credit (LIHTC) indicates
that 42 percent of properties completed between 1987 and 1998 were for older people (Kochera,
2002). The survey asked property managers to estimate the number of tenants who were frail
or disabled (defined as having difficulty walking or performing everyday tasks); their responses
indicate that about one-third of the residents were frail or disabled (Kochera, 2002).
In response to the service needs of residents, some subsidized-housing programs have hired des-
ignated staff, such as a service coordinator. This person coordinates the “provision of supportive
services to the low-income elderly and non elderly people with disabilities to prevent premature
and inappropriate institutionalization, thereby improving residents’ quality of life” (Levine and
Robinson Johns, 2008: 1). Duties for the position include determining the service needs of eligible
residents and then linking residents with services available in the local community. A survey of
HUD-assisted developments reported that 46 percent had a HUD-funded service coordinator,
8 percent had a coordinator funded through other sources, and 43 percent never had a service
coordinator (Levine and Robinson Johns, 2008). An older study of HUD 202 properties found that
slightly more than one-third of the residents had a service coordinator (Heumann, Winter-Nelson,
and Anderson, 2001). A survey of LIHTC-financed properties reported that 21 percent of residents
had an on-staff service coordinator, and 47 percent of the properties reported that residents could
access a community-based service coordinator (Kochera, 2002).
Although property managers can determine the need for some services required by older residents,
property management staff might lack information about residents who fear that disclosure of
medical, psychiatric, or social problems will affect their housing tenure. Service coordinators are
more likely to have an accurate assessment of the service needs of residents, but, as indicated
previously, these coordinators are not available to residents in many properties. Neither property
managers nor service coordinators are likely to have the skills to accurately and systematically as-
sess the bio-psycho-social functioning of older residents. All of these factors informed the decision
of the housing sponsor described in this article to conduct the comprehensive health-related needs
assessment described in this article.
Cedar Sinai Park
The housing sponsor initiating the assessment described in this case study, Cedar Sinai Park (CSP),
is a nonprofit, faith-based organization that provides comprehensive retirement and long-term
healthcare services to older adults. Multiple facilities are located on a 27-acre campus in Portland,
Oregon, including a long-term care facility and assisted-living and active-lifestyle apartments. CSP
recently purchased a 17-story apartment building located in downtown Portland as part of its or-
ganizational mission to serve the needs of low-income older people. The building, which has 235
one-bedroom apartments, was privately built in 1979 under a HUD Section 8 housing contract

50 Aging in Place
Cotrell and Carder
to provide subsidized housing for low-income older and disabled individuals. The most notable
feature of the resident population is that approximately 40 percent of the residents do not speak
English and represent three distinct cultural groups: Chinese (both Mandarin and Cantonese)
speakers, Russian speakers, and Farsi speakers. A small number of Korean speakers also live in the
highrise building.
CSP aimed to extend the option for residents to age in place by making available needed long-term
care services rather than expecting residents to move out if they require more care. Facing an
expected demand for choice among lower income members of the baby boom cohort, CSP was
motivated to explore a variety of community-based care models, including housing with services.
As long-term healthcare providers, they realized that it is not financially sustainable to meet the
level of demand for health-related services using traditional institutional approaches. Their objec-
tive was to collaborate with local service providers and with county, state, and federal government
and organizational leaders, all of whom have a vested interest in creating successful models of
housing with supportive services. CSP believed that to be considered successful, models must
reduce healthcare costs and operational inefficiencies while maximizing the independence and
quality of life of older adults.
CSP and PSU Partnership
The SSW at PSU and CSP have a long-standing partnership in providing practicum experiences in
gerontology for graduate students in social work and in collaborative research on topics regarding
long-term care. Research in gerontology is conducted by SSW faculty through the Regional Re-
search Institute for Human Services, a research unit of the SSW that does evaluation and planning
research in health and human services across the lifespan.
The housing sponsor and the first author, a member of the SSW gerontology faculty, met to
discuss mutual interests in CSP’s new sponsorship of the apartment building. The sponsor was
primarily interested in acquiring a description of the mental, physical, and social needs of the resi-
dents, especially those of the large immigrant population, to help establish priorities and allocate
resources for services. For example, the sponsor was considering an onsite day health and respite
program, a potentially costly venture if neither the need nor resident support existed.
The SSW partners wanted to explore the residents’ perceptions of health, well-being, and services
using a modified participatory method. This approach would include resident involvement to
actively identify and examine specific issues of health and well-being. Resident participation
addresses the need for motivation and buy-in from targeted consumers to produce positive
changes in health-related behavior. The process of conducting a health-related assessment could
be leveraged to increase personal control and ownership over issues of health and well-being by
involving the participants in the research process and outcomes. This buy-in would be important
for implementing future health-related services and research.
Both partners wanted to explore the feasibility of linking the benefits of assisted-services technol-
ogy with the needs of older and disabled tenants living in low-income housing. Both partners were
also interested in better understanding the residents’ needs and acceptable responses to the needs
of the various ethnic groups that lived in the building. A needs assessment was an important first

51Cityscape
Health-Related Needs Assessment of Older Residents in Subsidized Housing
step in pursuing the goal of providing services to enhance aging in place; it would be important
when applying for funding from external sources after the needs were identified.
The SSW team provided expertise in conceptualizing and implementing the assessment and
acquired a small planning grant from PSU to cover the assessment costs. The sponsor organized
stakeholders to provide feedback on the questionnaire and to identify additional resources and
partnerships. The stakeholders also helped interpret the study findings and develop program goals
and objectives based on the findings.
Because this project was university based, it provided assurance to residents that confidentiality
of information would be independently secured through the PSU Institutional Review Board
for protecting research participants. This assurance was particularly important to residents who
believed that disclosing information might affect their housing status. Information collected from
specific residents remained confidential, and only the PSU research staff knew the identity of the
participants.

Methods
Resident Sample and Recruitment
All tenants capable of providing informed consent were eligible to participate in the study. Several
issues arose when acquiring a list of eligible tenants that could be used to select a probability
sample. Turnover in tenant occupancy was especially rapid at that time because of the transition
in building ownership, which took some time to resolve, and an unusually high rate of deaths and
transitions to higher levels of care. Accurate tenant lists, especially those identifying ethnic groups,
were not available at the time. Many residents, particularly those who did not speak English, could
not be reached by telephone because they did not have one, or they required a translator if they
did have a phone. More importantly, omitting residents for sampling reasons would have created
considerable confusion and misunderstanding among those who were not selected and suspicion
among those who were. Residents may have been justified to feel uncertain about their continued
residency given their lack of familiarity with the new building sponsors. This uncertainty was a
potential problem in establishing trust and resident motivation for future health-related collabora-
tions. Although using a nonprobability recruitment strategy is problematic in assuring accurate
representation of the population, the assessment used multiple recruitment strategies to enroll as
many residents as possible in the study and to respond to residents’ concerns. These strategies
included the following:
• The assessment team held six open meetings, two in English and one each in the four other
main language groups, to explain the needs assessment, discuss residents’ perceptions of the
study, and request their participation. They held two meetings in English to accommodate day
and evening schedules. Because of the expense of interpreters, only one meeting each in Mandarin
and Cantonese Chinese, Russian, and Farsi was held. These meetings were particularly helpful
in building trust and beginning a public dialogue about health and community. At these meet-
ings, residents were able to make an appointment for an interview or sign a list to be contacted
for further information.

52 Aging in Place
Cotrell and Carder
• Following the open meetings, the assessment team posted informational flyers in the residents’
languages on the doors of those who had not been enrolled in the study and in public areas.
• Those residents who had been interviewed conveyed knowledge of the needs assessment to
nonparticipating residents, which produced additional volunteers. This snowball effect was
particularly effective among the Russian and Chinese speakers and resulted in a response rate of
more than 80 percent for these two groups.
• Residents who spoke limited English often volunteered to act as consultants to provide
information about the cultural behaviors and perceptions of their language group and provided
ongoing feedback about the assessment. This information was extremely useful in recruiting and
interviewing non-English-speaking residents and assessing the effectiveness and acceptability
of research interviewers. Consultants also helped explain historical events that led to the
immigration of the various groups and the regional differences represented within each group.
• The assessment team provided a $15 gift card to the local supermarket as an incentive to
each resident to participate in an interview. Although the gift card was a small amount, the
participants appreciated the material gift; many of them said that the gift card was a primary
motivation for participation.
The assessment team interviewed 130 residents (63 percent of the eligible population) for this
study. The previous service coordinator, a member of the property management staff, reviewed
the list of tenants to determine if the nonparticipants might represent a systematic bias in the
characteristics of residents who volunteered for the study. Among the individuals not included
were those who had guardians who needed to be contacted to provide consent to participate and
individuals who were largely isolated from the staff and residents of the building. Also, older
individuals with apparent dementia were underrepresented.
Data Collection. The questionnaire used for this project included basic physical, psychological,
and social measures of functioning; questions about the resident’s use of services; three questions
concerning the resident’s use of technology; and two open-ended questions about the resident’s
experience of the environment and community life of the apartment building. Open-ended ques-
tions were particularly helpful in identifying the issues of greatest concern to the resident. Answers
to these questions enabled the researcher to check the validity and reliability of items identified
in the structured aspects of the questionnaire and to identify and clarify items of concern not
mentioned during the structured interview. The researcher selected the Older Americans Resources
and Services (OARS) Multidimensional Functional Assessment Questionnaire (OMFAQ) developed
at Duke University as the foundation for the questionnaire because it contains most of the content
needed to assess functional abilities of residents and which services they use (Fillenbaum, 1988).
The five basic areas of functioning contained in the OMFAQ are predictive of nursing facility place-
ment (Brody et al., 2002), morbidity, and death (Miller and Weissert, 2000), and so are important
indicators for ability to age in place. The researcher then modified the questionnaire to fit the
characteristics of the resident population and the needs of this particular project. For instance, they
modified the scale for economic resources and the health insurance options to be consistent with
those available in Oregon. They also added other questions specific to the resident population.
Because many of the residents had immigrated as adults from China, Russia, Iran, and Korea, im-
migration and citizen status were important in determining eligibility for services.

53Cityscape
Health-Related Needs Assessment of Older Residents in Subsidized Housing
Both property owners and property management staff reviewed the questionnaire; they requested
questions related to problems observed by staff, such as failure to manage medications successfully.
Additional social and psychological scales were substituted to assess problems observed in social
interaction and psychological functioning. All scales selected for the questionnaire were previously
evaluated for reliability and validity and have been tested with older adults.
An ongoing issue in questionnaire construction was how to include the basic measures of func-
tioning and services use, add content specifically requested by partnering groups, and keep the
questionnaire to a length that could be administered during a single interview with individuals
who may fatigue easily. The questionnaire was pilot tested by graduate students in a gerontology
research course, and 30 older adults in various community-based settings completed an interview
using the questionnaire and provided feedback to the SSW students about their understanding of
the questions and interview length. Final modifications of the assessment tool, including a small
reduction in length, were made based on participant and student feedback. A copy of the final
instrument is available from the first author.
Interviewing the Residents
The assessment team interviewed residents over a 6-month period. To enhance the quality of
the data they collected, interviewers used face-to-face interviews with individual residents. They
conducted interviews in the apartments of residents or in another location of the participant’s
choosing. The length of the interviews ranged from 1 to 2.5 hours and varied depending on the
individual’s cognitive abilities, complexity of health conditions, and extensiveness of open-ended
comments. The SSW hired and trained three interviewers for English-speaking residents and five
interviewers for the non-English speakers. Most interviewers were current or former university
students or individuals who worked in social service organizations and were able to interview in
the evenings or on weekends. All English-speaking interviewers were experienced in interviewing
older adults and with administering evaluation instruments; they remained on the team through-
out the study.
Locating and training interviewers who spoke both English and one of the other four languages
were the biggest challenges to the project. Using the assistance of an interpreter to interview each
non-English-speaking resident would have been cost prohibitive and would have greatly increased
the length of the interview. Because of budget constraints, it was not possible to translate the entire
questionnaire into each language and then back-translate it. When possible, translated versions of
the scales were used, although the cultural validity of these instruments cannot be assumed for all
translated versions. Instead, bilingual interviewers verbally translated the questions and the partici-
pant’s responses. Suitable interviewers were sometimes difficult to find, and their availability was
often unpredictable because of conflicts with academic or work schedules. Training the bicultural
interviewers sometimes involved hours of dialogue as we worked through the questions to achieve
an understanding of the instrument that was culturally acceptable and yet captured the concepts
inherent to western medicine and supportive services. These interviewers provided invaluable
insight into the non-English-speaking communities and identified important areas of cultural
variation in the delivery of health-related services.

54 Aging in Place
Cotrell and Carder
Residents’ Participation and Debriefing
During the data analysis phase of the assessment, the assessment team held both formal and
informal check-in meetings with residents. Following the completion of the data analysis and
interpretation, the researcher prepared and had translated (as needed for each language group)
written reports summarizing the survey results. Health characteristics and risks and prioritized lists
of concerns and questions pertinent to each language group were emphasized in separate reports.
These translated reports were distributed during meetings that the assessment team held with each
language group. During these meetings, the CSP chief executive officer discussed the health and
service initiatives he envisioned for the building and spoke with the residents about their concerns
and suggestions. These efforts were used to further engage the residents as partners in their own
health care as the partners planned the transition from data collection to the next phase of the
project, identifying and implementing appropriate services (not discussed in this article).
Findings
Sample Description
A total of 130 residents were interviewed, although participation varied by language group: 50 percent
of the English speakers (n = 61), 81 percent of the Chinese speakers (n = 35), 83 percent of the
Russian speakers (n = 20), and 58 percent of the Farsi speakers (n = 11) participated, as well as
three out of the six Korean residents.
The mean age of the entire sample was 75.5 years, and 30 percent were 80 years of age or older.
This age is comparable to the mean age of 75.5 reported in a national survey of Section 202 resi-
dents (Heumann, Winter-Nelson, and Anderson, 2001). The Russian residents were significantly
older than other groups with a mean age of 82.3, and 60 percent were 80 years of age or older. No
statistical differences existed in the mean ages of the other groups, but only one of the Mandarin-
speaking residents was 80 years or older.
Females made up 75 percent of the sample, and 32 percent reported that they were married or
partnered, although not all were living with their spouse. Great educational diversity existed
among the residents, both between and within the language groups. About 24 percent had less
than a high school education, 19 percent completed high school, 19 percent reported some college
or trade school, 29 percent completed college, and 9 percent had postgraduate degrees. Of the
residents who immigrated to the United States, most (86.3 percent) did so when they were 50 years
of age or older and 55 percent were 60 or older. The median number of years of tenancy with the
building was 6, with the shortest period being 1 to 2 months and the longest being 23 years.
Health Status
Residents were asked to report their currently diagnosed illnesses, the extent to which these illnesses
interfered with their activities, and their prescribed medications (see exhibit 1). The most frequently
reported illnesses were common to older adults, although not all language groups reported the
same illnesses. Hypertension (64 percent) and arthritis (63 percent) were predominant illnesses

55Cityscape
Health-Related Needs Assessment of Older Residents in Subsidized Housing
Exhibit 1
Illness-Related Characteristics and Sensory Deficits of Residents (N = 130)
Illnesses
Mean # 4.3
Min/max 0–10
Illness interfering
Mean # 3.1
Min/max 0–10
Prescribed meds
Mean # 5.4
Min/max 0–17
No med strategy 27%
Difficult pain 30.5%
Poor or blind vision 20%
Poor or deaf hearing 17.7%
across all language groups. The mean number of illnesses per individual varied by language group,
ranging from 2.6 illnesses for one group to 6.9 for another group.
Similarly, medication usage varied among ethnic groups, with the average number of medications
as high as 8.7 in one group to a low average of 3.4 in another group. Residents in this study took
between 0 and 17 prescribed medications, and 25 percent of them took 8 or more. More than
one-fourth of residents who took 2 or more medications could not identify a strategy for consis-
tently taking their medications. We were interested in the complexity of the physician-prescribed
medication regimen for the purpose of evaluating potential for a resident to adhere to the schedule.
The use of nonwestern, alternative, and over-the-counter treatments and medications, however,
was frequent among respondents and complicated both the adherence strategy and the coordina-
tion of resident care. Residents were asked (1) about frequency of pain and whether they used
prescribed pain medications, (2) if they had poor vision or were legally blind with corrected vision,
and (3) if they had poor hearing or were deaf without the use of hearing aides. Nearly one-third
of the sample reported frequent and significant pain, and 20 percent had severe visual deficits that
could not be corrected with glasses. Of the residents interviewed, 18 percent reported poor hearing
or deafness without hearing aides, yet only 8 percent used hearing aides. Considerable variation
existed among the language groups on these factors.
Functional Status and Physical Activity
Instrumental Activities of Daily Living. Most residents in this sample were independent in their
instrumental activities of daily living (IADL), with the exception of heavy housekeeping (for example,
cleaning the bathtub, scrubbing the floor, and cleaning the windows) and transportation to places
beyond walking distance (see exhibit 2). A notable difference existed among the language groups
in their level of independence in the other IADLs, with some groups reporting extensive need and
others reporting only a need for some assistance with heavy cleaning. A need for heavy housekeep-
ing services was common in all language groups and was reported by more than 40 percent of the

56 Aging in Place
Cotrell and Carder
residents, many of whom reported being unable to perform these tasks even with assistance. More
than 25 percent of the sample, consistent across most language groups, required some assistance
with transportation that was beyond walking distance. Foreign language speakers mostly reported
problems resulting from language barriers to navigating the many options for public transportation
that exist near the building, while the English speakers reported problems with their ability to
access public transportation because of health conditions.
When individuals reported that their performance of an IADL task was independent but difficult,
carrying heavy objects and heavy housekeeping were most frequently identified as the reason
for this difficulty. Many residents who reported such difficulty thought they could not continue
performing these tasks unassisted much longer.
Personal Activities of Daily Living. Nearly all residents were independent in personal ADLs, and
one language group reported nearly all of the need for assistance (see exhibit 3). The exception was
assistance in bathing, reported by two groups. Most residents requiring help when bathing were
afraid of falling (and some had previously fallen) when they stepped into and out of the bathtub.
Physical Abilities. In a measure of physical abilities separate from IADL and ADL, we looked at
an individual’s core physical abilities that reflect endurance, strength, coordination, and range
of motion. This measure provided a more explicit description of problems with ambulation and
Exhibit 2
IADL Skill % Independent
% Independent/
Difficult
% Some Help % Unable
Status of Instrumental Activities of Daily Living Skills (N = 130)
Finance management 90 (3) 3.8 3.8
Medications management 90 (3) 5.4 (3)
Telephone 90 4.6 3.8 (2)
Services 84.6 (1) 8.5 6.2
Meal preparation 78.5 6.9 3.8 10.8
Shopping 74.6 7.7 11.5 6.2
Light housework 72.3 7.7 4.6 15.4
Transportation 66.2 6.2 20.8 6.9
Carry objects 64.6 16.9 4.6 13.8
Heavy housework 46.9 10.8 8.5 33.8
IADL = instrumental activities of daily living.
Note: Numbers in parentheses indicate actual counts that are fewer than five residents.
Exhibit 3
ADL Skill % Independent
% Independent/
Difficult
% Some Help % Unable
Status of Personal Activities of Daily Living Skills (N = 130)
Dressing 84.6 11.6 (4) (1)
Grooming 93.1 (4) (5) 0
Bed transfer 88.5 9.2 (2) (1)
Bathing 78.5 8.5 11.5 (2)
ADL = activities of daily living.
Note: Numbers in parentheses indicate actual counts that are fewer than five residents.

57Cityscape
Health-Related Needs Assessment of Older Residents in Subsidized Housing
other physical movements. It is clear that a large percentage of residents reported deficits in core
physical abilities (exhibit 4). In addition, approximately 30 percent of residents reported falling
in the past year and that balance interfered greatly with their activities; 25 percent of residents
regularly use canes or walkers. Language groups varied greatly; for instance, 89 percent of one
group reported they had no problems with walking, while only 20 percent of another group
reported no difficulties. Residents often mentioned concerns about experiencing undiagnosed
problems with balance, strength, or range of motion. Some individuals received a few sessions of
physical therapy after an injury or surgery, but the insurance benefits were too limited to achieve
much long-term remedial benefit.
Residents were also asked whether they pursued any type of physical activity on a regular basis.
Many individuals reported participating in regular exercise (69 percent), but the primary exercise
reported was short walks on an irregular basis (for example, roundtrip destinations located within
two to four blocks). For those who walked for exercise, many stopped their activity when the
weather was inclement. Only one language group reported a varied exercise program that included
classes and social sports several times a week.
Exhibit 4
Core Skill A Little A Great Deal Total
Percentage of Residents Reporting Difficulties With Core Physical Skills (N = 130)
Walking 23.1 29.2 52.3
Balance 27.7 20.8 48.5
Stairs 22.3 32.3 54.6
Reaching 10.0 22.3 32.3
Lifting 24.6 23.1 47.7
Carrying 22.3 21.5 43.8
Social and Mental Health Status
Not all residents reported a support network of friends and family (see exhibit 5 below). Many
residents have no contact with family but have developed support networks with other residents or
individuals outside the residence. Only seven residents reported that they had no one they could
call on for help if they had a problem or an emergency. Individuals who were unable to extend
their social contacts to the broader community because of health or other factors, however, could
depend only on the microneighborhood of the building to develop adequate social networks,
which did not always occur.
Non-English speakers are more vulnerable to isolation because of the language barriers that
may discourage them from easily taking part in community activities. Having a close network
of individuals who share the same language, however, provided support for many non-English
groups. Most non-English speakers mentioned a language barrier as the most important issue in
their open-ended remarks. They requested English classes, more translation services, and access to
media in their languages.
Many residents reported feeling lonely occasionally, but reports of frequent loneliness were rare.
The degree to which residents reported that they would like to have more relationships with other

58 Aging in Place
Cotrell and Carder
Health Need Percentage
At risk of social isolation* 31.5
Often lonely 9.4
More opportunity for relationships
A little 41.5
A great deal 32.3
Depression** 29.5
Mental health worse than 5 years ago 31.5
MMSE score of 26 or lower 22.4
MMSE = Mini-Mental State Examination.
*Scores lower than 12 on Lubben Social Network Scale.
**Scores 5 or greater on the Geriatric Depression Scale.
residents in the building varied greatly among language groups. Interestingly, the degree of reported
loneliness was not always associated with the desire for more relationships with other residents.
Depression, as measured by the Geriatric Depression Scale, was reported across all language groups;
however, the percentages of individuals reporting depression varied among language groups from a
low of 9 percent in one group to a high of more than 50 percent in two other groups. Most reports
of depression scored within the mild range. About one-half of the residents evaluated their current
mental health as about the same as 5 years earlier, while about one-third of residents felt it had
worsened. The perception that their mental health had worsened was usually attributed to health
problems (including memory problems) or the death of individuals close to them.
The Mini-Mental State Examination (MMSE) was used as a brief screen for cognitive impairment.
MMSE scores of 26 or lower were identified (see exhibit 5) as possible instances of dementia based
on an adjustment of cutoff scores that was suggested by Van Gorp et al., (1999). The authors
determined that the best overall cutoff score, intended to reduce instances of misclassification of
undiagnosed cases of dementia (false positives), is a score of 26 or less. This adjustment produces
more accurate classification rates than either the original MMSE cutoff score of 23 or the sole use
of age and education as adjusted norms. Approximately 22 percent of residents across all language
groups reported MMSE scores of 26 or lower (ranging from 19 to 26). Because our recruitment
efforts did not reach individuals who were cognitively unable to volunteer or independently follow
through with study participation, the rates reported in this survey were probably conservative and
tend to represent milder forms of impairment.
Exhibit 5
Percentage of Residents Reporting Social/Mental Health Needs (N = 130)
Service Use
Exhibit 6 summarizes the most frequently used services by residents. Nearly all residents across
language groups saw a physician within 6 months before the interview, and approximately 22 percent
had been admitted to the hospital during this period. Two of the language groups accounted for
most of the hospitalizations. Patients’ stays in the hospital ranged from 1 to 20 days, with most
lasting only 1 to 2 days. One language group reported using more services than any of the other

59Cityscape
Health-Related Needs Assessment of Older Residents in Subsidized Housing
Services Used Percentage
Doctor visit within past 6 months 91.5
Hospital admission within past 6 months 21.5
Physical therapy 14.0
Homemaker 21.7
Shopping 11.6
Meal preparation 14.0
Personal care 11.6
Mental health services 10.9
groups. Only four residents reported using medication consultation or a service to check and
organize their medications, while an additional three individuals reported receiving assistance in
managing their medications from an informal source.
Discussion
This section provides a brief discussion of the four primary assessment domains followed by a
summary and implications.
Health Status
In general, most residents reported that their illnesses interfered very little or not at all with their
life. Illnesses such as hypertension, diabetes, or glaucoma, however, may be silent, threatening
one’s independence if these conditions go undiagnosed and untreated (Butler, 2008). For instance,
hypertension is one of the two most frequently reported illnesses in this sample, yet it does not have
the same immediate and noticeable effect on ability to perform daily activities as arthritis, the other
highly reported illness, does. Providing education and health guidance for high-risk but silent con-
ditions before they produce functional decline is one important way of promoting aging in place.
In this sample, the large number of medications taken by a sizable percentage of the residents is
worrisome, especially given that few residents felt they needed any assistance in managing their
medications, and many residents could not identify any strategy for taking multiple medications
accurately. The average number of prescription medications used by these residents is 5.4, which is
comparable to residents of licensed assisted-living facilities who average 6 medications (Armstrong,
Rhoads, and Meiling, 2001). Even in assisted-living facilities, where most residents receive care
services, finding the best medication management strategy is a challenge (Carder, Zimmerman, and
Schumacher, 2009). The implications for poorly or mismanaged medications include increased
negative drug interactions, increased side effects, increased falls, and increased instances of
resident hospitalization and institutionalization (Hanlon et al., 2002; Tinetti and Speechley, 1989).
Many residents, including both English and non-English speakers, said that they substituted and
added alternative treatments to their medication regimen without the knowledge or recommenda-
tion of their primary care physicians. A final problem for residents with multiple illnesses and
Exhibit 6
Percentage of Residents Using Services in Past 6 Months (N = 130)
Note: R-square for the current formula is 0.787; 0.927 for the Administration’s proposal.

60 Aging in Place
Cotrell and Carder
medications is that treatment requires more out-of-pocket expense, which may exceed affordability
for low-income people. Inadequate finances may lead to reduced compliance with medical treat-
ment and inadequate contact with medical professionals. Residents with high numbers of illnesses
and prescribed medications often reported a lack of resources to meet medical needs, most often
resulting from high numbers of medical copays. Improvement to existing services include, greater
access to consultations on specific medications, greater access to information about alternative
treatments and potential negative interactions with other medications in the patient’s regimen, and
more assistance in developing strategies to assure adherence to prescribed regimens. These con-
sultations should also be accessible to those who do not speak English and may have nonwestern
views of medicine.
Finally, this diverse sample of residents highlights the need to consider the distinct health profiles
that various ethnic and racial groups may have. The assessment results helped to identify some of
the differences among language groups that may represent distinct health risks, patterns of service
use, and lifestyle behaviors that contribute to health resiliency. Identifying these differences can al-
low for more specific and cost-effective targeting of health-related services. For instance, attention
should be given to the need to locate bilingual health providers and individuals who can accom-
pany non-English-speaking residents to medical appointments when they do not have friends or
family to provide an accurate translation of medical information. Non-English-speaking residents
often complained of excessively long waits to see a physician and did not always understand their
physician’s diagnoses or recommended treatments.
Functional Status and Physical Activity
Functional status is usually the basis for determining an individual’s eligibility and cost of long-
term care services, so it is important in any assessment of needs (Kane, 2000). As a measure of an
individual’s functional status, both IADLs (Lawton and Brody, 1969) and ADLs (Katz et al., 1963)
were assessed. An individual’s loss of ability to perform these activities (that is, a decline in their
functional status) increases their risk of institutionalization and death (Miller and Weissert, 2000).
Heavy housekeeping and lifting are the most widely reported unmet service needs among residents
across language groups. These needs were often reported by individuals who were not eligible for
homemaker services but could not afford to purchase them privately. Transportation to places be-
yond walking distance was the next most frequently reported need. Most residents had easy access
to different forms of transportation and rarely reported a complete inability to use transportation.
Providing language-appropriate instruction to diverse residents about the use of local transporta-
tion systems, especially to new tenants, would be particularly helpful in this setting.
Residents seldom reported unmet personal care needs. The assessment, however, provided data on
structural problems in the building that contributed to falls and limited accessibility for residents
using wheelchairs and walkers in bathrooms equipped with bathtubs only. A group of mobility-
impaired residents provided specific information on inaccessible areas of the building or areas that
were difficult to navigate safely. The assessment also identified which non-English-speaking groups
were receiving needed services from providers sponsored by their ethnic communities and which
were without such resources.

