JPB Report by Jonathan Rose Companies

Communities of Opportunity Study Design Mailman School of Public Health

Table of Contents Chapter One | Introduction

Chapter Two | Background

Chapter Three | Academic Literature Review

Chapter 1 Introduction The notion that housing-based interventions can significantly improve health and well-being for residents of affordable housing is reasonable, but the empirical

evidence needed to develop and implement effective programs and policies is largely lacking.

PREFACE The notion that housing-based interventions can significantly improve health and well-being for residents of affordable housing is reasonable, but the empirical evidence needed to develop and implement effective programs and policies is largely lacking. We undertook the present work to better understand existing gaps between practice, evidence and current housing policies, and to develop a strategy to formally study the impact of intervention components on measurable resident health indicators. In the process of this work, we aimed to review the published and unpublished evidence, describe in detail the experiences of residents in one selected housing site, develop a toolkit of housing intervention methods, and design a large-scale study to test the cost-effectiveness of affordable housing-based interventions as measured by resident health outcomes. Our goal was to identify strategies that can be implemented at scale by a wide range of for-profit and not-for-profit affordable housing owners at nominal cost, improving the lives of their residents and the stability of their developments, while documenting cost savings for both the building owners and the health care system. Here we provide a summary of our rationale, objectives, process and results, and conclusions. RATIONALE We bring to this work a preconceived but largely untested Communities of Opportunity (CoO) model that seeks to leverage housing as a pathway to comprehensive resident health and well-being, using a resident-centered participatory framework including programs and services to support residents’ needs and desires. This model posits that a range of resident health benefits can be obtained by bundling green building and maintenance practices, resident-centered programs and services, physical amenities, and linkage to health resources via the co-location of health and health-related services

Communities of Opportunity Study Design

delivered within housing settings. Further, the model embraces a process of co-production whereby residents play a critical role in the design, implementation and sustainability of housing-based health interventions. Finally, we recognize that housing-level health interventions are embedded within a larger ecosystem of neighborhood institutions and community-level socioeconomic conditions that also impact resident health and well-being. Awareness of these multi-level influences on resident health will inform the choice of appropriate and sustainable interventions, thereby optimizing positive health and social outcomes for residents of all ages living in affordable housing. A foundation for the CoO model is the established body of evidence on the positive health impacts of green buildings, demonstrated by the affordable housing sector and rigorously evaluated over the past decade. This attention to the critical impact of healthy physical environments and the reduction of risks associated with hazardous exposures was a central tenet of our work, and we aimed to further evaluate the health-related impact of selected environmental interventions. Despite our awareness that characteristics of the physical space may be influential drivers of health outcomes, we understood that the impact of the physical environment likely works via complex pathways involving quality of life, psychosocial stress, and other factors that affect physical and mental health. A key and somewhat poorly measured ingredient relates to resident engagement and feelings of efficacy and/or satisfaction with living conditions. One element of resident engagement involves co-production whereby residents play a critical role in the design, implementation and sustainability of housing-based health interventions. Initially developed for chronic disease management in clinical settings whereby medical providers and patients collaborate to achieve clinical benchmarks, co-production has been variously introduced but rarely evaluated in housing settings. The strategy may be implemented using Resident Services Coordinators to interactively identify residents’ assets, needs, and preferences in the design of housing-based interventions, and is consistent with the principles of community-based participatory methods, and serves to inform the design, management and sustainability of healthy affordable housing. A second element that may enhance the health impact of housing based physical and social interventions concerns the shared perception that residents can organize and influence the quality of life in their housing site. Borrowed from the sociology of crime and subsequently applied to the field of education, this sense of power and control is termed collective efficacy, and describes the degree to which residents of the housing site may participate in and cooperate to improve the quality of their residential community. The Communities of Opportunity model embraces this idea, and aims to better understand how the design, implementation and uptake of housing-based interventions can be enhanced by the adoption of shared community values. Several steps were required to move toward the overarching goal of designing a research study to formally evaluate the resident and community health impact of selected housing-based interventions. To accomplish the scope of work, we assembled an interdisciplinary research team, made up of academics, community practitioners, and leaders in the affordable housing field from Co¬lumbia University Mailman School of Public Health, Jonathan Rose Companies, Enterprise Community Partners, Harvard University T.H. Chan School of Public Health, Success Measures at NeighborWorks America, and the Dartmouth Institute for Health Policy & Clinical Practice.