61Cityscape
Health-Related Needs Assessment of Older Residents in Subsidized Housing
Most residents reported that they exercised, but very few approached the level of activity recom-
mended in Healthy People 2000 and The National Blueprint: Increasing Physical Activity Among
Adults Age 50 and Older (CDC, 2007). A frequent response to the open-ended questions concern-
ing health-related suggestions included access to onsite exercise equipment and a desire to pursue
an exercise program. Extensive literature supports the strong positive effects of exercise on many of
the most debilitating health conditions of older adults, including but not limited to falls, diabetes,
obesity, hypertension, cardiovascular disease, pain, depression, and even cognitive deficits. In-
creasing the physical activity of older residents and promoting a culture of health among residents
would greatly improve both the general effectiveness and cost effectiveness of health-related sup-
portive services in subsidized housing. The Centers for Disease Control and Prevention (2007) and
Environmental Protection Agency (2007) both provide strategies for reaching this goal.
Social and Mental Health Status
About one-third of the participants in this study reported social networks that may not provide
adequate social support. Inadequate social support (social isolation) has been considered a health
risk by the World Health Organization for more than 20 years and has been extensively researched
(CDC and NACDD, 2008). Supportive ties to others have been found to enhance the physical and
mental health of individuals, providing a preventative effect and reducing the severity of existing
health problems. Social networks can also provide an individual a safety net in times of need. Methods
that may address this need include creating opportunities for enhancing meaningful social connec-
tions through activities that build community and an individual’s sense of belonging and through
the use of mental health services that address individual barriers to developing social connections.
Mental and emotional health is an important part of overall health and well-being, not only for
the distress that conditions such as depression can cause, but also because these conditions affect
physical health and motivation for self care (Stephens, 1988). Providing mental health support to
address depression, a condition frequently experienced by older adults, and other mental health
disorders is a critical and often missing piece of health-related services. Untreated mental health
conditions can contribute to the development of social behavioral problems that influence length
of tenancy for individuals in independent housing. Services that address these mental health
conditions are not adequately funded (Kleyman, 2005), and geriatric-mental-health professionals
are often difficult to locate (Rosen, 2005). Mental health support was an important unmet need
reported by all resident groups in this study.
Individuals with varying stages of cognitive impairment are a major challenge for any aging in place
initiative. In this study, 22 percent of residents demonstrated performance on the MMSE that sug-
gests some problems with cognitive functioning, especially memory loss. Because many things can
produce alterations in cognitive abilities, evaluation for underlying causes is an important first step.
Barriers to the evaluation of cognitive functioning in non-English-speaking populations include the
availability of culturally appropriate assessment instruments and personnel capable of administering
them. It should not be assumed that individuals diagnosed with progressive dementia cannot live
independently in subsidized housing, especially during the earlier stages of the illness. Subsidized
housing combined with appropriate supportive services can extend the duration of an individual’s
independence; the degree to which this is possible is just beginning to be explored.

62 Aging in Place
Cotrell and Carder
Service Use
In general, the residents who reported heavy service needs were also heavy users of services. When
we review IADL and ADL needs, heavy housekeeping and lifting stand out as the two most widely
reported unmet services need among residents.
Other needs identified by the assessment included medication management, mental health services,
and physical therapy, yet the use of services in these areas is meager. Poor adherence to a medica-
tion regimen is often not acknowledged as a problem by individuals because they are unaware of
their actual compliance rate and because they often lack awareness of the potential dangers in the
complexity of their drug regimen (both prescribed and not prescribed.) Mental health services are
probably underutilized because of the unavailability of affordable mental health services for older
adults, the questionable acceptability of such services (especially to many non-English-speaking
individuals), and a lack of awareness and knowledge of mental health symptoms. Finally, given the
high number of reported difficulties with core physical skills and fall risk, a significant need exists
for physical therapy and other remedial and preventative programs to address physical deficits in
strength, balance, endurance, coordination, and range of motion. Many residents need consulta-
tion with a physical therapist to develop a personalized rehabilitative or preventative program,
including evaluations for fall risk and generating appropriate referrals.
Summary and Implications
Conducting a multidimensional needs assessment is an effective tool for identifying the service
needs of older adults who reside in subsidized housing. This case study suggests that most
residents of this Section 8 building are not at near risk of hospitalization and nursing home admis-
sion; however, a significant few are. The findings helped the housing sponsor determine that most
residents did not need onsite adult day care. Assessment data such as that described in this article
can be used to identify and target services to the residents who are at highest risk, thus preventing
costly mistakes made from less objective approaches to decision making. Residents in this study
identified significant needs differences among language groups and age groups, trends that can be
used to plan culturally sensitive and age-appropriate responses.
After service options are implemented, evaluation of each service option’s effectiveness should be
weighed against its identified goals. Service modifications can be made throughout the evaluation
to further improve the services and model of service delivery. Periodic reassessments of residents’
health status could be used to inform the housing sponsor and service provider, if any, if the resi-
dents’ profile of health needs has changed. Resident participation in these efforts helps to ensure
that services are consumer focused and that older adults stay active in their own health care.
University-community partnerships can be win-win relationships. Subsidized housing for older
adults can provide rich opportunities for university researchers and evaluators to explore questions
critical to gerontology while providing valuable information to property owners and older resi-
dents. University-community partners can apply for external funding to pursue needs assessments,
program evaluations, and other applied research projects. Both students and residents benefit from

63Cityscape
Health-Related Needs Assessment of Older Residents in Subsidized Housing
university-sponsored internships and class projects that integrate learning and service opportunities.
Housing sponsors, in turn, receive systematically collected information to help them plan and
evaluate services. Universities usually provide an accepted protocol for collecting personal health
information in research-defined projects. This protocol allows residents the opportunity to discuss
their health and housing concerns with professionals who are not affiliated with the housing provider.
In the case of the present study, a school of social work with faculty expertise in gerontology was
an existing partner of the housing sponsor. Other disciplines with training in geriatric assessment
might include nurses, physical or occupational therapists, physicians, or psychologists. A college or
university with a designated program in aging (gerontology or geriatrics) would be a good starting
point for identifying such professionals.
We need to know more about the residents of subsidized housing for older people. Future projects
should include multiple housing communities, possibly in partnership with state or local housing
and aging services offices, to profile the larger population of older people who live in subsidized
housing. We need to evaluate how the information gained in comprehensive health-related as-
sessments will improve the health and quality of life of residents at the same time that it addresses
organizational needs of housing sponsors, such as reduced tenant turnover and readmissions from
hospitals, housing stability, and community partnerships.
It is important to keep ahead of the game. Providing services to those in need is an important goal
of aging in place, but identifying and addressing health risks that will lead to functional losses and
needs for supportive services are critical. Screening for these risks, educating and encouraging
older adults to pursue proactive health behaviors, and creating a culture of health awareness is
critical for reducing unnecessary disability and costly services.
Finally, federal attention to the need to coordinate housing and services is increasing, as indicated
by a recent letter to housing authority directors from HUD and the Centers for Medicare and
Medicaid Services (CMS) that “urges” public housing authorities to provide a “local admission
preference” for current nursing home residents (HUD, 2009). This call for admission preference
responds to the Supreme Court’s 1999 Olmstead ruling that states must afford people with
disabilities the opportunity to reside in the community rather than in an institution (Folkemer
and Coleman, 2006). How authorities will respond to this joint HUD-CMS request is currently
unfolding, but this federal attention suggests that housing providers and service agencies will
need to work together to systematically assess residents’ needs. They can then use the findings to
strategically coordinate services for individuals whose health-related needs might be greater than, if
not comparable to, those described in this article.
Acknowledgments
The authors acknowledge financial support for this project from Portland State University, Office
of Research and Sponsored Projects.

64 Aging in Place
Cotrell and Carder
Authors
Victoria Cotrell is an associate professor at the School of Social Work at Portland State University.
Paula C. Carder is an assistant professor at the Institute on Aging at Portland State University.
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67Cityscape: A Journal of Policy Development and Research • Volume 12, Number 2 • 2010
U.S. Department of Housing and Urban Development • Office of Policy Development and Research
Cityscape
Health Indicators:
A Proactive and Systematic
Approach to Healthy Aging
Fredda Vladeck
Rebecca Segel
United Hospital Fund
Mia Oberlink
Michal D. Gursen
Center for Home Care Policy and Research,
Visiting Nurse Service of New York
Danylle Rudin
Consultant
Abstract
The challenge of serving a burgeoning elderly population that has an increasing burden
of chronic illness cannot be met within the existing paradigm of “one hip fracture at a
time”—a limited approach using discontinuous, reactive responses to crises that can
be prevented or delayed. As the gap between needs and resources continues to grow,
and as the understanding of how to effectively manage chronic conditions improves, a
proactive system is needed: a community-oriented, evidence-based approach involving
three components—self-care, medical care, and community care and support systems.
Merely locating traditional health and social services in communities is not sufficient;
any endeavor to effectively integrate these three components at the community level
requires good data, strategic partnerships, thoughtful targeting, explicit cross-sector
standards, and the capacity to track and measure the effort’s effectiveness.
This article describes a data-driven, community-based, collaborative effort under way
in 34 low- and moderate-income communities in New York City. The Health Indicators
in NORC (naturally occurring retirement community) Programs initiative, started in
2007, has enabled community-based programs with limited resources to become more
systematic in addressing the management of clients with diabetes, heart disease, or an
increased risk for falls.

68 Aging in Place
Vladeck, Segel, Oberlink, Gursen, and Rudin
Background
In 2000, the Centers for Disease Control and Prevention (CDC) embarked on an ambitious na-
tional campaign, called Healthy People, with the intent of improving the health of the American
people (HHS, ODPHP, 2010). Using key health indicators to measure the health of the nation every
10 years, the CDC established improvement objectives related to: what individuals can do to better
care for themselves (self-care), what service providers can do to ensure that people have access
to and are receiving appropriate care (medical care), and what communities can do to overcome
known environmental barriers or stresses and provide appropriate supports to promote residents’
health and well-being (community care). The Administration on Aging, as part of the wider
government goal of improving health, has turned to evidence-based models as a way to promote
healthy aging. Evidence-based health promotion programs (including A Matter of Balance, Healthy
IDEAS [Identifying Depression, Empowering Activities for Seniors], PEARLS [Program to Encour-
age Active, Rewarding Lives for Seniors], Chronic Disease Self-Management Program, and others)
are now offered by the Administration on Aging’s network of aging-services providers. Because
“many communities lack the chronic disease and risk factor data to effectively set priorities and
evaluate programs” (Brownson and Bright, 2004), evidence-based health promotion programs are
being offered to all older adults (regardless of their health condition) to prevent, slow the pro-
gression of, or lessen the consequences of health problems prevalent among the elderly, such as
hypertension, diabetes, heart disease, and an increased risk for falls.
About 80 percent of today’s elderly population has a single chronic condition and 62 percent has
more than one (HHS, AHRQ, 2010). Effective care and management of chronic conditions require
a complex set of coordinated activities among clients, health providers, and community support
systems––a necessary partnership that can accomplish the right things, in the right communities,
with the right people, at the right time.
Health Indicators in NORC (naturally occurring retirement community) Programs (Health Indica-
tors) is a data-driven, quality-improvement process that employs evidence-based interventions
and strategies to measurably improve the health status of older adults. This article begins with
an overview of the NORC program model in New York City, followed by a description of Health
Indicators and its results to date.
The NORC Program Model
Throughout the United States, an increasing number of older adults live in communities not built
specifically for the elderly—naturally occurring retirement communities, or NORCs. First used by
Michael Hunt in 1984, the term NORC is now used as a demographic descriptor for age-integrated
housing developments or neighborhoods where older adults comprise a significant portion of
the residents. NORCs cannot be built; rather, they evolve over time, in a variety of ways. Adults
remain in communities where they raised their families; young people leave in search of oppor-
tunities, leaving behind older generations; and older adults move to a building or neighborhood
because of amenities and services that fit with their retirement lifestyle. Analyses of census data
from 1990 and 2000 document steady growth in the number of NORCs in urban centers and first-

69Cityscape
Health Indicators: A Proactive and Systematic Approach to Healthy Aging
ring suburbs in metropolitan areas across the United States (Lanspery and Callahan, 1994; Puentes
and Warren, 2006).
NORCs consist of heterogeneous mixes of older adults in varying stages of health and well-being,
with a variety of interests and needs that fluctuate over time. The relatively dense population in
NORCs has made it possible to rethink conventional service delivery paradigms. Historically, ag-
ing, health, and long-term care services have been delivered to individuals in silos, disconnected
from the community where an older adult lives. This approach bases service on a categorical eligi-
bility that is usually triggered by a crisis and often involves a hospital stay.
NORCs have given policymakers and service providers the opportunity to shift their efforts from
delivering specific services to specific individuals to focusing on the health and well-being of
subpopulations of seniors within communities. In 1986, the first NORC Support Service Program
(NORC-SSP, or simply “NORC program”) began in response to the needs of a large concentration
of older adults in Penn South Houses, a housing development in New York City. Using a mix of
philanthropic funds and support from the housing company itself, a new service program integrat-
ing housing, social services, and health services was developed (Vladeck, 2004).
Based on the success of the original Penn South program and two other similar housing develop-
ments, in 1995, New York State provided financial support for the NORC program model because
of its innovative approach to a public policy focused on aging in place; New York City followed
suit in 1999. Today, $11.4 million in city and state funding leverages an equal amount in private
sector revenue and in-kind support for 54 NORC programs operating in moderate- and low-
income housing developments and neighborhoods. NORC programs have since been started in
communities in 25 other states, and the model is now being tested as part of the Administration on
Aging’s Community Innovations for Aging in Place Demonstration Program.
New York City’s NORC programs are structured partnerships among housing developments (or
neighborhoods), residents, health and social service providers, and other community stakeholders.
These programs work at both the community level and individual level to address the challenges
to aging in place in the NORC. The NORC model builds communities and provides for services
aimed at the following:
Empowering older adults to take on new roles in their community.•
Fostering connections among residents within the community.•
Maximizing the health and well-being of all older adults in the NORC.•
The 34 NORC programs funded by New York City are located in large and small public and
private housing developments and are composed of both garden-style apartment complexes and
single-family homes. Ten NORCs are located within New York City Housing Authority (NYCHA)
public housing developments. In most instances, the lead agency is a social service provider from
the network of aging-services providers; the health service partner is typically a home care agency,
a local hospital, a nursing home, or a combination. Social workers, nurses, and residents staff
NORC programs (UHF, 2010). Many of the program’s health partners provide nurses as an in-kind
resource to the programs, with each program receiving between 2 to 55 hours per week.

70 Aging in Place
Vladeck, Segel, Oberlink, Gursen, and Rudin
NORC programs, which integrate housing, social service, and health care for seniors, are located
at the intersection of self-care, medical care, and community resources––making them ideally situ-
ated to maximize the health and well-being of older adults (exhibit 1).
Self-Care
Community
Care
Medical Care
NORC
Program
•Diagnosis
•Treatment
•Disease Management
Source: United Hospital Fund, 2008.
•Environment
•Resources
•Support
•Empowerment
•Self-Advocacy
•Lifestyle Choices
Exhibit 1
Community Chronic Care Model
Source: United Hospital Fund, 2008
Origins of Health Indicators
The extent of positive effects that NORC programs have on the health of older adults in their com-
munities has been a challenge to measure from the programs’ inceptions. The programs’ staff had
few resources to determine which health risks were most prevalent in their community, making it
difficult to connect residents’ needs to appropriate services, and thereby limiting the staff’s ability
to reduce primary health risks to residents living with chronic conditions. Consequently, before
2007, the health components of the NORC programs focused on providing health education and
health promotion activities (lectures on specific health topics and a range of physical and cognitive
exercises); blood pressure checks (a very popular offering); and nurses monitoring the health of
frail or medically complex residents, to help residents (and their caregivers) manage health condi-
tions and to help residents navigate the healthcare system maze. Powerful stories of individuals
who had been helped illustrate the value of NORC programs. The success rate of the program is
measured by the number of forestalled hospitalizations and nursing home placements attributed to
program interventions.
Shifting from a case-by-case, reactive crisis management style to a systematic, proactive practice
style based on evidence required fundamental changes by NORC program staff. They needed
to learn how to collect, interpret, and use relevant data to target their efforts toward a particular

71Cityscape
Health Indicators: A Proactive and Systematic Approach to Healthy Aging
health issue; appropriately integrate and apply standards of practice; develop strategies to exchange
relevant information with other sectors and leverage additional resources; and measure the effec-
tiveness of their interventions over time.
Health Indicators in NORC Programs
In 2007, New York City’s Department for the Aging (DFTA) turned to the United Hospital Fund
(the Fund), a research, policy, and grant-making organization focused on shaping positive change
in the healthcare delivery system, to help NORC programs move to evidence-based practice. To
help develop and implement the Health Indicators initiative, the Fund engaged the Center for
Home Care Policy and Research of the Visiting Nurse Service of New York as a technical consultant
for data collection tool development, website and database development and management, and
data analysis.
Health Indicators involve three steps:
Identifying key health risks in a community-client population through a baseline survey.1.
Targeting, designing, implementing, and evaluating interventions focused on a specific health 2.
condition, using a quality-improvement process.
Periodically following up to measure effectiveness and identify new health risks. 3.
The following paragraphs describe Health Indicators—the tools, the processes, the Fund’s imple-
mentation process across New York City’s NORC programs, and the results thus far.
Step One: Identifying Key Health Risks
The Health Indicators process begins with a survey examining three of CDC’s key components of
healthy aging. It is based on the belief that effective NORC programs promote healthy aging by
ensuring that older adults (1) have access to health care; (2) engage in health promotion, disease
prevention, and wellness activities; and (3) are able to manage their chronic conditions. (See
appendix A for domains and indicators.) The Fund developed a 75-item survey instrument that
corresponds to the three components and their relevant indicators. The instrument draws on stan-
dard or slightly modified questions derived from validated national and local surveys, including
the Behavioral Risk Factor Surveillance System (HHS, CDC, 2010), the National Health Interview
Survey, the U.S. Census, and the AdvantAge Initiative tool (VNSNY, Center for Home Care Policy
& Research, 2010).
1
It takes 15 to 20 minutes for NORC program staff (social workers, nurses, or
administrative staff) to administer the survey to clients and about 5 minutes to enter it into a web-
based, electronic database developed specifically for Health Indicators. To get started, program
directors were instructed to administer the questionnaire over a 3-month period to the health and
case management staff and to health and case assistance clients seen during the course of their regu-
lar work. Interviews were conducted in person at the NORC program offices or in clients’ homes.
1
The AdvantAge Initiative is a project that has developed tools and processes to help communities measure their elder-
friendliness (Visiting Nurse Service of New York, Center for Home Care Policy and Research, 2010).

72 Aging in Place
Vladeck, Segel, Oberlink, Gursen, and Rudin
The report format developed for the programs focused on identifying the most prevalent health
conditions in each individual NORC program and in the aggregate of all programs. Reports identi-
fied and described the characteristics of people with the identified health conditions and explored
differences by demographic characteristics and health condition. The Fund helped each program
use the data to begin a conversation with community stakeholders about the findings. Each NORC
program was given comparative city, state, and federal data, when available, in a standard format
that arrayed program findings and comparative data for easy sharing with program partners and
community stakeholders.
A total of 5,069 surveys were completed and entered into the database, representing 44 percent
of the client caseloads across the NORC programs from 2006 through 2007. For the first time, each
NORC program (and DFTA) had information about the most prevalent health risks in each commu-
nity and learned how seniors with heart disease, diabetes, or an increased risk for falls were faring.
Survey Results
Demographics. As exhibit 2 illustrates, the 5,069 seniors surveyed were predominantly female
(76 percent), lived alone (58 percent), and were White non-Hispanic (56 percent); 37 percent
were either Black non-Hispanic or Hispanic. Of those surveyed, 66 percent were between the ages
of 65 and 84, and 26 percent were 85 or older. NORC programs in NYCHA developments had
a high concentration of ethnic minorities (72 percent non-White) and a higher concentration of
younger residents than seen in non-NYCHA (that is, private, moderate-income) developments:
51 percent versus 27 percent were 60 to 74 years old and 48 percent versus 72 percent were 75 or
older, NYCHA versus non-NYCHA, respectively.
Exhibit 2
Characteristic
Aggregate (100%) NYCHA (32%) Not NYCHA (68%)
N=5,069 N=1,615 N=3,454
Demographic Characteristics
Age 60–64 7% 10% 5%
65–74 28% 41% 22%
75–84 38% 34% 40%
85+ 26% 14% 32%
Gender Male 24% 24% 24%
Female 76% 76% 76%
Race/ethnicity White (Non-Hispanic) 56% 26% 70%
Black (Non-Hispanic) 18% 20% 17%
Asian 5% 9% 4%
Hispanic 19% 43% 8%
NYCHA = New York City Housing Authority.
Note: Percentages may not add to 100 percent because of rounding and missing data.
Source: United Hospital Fund Health Indicators in NORC Programs Initiative, 2007 through 2008
Access to Health Care. Nearly all the seniors surveyed had primary health insurance coverage
(99 percent) and prescription drug coverage (95 percent). Most had a regular source of care (96 percent);
among those, virtually all had seen their doctor at least once in the past year, and 22 percent of

73Cityscape
Health Indicators: A Proactive and Systematic Approach to Healthy Aging
them had seen their health provider seven times or more over the year. Of those surveyed, 34 per-
cent had used an emergency room in the past year, and 13 percent had done so more than once.
Health Promotion and Disease Prevention. Respondents in the 65-and-over age group were
slightly more likely to rate their health fair to poor (46 percent) than the 65-and-over population
of New York City as a whole (40 percent), as shown in exhibit 3. These figures exceeded the state-
wide rate (28 percent) and the national rate (26 percent), a difference that held true even when
including younger respondents by expanding the age group to 60 and over. A self-reported health
status of fair to poor was dramatically more common among people with certain chronic condi-
tions—for example, 57 and 62 percent, respectively, for people with diabetes and heart disease.
Nearly all the clients surveyed (96 percent) reported taking at least 1 medication, and 15 percent
reported taking 10 or more. In 2007, the group had higher rates of flu immunization (77 percent)
and pneumonia vaccination (58 percent) than the citywide rates (57 and 48 percent, respectively).
Only 4 percent of the women surveyed had never had a mammogram, and only 24 percent of all
seniors surveyed had never had a colonoscopy, compared with a citywide rate of 33 percent for
people over 65 (NYC DOHMH, 2006). The rate of social connections (frequency with which indi-
viduals see or speak to family members and friends) was high, at 93 percent, and 77 percent of the
seniors surveyed reported leaving their homes three times a week or more. The levels of physical
activity were consistent with national rates: 28 percent of seniors surveyed reached the recom-
mended level of physical activity, and 35 percent reported no physical activity.
46 46
40
28
26
0
10
20
30
40
50
Indicators
(Age 60+)
Indicators
(Age 65+)
City*
(Age 65+)
State*
(Age 65+)
USA*
(Age 65+)
Percent
Exhibit 3
Fair/Poor Health Status (Indicators data compared with city, state, and national data)
* Percentages are rounded to the nearest whole number.
Sources: United Hospital Fund Health Indicators in NORC Programs Initiative, 2007 through 2008; www.nyc.gov (city); http://
www.cdc.gov (state); http://www.cdc.gov (USA)
Chronic Conditions. Only 16 percent of seniors surveyed reported having no chronic conditions.
Overall, 25 percent had diabetes, 32 percent had heart disease, 66 percent had hypertension,
20 percent had lung disease or breathing problems, 26 percent were overweight or obese, 12 percent

74 Aging in Place
Vladeck, Segel, Oberlink, Gursen, and Rudin
had suffered a stroke (in two of the NORC programs, 20 percent or more had suffered a stroke),
63 percent had arthritis, 32 percent had osteoporosis, and 27 percent had fallen in the past 12 months.
The power of the data is better revealed by looking at some of the findings in more detail. Diabetes
data provide a useful example. Of those surveyed, 25 percent had diabetes. (The citywide preva-
lence of diabetes in a comparable age group is 23 percent). Of the NORC program clients with
diabetes, 57 percent rated their health as fair to poor, and nearly one-fifth (18 percent) acknowl-
edged difficulty managing the disease. Although diabetes is not curable, effective management of
the disease can slow its progression and prevent life-threatening consequences.
The data also document patterns of chronic disease prevalence by community. Exhibit 4 shows the
diabetes rates for seniors served by New York City’s NORC programs. Each bar represents a NORC
program. The gray bars represent the 10 programs in public housing, all of which are above the
aggregate rate (25 percent), mirroring the prevalence of diabetes in New York City as a whole—
namely, that it is concentrated in non-White, poorer, and younger populations.
Collectively, the data painted an informative picture of the health and well-being of seniors served
by New York City’s NORC programs. Access to care appeared not to be an issue because most
NORC residents reported having insurance and a regular source of medical care. The surveyed
seniors reported seeing their doctors frequently and taking a lot of medication. Nonetheless, they
suffered from multiple chronic conditions and reported not feeling well. Overall, the data por-
trayed a population that needed help systematically addressing the health risks and symptoms
associated with chronic conditions and common health problems. The challenge for NORC pro-
grams was to make that help relevant to its clients.

8
9
12 12 12
13
14
15
16 16 16
19
22
24 24
25
26 26 26
27 27
28
30
31
32
33 33
36
37
38 38
39
42 42
0
10
20
30
40
50
Percent
Average
25%
NORC Programs
Exhibit 4
Prevalence of Diabetes Mellitus by NORC Program
Gray bars represent New York City Housing Authority programs.
Source: United Hospital Fund Health Indicators in NORC Programs Initiative, 2007 through 2008

75Cityscape
Health Indicators: A Proactive and Systematic Approach to Healthy Aging
Step Two: Targeting, Designing, Implementing, and Evaluating Interventions
Standards of Practice. After discussions with program partners and community stakeholders,
NORC programs selected from heart disease, diabetes, or increased risk for falls (based on what
was most prevalent) as a target for their interventions. To determine how well the NORC programs
were addressing the known risk factors associated with the target condition, the Fund developed
NORC Program Standards of Practice (SOPs), which reflect best practices and clinical guidelines
in self-care, medical care, and community supports. The SOPs cover five areas: Knowing and
Managing Your Numbers, Appropriate Medication Management, Healthcare Maintenance, Diet and
Physical Activity, and Education and Information. Each SOP contains a series of detailed measures
relating to the standard. The SOPs and measures were based on extensive literature reviews, estab-
lished clinical guidelines, and evidence-based best practices. After being adapted for use by NORC
programs, they were reviewed by a board-certified geriatrician and a group of NORC program
nurses. (See appendix B for the SOPs.)
Quality Improvement. With NORC Program SOPs in place, a continuous quality-improvement
process was designed in which program staff identify gaps in meeting the SOPs (“benchmarking”), set
improvement goals and objectives, develop and implement strategies to reach their goals and ob-
jectives, measure progress through benchmarking at appropriate intervals, and repeat the process.
Benchmarking Process. The Health Indicators benchmarking tools comprise a short series of
questions that NORC program staff complete by chart review, thus reinforcing for staff the crucial
importance of documentation. The questions were designed to gauge what program staff know
and have documented about their clients and to measure change in that documentation over time.
For questions addressing the measures of the different SOPs, the choices are “yes,” “no,” or “don’t
know.” (For example, “Is NORC program nurse monitoring client’s blood pressure at least quar-
terly?”) Even movement from a “don’t know” to a “no” at different time points represents progress,
because the program then knows who needs further attention (and what sort of attention), which,
if effectively delivered, will generate a “yes” in time.
To assist programs with documentation, checklists were developed that align the SOPs and the
benchmarking tools. Program staff use the checklists to track each client’s status. The checklists re-
semble one-page nursing flowsheets, with space to record clinical values and boxes to check when
these results are reviewed with the client.
The tools yield valuable information about both the individual NORC program clients and about
the programs themselves. At an individual level, the checklist can indicate specific courses of
action. When aggregated, the benchmarking results make it possible to look across all clients
with a particular health issue to identify patterns among the group and devise and test strategies
that increase program effectiveness. For example, if a large percentage of the diabetic clients in a
program are not getting the recommended level of physical activity, the program might consider
starting an evidence-based exercise program specifically for this group. Such information is
invaluable to programs if they are to deliver more targeted and systematic interventions. Without
it, programs have no way of knowing which seniors need assistance, what kind of assistance they
need, and whether the assistance is helping them effectively manage their diabetes.