Chapter 1 Introduction

OBJECTIVES Our two-year long collaborative pilot project had two primary objectives. 1.

Conduct a Knowledge Landscape This includes an extensive literature review spanning academic publications, field reports and other unpublished documents; key informant interviews to better understand the intervention elements and process; and a case study of an illustrative affordable housing site.

Develop a protocol to formally test the health effects of housing-based interventions This includes a large-scale study design, rigorous measurement, intervention components, engagement techniques using the principles of co-production and collective efficacy, to initiate community-engaged data collection and field testing.

PROCESS First, our team completed the Knowledge Landscape including an extensive literature review of housing-based interventions spanning academic publications, field reports, and practitioner-based knowledge. To complement the review, we conducted a case study of an affordable housing site, Grace West Manor in Newark, New Jersey, drawn from the Jonathan Rose Companies portfolio, as well as key informant interviews, to illustrate the practice-based experience of implementing elements of the Communities of Opportunity model. Information about interventions to ensure the health and safety of affordable housing residents is fragmented and difficult to access, especially practice-based strategies that may not appear in the professional literature. There are few formal evaluations of program success and scalability, and virtually no guidelines for selecting the most promising interventions based on the goodness of fit within the wider community setting. A critical goal of this work has been to operationalize components of the CoO model and determine how best to evaluate its impacts. Borrowing from previous successes, we looked to the integration of green building elements and the science to support its benefits to health. Initially, the benefits of building green affordable housing were justified primarily by economic returns; its health impacts were merely hypothesized but not yet proven. Once rigorous evaluation of the health and economic impacts were established, a range of public policy and financing programs were enacted that have led to widespread adoption of green housing practices across housing sectors. Today, over 75% of all new affordable housing, currently being built or significantly renovated, meet green criteria. However, while healthy green practices are commonly incorporated into new and renovated housing stock, many residents of affordable housing still live in un-renovated housing that may have significant capital needs related to missed opportunities for health benefits. The connection between housing conditions and health is undeniable (Rauh 2008; Jacobs 2009; Adamkiewicz 2011), yet the field still lacks rigorous analytical

Communities of Opportunity Study Design

modeling to demonstrate exactly how physical and social living environments shape health risks individually and jointly. To be clear, characteristics of the physical space are indeed influential drivers of health outcomes, but the review suggests that an improved physical environment likely affects resident health and well-being via interactions with other health-related enhancements to the residential environment, via both direct and indirect pathways involving quality of life, psychosocial stress, and other factors that affect physical and mental health. At the completion of this work, we designed a sample protocol for the future study, Health Effects of Housing-based Interventions: An Ecological Study, including resident engagement strategies and multi-level measures of resident, building and community health. This included a suite of methods for data collection, targeted interventions, and monitoring the fidelity of implementation. We explored sample size for targeted recruitment and the location of future study sites. We identified secondary data sources for community-level assessments, using Opportunity360 developed by Enterprise, as a starting point and supplemented with other more locally specific data sources. This report is organized in five parts. First, the background section features the conceptual and historical underpinnings of the Communities of Opportunity model, and offers insights on key dimensions and focus areas of the model. Second, we present the results of our scoping review of the academic literature which is organized thematically to reflect the breadth of housing-based health interventions and corresponding empirical evidence to which we applied rigorous assessment criteria to determine the quality of evidence and what gaps and opportunities exist to further develop the field. This section also offers an overview of the grey literature, including programs and initiatives that are described in non-peer-reviewed sources. Third, we present findings from key informant interviews which provide the perspectives of practitioners in the field as they have implemented resident-centered programs in affordable housing settings. Fourth, we showcase one site that has fully implemented the CoO model. Lastly, we provide a blueprint of methods to rigorously study the model. In the discussion and conclusion section, we summarize our findings and provide recommendations for future directions.