76 Aging in Place
Vladeck, Segel, Oberlink, Gursen, and Rudin
The quality improvement process began in December 2008, when programs conducted their initial
benchmarking (referred to below as “T1”). All programs were provided with a registry of clients
affected by the selected health issue, derived directly from the initial Health Indicators data. (Pro-
gram staff can continually update the registry as other clients are identified with a particular health
condition or existing clients die or move away.) Using the initial benchmarking reports as their
guide, programs then set improvement goals and specific objectives. They developed and imple-
mented improvement strategies and saw the fruits of their labor when the second benchmarking
occurred 6 months later, in July 2009 (“T2”).
Benchmarking Results
Results from the first two benchmarking periods provide a solid measure of the utility of the qual-
ity improvement process in helping programs systematically address health needs by following the
NORC Program SOPs. This section of the article focuses on the results for programs addressing
diabetes, although similar progress was seen in programs addressing heart disease and increased
risk for falls. Across all issue areas, improvement was seen in measures within the different SOPs
(Knowing and Managing Your Numbers, Appropriate Medication Management, Healthcare Main-
tenance, Diet and Physical Activity, and Education and Information), although this improvement
occurred at different rates for different measures and standards.
The 10 programs focusing on diabetes ask the question, “Has client’s hemoglobin level (HbA1c)
been tested at least twice in the past 12 months?” (The HbA1c test shows average blood glucose level
over the past 2 to 3 months. See appendix B for other standards of practice concerning diabetes.)
At T1, the “don’t know” response was given for 89 percent of the clients; at T2, this number fell to
70 percent. The percentage of “yes” responses increased over time as well (exhibit 5).
Similar patterns were seen for other indicators of effective diabetes management and control. In
response to a question about whether blood pressure was being measured quarterly, the percent-
Exhibit 5
Diabetes: HbA1c Tested at Least Twice in Past 12 Months
DK = Don’t know. N = No. Y = Yes.
Source: United Hospital Fund Health Indicators in NORC Programs Initiative, 2007 through 2008
10
1
89
28
2
70
0
20
40
60
80
100
T1, N=366
Y
T2, N=241
NYNDK DK
Percent

77Cityscape
Health Indicators: A Proactive and Systematic Approach to Healthy Aging
age of “don’t know” responses decreased from 34 percent at T1 to 26 percent at T2, and “yes”
responses increased from 26 to 49 percent. In response to a question about cholesterol testing, the
percentage of “don’t know” responses decreased from 75 to 56 percent between T1 and T2, and
“yes” responses increased from 24 to 44 percent.
The bar charts in exhibit 6 also show steady improvement in the documentation of annual dilated
eye exams for clients with diabetes between T1 and T2. Similarly, documentation improved on
whether clients had an individualized diet plan—another essential component of effective diabetes
care. “Yes” responses increased to 32 percent at T2 from 17 percent at T1.
NORC programs that focused on the other target conditions documented similar patterns in the
benchmarked results. For example, the 15 programs that focused on heart disease asked program
staff (in a questionnaire) if they knew whether their clients had a cholesterol test within the past
12 months. The response of “yes” increased from 36 to 62 percent and the “don’t know” response
decreased from 61 to 37 percent. Similarly, the “yes” responses to a question about the presence
of EKG documentation rose from 36 to 64 percent. The eight programs that selected to focus on
fall risk reduction documented dramatic improvements in several key measures: in orthostatic
hypotension assessment, where the “yes” response rose from just 10 percent to 60 percent, and the
“don’t know” response dropped from 37 to 4 percent; in trigger drug assessment, where the “yes”
response rose from 19 to 72 percent, and the “don’t know” response dropped from 35 to 6 percent;
and in assessments of gait, balance, and strength, where the “don’t know” response dropped from
69 to 35 percent. We expect even more progress as this process continues and programs learn to
work differently, both as a team and in the community.
It was not surprising that results from the first benchmarking period showed a high percentage of
“don’t know” responses. Previously, interventions were mere reactions to crises that happened to
be noticed, rather than intentional responses in a systematic, comprehensive approach. The high
Exhibit 6
Diabetes: Dilated Eye Exam in Past 12 Months
DK = Don’t know. N = No. Y = Yes.
Source: United Hospital Fund Health Indicators in NORC Programs Initiative, 2007 through 2008
28
2
70
48
4
48
0
20
40
60
80
100
Percent
T1, N=366
Y
T2, N=241
NYNDK DK

78 Aging in Place
Vladeck, Segel, Oberlink, Gursen, and Rudin
percentages documented for “don’t know” responses prompted the creation of a set of straightfor-
ward objectives that included regularly performing specific tasks, asking clients basic questions
about their health care, and documenting these activities accordingly. Armed with the bench-
marking data, NORC programs can measure improvement using the SOPs at both the client and
program levels and follow up with individuals to address their specific needs. Each benchmarking
question is designed to trigger a deliberate and evidence-based response.
Followup takes many forms, requires strategy development and implementation, and is often
tailored to the individual. Using diabetes control as an example, clients first must be educated
on the importance of the hemoglobin level test. The NORC programs require a copy of the lab
results—either from the client or directly from the healthcare provider. Depending on the lab
results, followup care may be recommended. Does the diabetic client require a medication change
by a doctor, or nutrition counseling? Or, in the case of an eye exam, it is important to know why
a client has not had one in the past 12 months. For example: Does the client have an issue of ac-
cess? Is the lapse based on a client’s fear? Are there other barriers, such as a lack of transportation?
The followup questions and practices that result from the benchmarking have practical value for
individual clients, because they indicate who may need assistance managing health needs and what
form that assistance should take.
The benchmarking results are promising up to this point. Across all three health issues, programs
have seen dramatic improvements in what they know and document, and they are also making
great strides in developing and implementing strategies to better address clients’ needs. Changing
the programs’ practices will not happen overnight, but programs are seeing the value of a targeted
and systematic approach, which sets clear goals and objectives, and are measuring progress at
regular intervals. Because benchmarking by these programs continues through 2010, DFTA is care-
fully examining how to incorporate elements of this data-driven, quality-improvement process into
its own performance standards and measures across all its service delivery systems.
Step Three: Periodically Following Up
In 2011, participating programs will resurvey their client populations using the Health Indicators
survey to identify new or emerging health risks. From there, programs can identify any new health
issues on which to focus their quality improvement process. Eventually, the Standards of Practice
will be embedded into regular program practice, helping to maximize the health and well-being of
NORC program clients, and programs will no longer pursue a practice of “one hip fracture at a time.”
Conclusions
As the nation grapples with the growing burden of chronic illness, especially in the elderly, both
healthcare and aging-services providers have been encouraged to strengthen their participation in
preventive efforts, especially in better educating patients about reducing and managing risk factors.
The healthcare provider community, at varying rates among different institutions, is gradually
adopting quality-improvement strategies and tools to focus on doing a better, more systematic job
of managing the health of their patients with chronic illness or patients at risk for chronic illness.

79Cityscape
Health Indicators: A Proactive and Systematic Approach to Healthy Aging
Aging-services providers have been asked to encourage willing older adults to adopt healthier life-
styles by using an assortment of “evidence-based” health promotion programs.
These prevention and risk reduction efforts have largely taken place within the separate organiza-
tional silos of health care and aging services. This separation is particularly counterproductive with
respect to older adults, many of whom have multiple chronic health conditions requiring coordi-
nated, integrated management and care. Health promotion and preventive activities are of limited
use if they are not getting to those who need them most, when they need them, and where they
need them. NORC programs are perfectly positioned to take on the integrative functions of bring-
ing together the separate realms of self-care, medical care, and community-based support. Mere
positioning, however, is not sufficient; NORC programs also need specific tools to help improve
the health status of older adults in a measurable, systematic way.
Health Indicators, a highly replicable suite of tools and processes, has already been demonstrated
to help NORC programs shift practice from providing services on a first-come, first-served basis to
targeting those most at risk and helping them get the education, care, and support they need for
long-term living with chronic conditions. This approach should also be readily applicable to other
providers serving communities with dense concentrations of older adults. To date, most aging-
services practitioners have lacked the knowledge and tools to engage in evidence-based
community health practice and, instead, do what they know best—react to specific acute illnesses,
or install broad health promotion programs that are not targeted to a particular population. Borrowing
experience from the healthcare community and adapting the quality-improvement process for
community-based aging-services providers, Health Indicators uses data to drive what aging-servic-
es providers do and with whom they do it. It changes the expectations of community-based aging-
services providers, shifting focus from the reactive provision of units of service to a more proactive,
targeted, and systematic approach, continually measuring not only what they do, but also its effects,
and enabling them to modify their strategies on the basis of reliable data. Although community-
based aging-services providers will experience a steep learning curve in adopting such a change in
approach, they can achieve the change.
In addition to helping community-based aging-services providers, Health Indicators also provides
a vehicle for attaining the long-sought, but rarely realized, aspiration to better integrate health and
social services in programs for the elderly. By providing accessible and understandable tools for
aging-services providers, drawn largely from healthcare literature, Health Indicators equips provid-
ers to, first, work more effectively with the healthcare community and, second, to educate their
clients in how they can better manage their own health care. At the same time, Health Indicators
empowers the aging-services providers to monitor the performance of the healthcare system in the
interest of their shared clients. In so doing, it creates a standardized, medically validated playing
field on which aging-services and healthcare providers—and their clients—can work cooperatively
to achieve shared goals.
Rooted as it is in the quality-improvement principles of continual feedback, learning, and pro-
grammatic adaptation, Health Indicators is, by definition, a work in progress. We already have
come far enough, however, to have confidence that it can serve as the framework for long-sought
changes in service delivery that will bring both short-term and long-term benefits to improve the
health and well-being of elderly clients.

81Cityscape
Health Indicators: A Proactive and Systematic Approach to Healthy Aging
Connection to family, neighbors & friends •
Frequency of leaving the home•
3. Health Conditions
Diagnosis and management of health conditions (diabetes, lung disease or breathing •
problems, high blood pressure, heart disease, stroke, arthritis, osteoporosis, obesity)
Interference with activities of daily living due to poor health •
Falls •
Depression •
Use of assistive devices (eyeglasses, hearing aid, cane, walker, wheelchair, shopping •
cart, personal emergency device)

82 Aging in Place
Vladeck, Segel, Oberlink, Gursen, and Rudin
Appendix B
NORC Program Standards of Practice for Care of Client
With Diabetes
Standard of Practice 1: Knowing and Managing Your Numbers
Elements of Practice for Knowing and Managing Your Numbers
1. HbA1c tested and reviewed with doctor at least twice annually at least 3 months apart or as
otherwise prescribed.
1a. Adherence to prescribed changes in care regimen as needed.
2. Blood pressure tested at least quarterly or as prescribed by doctor and discussed with client.
2a. Adherence to prescribed changes in care regimen as needed.
3. Lipids tested and reviewed annually with doctor or as otherwise prescribed.
3a. Adherence to prescribed changes in care regimen as needed.
4. Microalbumin level in urine tested and reviewed annually with doctor or as otherwise
prescribed.
4a. Adherence to prescribed changes in care regimen as needed.
5. Weight goal identified by appropriate professional and discussed with client (weight loss, gain,
or maintenance).
5a. Appropriate followup to ensure progress toward weight goal.
Standard of Practice 2: Appropriate Medication Management
Elements of Practice for Appropriate Medication Management
1. Glycemic control with glucose monitor (if prescribed)—glucose level tested as prescribed by doctor.
1a. Adherence to prescribed changes in care regimen as needed.
2. Annual medication review by doctor, nurse, or pharmacist.
• Medication review with each change in medication regimen (addition or subtraction of
medication, dosage adjustment).
• Medication review with any significant change in health status.
2a. Medication regimen adjustment by doctor(s) as needed.
2b. Adherence to prescribed medication regimen.
3. Medication understanding assessment by NORC program nurse every 6 months.
3a. Education and followup as needed.

83Cityscape
Health Indicators: A Proactive and Systematic Approach to Healthy Aging
Standard of Practice 3: Healthcare Maintenance
Elements of Practice for Healthcare Maintenance
1. Full foot examination at least annually by trained healthcare provider.
• Foot inspection at each primary care visit.
• Self-examination daily.
2. Dilated eye examination annually.
2a. Followup vision care as appropriate.
3. Flu vaccination annually.
4. Pneumonia vaccination one time after age 65 or as otherwise indicated.
5. Smoking cessation services and ongoing support offered if client smokes.
Standard of Practice 4: Diet and Physical Activity
Elements of Practice for Diet and Physical Activity
1. Individualized diet plan provided by appropriate professional.
1a. Adherence to prescribed diet.
2. Physical activity as prescribed.
Standard of Practice 5: Education and Information
Elements of Practice for Education and Information
1. Diabetes education provided by diabetes educator or appropriate healthcare professional as
needed.

84 Aging in Place
Vladeck, Segel, Oberlink, Gursen, and Rudin
Acknowledgments
The authors thank the New York City Department for the Aging for its support, NORC programs
and staff for participating in this initiative, and Miles P. Finley for editorial assistance.
Authors
Fredda Vladeck is the director for the Aging in Place Initiative, United Hospital Fund.
Rebecca Segel is the program manager for the Aging in Place Initiative, United Hospital Fund.
Mia Oberlink is the senior research associate at the Center for Home Care Policy and Research,
Visiting Nurse Service of New York.
Michal D. Gursen is the research project manager at the Center for Home Care Policy and Research,
Visiting Nurse Service of New York.
Danylle Rudin is a consultant to the United Hospital Fund.
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Interactive Health Data.” http://www.nyc.gov/health/epiquery (accessed April 13, 2010).
Puentes, Robert, and David Warren. 2006. One-Fifth of America: A Comprehensive Guide to America’s
First Suburbs. Washington, DC: The Brookings Institution.
United Hospital Fund (UHF). 2010. “NORC Blueprint: A Guide to Community Action.”
http://www.norcblueprint.org (accessed April 13, 2010).
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Quality (AHRQ). 2010. “Medical Expenditure Panel Survey (MEPS).” http://www.meps.ahrq.gov/
mepsweb/ (accessed April 13, 2010).
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U.S. Department of Health and Human Services (HHS), Office of Disease Prevention and Health
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85Cityscape: A Journal of Policy Development and Research • Volume 12, Number 2 • 2010
U.S. Department of Housing and Urban Development • Office of Policy Development and Research
Cityscape
Aging in Place Partnerships:
A Training Program for
Family Caregivers of
Residents Living in
Affordable Senior Housing
Alisha Sanders
Robyn Stone
Institute for the Future of Aging Services
Rhoda Meador
Cornell University
Victoria Parker
Boston University School of Medicine
VA Boston Healthcare System
Abstract
This article describes the development and testing of a program to expand the capacity
of family caregivers of residents in affordable senior housing properties and enhance the
partnerships between family caregivers and the housing properties to help residents meet
their needs and “age in place.” A needs assessment revealed that, although family care-
givers are providing a great deal of assistance to residents in affordable senior housing
properties, they can benefit from expanding their caregiving knowledge and skills. It also
revealed that the interaction between family caregivers and housing properties is often
minimal. Incorporating input from service coordinators, family caregivers, and resi-
dents, a two-part workshop was created and piloted in three affordable senior housing
properties. The first part focused on helping the family caregiver understand and build
empathy for the challenging tasks that residents and caregivers face; the second focused
more specifically on how family caregivers can strengthen their skills and knowledge
and partner with housing properties to support aging in place. Participants in the pilot
workshops reported being very satisfied with the workshops and more prepared to fulfill
their caregiving role. The program team will use the results from the training program
to refine the program and explore the potential for dissemination through a “train-the-
trainer” approach.

86 Aging in Place
Sanders, Stone, Meador, and Parker
Introduction
This article describes the development and testing of a program that was designed for the family
caregivers of residents in affordable senior housing properties. The program’s goal was to improve
support for and ensure the sustainability of the efforts of these family caregivers by increasing their
knowledge, building their skills, and strengthening their partnership with the housing properties’
service coordinators. The program had three key objectives:
• Identify the specific needs and knowledge gaps of these family caregivers to inform the
development of a training program that would help service coordinators and family caregivers
collaborate more effectively in providing support to elderly residents to help them remain in an
independent living setting.
• Make housing properties and service coordinators aware that family caregivers can be an
integral part of the service network and offer them useful skills on how to train and engage with
family caregivers.
• Teach family caregivers about the role of the housing property and service coordinator in
helping elderly residents remain safely in their apartments and about how they can establish a
partnership to facilitate independent living for their family member.
Background
About two million low-income seniors, most of whom are single women in their mid-70s to early
80s, live in federally subsidized independent rental housing (Wilden and Redfoot, 2002). Research
shows that older renters in subsidized housing are twice as likely as older homeowners to be disabled
(Heumann, Winter-Nelson, and Anderson, 2001). More than one-half of older renters report
limitations in activities such as walking and climbing stairs and one-third report difficulty shopping
or going to the doctor. In a 1999 survey, managers of the Section 202 Supportive Housing for the
Elderly Program reported that 30 percent of vacancies occurred because of transfers to nursing
homes (Heumann, Winter-Nelson, and Anderson, 2001).
The Institute for the Future of Aging Services (IFAS) has spent several years exploring the potential
of “affordable housing plus services,” a residential care model linking subsidized, multiunit,
independent housing for lower income older adults with needed services and supports. The goal
is to enable residents to “age in place” as their needs change, rather than having to transfer to a
higher and more costly level of care. By doing so, the strategy may provide a means for meeting
some of the long-term care needs of lower income seniors who want to remain in an independent
living setting as they age.
In one study, IFAS examined how three affordable senior housing communities in Colorado
helped residents maintain independent living despite their growing frailty and/or disability
(Washko et al., 2007). Each community was committed to helping residents age in place and
had developed a strategy to foster independent living and support aging residents in the face of
changing needs. Two of the three properties employed formal service coordinators to help elderly
individuals obtain needed services. One property offered an extensive array of “inhouse” services.

87Cityscape
Aging in Place Partnerships:
A Training Program for Family Caregivers of Residents Living in Affordable Senior Housing
Each property was embedded in a community with a broad network of aging-service providers. In
what was a surprise to IFAS researchers, the study found that residents did not report using many
formal services but did rely to a significant extent on family caregivers. Interviews with housing
staff buttressed the important role families played in these housing settings. Family support was
considered crucial to a resident’s general well-being and an essential factor in whether the property
was able to help residents maintain their independence. Staff also thought that the availability of
informal care was uneven and that, as a result, some residents suffered.
Unpaid family caregivers have traditionally been the primary source of long-term care in the
United States, and more than 90 percent of long-term care recipients receive some informal care
(Cafferata, Sangl, and Stone, 1987; Houser and Gibson, 2008; Spillman and Black, 2005). Re-
search shows almost all informal caregivers value their caregiving roles and feel appreciated by the
care recipient (Donelan et al., 2002; Toseland and Smith, 2001). A substantial body of research,
however, also demonstrates that caregivers’ physical and mental health can be compromised by
caregiving responsibilities (Feinberg, Wolkwitz, and Goldstein, 2006). A recent analysis of national
data found caregiver stress as a key variable in the decision to place a family member in a nursing
home (Spillman and Long, 2007).
Numerous studies have also examined the efficacy of programs to educate and train caregivers
(Knight, Lutzky, and Macofsky-Urban, 1993; Pillemer et al., 2003; Toseland, Smith, and McCallion,
2001; Zarit and Terri, 1992). Most of these studies find that caregiver education and training
programs have some effect on (1) increasing knowledge about services and resources, (2) improving
caregiver well-being, and (3) improving caregiver problemsolving skills (Toseland and Smith, 2001).
Researchers have also documented important differences in the caregiving experiences of African-
American, Hispanic, and White families (Janevic and Connell, 2001; Navaie-Waliser et al., 2001;
Weiss et al., 2005).
Few studies have addressed the role and effect of caregiving in community residential care settings,
such as assisted-living and senior housing. According to data from the National Long-Term Care
Survey, approximately 30 percent of children with a parent in a community residential care setting,
such as assisted living, provide informal care (Spillman and Black, 2005). Port, et al. (2005) analyzed
family involvement with residents with dementia in assisted-living settings and nursing homes and
found family caregivers of assisted-living residents more involved in helping with instrumental
activities of daily living (IADLs) and monitoring medical status and well-being than caregivers with
family members in nursing homes. Caregivers of assisted-living residents also wanted more advice and
encouragement from the facility to support their caregiving roles (Port et al., 2005). Another study
examined effects of a care management intervention to help family caregivers of adult daycare users
develop problemsolving and coping skills and better manage the problem behaviors of their family
members. The study found the intervention reduced symptoms of depression, enhanced overall
perceived well-being among caregivers, and increased the use of formal services by users of the adult
daycare program (Gitlin et al., 2006).
Researchers have paid little attention to the role played by family caregivers in helping maintain
independent living of aging residents in publicly subsidized housing. The IFAS study of the
three senior housing communities in Colorado described previously is one of the few to actually
interview families, residents, and housing staff about informal caregiving and its perceived effect

88 Aging in Place
Sanders, Stone, Meador, and Parker
on care recipients. IFAS researchers and their partners are convinced that strategies to link publicly
subsidized rental housing communities to both formal services and informal care offers low- and
modest-income seniors a new and important choice about where they can live despite increasing
disability and declining health. Most of these seniors will not be able to afford assisted living,
which largely remains a high-end product (Wright, 2004). Most older adults want to remain in
their own homes as long as possible (AARP Public Policy Institute, 2009).
Methods
The goal of this program was to develop and test a program that would expand the capacity of
family caregivers of residents in affordable senior housing properties and enhance the partnerships
between family caregivers and the housing properties. The research team identified a purposive
sample of four properties in the Washington, D.C. area to participate in the pilot program. To
participate, the housing property was required to have at least one service coordinator, at least 100
units, and a diverse resident population to capture any ethnic/cultural issues that might need to be
considered for the family caregiver-training program. One site was dropped during the program
development phase because the property was unable to participate fully in the required activities.
The three remaining pilot sites were HUD-subsidized properties, including two Section 202
properties and one Section 236 property. Section 202 and Section 236 are programs restricted to
low- and very low-income individuals that, through different subsidy mechanisms, offer residents
affordable rents generally no higher than 30 percent of their monthly income. The median income
of residents in Section 202 properties across the country is $10,236. In Section 236 and other
related HUD-subsidized properties, it is $10,526 (Haley and Gray, 2008). Two of the pilot sites
were located in inner cities and one was in a suburban setting. As exhibit 1 shows, the properties
were racially and ethnically diverse.
Exhibit 1
Property 1 Property 2 Property 3
Characteristics of Pilot Sites and Residents*
Location Washington, DC Baltimore, MD Rockville, MD
Property type Section 202 Section 202 Section 236
Number of units 140 200 250
Residents’ age Under 75: 42%
75–84: 40%
85 and over: 19%
Under 75: 52%
75–84: 38%
85 and over: 10%
Under 75: 11%
75–84: 31%
85 and over: 58%
Residents’
race/ethnicity
Latino: 29%
White: 51%
Black: 30%
Asian: 0%
Native Hawaiian: 0%
American Indian: 0%
Other: 6%
Latino: 4%
White: 17%
Black: 80%
Asian: 2%
Native Hawaiian: 1%
American Indian: 7%
Other: 0%
Latino: 0%
White: 96%
Black: 2%
Asian: 1%
Native Hawaiian: 0%
American Indian: 0%
Other: 1%
Mean time in property (range) 6.9 years
(6 months–30 years)
7.2 years
(6 months–26 yrs)
4.5 years
(6 months–21 years)
* Residents’ characteristics represent those residents who participated in the self-administered survey (Property 1, n=53,
response rate=35%; Property 2, n=96, response rate=49%; Property 3, n=100, response rate=36%).

89Cityscape
Aging in Place Partnerships:
A Training Program for Family Caregivers of Residents Living in Affordable Senior Housing
Family caregivers of residents in the three pilot sites were recruited through a variety of mecha-
nisms. Invitation letters were distributed to every resident living at the property to pass on to their
family members and flyers were posted in prominent areas throughout the properties. In addition,
the service coordinators contacted family caregivers to inform them of the program and also
provided names of family caregivers to the research team who then contacted the caregivers and
invited their participation.
Several activities were conducted on the properties to help inform the development of the
program, including interviews with five service coordinators (n=5), focus groups with a total
of 30 residents, and focus groups with a total of 25 family caregivers of residents. In addition,
self-administered surveys were conducted with residents in the participating housing properties
(response rate=35 to 49 percent across the three properties) and with family caregivers recruited
to participate in the program (response rate=70 percent). By combining the data gathered during
these activities with the research on family caregiving and the program teams’ prior experience
in developing family caregiver-training programs, a workshop curriculum was developed. The
program and the components of the workshop curriculum are detailed later in the article.
Family caregivers of residents in each of the housing sites were recruited (n=56) to participate in
the pilot program and were randomly assigned to either an intervention group or a control group.
Those in the intervention group subsequently attended the caregiver-training workshop, which
was held in each of the three pilot sites.
A post-training survey was sent to all family caregiver participants (both intervention and control
group) approximately 6 months after the completion of the caregiver-training workshops to attempt
to gauge what effect the workshop may have had on the attendees. The small number of surveys
returned for both groups, however, was insufficient to draw meaningful statistical conclusions.
The Need for and Status of Family Caregiving in Affordable
Senior Housing Properties
Little is known about the health and functional characteristics of residents of affordable senior
housing properties. To better understand the residents’ potential support needs and therefore the
type and degree of engagement that may be required of a family caregiver, the self-administered
resident questionnaire included questions about their physical health and functional status.
Because no previous study has examined family caregiving in affordable senior housing properties,
the program team also attempted to understand the level and intensity of caregiving that was
occurring at the pilot sites.
Resident Health and Functional Needs
Of the residents who answered the questionnaire, 60 percent reported they were in good to excellent
health, but 40 percent perceived their health as fair to poor. Residents were asked to self-report
specific health conditions or problems they were experiencing. Exhibit 2 shows that the most com-
monly reported health conditions across the three properties were high blood pressure (65 percent
of all respondents), arthritis (51 percent), heart problems (30 percent), and diabetes (26 percent).

90 Aging in Place
Sanders, Stone, Meador, and Parker
Because individuals suffering from multiple health conditions tend to have more complex health
and supportive care needs, the program team examined the proportion of residents experiencing
multiple conditions. As shown in exhibit 3, nearly one-half of the residents across the three
properties reported experiencing three or more of the health conditions listed in exhibit 2.
Residents were also asked about their functional status to help understand the levels and types
of disabilities residents are experiencing and the need for assistance to compensate for functional
limitations. Exhibit 4 presents the proportion of residents reporting functional limitations.
Functional limitations are classified into two categories: limitations in activities of daily living
(ADLs), such as eating, bathing, dressing, getting in and out of bed, and using the toilet, and
limitations in IADLs, such as preparing meals, managing money, shopping, doing housework, and
using a telephone. Across the three properties, slightly more than one-half of the residents reported
needing assistance with one or more IADL and one-third need assistance with one or more ADL.
Exhibit 2
Exhibit 4
Exhibit 3
Property 1 (%) Property 2 (%) Property 3 (%) Combined (%)
Property 1 (%) Property 2 (%) Property 3 (%) Combined (%)
Property 1 (%) Property 2 (%) Property 3 (%) Combined (%)
Health Conditions Reported by Residents
Residents Reporting Functional Limitations
Residents Reporting Multiple Health Conditions
Glaucoma 17.0 16.1 19.8 17.8
Wear hearing aid 7.6 7.5 31.3 16.9
Diabetes 24.5 40.8 12.5 26.0
Cancer 5.7 10.8 15.6 11.6
Lung disease 9.4 6.4 8.3 7.8
Heart problem 30.2 30.9 28.1 29.6
Psychiatric problem 7.5 7.5 10.4 8.6
Arthritis 50.9 51.1 51.0 51.0
High blood pressure 45.3 81.9 57.9 64.5
Chronic pain 18.9 24.5 27.1 24.3
ADLs
No limitations 73.6 66.3 62.0 66.5
One limitation 15.1 11.2 19.0 15.3
Two or more limitations 11.3 22.5 19.0 18.2
IADLs
No limitations 52.8 47.2 47.0 48.4
One limitation 11.3 10.1 7.0 9.1
Two or more limitations 35.9 42.7 46.0 42.5
No health conditions 18.9 3.2 9.4 9.1
1 to 2 conditions 41.5 45.9 39.5 42.4
3 or more conditions 39.6 50.9 51.1 48.5
Columns do not total 100 percent because residents may have reported multiple health conditions.
ADLs = activities of daily living. IADLs = instrumental activities of daily living.
Columns total 100 percent for ADLs and for IADLs.
Columns total 100 percent.