Chapter 1 Introduction

Chapter 2 Background The recognition of housing as a key determinant of health is well established. Recent work has identified four key features of housing that are linked to health and contribute to the exacerbation of health disparities that adversely affect vulnerable populations.

The recognition of housing as a key determinant of health is well established. Recent work has identified four key features of housing that are linked to health and contribute to the exacerbation of health disparities that adversely affect vulnerable populations. The four pillars - housing affordability, quality, (in)stability and neighborhood opportunity structures - represent the basis by which cost, consistency, conditions and context work independently and in tandem to create or jeopardize opportunities for healthy individuals and families (Hernández and Swope, 2019; Swope and Hernández, 2019). By this measure, affordable housing providers are in a unique position to influence the health trajectories of residents in the following ways. First, the premise of subsidized housing is to ensure affordability based on a householder’s income and ability to pay. The logic is that housing costs should be no more than roughly 30 percent of household income, leaving additional funds for other basic necessities, such as food, medical expenses, childcare, utilities and transportation. This further assumes that additional financial resources can support health through, for example, healthier food or reduced stress and mental strain. Second, greater housing affordability should ensure more stability, which is primarily considered a positive attribute except if residents are unduly exposed to hazardous housing and neighborhood conditions that stem from lack of choice to reside in more healthful environments. Third, a significant concern about subsidized housing is that due to deferred maintenance and lack of renovations, the quality of residential units is compromised. Due to market segmentation and policies and practices that hinder the adequate maintenance and upkeep of residential complexes, conditions such as pest infestation, mold, energy inefficiencies and secondhand smoke exposures are most common in the affordable housing sector. This often means that the poorest residents are often relegated to the lowest quality residential units and experience significant health risks associated with housing with maintenance defects. Moreover, affordable housing units are often located in low-resource communities where opportunities for healthy lifestyles are encumbered by concentrated poverty, poor quality schools, limited access to healthy foods, violence and crime, and disproportionate incarceration rates, along with other markers of neighborhood disadvantage. Placed-based interventions are essential to addressing the social determinants of health and housing settings are a foundational aspect of this approach.1 Increasing urbanization and residential density reinforce the reality of co-existence in the built environment particularly so in multi-unit housing. From a public health perspective, there is much to be gained by capitalizing on the social and spatial value of multiple-unit dwellings to promote health given that apartment buildings naturally connect people via a common address. Furthermore, multiple-unit housing provides a platform to reach multi-generational populations in situ thereby reducing barriers to participation in health promoting activities. Vulnerable populations including low-income and racial and ethnic minorities disproportionately reside in multiple-unit housing, thereby serving as a critical site to target harder-toreach populations most adversely impacted by health and socioeconomic disparities. Recent research initiatives suggest that residential settings are promising venues for health promotion and public health impact. This is especially true in the affordable housing sector which meets a critical need for its residents. Housing intervention models have generally focused on two approaches: first, a community and regional approach where housing is considered the access point for resources and services in the surrounding area rather than the building setting. The second approach has been to focus narrowly the provision of health and medical services in housing settings while not only appreciating the social determinants of health and programming that supports health beyond linkage to health services. Below