91Cityscape
Aging in Place Partnerships:
A Training Program for Family Caregivers of Residents Living in Affordable Senior Housing
The residents’ health and functional status information suggests a large proportion living in
independent housing have chronic conditions and/or functional limitations that put them at risk
for falls, increased emergency department use, preventable hospital stays, and nursing home
placement. Families and service coordinators face these concerns as they attempt to help elderly
residents remain in their apartments and communities. These data also provide insight into the
types of interventions that could be achieved through partnerships between the families and properties.
The Level of Family Caregiving Occurring in Affordable Senior Housing Properties
The extent of family caregiving involvement with residents in the housing sites was influenced by
how the residents came to reside in the properties. In Property 1, several residents had relocated
to the area when they were younger for professional reasons and many did not have family in the
area. In Property 2, many residents were native to the community and their families also lived in
the area. In Property 3, most residents had relocated to the area late in life to be closer to their
children. In the resident self-administered survey, 59 percent of residents in Property 1 reported
they had family in the area that could assist them when needed compared with 79 percent in
Property 2 and 89 percent in Property 3.
Service coordinators at all three properties reported that they see a range of family member
engagement, from those who visit residents regularly and frequently to those who come occasion-
ally and those who never visit. In one property, the service coordinator estimated that one-fourth
to one-third of residents have a high level of involvement with their family. In another, the service
coordinator estimated approximately 35 percent of residents have families that are actively engaged
and consistently at the property every week.
Residents were asked in the survey about the level of interaction they have with their family
members and the type of assistance they typically receive from them. As exhibit 5 shows, almost
one-half of the resident respondents across the three properties have family members call them
daily and 38 percent receive a call weekly. In addition, 18 percent receive daily visits from a family
member and 42 percent have a weekly visit.
Exhibit 5
Property 1
n=44 (%)
Property 2
n=90 (%)
Property 3
n=97 (%)
Combined
n=231 (%)
Resident and Family Member Interaction
Call
Daily 36.4 50.0 50.5 47.6
Weekly 38.6 36.7 38.1 37.7
Monthly 18.2 8.9 9.3 10.8
Less than monthly 2.3 3.3 1.0 2.2
Never call 4.5 1.1 1.0 1.7
Visit
Daily 19.5 25.0 11.5 18.2
Weekly 29.3 35.2 54.2 42.2
Monthly 17.1 25.0 16.7 20.0
Less than monthly 22.0 11.4 14.6 14.7
Never visit 12.2 3.4 3.1 4.9
Columns total 100 percent for calls and for visits.

92 Aging in Place
Sanders, Stone, Meador, and Parker
Family caregivers who participated in the pilot program were also surveyed about the frequency
of assistance they provide their family member living at the participating housing sites. Of those
surveyed, 18 percent said they assist daily and 44 percent said they help their family member
multiple times each week. Nearly all family caregivers talk with their family member on the phone
either daily (49 percent) or multiple times a week (46 percent).
Residents were also asked to describe the intensity of assistance they receive from their family
members. As exhibit 6 shows, one-fourth of respondents reported receiving “considerable assistance”
from their family members. Almost one-third reported that they “do not need assistance”; however,
it should be noted that, later in the survey, many of these residents described the types of assistance
their family members provide them. When asked how they felt about the level of assistance they
receive from their family members, 80 percent of respondents felt they receive “just the right
amount,” but 18 percent wished they received “more assistance.”
Residents reported receiving assistance from their family members in several areas. As exhibit 7
shows, the most frequent areas of assistance included transportation (53 percent), shopping or
running errands (49 percent), companionship (37 percent), arranging medical care and communi-
cating with doctors (33 percent), and tracking bills or other financial matters (33 percent). In focus
Exhibit 6
Exhibit 7
Property 1
n=45 (%)
Property 2
n=87 (%)
Property 3
n=93 (%)
Combined
n=224 (%)
Property 1
n=40 (%)
Property 2
n=76 (%)
Property 3
n=87 (%)
Combined
n=203 (%)
Intensity of Assistance From Family Members
Areas of Assistance From Family Members
Do not provide assistance 18.2 14.9 8.6 13.0
Limited assistance 11.4 10.3 21.5 15.2
Moderate assistance 13.6 16.1 18.3 16.5
Considerable assistance 13.6 27.6 26.9 24.5
I do not need assistance 43.2 31.0 24.7 30.8
Transportation 26.8 63.2 57.5 53.4
Shopping or running errands 25.0 60.5 49.4 48.8
Housekeeping/laundry 15.0 18.4 13.8 15.8
Preparing meals 12.5 19.7 4.6 11.8
Personal care needs 5.0 10.5 3.4 6.4
Managing medications 5.0 11.8 14.9 11.8
Arranging medical care/communicating
with doctors
20.0 26.3 44.8 33.0
Tracking bills or other financial matters 12.5 29.0 46.0 33.0
Financial assistance 22.5 18.4 17.4 18.8
Finding and applying for benefits and
services programs
5.0 18.4 18.4 15.8
Companionship 35.0 31.6 43.7 37.4
Social activities 30.0 31.6 24.1 28.1
Columns total 100 percent.
Columns do not total 100 percent because residents may have reported multiple areas of assistance.

93Cityscape
Aging in Place Partnerships:
A Training Program for Family Caregivers of Residents Living in Affordable Senior Housing
groups with residents, many participants stated they were getting a great deal of assistance from
their family members, but some had family who were not as active. Some participants noted that
their children were working and caring for their own children, and they appreciated that they did
not always have a great deal of time to spend with them.
Family caregivers participating in the program also reported assisting their family members with a
variety of activities. More than one-half of respondants said they are assisting their family member
with six or more tasks. The most common areas in which family caregivers reported providing
assistance include socializing, transportation, running errands, monitoring medical care, and
managing bills and other paperwork. Discussion in the focus groups with family caregivers echoed
that many are providing their family members with an extensive level of support. Some visit daily
or multiple times per week to prepare meals, handle household chores, pick up and monitor
medications, handle financial obligations, manage and take their family member to medical
appointments, shop for or take their family member shopping, and provide companionship. Some
family caregivers’ description of their family member and the level of assistance they are provid-
ing them illustrate that their family member would likely be unable to remain in “independent”
housing without their continued support.
Informing the Development of the Workshop Curriculum
To help inform the content of the family caregiver-training program, the program team gathered
information from the surveys completed by the residents and family caregivers and from the
interviews and focus groups with service coordinators, family caregivers, and residents. Key
findings from the team’s analyses are summarized in the following paragraphs.
Issues Experienced in the Caregiving Relationship
Service coordinators in the pilot sites were asked about the nature and magnitude of the issues they
see residents and family caregivers experiencing in their interactions with each other. Residents
and family caregivers participating in the focus groups were also asked about their experiences in
their caregiving relationship. Several dynamics were revealed.
Service coordinators believed family caregivers and residents experience tensions over the evolving
roles and boundaries between each other. Some family caregivers, the service coordinators believe,
are reluctant to step in and do things for their family member because that is not their traditional
role in the relationship. They feel uncomfortable telling their family member how to act and are
concerned about violating their privacy; these issues become even more prominent as the resident’s
abilities decline. The service coordinators also reported that residents and family caregivers experi-
ence conflicts between the giving and receiving of care.
Participants in both the resident and family caregiver focus groups echoed these challenges.
Parents and children frequently mentioned they are experiencing a role reversal in which the child
is now acting as the parent and vice versa. Other caregivers, however, were unable or unwilling to
assume any power in the relationship, and were constantly bending to the demands of their family
members. Some caregivers spoke of how their older family member may be in denial of or embar-
rassed by their changing conditions and are unwilling to ask for and/or accept help or change their

94 Aging in Place
Sanders, Stone, Meador, and Parker
habits and practices. Several family caregivers described balancing their desire to preserve their
family members’ ability to make their own decisions while taking responsibility for their safety and
the safety of those around them.
Service coordinators also believed that some family caregivers are in denial of their family mem-
ber’s physical or mental decline and do not understand how their functioning will change as they
age. Family caregivers want their family members to continue to act and behave as they always
have—getting dressed every day, enjoying cooking, socializing frequently, walking at a reasonable
pace, etc. Service coordinators thought that caregivers sometimes believe their family member is
“being difficult,” or they may be unwilling or unable to recognize that a change in behavior may be
a sign of a health-related problem.
Service coordinators observed that family caregivers often have their own responsibilities that can
make it difficult to help their family members, especially those needing a greater level of assistance.
Many caregivers are employed and have their own families to care for, making it challenging to
find adequate time to assist with their family members’ needs.
Service coordinators thought that family caregivers in general had limited knowledge about the
services available in the community. The survey of family caregivers participating in the pilot
program supported this perception. Although about one-fourth were “mostly” or “very” aware of
the resources available in the community that could potentially help meet their family members’
needs, 62 percent were only “somewhat aware” and 12 percent were “not at all aware.”
Service coordinators were asked about the areas in which they thought family caregivers needed
additional knowledge and skills to enhance their caregiving capacity. Coordinators believed family
caregivers need a better understanding of the aging process and how that process would affect their
family member’s physical and mental health and functional status. Service coordinators thought
family caregivers often lose patience with family members who may be experiencing a decline and
think the family member is “being difficult” or stubborn. Coordinators thought family caregivers
need to understand how these changes would affect their ability and desire to partake in their daily
tasks and hobbies. They also need to recognize when a change in behavior may be the sign of a
health-related issue that needs to be addressed.
Service coordinators also believed family caregivers need to be taught about handling a resident’s
transition back to their apartment after a hospital stay. Family caregivers often do not know what to
ask of the physicians and discharge planners to ensure their family member is, in fact, ready to return
home. Coordinators thought that the elderly relative or the family caregiver do not have the neces-
sary knowledge and resources to successfully manage post-hospitalization care. Service coordinators
also believed family caregivers need greater awareness in the area of medication management. They
thought some need to have better oversight of the resident’s medication regimen and recognize that
changes in physical and mental health can be related to complications with medications.
Family Caregivers’ Perceptions of Their Caregiving Role and Experience
Family caregivers participating in the pilot program were asked in the survey and in focus groups
about their perceived role and experiences as a caregiver. Some family caregivers did not identify
themselves as “caregivers.” In fact, during the focus groups, several caregivers asked why the

95Cityscape
Aging in Place Partnerships:
A Training Program for Family Caregivers of Residents Living in Affordable Senior Housing
program team was asking them about the assistance their family members needed or that they
provided because their family members lived in “independent” living properties. The resulting
perception was that they were therefore not caregivers to their family members.
In addition to asking the family caregivers what types of assistance they provided their family
members, the survey also asked caregivers about their use of community services and resources
to meet their family members’ needs. When asked how often they or their family members access
services from the community, 61 percent said “rarely” or “never.” Among the family caregivers who
answered rarely or never, the top reasons given for why they do not access outside services were:
“I can take care of my family member’s needs on my own” (48 percent), “my family member won’t
let anyone other than me assist them” (33 percent), “we can’t afford to purchase services”
(24 percent), and “I’m not aware of available services” (24 percent).
During the focus groups, several family caregivers also spoke of how it was their “duty” to assist
their family member. They believed that because their family member had raised them, it was now
their obligation to help their family member. Some family caregivers also said they were the only
person their family member would allow to assist them; their family member was reluctant to have
strangers entering their apartment or knowing the details of their lives. A handful of participants,
particularly those who appeared to be newer caregivers, seemed unaware of the community
resources that could possibly help their family member.
The survey also asked family caregivers about the effect their caregiving experience has had on
them personally (see exhibit 8). In general, the respondents did not feel overwhelmingly stressed
or burdened by their caregiving relationship, although a sizable proportion did indicate that they
were sometimes strained by their responsibilities.
Several family caregivers participating in the focus groups initially indicated they were not
burdened by their caregiver role. As the discussions progressed, however, many began to reveal
Exhibit 8
Never/Rarely
(%)
Sometimes
(%)
Frequently/Always
(%)
Feelings About Family Caregiving Experience (n=38)
Do you feel that because of the time you spend
with your family member that you don’t have
enough time for yourself?
55.9 41.2 2.9
Do you feel stressed between caring for your
family member and trying to meet other
responsibilities for your family or work?
44.2 47.1 8.8
Are you afraid of what the future holds for your
family member?
26.6 41.25 32.3
Do you feel strained when you are around your
family member?
41.2 47.1 11.7
Do you feel your health has suffered because of
your involvement with your family member?
84.85 15.2 0
Do you feel you should be doing more for your
family member?
32.4 50.0 17.6
Do you feel burdened by caring for your family
member?
58.9 35.29 5.8

96 Aging in Place
Sanders, Stone, Meador, and Parker
the frustrations and challenges they experience in their caregiver relationship. As noted previously,
several participants believed it was their duty to care for their family member and may have felt
they were not allowed to feel burdened by the role. Most participants had never discussed their
experiences before, and the conversation with other family caregivers seemed to provide a comfort-
able opportunity for them to reveal their thoughts and feelings.
Family caregivers also expressed that, although the rewards of caregiving were obvious when they
started assisting their family member, rewards became harder to find over time as the interaction
shifted from being predominantly social to more indepth caretaking. Some respondants noted their
fear of the future for both themselves and their family members. About one-third of respondants
said they are frequently or always afraid of what the future holds for their family member. They are
concerned about how their family member may continue to decline over time and what they, in
turn, will have to juggle or drop in their own lives to meet their family member’s greater demands
and needs. Several caregivers were also very anxious about the possibility of their family member
eventually moving to a nursing home; some said they would never allow it. In their opinions,
nursing homes were bad places, and it seemed they perceived their family member moving to a
nursing facility as a sign of their own failure as a caregiver. In some instances, the family member
had told the caregiver they would never go to a nursing home. In other instances, however, the
family member had told them they would go to a nursing home when necessary, but the family
caregiver could not envision allowing the move to happen.
Interaction Among the Housing Properties, Service
Coordinators, and Family Caregivers
The family caregiver survey asked caregivers about their expectations of the housing property
concerning their family members’ needs for services and supports as they age. As exhibit 9 shows,
nearly two-thirds of respondents expect the housing property “to tell my family member or me
about services that might help my family member.” More than one-fourth of participants, however,
said, “I have no expectations of them; this is an independent living property.”
About three-fourths of survey respondents are aware of the service coordinator and in an open-
ended question described the role as providing information on service and resources, helping
arrange and coordinate services, or just generally “helping.” Approximately one-fourth of respon-
dents are either not aware of the service coordinator or do not know what they do.
Exhibit 9
Expectations of the Housing Property
Caregivers Who Selected
the Expectation (%)
Expectations of the Housing Property (n=38)
I have no expectations of them; this is an independent living property 26.5*
To check on my family member and alert me when there are problems 47.1
To tell my family member or me about services that might help my family
member
64.5
To help arrange for the services my family member needs 38.2
To provide my family member the assistance they need 14.7
I don’t know 2.9
* Percentages do not total 100 percent because respondents were allowed to select multiple answers.

97Cityscape
Aging in Place Partnerships:
A Training Program for Family Caregivers of Residents Living in Affordable Senior Housing
Of the family caregivers who were asked how often they approach the service coordinator for
information or advice regarding their family member, 62 percent said “never” or “rarely” and
32 percent said “sometimes.” Of those respondents who said rarely or never, 59 percent said, “I
generally already know how to take care of my family member’s needs” and almost one-fourth
said, “I can figure out the answer on my own.” Feedback from the service coordinators concerning
their level of interaction with family caregivers reflected the survey responses. Although some
family caregivers approach service coordinators frequently, coordinators said many never approach
them. Service coordinators believe family caregivers see the properties as apartment complexes and
do not expect property staff to assist them with issues related to caring for their family member.
Family caregivers confirmed this perspective in the focus groups. Several participants said they do
not expect housing property staff to assist them or their family member because it is “independent
living.” Service coordinators also said family caregivers often do not approach them until a crisis is
occurring and often have had no prior connection with them until the crisis.
When asked how much of a resource they consider the service coordinator to be with respect to
helping to meet their family member’s needs, 24 percent of survey respondents find them “some-
what helpful” and 36 percent find them “very helpful.” One-third, however, said they “never” ask
the service coordinator for help. Family caregivers gave little indication that it was challenging for
them to talk with the service coordinator about their family member’s needs, with only 6 percent
saying it is “very” or “somewhat” difficult. When asked if they believe the housing property and/
or service coordinator can play a role in helping them meet their family member’s changing needs,
approximately one-third reported “definitely” and just less than one-half said “somewhat.”
The Family Caregiver Program and Workshop Curriculum
The program team used the previously described findings, information gleaned from a literature
review of family caregiver training programs, and their collective experience in developing and
testing family caregiver training programs in other settings to develop the format for the training
program and the specific curriculum content.
Assumptions
The program team started with two assumptions about the caregiver-training program. It became
evident that both of these assumptions needed to be reexamined. The first assumption was that
the workshop curriculum would be adapted from an existing caregiver-training program called
Partners in Caregiving (PIC). PIC is a successful program that was initially developed to train
nursing home staff

and family caregivers about communication techniques and conflict resolution

skills and has been adapted for other care settings. As a result of the data gathered from service
coordinators, residents, and families, however, it became clear that PIC was not appropriately
adaptable for affordable housing communities. This conclusion was based on observed differences
in the nature of the settings, the relationships between the housing staff and the family caregiv-
ers, and the types of issues experienced in the relationship between residents and their family
caregivers. Because housing properties are intended for “independent” living, the property staff’s
responsibility for residents, and thus the power relationship between property staff and family
caregivers, is quite different from nursing home settings where the staff is responsible for residents’

98 Aging in Place
Sanders, Stone, Meador, and Parker
care. Thus, in an independent living setting, the level of tension and conflict between housing staff
and family caregivers is minimal. In addition, family caregivers of housing property residents are in
a much more active caregiving role because the housing property is not responsible for caring for
the resident. Family caregivers are playing a lead role in ensuring the residents get their needs met.
They must be much more knowledgeable about how to assist their family member and how to deal
with a variety of issues in their caregiving relationship.
The “independent” nature of the housing properties was a recurring subject of discussion in the
service coordinator interviews and the family caregiver focus groups. Service coordinators believed
their role is to support the resident in meeting their needs and by doing so become an advocate
for the resident. In some instances, they thought the advocate-resident relationship could result
in conflict during interactions with family caregivers. They also respect residents’ privacy and,
therefore, may know little about the resident and their family caregivers if the caregivers do not
seek out the service coordinator. Several family caregivers did not identify themselves as “caregiv-
ers” because their family member lived in “independent” housing and many did not expect the
housing properties to help support their family member because it was “independent” living.
For both groups, however, the goal was to help residents remain in their own apartments and to
ensure that residents remained active decisionmakers in their own lives.
It became clear that the program’s focus was not easing tensions between family caregivers and
property staff; rather, the focus was building mutual understanding between caregivers and
property staff to reinforce residents’ ability to safely age in place. Family caregivers contribute their
time and knowledge of the resident while service coordinators contribute their technical expertise
of available resources and services.
The second assumption was that the program would use a train-the-trainer model in which the
service coordinators in the housing property would be trained to deliver the caregiver-training
workshop and then would conduct the workshop with family caregivers. With their expertise on
available services and resources and established community relationships, service coordinators play
a key role in helping residents meet their needs. Because one goal was to enhance family caregivers’
use of this expertise, the program team thought it logical for service coordinators to conduct the
caregiver-training workshops both because of their expertise and to help establish a connection
between the two groups. A train-the-trainer curriculum was developed and the service coordina-
tors participating in the program attended a daylong, train-the-trainer workshop.
When the time came to conduct the actual caregiver-training workshops, however, it became
apparent that the participating service coordinators did not feel entirely comfortable in this
teaching role. Service coordinators may feel uneasy delivering the workshop for multiple reasons.
The background and training of service coordinators are quite varied, ranging from those without
college degrees to those with master’s degrees. Although they may be knowledgeable about services
and perform one-on-one education, many may not have prior experience working with family
caregivers or delivering group training. The service coordinators in the pilot program viewed
themselves primarily as advocates for the residents and seemed to express a concern that interact-
ing with family caregivers in this way may conflict with this role. Service coordinators are also
generally managing a large number of residents and may feel they do not have the time to take on
an additional program that is not directly focused on residents. In addition, not all senior housing

99Cityscape
Aging in Place Partnerships:
A Training Program for Family Caregivers of Residents Living in Affordable Senior Housing
properties have service coordinators who could deliver the workshop. Although the family caregiv-
ers of residents living in properties without service coordinators could benefit from enhancing their
caregiving skills and knowledge, some formal entity would have to be hired or partnered with to
deliver a training program such as the one developed for this pilot.
Recognizing the lack of willingness among the three pilot service coordinators to deliver the training,
the program team members themselves conducted the workshops in each of the three pilot housing
sites. Given the small number of sites in the pilot, it is not clear that all service coordinators would
be unwilling to deliver the workshop. Exploring alternative methods for delivery of the workshop,
however, will be the next phase in the refinement of the curriculum and delivery process.
The Curriculum
When developing the workshop curriculum, the program team considered all the information that
had been gathered through the service coordinator interviews and resident and family caregiver
focus groups. The team was also mindful of the family caregivers’ time constraints and tried to
keep the program length at a span that would not be overwhelming. The final program consists of
two 2-hour sessions. The intention is to deliver the sessions on different days; however, it is pos-
sible to deliver them in a single, longer session. The sessions are designed to be interactive, asking
for input from participants and incorporating role-playing activities to practice the knowledge and
techniques being taught.
Session one, entitled Understanding Aging in Place, focuses on helping the family caregiver
understand and build empathy for the challenging tasks that residents and caregivers face. The
session addresses the changes and needs that accompany the aging process, the changing role of
the caregiver in relation to those needs, and self-care strategies to help cope with the stress of the
caregiving role. Session two, entitled Helping My Resident Age in Place, focuses on helping the family
caregiver identify specific resources and strengthen specific skills that can help support their family
member. The session covers the roles of the service coordinator and housing property and how
they can work together with the family caregiver to better understand their family member’s needs
and the available services and resources to help meet those needs and to improve communication
skills to enhance positive interaction with their family member.
Satisfaction With Family Caregiver-Training Workshops
According to results from workshop evaluations, participants were overwhelmingly satisfied with
the family caregiver-training workshops. Two-thirds gave them an overall rating of excellent
and one-third said they were good. When asked how prepared they now felt to help their family
member age in place, nearly all participants said they felt well prepared or very well prepared. One
participant felt only somewhat prepared but also noted that he had picked up tools in the work-
shop that he is ready to try. All participants said they would recommend the workshop to others.
Asked what they liked most about the workshop, several participants said they appreciated that
they picked up new ideas and techniques to address some of the challenges they face in assisting
their family member. Participants also liked the role-playing exercises, which gave them the

100 Aging in Place
Sanders, Stone, Meador, and Parker
opportunity to practice applying what was taught in the workshop to issues they may face with
their family member. Several participants also noted that they appreciated the dialogue with other
participants and learning that they share common challenges and concerns and that they are not
alone in their caregiver experience.
Discussion
The program team’s conversations and surveys conducted with service coordinators, family care-
givers, and residents affirmed the need for a training program for family caregivers of affordable
senior housing residents. Clearly, both service coordinators and family caregivers are providing a
tremendous level of support and assistance to the residents in these settings. Although the health
and frailty levels of residents range across the properties, a number of residents need a great deal
of assistance and would likely be in nursing homes were it not for the support they are receiving,
primarily from family caregivers.
Family caregivers do appear to lack awareness of available services and resources in the community
and, sometimes, at the housing property. Although many feel they can take care of their family
member’s needs on their own, they recognize that a time may come when they need to access
outside services. Caregivers may also benefit from beginning to accept that it is permissible for
them to accept assistance and that they are not obligated to do everything for their family member.
Family caregivers also have to navigate difficult terrain in terms of accepting and adapting to the
changes in their family member’s condition and abilities, while at the same time helping their
family members come to terms with their declining independence. Family caregivers can benefit
from additional skills in handling these difficult conversations.
It also appears that, in many cases, family caregivers and services coordinators are not regularly
communicating with each other. As a result, they are not sharing their respective knowledge
and resources and may not be minimizing burdens on themselves or maximizing the success
they could have if they worked more cooperatively. For example, family caregivers sometimes
must have difficult conversations with their family member that touch on the resident’s loss of
independence. Caregivers may have to convince family members to stop a certain behavior, accept
assistance in particular areas, or discuss the potential need to move to a higher level of care. Service
coordinators participating in the pilot reported they can “play the bad guy” in these discussions
and help preserve the relationship between the resident and family caregiver. Service coordinators
may also have the expertise to identify behaviors or actions that are actually the result of a medical
problem that can be overcome, or they may be aware of resources for additional support that
might limit the effect on the family member or forestall a need to move to a higher level of care.
The dynamic interaction between the family caregivers who came together in the program was
surprising. It seemed several of the participants did not appreciate that they needed an outlet for
talking about their caregiver experiences and challenges before attending the focus groups, but
they highly valued the opportunity to share their thoughts and feelings. Many family caregivers as-
sumed natural peer-mentor roles during the focus groups, giving other participants advice on how
to deal with their issues. When the focus groups ended, participants asked when the group would
meet again and many lingered to talk with each other. None of the family caregivers in the focus

101Cityscape
Aging in Place Partnerships:
A Training Program for Family Caregivers of Residents Living in Affordable Senior Housing
groups had met before and almost all said they did not know other resident family caregivers, aside
from seeing people around the building.
In one workshop, the participants noted that they made up a natural support network because of
the commonality they share of having a resident in the property and the desire for that resident
to remain there. The group could be an opportunity to voice frustrations and challenges and to
share information and solutions they have learned that might help each other. Other participants
expressed concern for the residents in the properties who did not have family members to help
them. Building a family network could possibly bring additional resources to the property assist
these residents on occasion or provide other supports to the property.
One challenge in implementing the caregiver-training program is identifying the family caregivers
who are less engaged with their family member. An initial goal of the program was to develop a
training program that would encourage less active caregivers to increase and enhance the assistance
they are currently providing to better meet the needs of their family member. An attempt was
made to recruit minimally engaged family caregivers to participate in the pilot program; however,
the program team was unsuccessful in this effort. It may require a more targeted appeal from a
service coordinator or property staff to entice this type of caregiver. Perhaps the creation of family
caregiver peer groups that are active in the property could serve as an avenue for engaging these
less engaged family caregivers over time.
Another challenge is identifying the most appropriate trainers to deliver the curriculum. This
research found that the service coordinators in the pilot sites were not comfortable in the train-
ing role, in part because they were concerned that training families might conflict with their
responsibility as advocates for the residents. The coordinators also, however, did not believe they
had the skills to conduct the training. As the curriculum development moves from the pilot to the
refinement phase, decisions about who should do the training, including whether the curriculum
should be delivered by an independent third party, need to be addressed.
Next Steps
Given that nearly 2 million older individuals currently reside in some type of subsidized housing
and many are receiving some type of support from family caregivers, this program has the potential
to reach a large group of caregivers and elderly residents. The development and dissemination of
a successful caregiver-training program could significantly improve the ability of senior housing
properties to help their elderly tenants remain in their own homes by minimizing the need for
evictions and avoiding more costly transfers to assisted-living facilities or nursing homes. As
senior-housing providers experience the aging of their residents and are struggling to meet the
needs of an increasingly frail and disabled resident population, supporting family caregivers and
strengthening their partnerships with service coordinators may help make “aging in place” a reality
for many older adults in communities across the country.
Several next steps have been identified for this program. The program team would like to further
refine the caregiver-training workshop curriculum based on the experience of testing the pilot
program, feedback from participants, and suggestions from an expert advisory group that was
assembled to help guide the dissemination of the program. As part of this process, the team wants

102 Aging in Place
Sanders, Stone, Meador, and Parker
to explore potential community partners for delivery of the training and diffusion of the program.
One possibility includes developing a partnership with local area agencies on aging that are already
experienced with providing caregiver-training and support programs and with working with senior
housing properties. Other potential collaborators include local community groups such as AARP
chapters, Red Cross chapters, senior centers, social service organizations, or care managers. These
groups represent entities that may already be offering family caregiver-training programs, and
partnering with senior housing properties can provide an efficient mechanism for reaching a large
group of family caregivers and retaining their participation. After refining the workshop curriculum
and exploring different possibilities for disseminating the program, the program team would like to
conduct further evaluation to measure the effect of the program on the participating entities.
Acknowledgments
The authors acknowledge the generous funding from the Langeloth Foundation in support of the
development and testing of this training program. They also thank the service coordinators and
family members who took time out of their busy schedules to participate in the focus groups and
pilot training.
Authors
Alisha Sanders is a senior policy research associate at the Institute for the Future of Aging Services,
American Association of Homes and Services for the Aging.
Robyn Stone is the executive director of the Institute for the Future of Aging Services and senior
vice president for research at the American Association of Homes and Services for the Aging.
Rhoda Meador is the associate director for Extension and Outreach, New York State College of
Human Ecology at Cornell University.
Victoria Parker is an associate professor, Boston University School of Public Health, Boston
University School of Medicine, and a research scientist at the Center for Organization, Leadership
and Management Research, VA Boston Healthcare System.
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105Cityscape: A Journal of Policy Development and Research • Volume 12, Number 2 • 2010
U.S. Department of Housing and Urban Development • Office of Policy Development and Research
Cityscape
Real Estate Brokers’ Duties
to Their Clients: Why Some
States Mandate Minimum
Service Requirements
Anupam Nanda
University of Reading
Katherine A. Pancak
University of Connecticut
Abstract
This study attempts to determine why certain states have adopted real estate broker
minimum service laws in the United States. The federal government and academic lit-
erature assume that such laws were the result of anticompetitive industry collusion and,
therefore, serve no consumer protection justification. Using hazard models and state data
over 8 years, however, we find that factors reflecting state brokerage influence—strong
industry associations and broker membership on licensing boards—do not result in the
enactment of minimum service laws. Factors suggesting consumer protection motiva-
tions—greater number of complaints against brokers, stricter prelicensing requirements,
and a Democratic state legislature—increase the likelihood of law adoption.
Introduction
Ten states have recently enacted laws requiring a real estate broker
1
to provide a real estate con-
sumer (buyer, seller, landlord, or tenant) with a minimum level of services, including requirements
to help negotiate, to present and receive offers, and to answer questions. The U.S. Department of
Justice (DOJ) Antitrust Division and the U.S. Federal Trade Commission (FTC) both oppose these
1
In most states, a “broker” enters into an agency agreement with a client, and a “salesperson” works for a broker. Both bro-
kers and salespersons who represent a client are “agents” of the client. Both also need to be licensed by their state to engage
in the real estate business and, if licensed, are also referred to as “licensees.” Throughout this article, we use the term broker.