Communities of Opportunity Study Design

we provide a brief overview of these existing models focused on leveraging housing as an access point to opportunities before presenting our original Residential Communities of Opportunity framework. HOUSING AS A PATHWAY FOR OPPORTUNITIES AT THE COMMUNITY/REGIONAL LEVEL Based in the community and economic development sector, the first known articulation of a ‘Communities of Opportunity model’ was espoused by the Kirwan Institute for the Study of Race and Ethnicity at the Ohio State University in a report published in 2007. The Kirwan Institute’s Communities of Opportunity model focused on regional or community-level opportunity and on disentangling the “tale of two cities” narrative of segregation, disadvantage, lack of opportunity, disparity, inequity, and injustice. This model is inherently rooted in the importance of access to diverse social and economic populations, networks, workforce options, etc. The authors cite years of research demonstrating the health, social, economic, environmental, and educational risks of such concentrated disadvantage, all of which hinders a region’s ability “to become a vibrant, sustainable residential and employment magnet.” This regionally-focused model was intended to serve as a framework for promoting community development and fair housing that is responsive to the “complex and interconnected web of opportunity structures” within which people are situated and with the goal of visualizing the disparities to then remedy them. Guided by an inherently spatial paradigm, the conceptual basis of this model has been coupled with a mapping methodology which uses GIS and datasets to map distribution of opportunity in an area such that it can inform community development, address the need for equitable opportunities, improve living conditions, and advocate and implement informed, targeted, and strategic interventions for all in order to redevelop critical opportunity structures. These community mapping methods are a first step to implementing the COO framework, because it is critical to understanding, measuring, and representing the dynamics of opportunity within a region comprehensively and comparatively. To map a community, the Kirwan researchers used indicators of opportunity such as the availability of 1) sustainable employment; 2) high performing schools; 3) a safe environment; 4) access to highquality health care; 5) adequate transportation; 6) quality child care and safe neighborhoods. The model is based on the conviction that everyone should have fair access to these critical structures and that affirmatively connecting people to opportunity creates positive, transformative change in communities. The Institute also recognizes that the impacts of access to opportunity do not just affect individuals, but the fabric of the wider community. Additionally, the Kirwan Institute maintains that the model’s focus on affordable housing makes it more adaptive to the realities of complex regional dynamics. However, this model disregards the elements of the four pillars of housing described above. Taking inventory of the context alone and not the interplay between the proximal and distal conditions of housing (meaning what is happening inside and outside of buildings) is a missed opportunity to also appreciate how opportunity is structured within residential contexts not just by the surrounding environment. The authors of the report go so far as to argue that “where you live is more important than what you live in,” meaning that location is more important than housing quality. This is a fundamental point of divergence between the original Communities of Opportunity model espoused by the Kirwan Institute and the Residential CoO we have developed herein. Given the mechanisms of displacement that are most detrimental to low-income and minority populations including gentrification as places that were formerly disinvested in receiving resources to develop and improve housing and community offerings, it is critical to position housing as an anchor

Chapter 2 Background

to communities that may at once evolve and dislocate residents that are not well-established in their housing. Rather than ignore the interior housing context, we see residential setting as the primary vector of opportunity where, ecologically-speaking, residents can access support within their more immediate housing settings and also within the broader community. We believe that housing and neighborhoods should not be disregarded individually or pit against the other, given how intertwined they are in everyday life. We do, however, see important proximal benefits to investing in and offering services within housing settings and not merely focusing on community level offerings. TOWARD A BROADER BASED MODEL OF PUBLIC HEALTH PROGRAMMING IN RESIDENTIAL SETTINGS The implementation of housing-based health interventions is nuanced in practice. The Communities of Opportunity (CoO) Model1 developed by Jonathan Rose Companies (JRCo) and the Community Opportunity Fund (COF) embodies the philosophy of aligning the often siloed medical, public health, and social service sectors within the affordable housing sphere with the goal of creating opportunities for affordable housing residents to live healthier, happier, and more connected lives. (COF, 2019; JRCo, 2019a). The CoO Model seeks to increase positive health, educational, and socioeconomic outcomes by using housing—itself a most critical social service—as a primary vector that connects individuals to each other and to broader resources, through external partnerships and linkages to a variety of medical and social services and public health programs. In this way, the COO model goes beyond the mere provision of healthcare-related services to adopt a social determinants of health lens, seeking direct and indirect benefits to resident health and well-being. Specifically, the Communities of Opportunity aims to: 1) provide services and positive exposures to affordable housing residents in opportunity-deprived areas and 2) take a regional and asset-based approach that connects affordable housing residents to existing opportunity structures within and about their communities. By focusing on these areas of impact, the Communities of Opportunity model seeks to ensure that residents and staff are “happier, healthier and more connected.” The model is guided by a philosophy of system alignment and housing as the core delivery mechanism, with a vision of housing that extends beyond the mere provision of a residence, more than brick and mortar. In fact, the CoO approach seeks to leverage housing as a primary connection point, linking individuals to each other and to broader resources offered within the building and the community at large. In this model, affordable housing is coupled with health-based services through external partnerships, public health programming and social service linkages. JRCo’s mission in having implemented the CoO model is to: (1) improve resident socioeconomic, health, and educational outcomes; (2) encourage positive housing system results (e.g., improve tenant relations, reduce turnover); and (3) provide evidence needed to influence structural changes in the affordable housing sector to integrate this approach across subsidized housing portfolios nationwide (COF, 2019; JRCo, 2019a & 2019b). The CoO model is a novel solution to connecting vulnerable populations with high-quality, high-priority, necessary medical care, social services, and public health programming (COF, 2019; Cohn et al., 2000; Freeman et al., 2018; Golant et al., 2010; Hood et al., 2015; JRCo, 2019a; Nardone et al., 2013; Rabins et al., 2000; Robbins et al., 2000; Stewards of Affordable Housing for the Future, 2018a & 2018b; Urban Institute, 2014; Wright et al., 2016). Utilizing affordable housing as the alignment mechanism of these 1 While the Communities of Opportunity name is the same as that used by the Kirwan Institute, there is no relation and the JRCO/COF model was named and conceptualized completely independently and without knowledge of the previous model of the same name. The focus of the models are quite different.