106 Refereed Papers
Nanda and Pancak
types of requirements on the grounds that they are anticompetitive, and both agencies lobbied
heavily against state enactment. These types of laws are deemed anticompetitive, primarily because
they prevent a limited-service real estate broker from contracting with a seller to provide only
access to the brokerage multiple listing services (MLSs) for a flat fee.
The purpose of this article is to determine what factors might have compelled states to enact minimum
service laws despite significant federal government opposition. The analytical structure employs
hazard models, which use a unique and rich set of economic and institutional data for the housing
market in a yearly panel of the 50 states and the District of Columbia from 2000 through 2007.
According to this analysis, the strength of state industry associations and the presence of brokers
on state licensing boards both have a negative influence on the likelihood that state minimum
service laws will be adopted. State-level complaints against licensed brokers, Democratic control
of the legislature, stricter prelicensing requirements, and greater population growth have a positive
influence on the likelihood that state minimum service laws will be adopted.
Following this introduction, this article is divided into seven sections. The first section discusses
previous literature on minimum service laws for real estate brokers. The second section reviews
the various categories of minimum service laws and considers the legislative backgrounds of
states that have passed laws that require brokers to provide consumers with a minimum level of
services. The theoretical hypotheses about the probability that a state will pass minimum service
laws are discussed in the third section. The institutional and economic variables that influence the
enactment of minimum service laws are introduced in the fourth section. The fourth section also
contains hypotheses concerning the relationships between minimum service law adoption and
selected independent variables. The fifth section presents the empirical method used in this study.
The sixth section analyzes, compares, and contrasts the results obtained from different model
specifications. The final section is a summary of findings from this study, which offer potential
state legislative policy trends.
Previous Literature
A report, Competition in the Real Estate Brokerage Industry, compiled and published by the FTC and
DOJ in April 2007 (FTC and DOJ, 2007), addresses the effect of minimum service requirements
on brokerage competition and defines minimum service requirements as “laws and regulations
that enumerate specific tasks that a broker must perform for a client.”
2
Missouri brokerage law is
used as an example. In Missouri, all brokers entering into an exclusive brokerage agreement must
(1) accept delivery of and present offers and counteroffers to clients and customers; (2) help clients
and customers develop, communicate, negotiate, and present offers, counteroffers, and disclosure
notices; and (3) answer clients’ and customers’ questions relating to offers, counteroffers, disclosure
notices, and contingencies.
2
It is important to distinguish between minimum service laws that increase the brokerage services a consumer must
purchase as opposed to laws that define the special agency relationship between a broker and client. Many states have
provisions codifying common law agency fiduciary duties of obedience, loyalty, disclosure, confidentiality, accounting, and
reasonable care; these types of laws are not considered minimum service laws.

107Cityscape
Real Estate Brokers’ Duties to Their Clients:
Why Some States Mandate Minimum Service Requirements
The DOJ and FTC strongly assert that such minimum service requirements are anticompetitive
because they reduce a consumer’s choice of real estate brokerage services, force real estate consum-
ers to buy services they may not want, and block limited-service brokers from offering less than a
full package of real estate brokerage services. Although the report considers the claims of support-
ers who assert that such laws protect both consumers and brokers, the DOJ and FTC conclude that
no evidence exists to support these claims.
Very little academic literature exists on real estate broker minimum service laws. A handful of
authors have examined the issue tangentially when analyzing whether the real estate brokerage
service industry is competitive. Hahn, Litan, and Gurman (2006) identified state legislation
establishing minimum service requirements as one impediment to competition. Based on a review
of the academic literature and on interviews with real estate industry participants, the U.S. Govern-
ment Accountability Office (GAO) concluded that widespread use of the Internet in real estate
transactions should encourage more brokerage price variation, but may be hindered by obstacles
such as minimum service laws (GAO, 2006). Miceli, Pancak, and Sirmans (2007) determined that
minimum service laws might be an attempt to prop up a brokerage compensation scheme that
while possibly in the best interests of brokers, is not in the consumer’s interest. Magura (2007)
proposed that state minimum service laws have a chilling effect on broker price-cutting by ac-
commodating broker-steering behavior. White (2006) observed that mandatory minimum service
requirements for sellers’ brokers eliminated competition from discount brokers whose only service
would be to provide access to an MLS.
Levitt and Syverson (2008) analyzed whether any consumer protection justifications for broker
minimum service laws exist. They compared variables for houses listed with limited-service bro-
kers with those listed with full-service brokers. They found that houses listed with limited-service
brokers take longer to sell but eventually sell at similar prices to those listed with full-service
brokers. They weighed the tradeoff between the lower fees charged by a limited-service broker and
the longer time on the market, and reasoned that consumers using limited-service, flat-fee brokers
were not worse off than those using full-service, full-commission brokers. Based on this analysis,
their conclusion stated that broker minimum service laws are not needed to protect consumers.
Pancak (2008) examined specific state brokerage laws that could be interpreted as requiring a
minimum level of services. Identifying a wide range of regulatory provisions, she compared state
provisions with the DOJ’s website that lists states with minimum service laws.
3
She found that
the DOJ list was incomplete and incorrect. One primary weakness of the DOJ list is that some
states with language requiring brokers to “present offers in a timely manner” are included on
the anticompetitive list, but others are not. Without clear legislative history to the contrary, she
concluded that these types of provisions should be interpreted as requiring timely communication
when an offer is transmitted to the broker, not requiring that brokers be available to accept and
present offers.
3
The DOJ list is available at http://www.usdoj.gov/atr/public/real_estate/fee_details.htm. As of January 8, 2009, the DOJ
listed the District of Columbia and the following states as having limited choice because of minimum service requirements:
Alabama, Idaho, Illinois, Indiana, Iowa, Kansas, Maine, Missouri, Oregon, South Dakota, Texas, Utah, Washington, and
West Virginia.

108 Refereed Papers
Nanda and Pancak
Pancak determined the actual level of minimum service laws in all states and arranged them into
four categories: states with minimum service requirements in all brokerage relationships, states
with minimum service requirements in certain brokerage relationships, states requiring timely
communication of offers, and states with waivable minimum service requirements and/or that
require timely communication of offers. The data presented in the Pancak article are the basis for
the dependent variable in this article.
Enactment of State Minimum Service Laws for Real Estate
Brokers
Evidence presented below indicates that state REALTOR

associations have been primary support-
ers of state minimum service laws. The NATIONAL ASSOCIATION OF REALTORS

(NAR) has
not formally endorsed state minimum service laws, noting that some state associations are in favor
of such laws but others are not (NAR, 2005).

NAR has offered legal advice about such legislation,
emphasizing that associations have the right to propose and lobby for laws that they support, even
if the law is deemed anticompetitive by federal agencies.
4
Supporters of minimum service laws maintain that real estate consumers need to be able to expect
certain services from a broker hired to represent them, and laws are needed to guarantee a mini-
mum level of services (DOJ and FTC, 2007). In addition, if a seller working with a limited-service
broker does not receive assistance from that broker, the seller may need to ask for assistance from
the buyer’s broker. Supporters also claim that the buyer’s broker needs to be protected from having
the additional work of assisting a seller because the seller does not pay the buyer’s broker, and
helping the seller may create a dual agency conflict of interest. Finally, some proponents of the law
are concerned that a buyer’s broker may not be compensated when a seller using a limited-service
broker decides to deal directly with a buyer.
The DOJ and FTC have taken an aggressive stance against existing and proposed minimum service
laws. The DOJ website lists its efforts to eliminate minimum service laws, including links to numerous
press releases and letters to state governors, legislatures, and real estate commissions (USDOJ, 2009).

The DOJ and FTC can only urge states not to pass laws or to change current laws because the
federal government may not sue state legislatures (and boards acting according to legislative intent)
for federal antitrust violations.
5
The state agencies’ efforts have been met with mixed reactions.
Alabama, Idaho, Missouri, and Texas passed minimum service laws despite active federal opposi-
tion. New Mexico, Tennessee, and Michigan, however, changed proposed legislation to make
minimum service laws waivable resulting from lobbying efforts made by the federal agencies.
4
Roberts (2005) quoting Laurie Janik, general counsel for NAR, April 22, 2005, letter to state REALTOR association executives.
5
This was decided in the U.S. Supreme Court case of Parker v. Brown, 317 U.S. 342 (1943). The DOJ, however, has sued
NAR for the alleged anticompetitive nature of NAR’s Virtual Office Website (VOW) policy. NAR had adopted a policy
permitting brokers to selectively withhold or “opt out” of allowing other brokers to advertise MLS listing information on line.
The DOJ and the Association settled this lawsuit in 2008.

109Cityscape
Real Estate Brokers’ Duties to Their Clients:
Why Some States Mandate Minimum Service Requirements
In 2004, Illinois became the first state to adopt minimum service requirements, requiring all
exclusive brokerage arrangements between a broker and client to specify that the broker will
provide the following services:
• Accept delivery of and present to the client offers and counteroffers to buy, sell, or lease the
client’s property or the property the client seeks to purchase or lease.
• Help the client develop, communicate, negotiate, and present offers, counteroffers, and notices
that relate to the offers and counteroffers until a lease or purchase agreement is signed and all
contingencies are satisfied or waived.
• Answer the client’s questions relating to the offers, counteroffers, notices, and contingencies.
No specific discussion occurred regarding the need for this new provision during the state senate
consideration.
6
The Illinois Association of REALTORS

reported that the purpose of the require-
ment is to “promote greater professionalism and accountability within the industry and to provide
greater protections for real estate consumers.”
7
An article in Chicago Agent entitled “The Value of Full Service” provides additional insight into Illinois
real estate professionals’ opinion that minimum service requirements are needed (Biver, 2005). The
article states that the most common complaint from full-service brokers who have done deals with
limited-service brokers is that no other professional is representing the other side so the full-service
broker “feels the burden of doing both sides, and that doesn’t feel fair or right.” The full-service
brokers think that this predicament is unfair financially because they have to do more work for the
same commission.
Other states that have adopted minimum service requirements echo these types of consumer protec-
tion and broker protection rationale. The Texas Association of REALTORS

supported adopting a
minimum service law in Texas stating “it would help ease confusion in real estate transactions and
provide true consumer protections.” In testimony before the Texas Real Estate Commission, the
chairman of the association spoke in favor of the law, noting that he represented 70,000 members.
He cited reports of sellers feeling confused and not helped by their limited-service brokers, and
reports of buyers’ brokers having to step in and help (Evans, 2005).
The Alabama Real Estate Commission stated that the intent of its minimum service law, which
was passed in 2005, was to limit MLS-listing-only brokerage activity so that sellers would not be
left on their own in transactions without anyone to answer their questions (Alabama Real Estate
Commission,2005). In 2005, the Iowa Legislature passed Iowa’s law specifying content of broker-
age agreements.
8
Almost no legislative comments about why the bill passed exist; Iowa Real Estate
Commission minutes only mention that it was modeled after the Illinois minimum service law
(Iowa Real Estate Commission, 2005).
6
Illinois Senate Transcript, March 24, 2004, available at http://12.43.67.2/senate/transcripts/strans93/09300090.pdf.
7
Illinois Association of REALTORS
®
, Provisions of Senate Bill 2887 (Public Act 93-957), revised 10-04, available at
http://www.illinoisrealtor.org/Member/government/issues/sb2887.asp.
8
Iowa House File 375, an act relating to the duties imposed on a real estate broker by a brokerage agreement (unanimously
passed both the Iowa House and Senate).

110 Refereed Papers
Nanda and Pancak
In addition to a previous administrative regulation that required a broker to use reasonable care in
conveying information to a client, Arizona, in 2005, added additional language to the regulation
that imposed an affirmative obligation on the broker to take reasonable steps to help a client con-
firm the accuracy of the information. Although they did not explain why they made this change,
the Arizona Department of Real Estate (ADRE) stated that brokers must now actively advise clients,
and not just tell clients, “I don’t know, you figure it out” (ADRE, 2005)
An article reporting on Missouri’s minimum service law, which was passed in 2005, credits the
law’s passage to heavy lobbying efforts by the Missouri Association of REALTORS

(Wagar, 2005).
The Association purportedly hired a lobbyist for $50,000 to persuade the Missouri governor to
sign the bill, which passed both the Missouri House and Senate unanimously, despite requests
from the DOJ and FTC to veto it.
In 2005, Kentucky passed an administrative regulation that requires a broker representing a client
to perform specific services, including helping the client develop, communicate, negotiate, and
present offers and answering questions relating to offers. A broker’s failure to comply with the
minimum requirements is considered gross negligence. That this regulation is still on the books
in Kentucky is interesting because the Kentucky Legislature contemplated enacting a state statute
requiring similar services in 2006. After the state legislature received a letter from the DOJ, the
minimum service language was taken out of the proposed statute.
9
Even though the legislature did
not pass a minimum service law, the administrative regulation still stipulates a provision by which
brokers have to abide, and which precludes a consumer from buying an MLS-listing-only service.
In 2007, Idaho enacted a law that requires any broker entering into a written contract to “be avail-
able” to the client to receive and present offers in a timely manner. This language alone, however,
does not necessarily appear to require minimum services. In many states, this type of language is
generally understood to mandate prompt communication rather than require a specific service be
performed. For example, the Oklahoma attorney general found that language requiring a broker
to “be available” to receive all offers does preclude a broker and client from agreeing that the client
receive offers directly (Pancak, 2008). The Idaho Real Estate Commission, however, interprets the
Idaho law as mandating that brokers receive and review all offers, although a broker does not have
to provide advice to clients or negotiate on their behalf.
10
The bill’s purpose is to clarify that receiv-
ing and presenting offers is a duty that brokers owe clients. While the Idaho Real Estate Commis-
sion was considering drafting its own legislation, the Idaho Association of REALTORS

sponsored
a proposal that passed; the contact on that bill is the association’s director of government affairs.
11
Theoretical Model
Industry and government commentators have identified two predominant reasons why state
legislatures enact minimum service laws: consumer protection and broker pressure.
9
Kentucky Senate Bill 43. 2006. www.lrc.ky.gov/record/06RS/SB43.htm.
10
Idaho Real Estate Commission Guideline #23, effective July 1, 2007, adopted January 17, 2008; http://www.
idahorealestatecommission.com/guidelines/guideline23.pdf.
11
Idaho House Bill 135 (2007).

111Cityscape
Real Estate Brokers’ Duties to Their Clients:
Why Some States Mandate Minimum Service Requirements
The purpose of real estate licensing laws is to protect real estate consumers, which indicates that
consumer protection justifications for minimum service laws may exist. In particular, a state
experiencing a high level of real estate consumer complaints may enact laws to better protect
consumers from perceived broker misconduct or representational shortcomings. Therefore, the
first hypothesis we tested is as follows.
Hypothesis 1. A higher volume of complaints filed with a state real estate licensing board increases
the likelihood that a state enacts minimum service laws.
The DOJ and FTC allege that brokers have a vested interest in protecting their traditional broker-
age fee structure and therefore would pressure legislatures for minimum service laws.
12
Brokers
exert lobbying influence through state brokerage associations, and they serve on administrative
agencies regulating the brokerage industry that have significant influence on the endorsement of
new laws and regulations.
13
This leads us to two more hypotheses.
Hypothesis 2. The probability of enacting state minimum service laws increases when state broker
associations have greater political strength.
Hypothesis 3. The probability of enacting state minimum service laws increases when brokers
have a stronger influence on state real estate licensing boards.
Other factors may have also affected a state’s decision to enact minimum service laws. In the next
section, we provide details on other possible independent variables and the reasons they were
included in our empirical model.
Description of Variables
Since 2004, 10 states have enacted laws that require brokers to offer some minimum level of
service in either all broker relationships or only in exclusive broker relationships. Enactment dates
and relevant statutory or administrative regulatory provisions for each of these states are listed in
exhibit 1. This study analyzed both institutional and economic variables that may have affected the
likelihood of law adoption for all 50 states and the District of Columbia from 2000 through 2007
(408 observations). Using this time period allowed for sufficient observation in most of the states
before and after adoption of minimum service requirements. Exhibit 2 presents the variables used
in the analysis, and exhibit 3 reports the summary statistics of variables used in this study.
As reported by Pancak (2008), four other states also have laws requiring brokers to provide clients
with some type of minimum services, but these laws were enacted before 2000.
14
These states are
also listed in exhibit 1. Given that the anticompetitive concern about precluding limited-service
12
The agencies also discussed other motivations for the laws.
13
The Consumer Federation of America has speculated that a connection exists between minimum service laws and the
number of brokers serving on state real estate boards. See Woodall and Brobeck (2006).
14
In addition, seven states enacted laws since 2004 providing for minimum services: Florida, Michigan, Nevada, New
Mexico, Ohio, Tennessee, and Wisconsin (Pancak, 2008). The laws in those states, however, are not mandatory because
they allow a consumer to waive the services. For purposes of our analysis, we will include only states that enacted
nonwaivable minimum service laws after 2000.

112 Refereed Papers
Nanda and Pancak
Enacted After 2000
Alabama 2005 Alabama
Code
§§ 34-27-
84 (c)
At a minimum, all listing brokers must do the following:
• Accept delivery of and present all offers to help the
consumer negotiate offers.
• Answer the consumer’s questions relating to the transaction.
Arizona 2005
Year
language
was added
about taking
reasonable
steps to
help a client
confirm
information.
Arizona Ad-
ministrative
Code
R4-28-1101
Brokers must do the following for a client:
• Use reasonable care to obtain information material to
a client’s interests and relevant to the contemplated
transaction, and communicate the information to the client.
• Take reasonable steps to assist a client.
• Take reasonable steps to help a client confirm the accuracy
of information relevant to the transaction.
Brokers must perform acts expeditiously, and cannot
intentionally or negligently delay performance.
Idaho 2007 Idaho
Statute
§ 54-2087(3)
If a broker enters into a written contract to represent a client,
the broker must—
• Be available to the client to receive and present offers in a
timely manner.
This duty is mandatory and cannot be waived.
Although the state allows nonagency, this requirement applies
to all types of representation or customer service agreements.
Illinois 2004 225 Illinois
Compiled
Statutes
454, Article
15, Section
75
In an exclusive brokerage agreement, the broker must provide
the following services:
• Accept delivery of and present offers.
• Help the client develop, communicate, negotiate, and
present offers.
• Answer client questions.
Indiana 2006 Indiana
Code 25-
34.1-10-9.5
If a broker does not have an agency relationship with a
consumer, at a minimum the broker must perform the following:
• Be available to receive and present offers.
• Help negotiate, complete real estate forms, and communicate.
• Respond to questions.
If a second broker performs those duties for the consumer
because the first broker failed to perform them, an agency
relationship between the second broker and the consumer
would not exist.
If a broker does have an agency relationship with a client, the
broker must fulfill the terms of the agency relationship, and
present all offers immediately upon receipt.
Only applies to nonagency situations. Does not apply when a
broker represents a client in a transaction, but only when a
broker enters into a written agreement that does not involve
agency.
Exhibit 1
State
Year
Section
Enacted
Code or
Regulation
Section
Summary of Applicable Provision(s)
States With Nonwaivable Minimum Service Requirements (1 of 3)

113Cityscape
Real Estate Brokers’ Duties to Their Clients:
Why Some States Mandate Minimum Service Requirements
Exhibit 1
State
Year
Section
Enacted
Code or
Regulation
Section
Summary of Applicable Provision(s)
States With Nonwaivable Minimum Service Requirements (2 of 3)
Iowa 2005 Iowa Code §
543B.56A
At a minimum, all brokerage agreements must state that the
broker will do the following:
• Accept delivery of and present offers.
• Help the client develop, communicate, negotiate, and
present offers.
• Answer the client’s questions relating to the brokerage
agreements and negotiations.
• Provide prospective buyers access to listed properties.
Kentucky 2005 201
Kentucky
Admini-
strative
Regulations
11:045
At a minimum, all brokers representing a client must do the
following:
• Accept delivery of and present all offers.
• Accept all earnest money deposits that are presented to the
broker.
• Help clients develop, communicate, negotiate, and present
offers.
• Answer questions relating to offers.
Failure to comply with these minimum requirements is
considered gross negligence.
Regulations limits choice; it is interesting that a bill proposing
minimum services was defeated in 2006.
Allows nonagency transaction broker.
Missouri 2005 Missouri
Revised
Statute §
339.780 (7)
In an exclusive brokerage agreement, the broker must provide
the following services:
• Accept delivery of and present offers.
• Help the client develop, communicate, negotiate, and
present offers.
• Answer client questions.
Texas 2005 Texas
Occupations
Code Title 7
§ 1101.557
In an exclusive brokerage agreement, the broker must provide
the following services:
• Present offers to and from client.
• Answer client questions.
Utah 2005 61-2-27
Utah Code
Annotated
In an exclusive brokerage agreement, the broker must provide
the following services:
• Accept delivery of and present offers.
• Help the client develop, communicate, negotiate, and
present offers.
• Answer client questions.

114 Refereed Papers
Nanda and Pancak
State
Year
Section
Enacted
Code or
Regulation
Section
Summary of Applicable Provision(s)
Enacted Before 2000
California 1987 California
Civil Code
Section
2079
Listings brokers must conduct a reasonably competent and
diligent visual inspection of listed property, and disclose
all facts materially affecting the value or desirability of the
property that the inspection revealed.
Montana 1995 Montana
Code
Annotated §
37-51-313
(12)
Brokers must “endeavor to ascertain all pertinent facts
concerning each property in any transaction in which the
licensee acts” so the licensee can fulfill his or her obligation to
avoid error, exaggeration, misrepresentation, or concealment
of pertinent facts.
South
Carolina
Before 2000 South
Carolina
Code
of Laws
Section
40-57-135
(D) (1)
Brokers must do the following:
• Upon receipt, prepare and present offers.
• Deliver written acceptances of offers to all parties.
• Ensure that all of the terms and conditions of the transaction
are included in the offer.
• Ensure that changes or modifications made during
negotiation are in writing and initialed and dated by both
parties before proceeding with the transaction.
Wyoming Before 2000 Wyoming
Code §
33-28-111
(xxix)
Brokers must do the following:
• Advise buyer and seller of all terms of a proposed sale at the
time an offer is presented including estimated discounts and
closing costs.
• Submit all offers to a seller.
Exhibit 1
States With Nonwaivable Minimum Service Requirements (3 of 3)
brokers has only developed in the past decade, we assume that laws enacted before 2000 were
driven by factors different than those driving the laws enacted since 2004.
15
To check the robust-
ness of this assumption, we also ran the analysis with those four states removed from the sample.
As suspected, the change in magnitude, sign, and standard errors is negligible.
Institutional Variables
Most of the state institutional variable statistics that we used are derived from the Digest of Real Estate
Licensing Laws and Current Issues (reports from 1999 to through 2007), compiled by the Association
of Real Estate Licensing Law Officials

(ARELLO). These surveys consist of information collected
during the preceding year (generally in the second half of that year) for publication in the current
year. So, it implies a built-in lag in the ARELLO dynamic data items (that is, number of licensees
and complaints) that we use in the article. Statistics from other sources are noted in exhibit 2.
15
For example, California’s law requiring that listing brokers conduct a reasonable, competent, and diligent inspection of
listed property was in response to a California court case concerning property condition disclosure.

115Cityscape
Real Estate Brokers’ Duties to Their Clients:
Why Some States Mandate Minimum Service Requirements
Institutional Variable
Complaints Number of complaints per 100 real estate brokers
Association strength State NATIONAL ASSOCIATION OF REALTORS

membership
a
as a
percentage of active state brokers
b
Board strength Percentage of real estate industry members on the state licensing
board
c
Prelicensing education hours Prelicensing hours required for salespersons
d
Continuing education hours Continuing education hours requirement
Consumer protection fund Maximum consumer protection fund liability payout against a broker
(in thousands of dollars)
e

Political climate Binary variable indicating whether a state legislature is controlled by
Democrats or others (including Republicans)
f
Economic Variable
House price growth Average of percent year-over-year change in quarterly FHFA
purchase-only state-level house price index
Transaction growth Percent change in number of transactions
Gross state product growth Percent change in real gross state product
Population growth Percent change in population
Income growth Percent change in per capita income
Exhibit 2
Variable Definition
Independent Variables
FHFA = Federal Housing Finance Agency.
a
Data on NAR membership from NATIONAL ASSOCIATION OF REALTORS
®
monthly membership report for years ending
December 31, 1999–2007.
b
Association of Real Estate Licensing Law Officials (ARELLO) (1999–2007), “SALESPERSONS: Active Salespersons” and
“BROKERS: Active Brokers” plus “BROKERS: Active Associate Brokers.”
c
ARELLO (1999–2007), “# members” heading and “# Industry Members” heading. For California: The Governor appoints the
Real Estate Commissioner, who then appoints the Real Estate Advisory Commission 10 in total, 6 real estate brokers (industry
members) and 4 public members. http://www.dre.ca.gov/pdf_docs/ref01.pdf.
For Minnesota: We do not find any type of board or commission. The Governor appoints the Commissioner of the Department
of Consumer Protection, who oversees all real estate licensing activities. We assume zero percent industry representation in
the board.
d
ARELLO (1999–2007), “HOURS PRE-” heading.
e
ARELLO (1999–2007), “MAX. FUND Liability: Broker” heading.
f
Data compiled from the National Conference of State Legislatures.

116 Refereed Papers
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We use three independent variables to test our three hypotheses. Ideally, we want to test for
volume of complaints against real estate brokers offering minimum services filed with a state real
estate licensing board. The available data, however, do not make a distinction between complaints
against brokers offering minimum services and those offering full services. Therefore, we evaluated
the state’s overall volume of complaints filed against all types of real estate brokers. We expect the
volume of complaints filed with a state real estate licensing board to positively influence the likeli-
hood that a state enacts minimum service laws. We control for state size by looking at the number
of complaints per 100 real estate brokers and salesperson licensees in our analysis.
We measure the political strength of a state’s broker association by looking at NAR membership as
a percentage of total state brokers. If federal agencies were correct, we would expect an increase in
the percentage of state NAR membership to positively influence the likelihood that a state enacts
minimum service laws. We measure state broker influence on licensing boards as the percentage of
licensed brokers or salespersons serving on a state board, expecting higher levels of membership
would also positively influence the likelihood that a board will enact minimum service regulations
or encourage state legislatures to pass minimum service laws.
We include a few other institutional variables to control for in our analysis. Interestingly, these
variables also fit under the categories of either consumer protection or political pressure. Ease
of entry into the real estate brokerage profession in a state may concern traditional brokers who
fear competition from new limited-service brokers. A state’s prelicensing education hours are an
indication of licensing ease or difficulty. Also, a state’s continuing education hours can indicate
cost of maintaining a license. We expect a state’s prelicensing hour requirement and continuing
education hour requirement to be inversely related to the likelihood that a state enacts minimum
service laws: the easier it is to enter or stay in the profession, the more likely full-service brokers
may see limited-service brokers as a threat.
Many states have a consumer protection fund that compensates a consumer who is unable to collect
a monetary judgment against a broker. The dollar amount limit varies by state. We expect a higher
Exhibit 3
Variable
State-Level Characteristics: 2000–07: 408 Observations
N Mean Std. Dev.
Summary Statistics
Complaints 395 1.856 12.187
Association strength 393 50.688 15.435
Board strength 408 69.243 18.696
Prelicensing education hours 408 58.921 33.004
Continuing education hours 400 6.440 6.188
Consumer protection fund ($) 408 13,509.80 16,988.36
Political climate 408 0.367 0.483
House price growth 408 7.031 5.150
Transaction growth 402 2.656 10.630
Gross state product growth 408 2.464 2.087
Population growth 408 0.908 0.866
Income growth 408 4.380 2.805
Note: Because information is missing, some variables have fewer than 408 observations.

117Cityscape
Real Estate Brokers’ Duties to Their Clients:
Why Some States Mandate Minimum Service Requirements
dollar limit to encourage states to enact minimum service laws because boards and legislatures may
fear depleting their funds without these perceived additional consumer protection measures.
The political climate of a state often influences new legislation. We therefore include a variable
for partisan control in the state legislation. Based on common political perceptions, a state that is
controlled by a Democratic legislature may be more likely to pass a greater amount of consumer
protection legislation.
Economic Variables
We also control for the effect of housing market changes in our analysis by including fundamental
measures of state housing market activity and other state economic activity: house price trends,
percent change in housing transactions, population growth, percent change in per capita income,
and percentage change in real gross state product (GSP). To assess housing price changes, we use
the repeat sales purchase-only quarterly Housing Price Index (HPI), reported by the Federal Hous-
ing Finance Agency (FHFA). We took the average year-over-year rate of change for a year. The data
used for the other variables is obtained from the NAR, the U.S. Census Bureau, the U.S. Bureau of
Labor Statistics, and the U.S. Bureau of Economic Analysis.
Weak state-broker productivity, as measured by the number of state residential transactions per
year per real estate broker, may cause traditional full-service real estate brokers to feel the need
to protect their business activity from encroachment by limited-service brokers. If this is the case,
then we expect variables causing lower broker productivity to increase the likelihood of state
enactment of minimum service laws, and variables resulting in higher broker productivity to
decrease that likelihood.
Likewise, a decrease in any one of the other economic variables may threaten real estate broker
activity, encouraging a protectionist position that supports reducing brokerage competition by
restricting limited-service brokers. Therefore, we expect to see an inverse relationship between the
change in any one of these variables and the likelihood that a state adopts minimum service laws.
Methodology
Taking into account both the institutional and economic variables set forth in the previous section,
and following the works of Kiefer (1988), de Figueiredo and Vanden Bergh (2004), and Nanda
(2008), we employed a discrete-time proportional hazard model to determine which factors may
have led states to enact minimum service laws for real estate brokers. The hazard model allows us
to look at the pre-enactment time-period observations (that is, time to event data) to understand the
process that may lead to enactment. We model the law adoption process by specifying a probability
distribution for the survival spell until death, which is law enactment in the current context.
16
The probability distribution is given by
)Pr()( tTtF <=
(1)
16
The baseline specification draws on Kiefer (1988) and chapter 20 in Wooldridge (2002).

118 Refereed Papers
Nanda and Pancak
which specifies the probability that the random variable T is less than some value t; f(t) is the
corresponding density function. The hazard function can be represented as
dt
tSd
tS
tf
t
)(ln
)(
)(
)(
0
−==λ
mmmmm
ataxvkxvt ≤≤=
−1
,],[],,;[ λβθλ
(2)
)(
0
tλ is the rate at which spells will be completed at duration t, given that they survive until t.
A proportional hazard framework using time-invariant regressors can be written as
)(][];[
0
txkxt λλ =
(3)
where 0)( >xk is a nonnegative function of x, and 0)(
0
>tλ is the baseline hazard.
Time is separated from the explanatory variables so that the hazard is obtained by shifting the
baseline hazard (which is common to all units) as the individual hazard function changes based
on a function )(xk of observed covariates (that is, for all the cross-section units, the hazard is
proportional to the baseline hazard function). 0)( >xk

is parameterized as
)(]exp[];[
0
txxt λβλ =
(4)
We can specify baseline hazard by including a function of time. Because no state has ever repealed
a minimum service requirement law, we censor the data to the preadoption levels. We can estimate
the hazard model in equation (4) using a standard logit specification. We can also incorporate
time-varying covariates into the framework to obtain a conditional hazard function as
Mmxkxt
mmm
,........,1,],[],;[ == λβθλ
(5)
where θ is a vector of unknown parameters.
Equation (5) demonstrates that time-varying covariates have a multiplicative effect in each time
interval (for M intervals) and it allows for a flexible baseline hazard, which is common to all
units. Incorporating time-varying covariates may be justified because the law has been adopted at
different times by different states (Nanda, 2008). Because different states are likely to have different
distributions of the duration dependence and some relevant factors may not be observed (that is,
a potential omitted variable bias may exist), we control for the state-level heterogeneity. Following
Wooldridge (2002), we can incorporate heterogeneity into the framework as
dt
tSd
tS
tf
t
)(ln
)(
)(
)(
0
−==λ
mmmmm
ataxvkxvt ≤≤=
−1
,],[],,;[ λβθλ
(6)
where 0>v

is a continuously distributed heterogeneity term.
We try the most common distribution for specifying heterogeneity (or frailty), which is the gamma
distribution.
Results
We examined the enactment of minimum service laws along with time-varying covariates. Because
minimum service requirements were enacted in different states at different times (that is, a disparate
treatment exists because of state-level heterogeneity), we tried to bring in more information to the
estimation system by incorporating time-varying covariates. Varied level of state real estate associa-
tions’ strength may have a different effect on the probability of a minimum service law’s enactment.
When the industry association is well organized, the representatives may be reluctant to support

119Cityscape
Real Estate Brokers’ Duties to Their Clients:
Why Some States Mandate Minimum Service Requirements
legislation, but a weak association might, however, try to push for laws that protect its members.
Therefore, we introduce a spline function for the NAR association strength variable. We put the
‘break’ or ‘knot’ at the 50-percent-strength level (that is, we estimate the model using two variables
that represent greater than and less than 50-percent-strength levels).
Standard Discrete Choice Models
We present a hazard analysis framework in which we model the law enactment process condi-
tioned on the adoption having not yet occurred. We start with standard discrete choice models.
Exhibit 4 shows results from two different model specifications—logit and probit models. This
analysis is done with state-level data.
Exhibit 4
Regressor (1) (2)
Standard Discrete Choice Models (Dependent Variable: Law Adoption Dummy)
Complaints – 0.0631
(0.0728)
– 0.0435
(0.0387)
Association strength (<=50%) 0.0731
(0.0462)
0.0409
(0.0258)
Association strength (>50%) – 0.0726
(0.0392)
*** – 0.0381
(0.0198)
***
Board strength – 0.0239
(0.0154)
– 0.0117
(0.0078)
Prelicensing education hours 0.0396
(0.0119)
* 0.021*
(0.0058)
*
Continuing education hours – 0.0887
(0.1031)
– 0.0371
(0.0491)
Consumer protection fund 0.0001
(0.0001)
0.0001
(0.0001)
Political climate 2.2334
(0.8915)
** 1.1987
(0.4724)
**
House price growth 0.0849
(0.0689)
0.0471
(0.0382)
Transaction growth – 0.0653
(0.0291)
** – 0.0361
(0.0146)
**
Gross state product growth – 0.0331
(0.1511)
– 0.0187
(0.0778)
Population growth 1.7167
(0.5483)
* 0.9862
(0.2847)
*
Income growth 0.2259
(0.1416)
0.1255
(0.0731)
***
Fixed effect? Census division Census division
Model description Logit regression Probit regression
Pseudo R
2
0.361 0.366
Log likelihood – 53.139 – 52.744
N 248 248
* Denotes 1-percent significance level.
** Denotes 5-percent significance level.
*** Denotes 10-percent significance levels.
Notes: Robust standard errors are reported within parentheses. This analysis includes data for all 50 states and the District of
Columbia, from 2000 to 2007.

120 Refereed Papers
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In general, we find that stricter prelicensing educational requirements and weaker association
(less than 50 percent representation) may favor law enactment; a greater number of complaints,
stronger association (more than 50 percent representation), and stronger industry influence on
the licensing board may not support enactment of minimum service requirements. Interestingly,
Democratic legislature control increases the likelihood of minimum service law enactment.
Proportional Hazard Models
Models in exhibit 5 present more empirical results that further address the measurement error
problem and state-level heterogeneity. Exhibit 5 takes the specification, used in exhibit 4, and
reports alternative econometric specifications.
We assume that duration dependence (as represented by the hazard function) will follow the stan-
dard Weibull distribution model. Model (1) in exhibit 5 presents the baseline estimates from the
hazard model with time-varying covariates with no lagged values. In general, we find statistically
significant estimates that are consistent to a reasonable extent with our postulates. As assumed,
association strength—especially more than 50-percent representation—and industry influence put
significant negative feedbacks on the likelihood of enactment of the minimum service law. A more
active housing market seems to present positive feedback.
As suggested by Nanda (2008) legislators may not have observed current year values, however,
when deciding to pass a mandate. Furthermore, the law or the discussion around a possible
enactment might have affected the current year observations (that is, some endogenous feedbacks
may persist). To address this concern, we incorporate previous year’s values of the institutional
variables in model (2). Moreover, most institutional variables tend to be measured with error.
Legislators may want to consider historical averages over a longer period to evaluate the need for a
mandate. We take the average of 1-period and 2-period lagged values for the institutional variables
in model (3) to control for measurement error. The estimates show remarkable improvement,
validating the concerns of endogeneity and measurement error. We find statistically significant
estimates that are consistent with our assumptions. In model (3), association strength (especially
more than 50-percent representation) and industry influence put significant negative feedbacks on
the likelihood of enactment of the minimum service law. We also find that a stricter prelicensing
educational requirements and a greater number of complaints tend to favor a minimum service
requirement law’s enactment.
The process of enacting laws with minimum service requirements varies across states. Different
states in our sample may have different distributions for the duration dependence. In model (4),
we try to address this concern. We assume that the heterogeneity term ν in equation (6) is gamma
distributed. We do not, however, find any significant improvement over model (3).
17
Four states—
California, Montana, South Carolina, and Wyoming—adopted minimum service requirements
before 2000. To test the robustness of our results, we exclude those states and perform key model
analyses. The results do not show any significant differences from those shown in exhibits 4 and 5.
17
Because of many small, omitted influences on law adoption, normal distribution may represent data better than the
gamma distribution.

121Cityscape
Real Estate Brokers’ Duties to Their Clients:
Why Some States Mandate Minimum Service Requirements
Exhibit 5
Regressor (1) (2) (3) (4)
Proportional Hazard Models (Dependent Variable: Law Adoption Dummy)
Complaints – 0.1851
(0.6047)
0.0796
(0.0857)
0.2308
(0.0843)
* – 0.8812
(0.6068)
Association strength (<=50%) – 0.0873
(0.1863)
– 0.2737
(0.1826)
– 0.3729
(0.3028)
0.1082
(0.1016)
Association strength (>50%) – 0.2913
(0.1308)
** – 0.3228
(0.1287)
** – 0.5826
(0.1644)
* – 0.0693
(0.0535)
Board strength – 0.0813
(0.0333)
** – 0.1044
(0.0662)
– 0.1056
(0.0519)
** – 0.0113
(0.0203)
Prelicensing education hours 0.0951
(0.0269)
* 0.1269
(0.0552)
** 0.1794
(0.0587)
* 0.0281
(0.0171)
Continuing education hours – 0.1869
(0.2121)
– 0.4084
(0.3676)
– 0.3326
(0.3324)
– 0.0859
(0.0682)
Consumer protection fund 0.0001
(0.0001)
0.0001
(0.0001)
0.0001
(0.0001)
– 0.0001
(0.0001)
Political climate 6.3097
(1.2832)
* 8.4689
(3.9749)
** 9.7585
(3.9486)
** 0.2772
(0.9046)
House price growth 0.1809
(0.2043)
0.1154
(0.1031)
0.3443
(0.2113)
– 0.1528
(0.1067)
Transaction growth 0.1513
(0.0848)
*** 0.1531
(0.0961)
0.0882
(0.0669)
– 0.0573
(0.0346)
***
Gross state product growth – 0.2886
(0.3235)
– 0.6364
(0.5653)
– 1.1801
(1.0187)
0.0062
(0.2908)
Population growth 3.9629
(1.8336)
** 7.8001
(5.0208)
7.7221
(4.6801)
*** 0.7402
(0.6139)
Income growth – 0.2741
(0.1174)
** – 0.7081
(0.4464)
– 0.6719
(0.3091)
** 0.1592
(0.2101)
Model description Current
attributes
First lagged
attributes
Average of
first and
second lagged
attributes
Average of
first and
second lagged
attributes
Modeling concern More
information
Regulators
do not observe
current values
Institutional
variables
measured with
error
State–level
heterogeneity
Distribution for duration
dependence
Weibull Weibull Weibull Weibull
Distribution for
heterogeneity term
Gamma
Log likelihood – 20.401 – 18.692 – 14.151 – 29.858
N 248 223 192 294
* Denotes 1-percent significance level.
** Denotes 5-percent significance level.
*** Denotes 10-percent significance levels.
Notes: Models include logarithm of time as the baseline hazard specification. Robust standard errors are reported within
parentheses. This analysis includes data for all 50 states and the District of Columbia, from 2000 through 2007.

122 Refereed Papers
Nanda and Pancak
To facilitate interpretation of our results, in exhibit 6, we report odds ratios for the logit model
in model (1) of exhibit 4 and hazard ratios for model (3) of exhibit 5. Column (1) of exhibit 6
shows that for each additional hour of state prelicensing requirements, the odds of enacting a
minimum service requirement increase by a factor of 1.04. A one-percentage-point increase in
association strength raises the odds of not enacting a minimum service requirement by a factor of
0.93. In terms of the hazard ratio from column (2) of exhibit 6, for each increase of 1 complaint
per 100 brokers and each additional hour of state prelicensing requirements, the hazard rate of
enacting minimum service requirements increases by factors of 1.26 and 1.19, respectively. One-
percentage-point increases in association strength and industry influence suppress the hazard rate
of enacting a minimum service requirement by factors of 0.56 and 0.90, respectively.
Exhibit 6
Regressor
Model (1) Exhibit (4)
Odds Ratio
Model (3) Exhibit (5)
Hazard Ratio
Odds and Hazard Ratio
Complaints 0.9388 1.2596*
Association strength (<=50%) 1.0758 0.6887
Association strength (>50%) 0.9299*** 0.5584*
Board strength 0.9764 0.8998**
Prelicensing education hours 1.0404* 1.1966*
Continuing education hours 0.9151 0.7171
Consumer protection fund ($) 1.0001 1.0001
Political climate 9.3313** 17,300.52**
House price growth 1.0886 1.4111
Transaction growth 0.9368** 1.0922
Gross state product growth 0.9674 0.3072
Population growth 5.5661* 2,257.606***
Income growth 1.2535 0.5107**
* Denotes 1-percent significance level.
** Denotes 5-percent significance level.
*** Denotes 10-percent significance levels.
Conclusion
This article has examined institutional and economic influences on state real estate broker mini-
mum service laws. The federal government and previous academic literature have assumed that
the anticompetitive attitudes of traditional brokers are the driving force behind the enactment of
these laws, and that legislative evidence exists proving that state brokerage associations introduced,
supported, and lobbied for minimum service laws that passed. Our results, however, show that
stronger (more than 50 percent representation) state NAR presence and a greater percentage of real
estate industry members on licensing boards decrease the likelihood that minimum service laws
would be enacted in a state. Although many traditional real estate brokers may be vocal opponents
of limited-service brokerage, many other brokers may embrace the evolving nature of the broker-
age industry brought about by changing technology and new representational paradigms. On the
other hand, these variables are capturing quantity of influence rather than quality of influence,

123Cityscape
Real Estate Brokers’ Duties to Their Clients:
Why Some States Mandate Minimum Service Requirements
and may actually be limited in their ability to approximate broker and association influence on
minimum service law enactment.
Consumer protection was the stated purpose of many of the proposed minimum service bills that
passed into law. Our results indicate that the rationale may be sincere because the level of com-
plaints against brokers is considered the most significant indicator of enactment. This suggests that
states have made changes to broker licensing laws in an attempt to address perceived consumer
protection concerns or problems.
This article addresses the question of why minimum service laws were enacted. Legislative history
suggests that lobbying efforts by broker associations influenced enactment. Contrary to our
hypotheses that were based on this evidence, our empirical results indicate that stronger state
NAR presence and greater broker licensing board membership both decrease the likelihood that
minimum service laws will be enacted. We also found that a state experiencing high levels of
complaints against brokers was more likely to enact minimum service laws. These results demon-
strate that it may be overly simplistic for federal government agencies to allege that the brokerage
industry as a whole is pushing for enactment of minimum service laws for anticompetitive reasons.
State enactment of minimum service laws is more likely the result of the lobbying efforts of a handful
of influential state real estate professionals. More research is now needed to determine the actual
effect of enacted minimum service laws on both broker competition and on consumer protection.
Acknowledgments
The authors thank John Clapp, Mark Shroder, and three anonymous reviewers for their helpful
comments. All remaining errors are ours.
Authors
Anupam Nanda is a lecturer in the School of Real Estate and Planning at the University of Reading,
United Kingdom.
Katherine A. Pancak is a professor in residence in the Center for Real Estate and Urban Economic
Studies in the Finance Department at the University of Connecticut.
References
Alabama Real Estate Commission. 2005 (Fall). State of Alabama Real Estate Commission Update.
http://www.arec.state.al.us/pdf/Update/arec_update_rev1011.pdf (accessed April 7, 2009).
Arizona Department of Real Estate (ADRE). 2005. Arizona Department of Real Estate Bulletin 31 (2).
http://www.re.state.az.us/Bulletins/Bulletin_05.05.pdf.
Association of Real Estate Licensing Law Officials

(ARELLO). 1999–2007. Digest of Real Estate
Licensing Laws and Current Issues. Montgomery, AL: Association of Real Estate Licensing Law Officials.
Biver, Penelope. 2005. “The Value of Full Service,” Chicago Agent 2 (2). http://www.
chicagoagentmagazine.com/issue/article.asp?id=4&article=186&status=archived.

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dojstepsin.htm (accessed April 7, 2009).
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Hahn, Robert W., Robert E. Litan, and Jesse Gurman. 2006. “Bringing More Competition to Real
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126 Refereed Papers

127Cityscape: A Journal of Policy Development and Research • Volume 12, Number 2 • 2010
U.S. Department of Housing and Urban Development • Office of Policy Development and Research
Cityscape
Trailers and Trouble?
An Examination of Crime in
Mobile Home Communities
William P. McCarty
University of Illinois-Chicago
Abstract
The purpose of this study is to ascertain whether the amount of crime in mobile home
communities is greater than the amount of crime in other types of neighborhoods and
to determine whether the difference in crime levels is significant even after controlling
for multiple other variables. Using official crime reports and other data from Omaha,
Nebraska, the study finds no significant difference in population-weighted crime rates
between blocks with mobile home communities and other types of residential blocks.
Multivariate models show that the presence of mobile home communities did not significantly
affect crime rates. The implications of these findings for land use policy are explored.
Introduction
Mobile home communities (also known as manufactured housing communities or trailer parks)
are often portrayed negatively. Historically, mobile home dwellers have been accused of not paying
their fair share of taxes (Clark, 1972; Cowgill, 1941; Hager, 1954). Individuals living in residential
neighborhoods near mobile home communities often perceive the trailers as ugly and the lifestyle
of the inhabitants as questionable; consequently, they believe the communities diminish the value
of their homes (Bair, 1971b; Wallis, 1991). Decades of this antipathy have resulted in these mobile
home communities being relegated to blighted areas by municipal zoning boards, or not allowed at
all (Bair, 1971a; Bair, 1967; Drury, 1972; Worden, 1963).
Despite the persistence of this negative stigma, academic research focusing on crime and life
in mobile home communities has been virtually nonexistent. This lack of research is especially
surprising in the field of criminology, in which crime has been analyzed in urban neighborhoods
(for example, Sampson and Groves, 1989), rural areas (for example, Barnett and Mencken, 2002),
and public housing complexes (for example, Ireland, Thornberry, and Loeber, 2003), all of which

128 Refereed Papers
McCarty
have features in common with mobile home communities. Guided by the social disorganization
perspective, which often directs ecological studies of crime, this article examines the crime rates in
and around mobile home communities in Omaha, Nebraska. Two research questions are particu-
larly salient. First, how does the rate of crime on residential blocks with mobile home communities
compare with the rate of crime on residential blocks adjacent to mobile home communities
and with all other residential blocks?
1
Second, if significant differences do exist, do they remain
significant when controlling for other variables selected for consistency with the social disorganiza-
tion perspective?
Research on the spatial distribution of crime spans two centuries. In the 19th century, researchers
discovered that they could detect meaningful patterns in the concentration of delinquents and
crime by using ecological techniques (Balbi and Guerry, 1829; Mayhew, 1861). The work of
the Chicago School sociologists in the early 20th century helped advance similar ideas in the
United States (Park, Burgess, and McKenzie, 1925; Shaw and McKay, 1942). Shaw and McKay,
in particular, argued that poor, constantly changing, and heterogeneous areas lacked the regula-
tory capacity to enable residents to achieve their common goals. They described this inability to
regulate behavior as social disorganization (Shaw and McKay, 1942). Many subsequent works
have used this theoretical perspective to guide inquiries into the correlations between crime and
disorder (for example, Barnett and Mencken, 2002; Morenoff, Sampson, and Raudenbush, 2001;
Sampson and Groves, 1989; Warner, 2007).
A common theme for many of these works has been a focus on urban neighborhoods in large
cities, often characterized by a population composed of primarily minority residents. Much
less attention, however, has been given to poor neighborhoods that are traditionally composed
of non-Hispanic Whites. This lack of attention is not necessarily a function of oversight by
criminologists. Poor neighborhoods with predominantly non-Hispanic White populations are an
anomaly, especially in large cities. For example, Sampson, Raudenbush, and Earls (1997) found no
neighborhoods in Chicago, Illinois, that were of low socioeconomic status and had a population
that was at least 75 percent White. Thus, the current study is novel in analyzing a type of neigh-
borhood that is often of lower socioeconomic status and traditionally White (McDonnell, 1975).
The study presented in this article may well be the first study that has examined crime in mobile
home communities. The research results will try to illuminate whether processes that lead to crime
in poor urban neighborhoods with primarily minority populations have similar effects in poor
neighborhoods with primarily non-Hispanic White populations.
Mobile Home Communities: A Closer Look
Most scholarly work on mobile home communities is out of date, and references to crime in these
unique neighborhoods are nonexistent. Because little prior research on mobile home communities
is evident, knowledge of these neighborhoods can best be derived from U.S. Census data, vari-
ous trade publications that explore the evolution of this housing option, and a small number of
1
Residential blocks were defined as those blocks with a population of at least one individual, according to the 2000 Census.

129Cityscape
Trailers and Trouble? An Examination of Crime in Mobile Home Communities
academic publications that seek to explore life in mobile homes (Benson, 1990; Cowgill, 1941;
Johnson, 1971; MacTavish and Salamon, 2001; Marsh, Thomson, and Collins, 1982; Miller and
Evko, 1985). The following sections detail what is known about these communities from these
varied sources.
History of Mobile Home Communities
Mobile homes began to appear in the United States in the 1920s and 1930s. They started as
automobile accessories, slowly transforming into stand-alone units that were used as permanent
residences, often by older residents (Wallis, 1989). Mobile homes became more commonplace
during the buildup to World War II, when the federal government installed these structures to
accommodate the influx of workers who migrated to various cities to help in the nation’s wartime
manufacturing effort (Hager, 1954). After World War II, a fundamental shift in the demographics
of the traditional mobile home resident occurred. Instead of housing mostly transitory workers and
retired people, mobile homes became a means for younger, less educated, less affluent individuals,
who may have been excluded from the conventional housing market, to obtain housing (French
and Hadden, 1968; Marsh, Thomson, and Collins, 1982; Wallis, 1989).
As mobile home parks began gradually resembling traditional neighborhoods, President Richard
M. Nixon recognized their status as a viable form of housing in 1970 (Pappas, 1991). That year
also marked the first time that mobile homes were counted in the population census. In 1976, the
U.S. Department of Housing and Urban Development (HUD) implemented a standard for mobile
home safety and construction that all manufacturers were required to meet (Wallis, 1991). Osten-
sibly, this standard resulted in the vehicular aspects of the mobile home being deemphasized. The
term mobile home is, consequently, a bit of a misnomer, because many of these units are permanent
structures that are difficult, if not impossible, to move.
Mobile Homes Today
Mobile homes still represent a viable and popular form of housing today. According to the 2000
Census, 8.8 million mobile homes have been installed in the United States (U.S. Census Bureau,
2000). They represent 8.4 percent of the owner-occupied housing units and 4.3 percent of the
renter-occupied housing units in the United States (U.S. Census Bureau, 2000). To clarify the
perspective of these figures, mobile homes comprise the second largest percentage of all housing
units in the United States after single-family detached units (U.S. Census Bureau, 2003).
Mobile home communities have traditionally been homogeneous in terms of race and class
(Cowgill, 1941; Edwards, Lemmack, and Hatos, 1973; French and Hadden, 1968; Fry, 1979;
Johnson, 1971; MacTavish and Salamon, 2001; Wallis, 1991). These communities are usually
home to White residents who are employed, or were employed, in blue-collar occupations
(Edwards, Klemmack, and Hatos, 1973; Johnson, 1971; MacTavish and Salamon, 2001). Com-
pared with the wider community, mobile home residents have lower incomes and education levels
(Hart, Rhodes, and Morgan, 2002). Mobile home communities seem to be isolated from the wider
community as a culmination of decades of restrictive zoning practices and overt hostility (Edwards,
Klemmack, and Hatos, 1973; Johnson, 1971).

130 Refereed Papers
McCarty
Social Disorganization Theory
Public housing communities and mobile home communities have important features in common.
Studies of crime in public housing complexes are often based on a social disorganization/systemic
model (see Dekeseredy et al., 2003; Ireland, Thornberry, and Loeber, 2003; McNulty and Hollo-
way, 2000). High levels of poverty, residential instability, and ethnic heterogeneity were expected
to result in high levels of crime. This theoretical model has been supported with research that
often indicates higher crime rates in and around public housing developments. Roncek, Bell, and
Francik (1981), for example, found that blocks in Cleveland, Ohio, with public housing projects
had more index crimes
2
compared with blocks without public housing. Dunworth and Saiger
(1994) found that areas with public housing developments in Washington, D.C., Los Angeles,
California, and Phoenix, Arizona, had higher reports of violent crime than areas without public
housing (see also McNulty and Holloway, 2000; Newman, 1972). Although the populations of
public housing and those of mobile home communities differ in race and/or ethnicity, the residents
have in common undesirable locations, isolation from community services, lack of land ownership,
and demographic indicators of disadvantage.
Undesirable Locations
Restrictive zoning practices have severely limited the number of mobile home parks, virtually
excluding them from residential areas and often relegating them to undesirable locations on the
periphery of cities (Bair, 1971a; Bair, 1967; Dawkins et al., 2008; Drury, 1972; Worden, 1963). If
mobile homes are permitted in close proximity to residential areas, it is often in the least desirable
areas near flood plains, industry, or blighted properties (Wallis, 1991; Worden, 1963). Worden
(1963) noted that these zoning decisions were often justified on the grounds that mobile home
communities create sewage disposal problems, cause school overcrowding, or severely diminish
surrounding property values. Geisler and Mitsuda (1987) argued that restrictive zoning practices
reflect a conflict between economic classes because upper class, affluent homeowners seek to
control “lower class” mobile home residents by relegating them to undesirable locations.
The practice of continually allocating only blighted land for mobile home parks leads to a vicious
cycle (McDonnell, 1975). Negative sentiment toward mobile home parks is manifested in restrictive-
zoning practices that relegate mobile homes to undesirable areas. Placing mobile home parks in
these undesirable areas reinforces the notion that these neighborhoods represent substandard
communities (Wallis, 1991). Many communities adamantly oppose the development of this form
of housing (Geisler and Mitsuda, 1987).
A similar pattern exists for public housing. McNulty and Holloway (2000) reported that many
public housing projects were relegated to already poor, segregated, and impoverished parts of U.S.
cities. Ireland, Thornberry, and Loeber (2003) found that many communities strongly oppose
building or maintaining public housing.
2
The eight crimes (homicide and non-negligent manslaughter, robbery, forcible rape, aggravated assault, burglary, larceny/
theft, motor vehicle theft, and arson) the Federal Bureau of Investigation combines to produce its annual crime index.

131Cityscape
Trailers and Trouble? An Examination of Crime in Mobile Home Communities
Isolation From Community Services
Both public housing and mobile home communities are often isolated from essential city services,
especially the police. For public housing, physical isolation is exacerbated by a difficult dynamic
involving the residents, the police, and the public housing authorities (PHAs) that manage the
units. Holzman, Kudrick, and Voytek (1996) found that confusion exists over the ownership and
governmental responsibilities involving public housing. Police officers and PHAs often do not
share information about problems that may be occurring, and residents may be dissatisfied, fearful,
or distrustful of police (Holzman, Kudrick, and Voytek, 1996; Popkin et al., 1995; Skogan and
Annan, 1994). Venkatesh (2000) labeled public housing projects as “cities within cities” that are
virtually cut off from the larger community.
A similar level of isolation has affected mobile home residents for decades (Miller and Evko, 1985).
Mobile home residents may be isolated from routine police patrols because many of the streets in
these complexes are maintained and managed by the park owner instead of the city (Newcomb,
1971). As a result, police are less likely to patrol the neighborhood unless the park owner specifi-
cally requests or arranges for police patrols (Newcomb, 1971).
Lack of Land Ownership
PHAs own and manage their housing units, leaving little proprietary interest for the residents
(Holzman and Piper, 1998). Bowie (2001) argued that the lack of property ownership among
public housing residents exacerbates the crime problems in these communities. The situation in
mobile home communities is similar regarding land ownership, but certain differences in terms
of unit ownership exist. Most mobile home dwellers own the units in which they live but rent
space or land from the development owner (Miller and Evko, 1985). A small percentage of mobile
home residents who live in mobile home parks own both the unit and the land on which the
unit is installed. These developments are referred to as “mobile home estates” (Newcomb, 1971).
Excluding such estates, most mobile home dwellers do not own land, thereby decreasing the stake
these residents have in the community (MacTavish, Eley, and Salamon, 2006).
Similar Demographics
Besides race and ethnicity, the demographic profiles of public housing and mobile home develop-
ments are strikingly similar. Populations of both public housing (Raphael, 2001; Rosenbaum and
Harris, 2001) and mobile home (MacTavish and Salamon, 2001; Miller and Evko, 1985) communities
are characterized as having lower incomes. According to HUD, the average annual income for public
housing residents in the United States is $13,453 (https://pic.hud.gov/pic/RCRPublic/rcrmain.asp). In
1999, the median income for mobile home households was $28,041 (U.S. Census Bureau, 2003).
In contrast, the median household income for all households was $41,851 (U.S. Census Bureau, 2003).
Similarities also exist in terms of age distribution. Most heads of household living in public hous-
ing are between the ages of 25 and 44 or are over the age of 62 (Bowie, 2001; see also Holzman,
1996). This age distribution is quite similar to mobile home households, which usually consist
of young families or retired individuals (Wallis, 1989). A final demographic similarity involves
educational status: both populations have less formal education than the general population has
(Holzman, 1996; Wallis, 1989).

132 Refereed Papers
McCarty
Data and Methods
This study uses data on crime in Omaha, measured using official reports from the Omaha Police
Department from 2000, 2001, and 2002. Crime data were geocoded using MapInfo Professional
9.5 and then aggregated to the residential-block level. The data for most other variables came
from the 2000 Census. With the exception of median income, mobility, and overcrowding, those
Census variables were also tabulated at the residential-block level of analysis.
3
These data are avail-
able on the Census Bureau’s website (http://www.census.gov). Between 2000 and 2002, the city of
Omaha had 15 functional mobile home communities encompassing 32 city blocks; this collection
of communities represented a sufficient number for conducting the following analysis.
Unit of Analysis
This study used a residential-block-level analysis. The block represents the smallest unit of analysis
for which census data are tabulated (http://www.census.gov). Many advantages exist in using the
block as a unit of analysis. The block’s small size makes it a closer approximation to a neighbor-
hood than census tracts or ZIP Codes, which are too large to facilitate interaction, encourage role
obligations, or possess a unique rhythm like that found in street blocks (Appleyard, 1981; Jacobs,
1961; Roncek, 1981; Taylor, 1997). Larger units, such as census tracts, also tend to have greater
variability regarding socioeconomic status and housing condition (Roncek, 1981).
Identifying Mobile Home Communities
The study ultimately identified 15 mobile home communities by using the phone book, accessing
the Mobile Home Village website (http://www.mhvillage.com), conversing with manufactured
housing dealers, and conducting discussions with city government officials. Researchers visited the
sites to pinpoint the exact location of the development. They used city records to verify that those
sites were functional mobile home communities between 2000 and 2002, the same period used
for the crime data. All 15 communities studied met the definition of mobile home parks, in that
multiple units are placed on the same property (Hart, Rhodes, and Morgan, 2002). The smallest
community contained 10 mobile home units; the largest had close to 300 units.
Researchers, using MapInfo Professional 9.5, geocoded the locations of the 15 mobile home com-
munities, which encompassed 32 street blocks.
4
They also identified 67 blocks directly adjacent
to, but not in, mobile home communities to assess any possible crime diffusion effects occurring in
the areas immediately surrounding mobile home communities.
5
3
Census data for median income, mobility, and overcrowding are not available at the block level but are available at the
block-group level. Each block group contains, on average, 15 blocks. Data measuring the median income, mobility, and
overcrowding for each block group were therefore imputed to all the blocks therein.
4
Of the 32 blocks, 25 were entirely composed of mobile home communities. The other 7 blocks were partially composed of
mobile home communities; that is, other types of housing stock could also be found in those 7 blocks.
5
Adjacency was defined using Queen’s contiguity, which defines a location’s (or block’s) neighbors as those areas (or blocks)
with a shared border or vertex. Empirical examinations of public housing have found the presence of these structures may
affect levels of crime in surrounding neighborhoods (see Holloway et al., 1998; Massey and Kanaiaupuni, 1993).

133Cityscape
Trailers and Trouble? An Examination of Crime in Mobile Home Communities
Variables in the Analysis
Multiple variables were examined during the course of the study. The following sections will
discuss how the dependent and independent variables were measured as well as why they were
included in the analysis.
Dependent Variables
This study used two outcome measures of crime. It measured the violent crime rate per 1,000
residents by adding the total frequency of homicides, assaults, sexual assaults, and robberies for
each block from 2000 through 2002, dividing that number by the total number of residents per
street block, and then multiplying by 1,000. The study measured the property crime rate by adding
the total frequency of burglaries and auto thefts for each block from 2000 through 2002, dividing
that number by the total number of residents per street block, and then multiplying by 1,000.
6

To avoid short-term fluctuations and produce more stable measures, the crime data from 2000,
2001, and 2002 were combined into one measure. This common technique has been used in prior
research (see Roncek and Meier, 1991). Both crime rates were then transformed for the multivariate
analysis, using their natural logarithms to help normalize the distribution of both variables.
Independent Variables
The study researchers then undertook a multivariate regression analysis of both violent crime and
property crime rates across all city blocks. The two primary independent variables of interest are
(1) a dichotomous indicator of whether a block had a mobile home community and (2) a dichoto-
mous indicator of whether a block was adjacent to a mobile home community. The study also
included an interaction term representing the product of the dichotomous presence of a mobile
homes variable and the percentage of owner-occupied housing as an additional independent
variable in an alternative multivariate analysis. This variable was included to ascertain whether
home ownership had a distinctive effect in mobile home blocks. The analysis also included two
dichotomous indicators of whether a block had a public housing structure or whether a block was
adjacent to a public housing structure.
The study, which used 12 additional variables based on census data from the year 2000 in the
multivariate models, included median income, racial heterogeneity, and mobility as the fundamen-
tal social disorganization variables (Shaw and McKay, 1942). Racial heterogeneity was measured
as 1 minus the sum of the squared proportions for each racial group represented in the 2000
Census. This measure of heterogeneity is based on five major groups: Whites, African Americans,
American Indians, Asian Americans, and Hispanics. Mobility was operationalized in terms of the
percentage of residents who lived in a different house 5 years before the 2000 Census. The study
also included additional proxy measures of disadvantage or social disorganization, including
vacancy rate, percentage of owner-occupied housing, percent African-American residents, percent
Hispanic residents, percent single mothers, and overcrowding. The study measured overcrowding
as the total percentage of households with more than one occupant per room. The percentage of
males 15 to 21 years of age and the percentage of residents 65 years of age and older were included
6
Ideally, all eight index crimes would be included in the analysis. The data for larceny/theft and arson, however, were not
available.

134 Refereed Papers
McCarty
to control for characteristics of the population. The study included area of the block to control for
differences in crime that might be occurring because of the size of the block. Studies commonly
use all these variables in studies that explore the ecological correlates of crime (Sampson and
Groves, 1989; Sampson, Raudenbush, and Earls, 1997; Warner and Pierce, 1993).
Findings
Exhibit 1 provides descriptive statistics of violent crime and property crime rates and census
indicators across blocks with mobile home communities, blocks adjacent to mobile home com-
munities, and all other residential blocks in Omaha. The average median income for block groups
with mobile home communities ($37,690) in 2000 was lower than the average median income for
block groups adjacent to mobile home communities ($40,160) and for all other residential block
groups ($44,530). The average percentage of African-American residents (0.68) on blocks with
mobile home communities was substantially lower than the average percentage on blocks adjacent
to mobile homes (5.84) and on all other residential blocks (15.24). The average mobility rate (or
the percentage of residents living in a different house 5 years before the 2000 Census) on block
groups with mobile home communities (48.54) was higher than the rate recorded on adjacent
block groups (44.94) and on all other residential block groups (44.50) in Omaha. Finally, blocks
with mobile homes had larger average areas (29.68) and older populations (17.38 percent of
Exhibit 1
Variable
Mobile* Adjacent**
All Other
Residential Blocks***
Mean (SD) Mean (SD) Mean (SD)
Distribution of All Variables for Blocks With Mobile Homes, Blocks Adjacent to
Mobile Homes, and All Other Residential Blocks in Omaha, Nebraska
Outcome
Violent-crime rate
a
(2000-02) 51.52 (234.31) 49.22 (249.28) 53.10 (443.20)
Property-crime rate
a
(2000-02) 150.43 (584.41) 330.79 (846.16) 132.23 (749.84)
Explanatory
Racial heterogeneity 11.70 (14.26) 14.04 (17.03) 20.07 (19.67)
Median income
b, c
37.69 (8.32) 40.16 (11.22) 44.53 (22.89)
Mobility
b
48.54 (7.11) 44.94 (10.49) 44.50 (14.87)
Vacancy rate 6.40 (9.09) 1.98 (4.35) 4.55 (7.77)
% Owner-occupied housing 78.65 (21.07) 66.16 (36.46) 68.81 (31.60)
% Female head of household with
chlidren under 18 years of age
8.26 (7.21) 7.38 (14.33) 8.59 (11.72)
% African American 0.68 (1.44) 5.84 (13.24) 15.24 (27.55)
% Hispanic 6.60 (15.19) 3.10 (6.95) 7.01 (14.17)
Area of block (acres) 29.68 (71.76) 28.71 (46.65) 8.61 (16.49)
% 65 years and older 17.38 (11.27) 14.92 (18.82) 13.40 (13.58)
% Males 15 to 21 years of age 2.90 (3.28) 3.31 (3.90) 4.81 (5.08)
Overcrowding
b
4.34 (3.93) 4.48 (4.77) 3.73 (4.68)
SD = standard deviation.
* N=32. ** N=67. *** N=6,045.
a
Per thousand population.
b
Measured at the block-group level.
c
In thousands of dollars.

135Cityscape
Trailers and Trouble? An Examination of Crime in Mobile Home Communities
population 65 or older) than did adjacent blocks (28.71, 14.92 percent) and all other residential
blocks (8.61, 13.40 percent).
Blocks with mobile homes had an average of 51.52 violent crimes per 1,000 residents from
2000 through 2002. This crime rate compares with an average of 49.22 violent crimes per 1,000
residents on blocks adjacent to mobile home communities and 53.10 violent crimes per 1,000
residents on all other residential blocks from 2000 through 2002. Blocks with mobile homes
had an average of 150.43 property crimes per 1,000 residents from 2000 through 2002. Blocks
adjacent to mobile home communities had an average property crime rate of 330.79 per 1,000
residents and all other residential blocks had an average property crime rate of 132.23 per 1,000
residents.

An analysis of variance test indicated no statistically significant differences in the average
rates of violent crime and property crime among blocks with mobile home communities, blocks
adjacent to these communities, and all other residential blocks.
The study researchers then conducted separate regression analyses of the natural logs of property-
crime and violent-crime rates across all street blocks in Omaha.
7
The results of the property-crime
and violent-crime analyses appear in exhibit 2. The results of alternative models of property crime
7
In the analysis, researchers also used spatial lag models, which take into account spatial autocorrelation. Those results
virtually mirror the regression results reported here. The spatial lag model results are available on request.
Exhibit 2
Variable
Property Crime (natural log) Violent Crime (natural log)
b
a
t-statistic b
a
t-statistic
Coefficients From the Regression of the Natural Log of Property Crime Rates and the
Natural Log of Violent Crime Rates for Street Blocks in Omaha, Nebraska
Presence of mobile homes – 5.82 – 1.86 2.92 0.98
Adjacent to mobile homes 2.96 1.35 – 3.50 – 1.67
Presence of public housing 7.00 2.24* 6.32 2.12*
Adjacent to public housing 3.02 1.56 6.16 3.31*
Racial heterogeneity 0.06 3.80* 0.06 3.98*
Median income
b, c
– 0.01 – 14.66* &ndash; 0.01 – 8.49*
Mobility
b
0.01 0.44 0.02 1.06
Vacancy rate 0.13 3.94* 0.09 2.86*
% Owner-occupied housing – 0.18 – 18.18* – 0.14 – 14.39*
% Single mothers – 0.01 – 0.54 0.02 0.66
% African American 0.08 7.42* 0.13 12.49*
% Hispanic 0.03 1.39 0.01 0.30
Area of block 0.12 9.55* 0.10 8.48*
% 65 years and older – 0.03 – 1.56 – 0.04 – 2.21*
% Males 15 to 21 years of age – 0.01 – 1.10 0.08 1.76
Overcrowding
b
0.30 4.56* 0.43 6.94*
Intercept 4.71* 2.11*
Adj. R-squared 0.30 0.29
N = 6,144
* p < .05.
a
Unstandardized b-coefficients have been multiplied by 10 to avoid miniscule numbers.
b
Measured at the block-group level.
c
In thousands of dollars.

136 Refereed Papers
McCarty
Variable
Property Crime (natural log) Violent Crime (natural log)
b
a
t-statistic b
a
t-statistic
Presence of mobile homes 2.82 1.21 2.51 1.17
Adjacent to mobile homes 2.98 1.36 – 3.48 – 1.67
Presence of public housing 7.00 2.24* 6.33 2.12*
Adjacent to public housing 3.05 1.57 6.17 3.32*
Mobile home* % own-occupy – 0.43 – 2.89* – 0.29 – 1.97*
Racial heterogeneity 0.06 3.81* 0.06 3.98*
Median income
b, c
– 0.01 – 14.68* – 0.01 – 8.50*
Mobility
b
0.01 0.38 0.02 1.11
Vacancy rate 0.13 3.83* 0.09 2.77*
% Owner-occupied housing – 0.18 – 18.08* – 0.14 – 14.32*
% Single mothers – 0.01 – 0.49 0.02 0.70
% African American 0.08 7.45* 0.13 12.51*
% Hispanic 0.03 1.42 0.01 0.32
Area of block 0.12 9.47* 0.10 8.41*
% 65 years and older – 0.03 – 1.50 – 0.04 – 2.16*
% Males 15 to 21 years of age – 0.01 – 1.14 0.08 1.76
Overcrowding
b
0.29 4.51* 0.43 6.91*
Intercept 4.70* 2.10*
Adj. R-squared 0.30 0.28
N = 6,144
and violent crime containing the same independent variables plus an interaction term of mobile
home community with percentage home ownership appear in exhibit 3.
As exhibit 2 indicates, the dichotomous variable for the presence of a mobile home community was
not a statistically significant predictor of the natural log of property-crime rates or violent-crime
rates in Omaha. The dichotomous variable measuring whether a block was adjacent to a mobile
home community also failed to reach the standard of statistical significance in both models. The
three strongest predictors of property-crime rates were the percentage of owner-occupied housing,
median income, and the area of the block. The three strongest predictors of the violent-crime rate
were the percentage of owner-occupied housing, the percentage of African-American residents,
and median income. As exhibit 3 indicates, the inclusion of the interaction term of mobile home
community with percentage home ownership did have a significant effect on the natural log of
property-crime and violent-crime rates. The interaction term had a statistically significant and
negative effect on both crime measures, which indicates that increasing levels of home ownership
in mobile home communities distinctly decreased both crime rates. The other results were virtually
identical to what was found in exhibit 2.
Exhibit 3
Coefficients From the Regression of the Natural Log of Property Crime Rates and the
Natural Log of Violent Crime Rates for Street Blocks in Omaha, Nebraska, With the
Interaction Term of Mobile Home and Home Ownership
* p < .05.
a
Unstandardized b-coefficients have been multiplied by 10 to avoid miniscule numbers.
b
Measured at the block-group level.
c
In thousands of dollars.

137Cityscape
Trailers and Trouble? An Examination of Crime in Mobile Home Communities
Discussion
Official police data from 2000 through 2002 in Omaha indicate no statistically significant dif-
ference in the rates of crime between blocks with mobile home communities, blocks adjacent to
mobile home communities, and all other residential blocks. In regressions controlling for a variety
of other variables, the association of mobile home communities remained statistically insignificant.
Blocks adjacent to mobile homes also manifested no significant association with either property-
crime or violent-crime rates.
The study found that blocks and block groups with mobile home communities had lower percent-
ages of female-headed households, young males, and African Americans and a higher percentage of
home ownership than did the other types of blocks studied. Typically, these factors indicate lower
levels of disadvantage (Sampson, Raudenbush, and Earls, 1997; Sampson and Wilson, 1995).
This point is further reinforced by comparing blocks with mobile homes with blocks with public
housing complexes. In 2000, the 34 blocks with public housing structures had, on average, an
African-American population of 64.57 percent, a percentage of owner-occupied housing of 9.39,
and a median income of $16,280.
Perhaps the most glaring difference between blocks with mobile home communities and those
with public housing structures was the percentage of owner-occupied housing. The average
percentage of owner-occupied housing on blocks with mobile homes was 78.65. Many individuals
in these communities own their units (or mobile homes) and rent the land. This same arrangement
does not exist for public housing residents.
The difference in the percentage of home ownership may be one reason why the crime rates in
blocks with mobile home communities does not approach the level found in blocks with public
housing structures. Home ownership has been an important factor in predicting lower levels of
crime and disorder in a neighborhood in several previous works (see Roncek, 1981; Ross, 1977;
Sampson, Raudenbush, and Earls, 1997). It is argued that individuals who own a housing unit
have a greater stake, economically and socially, in maintaining the viability of the overall neighbor-
hood. This study found that an interaction term for the presence of a mobile home community
and the percent of households that are owner occupied had a statistically significant and negative
association with both violent-crime and property-crime rates over and above the negative associa-
tion of home ownership and crime in general.
Wilson (1987) and Sampson and Wilson (1995) have argued that higher rates of crime and disor-
der in low-income African-American communities exist because Whites and African Americans live
in distinct communities with different levels of structural disadvantage. In these truly disadvan-
taged areas, residents are socialized to participate in criminal and deviant behavior because most of
the other residents are already involved with criminal or deviant activities (Sampson and Wilson,
1995; Skogan, 1990). In addition, residents might deem criminal behavior the only option because
of persistent unemployment (Krivo and Peterson, 1996). Residents in mobile home communities,
in contrast, may at least have an owned asset, in the form of a manufactured home (Coleman,
1988; Yinger, 1995). They may also not face the level of discrimination that could be faced by
African-American residents who attempt to obtain housing (Krivo and Kaufman, 2004; Massey and
Denton, 1993; Turner, 1992).

138 Refereed Papers
McCarty
Despite the apparent better standing of mobile home communities relative to public housing
communities, mobile home communities in Omaha are not without problems. The descriptive
data in exhibit 1 indicate the average block or block group within a mobile home community is
characterized by a low-income population living in a large area with a higher vacancy and mobility
rate when compared with adjacent blocks and all other residential blocks (see MacTavish et al., 2006
for similar conclusions). Mobile home communities also have higher frequencies of crime than the
average Omaha block has. The average raw frequency (before being converted to population rates)
of violent crime from 2000 through 2002 was 1.62 offenses in blocks with mobile home commu-
nities, .96 offenses in blocks adjacent to mobile home communities, and 1.24 offenses in all other
residential blocks. For property crime, the average frequency was 5.84 offenses in blocks with
mobile home communities, 4.54 offenses in blocks adjacent to mobile home communities, and
3.43 offenses in all other residential blocks. In their subjective experience, the residents of mobile
home communities may not fully adjust for population in their encounters with crime, and they
might well perceive their neighborhoods as more dangerous than average. They have some protec-
tive factors against crime, however, that the residents of “truly disadvantaged” communities lack.
Policy Implications
The results of the study suggest that cities and other municipalities should not be so reticent to
allow the creation or expansion of mobile home communities. Mobile home developments are
not dens of crime and disorder (Dawkins et al., 2008). The presence of such communities, at
least in Omaha, does not significantly increase crime rates, after controlling for a variety of other
demographic factors. Communities have a vested interest in providing housing options for those
residents who are less affluent or cannot afford to own a traditional home. Dawkins et al. (2008)
found that the price of manufactured housing is less than one-half the price of site-built housing,
after adjusting for land costs. Finding affordable housing was a matter of deep concern for many
communities even before the current economic crisis. Apprehension about mobile home commu-
nities, especially in terms of their possible effect on crime, may be overstated. The evidence of this
article is supportive of Dawkins et al. (2008), who urge that local regulators should seek to make
sure that the permitting system is disposed toward allowing greater placement of mobile home or
manufactured-housing communities.
A more positive treatment of manufactured housing by planning commissions is undoubtedly
difficult to achieve given the prevailing negative sentiment regarding mobile home communities.
One factor driving this negative sentiment is the unsightly appearance of some mobile home
communities, especially those with units built before the HUD standards were implemented in
1976. MacTavish, Eley, and Salamon (2006) point out that finding effective ways of replacing old
units with new units is one of the most pervasive structural problems in mobile home communi-
ties. Some communities have had success using Community Development Block Grant funds and
other local funds to help finance the replacement of older and dilapidated units (MacTavish, Eley,
and Salamon, 2006). The replacement of older units can not only improve the appearance and
functionality of mobile home communities but can also address the issue of overcrowding, which
is significantly and positively associated with both violent-crime and property-crime rates.

139Cityscape
Trailers and Trouble? An Examination of Crime in Mobile Home Communities
The limitations of this study need to be acknowledged and, in future work, transcended. The use
of block-group data in lieu of block-level data for three census indicators may affect the precision
of these indicators. It is difficult to generalize the findings of the current study to mobile home
communities in all areas of the United States; for example, in some places, especially in warm
climates, mobile home communities cater to affluent and mostly retired individuals (Hart, Rhodes,
and Morgan, 2002). Undoubtedly, the findings would be different for that type of mobile home
community. The 15 communities studied in Omaha, however, were quite diverse, ranging from
what Hart, Rhodes, and Morgan (2002) call utilitarian mobile home communities to upscale
mobile home communities.
Future research about mobile home communities could take several directions. As Dawkins et al.
(2008) suggested, the study of manufactured housing communities is stymied by the limited
amount of data that exist about these developments. A more thorough collection of data about
manufactured housing communities would help catalyze future research and understanding of
these unique developments. Future studies of crime and residents’ life in mobile home communi-
ties might also consider the extent of drug-related crimes, residents’ relations with police, and
relations among residents. Further, the physical designs of these communities and their possible
effect on opportunities for crime should also be explored. Future scientific research may help erode
existing stereotypes that are imbedded in decades of friction between mobile home communities
and larger municipalities. Extending beyond this rhetoric allows municipalities, police, managers
of mobile home communities, and residents to accurately identify and address the problems these
unique neighborhoods face.
Acknowledgments
The author thanks Lisa Sample, Pete Simi, Amy Anderson, and Jeffrey Peake for their significant
contributions and guidance on this project. He also thanks Rebecca Murray and Marc Swatt for
their assistance with the data for this project. Finally, a special thanks to Yaw Boateng for his
helpful and productive input on this manuscript.
Author
William P. McCarty is an assistant professor in the Department of Criminology, Law, and Justice at
the University of Illinois-Chicago.
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145Cityscape: A Journal of Policy Development and Research • Volume 12, Number 2 • 2010
U.S. Department of Housing and Urban Development • Office of Policy Development and Research
Cityscape
Recovery Act of 2009—
Public Housing Capital Fund:
Obligations and Number of
Jobs by ZIP Code
Todd W. McNeil
KBM Group, Inc.
Graphic Detail
Geographic Information Systems organize and clarify the patterns of human activities on
the earth’s surface and their interaction with each other. GIS data, in the form of maps,
can quickly and powerfully convey relationships to policymakers and the public. This
department of Cityscape includes maps that convey important housing or community
development policy issues or solutions. If you have made such a map and are willing to
share it in a future issue of Cityscape, please contact david.e.chase@hud.gov.
The American Recovery and Reinvestment Act of 2009 (Recovery Act) is an unprecedented effort
to jumpstart the economy, create or save millions of jobs, and address long-neglected challenges.
The Recovery Act investments in the U.S. Department of Housing and Urban Development (HUD)
programs will generate tens of thousands of jobs, modernize homes to make them more energy
efficient, and help the families and communities hardest hit by the economic crisis. The Recovery
Act includes a $4 billion appropriation for the Public Housing Capital Fund. The Public Housing
Capital Fund program is expected to benefit the nation by (1) creating jobs; (2) transforming public
housing into energy-efficient, green communities; (3) redeveloping distressed public housing; (4)
addressing the needs of public housing residents who are elderly and disabled; and (5) providing
funding for public housing projects that lack the private capital to proceed with development.
HUD has developed a series of maps using the Recovery Act program data from internal sources
and external sources such as the FederalReporting.gov
1
and Recovery.gov
2
websites. One such map,
shown in exhibit 1, represents the Public Housing Capital Fund program’s distribution of funding
1
FederalReporting.gov is the governmentwide data collection system for federal agencies and recipients of federal awards
under Section 1512 of the Recovery Act. Recipients access FederalReporting.gov to fulfill their reporting obligations.
Federal agencies, prime recipients, and subrecipients are required to submit data quarterly for grants, loans, and federally
awarded contracts under the Recovery Act. Recipient data is posted on the Recovery.gov website after it passes a quality
assurance check.
2
Recovery.gov was created under the American Recovery and Reinvestment Act of 2009 to foster greater accountability and
transparency in the use of funds made available. The site’s primary mandate is to give taxpayers the user-friendly tools to
track Recovery Act funds.

146
McNeil
Graphic Detail
obligations and number of jobs by ZIP Code
3
. For example, exhibit 1 depicts the state of Pennsyl-
vania with two major urban centers, Pittsburgh and Philadelphia, as insets. Pennsylvania is used as
an example to show a graphic representation of Recovery Act program data.
Exhibit 1 illustrates areas of funding obligations by ZIP Code for the fourth quarter of 2009. The
funding obligations are in ascending order and are indicated in grayscale on the map. A second
dataset illustrates the number of jobs created or saved by ZIP Code for the same quarter. The cities
with more than 25,000 in population are labeled at their ZIP Code centroid.
Exhibit 1 shows that the highest amount of funding obligations occurs within two ZIP Code areas
within the two largest urban centers, Philadelphia and Pittsburgh. Philadelphia, a large-sized
urban area, accounts for $126,518,000, or 45 percent of the total funding for Pennsylvania.
Pittsburgh is a medium-sized urban area and is represented as two ZIP Code areas that account for
$27,099,200, or 10 percent of the total funding for Pennsylvania. The remaining $126,622,616, or
45 percent, is distributed among the remaining ZIP Code areas that are found in small-sized urban
areas. For example, Harrisburg is a small-sized urban area and is represented as two ZIP Code areas
3
ZIP Codes are mapped at their centroids—a point representing the geographic center of the polygon for a 5-digit ZIP Code.
Exhibit 1
Recovery Act of 2009—Public Housing Capital Fund Obligations and Jobs by ZIP Code
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Number of Jobs by ZIP Code
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Obligations by ZIP Code
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147
Recovery Act of 2009—Public Housing Capital Fund:
Obligations and Number of Jobs by ZIP Code
Cityscape
that account for $9,035,250, or 3 percent of the total funding
4
. Finally, Chester, another small-
sized urban area, accounts for $8,409,770, or 3 percent of the total.
As of December 2009, recipients of Public Housing Capital Fund grants in Pennsylvania have
created or saved a reported 611 jobs based on recipient-reported data from FederalReporting.gov.
The total number of jobs created or saved by all Recovery Act programs for all agencies is 12,248
for Pennsylvania as reported on Recovery.gov. The highest number of jobs created or saved occurs
in a ZIP Code area in Philadelphia. Philadelphia accounts for 128 jobs, or 21 percent of the total
jobs created or saved in Pennsylvania. In addition, Harrisburg accounts for 82 jobs, or 13 percent
of the total jobs between the two ZIP Codes. Pittsburgh, which received the second highest funding
amount, accounts for 5 jobs or less than 1 percent of the total jobs between two ZIP Codes.
Finally, Chester, Williamsport, and Pittston, all small-sized urban areas, created or saved roughly a
combined 143 jobs, or 23 percent of the total.
This map is intended to provide a snapshot view of the distribution patterns of funding and job
creation under the Recovery Act 2009 Public Housing Capital Fund program in Pennsylvania. It
suggests that the patterns would be similar in other states or metropolitan areas. Researchers and
planners concerned about Recovery Act funding in their regions should consider exploring the
HUD Recovery Act data to see whether these divergent patterns are consistent with facts on the
ground and whether they hold true across other metropolitan areas for other programs. HUD is
very interested in finding out how researchers are able to use the Recovery Act data. If you create
any maps using the Recovery Act data that you want to share, or if you have any questions or
comments, please send them to david.e.chase@hud.gov.
Acknowledgments
The author thanks David Chase for his assistance in editing this article.
Author
Todd W. McNeil is a GIS programmer and analyst at KBM Group, Inc.
4
Some state-level grants are reported at the state capital rather than at their place of performance. This reporting variance
could skew the results for Harrisburg.

148
McNeil
Graphic Detail

149Cityscape: A Journal of Policy Development and Research • Volume 12, Number 2 • 2010
U.S. Department of Housing and Urban Development • Office of Policy Development and Research
Cityscape
Using the Health and
Retirement Study To Analyze
Housing Decisions, Housing
Values, and Housing Prices
Hugo Benítez-Silva
The State University of New York-Stony Brook
Selçuk Eren
Levy Economics Institute of Bard College
Frank Heiland
The City University of New York-Baruch College
Sergi Jiménez-Martín
Universitat Pompeu Fabra, and FEDEA
Data Shop
Data Shop, a department of Cityscape, presents short articles or notes on the uses of
data in housing and urban research. Through this department, PD&R introduces readers
to new and overlooked data sources and to improved techniques in using well-known
data. The emphasis is on sources and methods that analysts can use in their own
work. Researchers often run into knotty data problems involving data interpretation
or manipulation that must be solved before a project can proceed, but they seldom get
to focus in detail on the solutions to such problems. If you have an idea for an applied,
data-centric note of no more than 3,000 words, please send a one-paragraph abstract to
david.a.vandenbroucke@hud.gov for consideration.
Abstract
Few existing surveys provide detailed longitudinal information on households and
their homes. This article introduces a data source, the Health and Retirement Study
(HRS), which has this detailed information but has received little attention by housing
researchers to date. The HRS is a rich longitudinal data set that provides information
on house values, house prices, and detailed personal characteristics of those who own
and sell their homes. The HRS is a nationally representative longitudinal survey that
originally sampled 7,700 households headed by an individual aged 51 to 61 in the

150
Benítez-Silva, Eren, Heiland, and Jiménez-Martín
Data Shop
Introduction
Although the Health and Retirement Study (HRS) is the longitudinal data set of choice to analyze
the retirement behavior, the decisionmaking regarding Social Security as well as the savings and
health status of older Americans, given its wealth of demographic, health, and socioeconomic
data, it has been rarely used to analyze questions regarding the housing market.
1
A seldom-used
section of the HRS, however, provides very detailed information about real estate transactions by
households, which enables researchers to repeatedly observe self-reported house values, the selling
prices of properties sold in the 1994-to-2008 period, and the prices originally paid as far back as
the 1950s.
The HRS is a nationally representative longitudinal survey of 7,700 households headed by indi-
viduals aged 51 to 61 as of the first interviews conducted in 1992 and 1993. It has since been
expanded to include even older households that were previously surveyed in the Assets and Health
Dynamics Among the Oldest Old (AHEAD) and younger cohorts, such as the Children of the De-
pression Age (CODA) and War Babies, which refresh and complement the original sample.
This article addresses the advantages and disadvantages of using this source of data to analyze
housing-related behaviors and housing market outcomes. It provides information about the in-
struments available in the HRS and how to construct important additional variables, questions
answered by the respondents, and empirical strategies intended to overcome some of the problems
with these data. The article illustrates the use of these data by presenting an interesting empirical
application that analyzes the accuracy of self-reported home values and shows a slight overestima-
tion of housing values by older Americans.
1
See Juster and Suzman (1995) and Gustman, Mitchell, and Steinmeier (1995) for an overview of the HRS. Also see the
online publication, “Growing Older in America” at http://hrsonline/isr.umich.edu.
Abstract (continued)
first interviews in 1992 and 1993. It now also samples additional cohorts of older
Americans. Although the HRS is the data set of choice when analyzing the retirement
behavior, savings, and health status of older Americans, given its wealth of demographic,
health, and socioeconomic data, it has been rarely used to answer questions regarding
the housing market. A seldom used section of the questionnaire provides detailed
information about real estate transactions by households, however, enabling researchers
to repeatedly observe both self-reported house values and the actual selling prices of
properties sold since 1992 (originally bought in the past five decades). The article
describes a number of important housing-related measures available in the HRS
and illustrates the usefulness of these data by conducting a statistical analysis of the
accuracy of self-reported home values. Specifically, we analyze the predictive power of
self-reported housing wealth when estimating housing prices using the HRS data. The
evidence shows a slight overestimation of housing values by older Americans.

151
Using the Health and Retirement Study To Analyze
Housing Decisions, Housing Values, and Housing Prices
Cityscape
An Unfamiliar Source of Housing Data
Using data that track particular properties over time has many advantages. For example, they enable
the researcher to account for the characteristics of the houses in a detailed analysis of the dynamics
of prices by regions of the country. Such surveys, however, rarely provide access to detailed infor-
mation about the characteristics of the owners of those houses, their behaviors, and how much they
think their houses are worth.
2
Although, at first glance, self-reported house values might not seem
a key variable of interest for housing economists, it does provide essential information to research-
ers in a variety of fields who use household-level data and who need reliable measures of household
wealth. Housing wealth is one of the pillars of the well-being of American families. It represents
more than 60 percent of the average net wealth of U.S. households, according to the Federal Re-
serve’s 2004 Survey of Consumer Finances.
3
Hence, many important decisions that households
make are expected to be influenced by what they believe their houses are worth. Consequently,
what the owner thinks the property is worth is very valuable information for researchers who seek
to understand household decisionmaking.
What Americans think their houses are worth should be a primary concern to all housing econo-
mists, because, without understanding how the valuation evolves and how it is determined, we
cannot understand the homeowners’ selling decisions, both in terms of whether they decide to sell
and at what price they agree to do so. Self-reported housing values may provide only a very noisy
picture of the actual value of the property. It would be ideal to also have access to selling prices
and compare the two measures to analyze whether reported values can be taken at face value and
can be readily combined with other measures of wealth when studying the decisionmaking at the
household level.
The HRS is a high-quality longitudinal data set, largely unknown in the housing literature, which
provides two types of variables: (1) what individuals think their house is worth and (2) the price at
which they sell the home (if a sale occurs). Up until the recent work by Benítez-Silva et al. (2009),
researchers had not fully exploited the level of detail on housing wealth information available in
the HRS.
4
Selected earlier research (for example, Farnham and Sevak, 2007) has used the self-re-
ported home value information in the frequently used housing wealth section of the study but did
not explore the rich data on housing transactions from the responses to the questions in the capital
gains section of the HRS.
2
Most studies use the American Housing Survey, which follows houses rather than households, or the Survey of Consumer
Finances (SCF), which is not a panel data survey. See Agarwal (2007), Goodman and Ittner (1992), and Kiel and Zabel
(1999). The first study on this issue was published by Kish and Lansing (1954), using the 1950 SCF, and it was not until
Kain and Quigley (1972) that the assessment of self-reported home values was revisited. Kain and Quigley (1972: 803)
acknowledge that “…the only accurate estimate of the value of a house is its sale price…”; however, due to data limitations
and what they perceived as possibly serious selection problems, their analysis focused, as did the early study, on comparisons
of households’ self-reports with appraisals by experts. The latter can be considered indirect market assessments, because they
use information on similar properties and try to account in the econometric study for the observable characteristics of the
property.
3
See Bucks, Kennickell, and Moore (2006). This fraction is considerably lower than in some European countries. For
example, in Spain, housing wealth represents 87.5 percent of net wealth.
4
Venti and Wise (2002) and Farnham and Sevak (2007) analyze the role of housing in retirement decisions, using the
information in the housing wealth section.

152
Benítez-Silva, Eren, Heiland, and Jiménez-Martín
Data Shop
This article takes advantage of the detailed information on housing transactions and valuation
provided in the HRS by combining data from the wealth section with information from the largely
unfamiliar capital gains section. It is important to note from the outset a number of weaknesses
and limitations of these data. First, the HRS was created to analyze the socioeconomic situation
and decisions of older American households; therefore, it represents only that age group and that
cohort, and, although it has incorporated some other cohorts, it continues to only represent those
considered to be older Americans. Ideally, we would have this richness of information for a wider
cross-section of the population, but the data sets designed to represent all American households,
such as the Panel Study of Income Dynamics, do not have the level of detail that we are interested
in here. Another weakness of the HRS, which is common to any household-level survey, is that all
the information we discuss here is self-reported and, therefore, subject to measurement errors, mis-
reporting, and possible biases. Ongoing debate continues in the literature about the usefulness and
quality of self-reported data, but it is generally believed that when considerable consistency among
several sections of the survey can be demonstrated, the more serious concerns about self-reporting
are unlikely to dominate over the usefulness of the data.
The Information Available in the Health
and Retirement Study
The housing wealth section of the HRS asks respondents about the value of their homes (and farms
or mobile homes) if they were to sell them today, the mortgages on their homes (first or second
mortgages), and any home equity loans, home equity lines of credit, or other debts backed by
their properties. The questionnaire also asks about the price at which the home was originally pur-
chased, the month and year of that purchase, and real estate taxes paid on the property. The key
element of self-reported housing wealth information is that it directly asks heads of household to
estimate their home’s current selling price. We have no way to know whether the person is think-
ing of selling the house, or whether it is even for sale at the time of the interview. We also have no
information about the quality of the individual’s assessment, at least not in this section of the ques-
tionnaire. New respondents, or those who say that they moved between waves, get to answer this
part again.
Researchers have typically not gone beyond these questions in the HRS, but the survey also pro-
vides detailed information about real estate transactions that happen between waves. These ad-
ditional questions, however, are asked in a completely different section—the capital gains section
(called the asset change section in later waves). This section not only asks about transactions on
primary and secondary residences but also about the sales of business properties, other real estate,
and even financial assets.
The information on housing transactions is very detailed. The survey gathers from the respon-
dents whether the household has bought, sold, or bought and sold a property since the previous
interview and, if one of the options is the case, the price at which the house was sold as well as
bracketed ranges of sale prices for those who do not answer the direct amount question. Further-
more, the questionnaire also asks about the original purchase price of the home and the date of
that purchase. One shortcoming of the wording of these questions is that they are not asked sepa-

153
Using the Health and Retirement Study To Analyze
Housing Decisions, Housing Values, and Housing Prices
Cityscape
rately for both primary and secondary residences, so unless we match the information against an-
swers in the housing section, we do not know whether the transaction was made on the primary
or secondary residence. This matching is possible, but it only works if the individual purchased
the primary and secondary residences in different years. If the transaction happened in the same
year, there is no way to definitively know which property the person is talking about without
looking at the reported values and guessing for which property the person has supplied the infor-
mation. The latter option is time consuming and error prone because it requires going over every
questioned transaction.
The survey also asks respondents about improvements made to the properties (again not differenti-
ating between primary and secondary residence), both in terms of whether any improvements were
made and the value of that work (which includes the value of the work they might have done them-
selves). Overall, this survey presents a fairly detailed picture of the housing assets these older Ameri-
can households have and the transactions they have completed during the 1992-to-2008 period.
With all these pieces of information, we can construct a number of useful variables beyond self-
reported housing values, sale prices, and original purchase prices, such as the average capital gain
that households experienced on their properties, the average equity in the properties, the number
of years households own a house before selling it, and information about the property owners re-
garding their age, marital status, race, income, and so on.
Exhibit 1 summarizes some of the characteristics of financially knowledgeable homeowners and
their assets. The columns break down the sample according to the selection criteria: whether or not
individuals sell their house during the 1992-to-2002 period for which we are analyzing data. Note
that, given the longitudinal nature of the sample, homeowners may be observed up to six times but
are asked whether they sold a house they owned at only five of those occasions.
From the 1,086 observations we have in the first six waves of the HRS that report valid positive
selling prices on households’ homes and, at the same time, reported a valid value of a home they
previously owned, we eliminated 210 observations because we did not have valid information
about when they bought that home or when they sold it. Not having information on the first
variable (when they bought the home) does not allow us to match the property exactly, and not
having information on the second variable (when they sold the home) prevents us from using the
difference in months between the time of the self-reported value and the time they sold the prop-
erty, which is an important variable in our econometric application. We also eliminated home-
owners who reported a sale price 0.2 times the self-reported house value and less, or 5 times the
self-reported house value and more (a total of 40 individuals). These extreme values occur mostly
due to coding errors.
5
5
Because of all these restrictions, our estimated sample is reduced to the 836 observations used in the ordinary least squares
estimations. The selection-corrected estimations use only 665 observations because we lose some observations by including
home equity in the selection equation as an exclusion restriction that allows us to nonparametrically identify the selection-
corrected specification.

154
Benítez-Silva, Eren, Heiland, and Jiménez-Martín
Data Shop
As shown in exhibit 1, those who did not sell a house during the observed period reported lower
home values, purchase prices, and capital gains. The average home tenure for sellers is shorter
than for nonsellers, but it is still almost 18 years. On the other hand, nonsellers have less home
equity, are less likely to be White, have lower educational attainments, and lower earnings. The
marital status, average age, and gender composition are similar for both sellers and nonsellers.
Looking at the sellers, we observed that self-reported home values are greater than selling prices
by around 2 percent.
Exhibit 1
Summary Statistics
Selling price 140,022 114,673
Self-reported house value 143,199 108,510 122,947 111,984
Original purchase price 79,929 85,219 56,838 74,982
Capital gains 63,269 75,570 66,109 84,833
House tenure 17.41 11.30 21.28 11.41
Home equity 103,911 98,623 96,101 95,982
Bachelor’s degree 0.3779 0.485 0.28 0.448
Professional degree 0.1411 0.348 0.109 0.311
Married 0.726 0.446 0.747 0.434
White 0.886 0.317 0.782 0.412
Age 61.52 5.84 61.53 5.65
Male 0.559 0.496 0.543 0.498
Earnings 87,820 113,314 75,525 119,157
Number of observations 836 18,144
Variable Name
Sellers Nonsellers
Mean Standard Deviation Mean Standard Deviation
An Empirical Application: Testing the Accuracy of
Self-Reported Housing Wealth
This interesting source of data can be used in a variety of ways to supplement, complement, and
even contrast information on housing values, housing prices, and characteristics of homeowners
obtained in other surveys. In this section we provide a simple empirical analysis that tests within a
simple regression model the accuracy of self-reported housing wealth measures in the HRS.
In the data, we observe the market value of a property when the individual reports the transaction
price of a house they have sold since the last survey wave. Therefore, the self-reported house value
is obtained from the previous wave of data. Given data collection every other year only, as many as
24 months may pass between the measurement of the sale price and the self-reported house value.
In the interview, individuals are asked about the current market value of their homes rather than
asked to forecast the price for a future period. To correct for possible bias in the estimation of the
coefficient of interest resulting from possible appreciation (depreciation) of the value of the house

155
Using the Health and Retirement Study To Analyze
Housing Decisions, Housing Values, and Housing Prices
Cityscape
6
Notice that this discrepancy in the timing of the assessment suggests that the relationship in (1) is potentially nonlinear.
We have allowed for the difference in months to enter nonlinearly (which could capture changing economic conditions
in the months before the sale, which could affect the price, like movements in the interest rates), but the results have not
changed. One possible alternative would be to adjust all the observed prices to the same time period. This adjustment,
however, may create some unwanted measurement error because, in many cases, only a few months of difference existed
between reports. The results of our preferred specification remain literally unchanged; therefore, the empirical evidence
suggests that those who sell shortly after the interview do not report systematically more accurate estimates of the selling
price of their properties than those who sell shortly before the following interview.
7
There is no reason to believe that the model should contain a constant, because no minimum market value exists for the
houses, and the left- and right-hand sides are measuring the same asset. In fact, we have run several empirical specifications
with a constant and it comes out to be insignificant, as expected, no matter how we specify the model. In the empirical
work, we present results with and without a constant in the regression.
during that time, we control for the number of months between the observances of these two vari-
ables.
6
The ordinary least squares (OLS) specification can then be written as follows:
(1)
where represents the self-reported house value from the previous wave, and represents the
number of months between the time the market price refers to and the time of the self-reported
home value estimation. The dependent variable is the price of the property reported by the indi-
vidual, and, if the homeowners predict the market value of their house accurately, we expect to
find that . If homeowners overestimate (underestimate) the value of their home,
then the estimated slope coefficient will be less than (more than) one.
7
One underlying concern with the OLS specification presented is that we only estimate the relation-
ship of interest for the sample of sellers. If sellers are very different from nonsellers on unobserv-
able characteristics, we would not be able to generalize our results to the whole population. We
follow the classic work of Heckman (1979), which reformulates this selection problem as a specifi-
cation bias that has as a source the omission of a variable that represents the sample selection rule.
We correct this problem by adding the inverse mills ratio, which results from estimating a selection
equation, into the equation of interest. This selection equation can be the result of a probit estima-
tion if we assume a Gaussian distribution of the error term of the binary choice model of selling a
property. It is common to add an exclusion restriction to this selection equation to obtain nonpara-
metric identification of this nonlinear model (the parametric identification is guaranteed by the
nonlinearity of the model), and in our case the variable we use is the home equity on the home.
Exhibit 2 presents the results from the different specifications and estimation strategies. The OLS
estimate of , the coefficient on the self-reported house value when estimated without a constant,
is 0.903. This point estimate implies an overestimation of about 10 percent in house values. If we
estimate the model with a constant, the coefficient of interest goes down to 0.887, but the con-
stant is estimated as not statistically different from zero. Both specifications explain a very large
proportion of the variation in selling prices, which confirms the reliability of the model we pres-
ent in this article.

X
i
t1null

156
Benítez-Silva, Eren, Heiland, and Jiménez-Martín
Data Shop
Accounting for selection, we find the coefficient of the inverse mills ratio to be statistically insignif-
icant, suggesting that there is no evidence that sellers differ from nonsellers in unobservable ways.
8

Although the coefficient for reported house values decreases slightly, the standard errors increase.
While given the precision of our estimates, we cannot reject the hypothesis that agents are assess-
ing the value of their houses with accuracy; the point estimates indicate considerable overestima-
tion of the value of the properties.
One additional concern with this model, which is explored in some detail in Benítez-Silva et al.
(2009), is the endogeneity of self-reported home values due to unobserved heterogeneity grounded
on local market conditions and unobserved house characteristics.
8
In a related context but estimating a different type of home sale price equation, Ihlanfeldt and Martínez-Vázquez
(1986) also found no evidence of sample selection bias when estimating an equation of sale prices.
Exhibit 2
The Accuracy of Self-Reported Home Values
Self-reported house value 0.887 0.087 0.903 0.0601 0.894 0.092
Months between the
report and the sale
468.41 351.06 741.04 407.13 527.62 389.24
Constant 7,056 13,411 — —
Inverse mills ratio — — 3,277 6,748
Adjustment R-squared 0.7067 0.882 0.8763
Observations 836 836 665
OLS = ordinary least squares.
Dependent Variable:
Sale Prices
OLS OLS, No Constant Selection Corrected
Coefficient
Standard
Error
Coefficient
Standard
Error
Coefficient
Standard
Error
Conclusions
Few existing surveys enable researchers to study households and their homes over time. The pur-
pose of this article is to introduce one data source, the Health and Retirement Study (HRS), which
has this information but has received little attention by housing researchers to date. The HRS is a
longitudinal data set that provides information on self-reported house values, house prices, and
detailed personal characteristics of those who own and sell their homes. The HRS is well known
and frequently used among researchers in the fields of aging and retirement, but its rich section on
housing, covering the prices of properties sold after 1992 and the prices of properties bought as
early as the 1950s, is not well known and has rarely been used. This article discusses the potential
and the limitations of the housing data collected in the HRS. We describe the housing-related in-
struments available in the HRS and show how to construct a number of important additional mea-
sures related to housing transactions and wealth. We illustrate the usefulness of these longitudinal
data for housing research by conducting a statistical analysis of the accuracy of self-reported home

157
Using the Health and Retirement Study To Analyze
Housing Decisions, Housing Values, and Housing Prices
Cityscape
values. This application is motivated by the fact that self-reported home values are widely used as a
measure of housing wealth by researchers employing a variety of data sets and studying a number
of different individual and household-level decisions.
Acknowledgments
Hugo Benítez-Silva acknowledges the financial support from Grant Number 5 P01 AG022481-04
from the National Institute on Aging on a related project. Benítez-Silva and Frank Heiland thank
the Michigan Retirement Research Center for their support on a related project. Sergi Jiménez-
Martín and Benítez-Silva acknowledge the financial support of the Spanish Ministry of Education
through project number SEJ2005-08783-C04-01. Any remaining errors are the responsibility of
the authors.
Authors
Hugo Benítez-Silva is an associate professor and Director of Graduate Studies in the Department of
Economics at The State University of New York-Stony Brook.
Selcuk Eren is a research scholar at the Levy Economics Institute of Bard College.
Frank Heiland is an assistant professor and CUNY Institute for Demography Faculty Associate in
the School of Public Affairs at The City University of New York-Baruch College.
Sergi Jiménez-Martín is an associate professor in the Department of Economics at the Universitat
Pompeu Fabra and Fundación de Estudios de Economía Aplicada.
References
Agarwal, Sumit. 2007. “The Impact of Homeowners’ Housing Wealth Misestimation on Consump-
tion and Saving Decisions,” Real Estate Economics 35 (2): 135–154.
Benítez-Silva, Hugo, Selcuk Eren, Frank Heiland, and Sergi Jiménez-Martín. 2009. How Well Do
Individuals Predict the Selling Prices of Their Homes? Unpublished paper.
Bucks, Brian K., Arthur B. Kennickell, and Kevin B. Moore. 2006. “Recent Changes in U.S. Family
Finances: Evidence from the 2001 and 2004 Survey of Consumer Finances,” Federal Reserve Bul-
letin 92: A1–A38.
Farnham, Martin, and Purvi Sevak. 2007. Housing Wealth and Retirement Timing: Evidence from
the HRS. Working paper 2007-172 (October). Ann Arbor, MI: University of Michigan, Michigan
Retirement Research Center.
Goodman, John, Jr., and John B. Ittner. 1992. “The Accuracy of Home Owners’ Estimates of House
Value,” Journal of Housing Economics 4: 339–357.

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Gustman, Alan L., Olivia S. Mitchell, and Thomas L. Steinmeier. 1995. “Retirement Measures in
the Health and Retirement Study,” Journal of Human Resources 30 (Supplement): S57–S83.
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Ihlanfeldt, Keith R., and Jorge Martínez-Vázquez. 1986. “Alternative Value Estimates of Owner-
Occupied Housing: Evidence on Sample Selection Bias and Systematic Errors,” Journal of Urban
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the American Statistical Association 67: 803–806.
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Venti, Steven F., and David A. Wise. 2002. “Aging and Housing Equity.” In Innovations in Retirement
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of Pennsylvania Press and the Pension Research Council: 254–281.

159Cityscape: A Journal of Policy Development and Research • Volume 12, Number 2 • 2010
U.S. Department of Housing and Urban Development • Office of Policy Development and Research
Cityscape
Gino Aisenberg
Brent Ambrose
Mark Austin
Barbara Brown
Peter H. Brown
Barbara Butrica
Charles Capone
Mary Cunningham
Amy Crews Cutts
Andrew Dannenberg
Zhu Xiao Di
Gary Engelhardt
Allen Furr
Jacqueline Geoghegan
John Goering
Edward Goetz
Peter Hall
Timothy Ireland
Jim Kennedy
Referees 2009–10
The Office of Policy Development and Research gratefully acknowledges the contributions
of the referees listed below and their efforts toward making Cityscape worth reading.
Ben Keys
Morris Kleiner
Marc Law
Daniel Lichter
Robert Litan
Jeff Lubell
Kate MacTavish
Janice Madden
Carson Mencken
Stephen Metraux
Robert Olshansky
Satyendra Patrabansh
Susan Popkin
Hazel Prelow
John Quigley
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Bill Reeder
Andrew Reschovsky
Barbara Robles
Emily Rosenbaum
Claire Rubin
Joseph Schilling
Terry Schum
William Siembieda
Stacy Sirmans
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Ed Szymanoski
Paul Toro
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Cityscape
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Office of Policy Development and Research
Washington, DC 20410-6000
Official Business
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and Urban Development
Contents
Symposium
Aging in Place
Guest Editors: Cheryl A. Levine, Gavin Kennedy, and Emily Rosenoff
Guest Editors’ Introduction ..........................................................................................1
Assessing the Quality of Care Found in Affordable Clustered Housing-Care
Arrangements: Key To Informing Public Policy ..............................................................5
by Stephen M. Golant, Pamela Parsons, and Peter A. Boling
Integrating Community Services Within a NORC: The Park La Brea Experience ............29
by Susan Enguidanos, Jon Pynoos, Maria Siciliano, Laura Diepenbrock,
and Susan Alexman
Health-Related Needs Assessment of Older Residents in Subsidized Housing ...............47
by Victoria Cotrell and Paula C. Carder
Health Indicators: A Proactive and Systematic Approach to Healthy Aging ..................67
by Fredda Vladeck, Rebecca Segel, Mia Oberlink, Michal D. Gursen,
and Danylle Rudin
Aging in Place Partnerships: A Training Program for Family Caregivers of
Residents Living in Affordable Senior Housing ............................................................85
by Alisha Sanders, Robyn Stone, Rhoda Meador, and Victoria Parker
Refereed Papers
Real Estate Brokers’ Duties to Their Clients: Why Some States Mandate Minimum
Service Requirements .............................................................................................105
by Anupam Nanda and Katherine A. Pancak
Trailers and Trouble? An Examination of Crime in Mobile Home Communities ............ 127
by William P. McCarty
Departments
Graphic Detail
Recovery Act of 2009—Public Housing Capital Fund: Obligations and Number of
Jobs by ZIP Code ...................................................................................................145
by Todd W. NcNeil
Data Shop
Using the Health and Retirement Study To Analyze Housing Decisions,
Housing Values, and Housing Prices ........................................................................149
by Hugo Benítez-Silva, Selçuk Eren, Frank Heiland, and Sergi Jiménez-Martín
Referees 2009–10 ..............................................................................................159
Vo l u m e 12, Nu m b