Communities of Opportunity Study Design

three sectors through the CoO model allows for improved access to people, community, and place, thereby better meeting residents’ complex needs, reducing barriers to participation (i.e., time and logistics), and creating facilitators to meeting those needs (i.e., convenience of onsite wraparound services) (Hernández, 2018; Swope & Hernández, 2019; Wright et al., 2016). As depicted in Figure 1., the core components of the CoO model include five central facets, namely 1) resident engagement, 2) a resident services coordinator position, 3) program partners and funding sources, designated space for programs and informal connections, 4) property management and maintenance that support healthy homes and 5) research and evaluation. Figure 1. Core Components of the Residential Communities of Opportunities Model

In the CoO model, resident engagement is a central feature that links the various parts. It refers to the active participation of residents in determining the nature of programs offered and assisting in their design, implementation, leadership and sustainability. The co-production process entails learning from the residents about their interests, assets and needs. This is often done through the ‘needs assessment’ methodological approach which is often based on focus groups, surveys, and in-depth interviews. A meaningful resident engagement strategy ensures that the programming that is offered aligns with resident priorities and that they are valued partners and decision-makers in the

Chapter 2 Background

programming process. In some cases, it is appropriate to work with tenant associations to validate established infrastructure and balance power. Resident service coordinators are core to building rapport with tenants, establishing outside partnerships and coordinating programs. The RSC role is meant to support residents and encourage their participation in planning and attending programs. Training in social work and related fields helps to ensure that RSCs can identify resident needs, effectively manage relationships and appropriately link to programs and services. RSCs play an administrative role in scheduling and coordinating programs, though they also have a relational function with tenants and outside partners. Outside of residents, RSCs are key to the successful implementation of the CoO model. Program partners and funding are a third component of the model. While there are some programs that can be offered using internal resources, minimal supplies and general knowledge, other initiatives require outside help to effectively implement. For instance, programs that link residents to food resources, medical services or specialized public health trainings are best served by external partners. Sometimes, from an outreach perspective, program providers benefit from hosting programs that reach their target population where the onus of travel is on the provider rather than participants. Funding for the programs may come from government or philanthropic organizations, though fluctuations may affect the continuity of programming. Consistent programming is important for residents to come to expect a regular time to connect with fellow residents and receive services. Moreover, the space considerations regarding where to host the programs are often managed internally within the residential sites, which is another benefit to providers and participants alike.

Communities of Opportunity Study Design

Designated space for programs and informal connections are a critical dimension of the CoO model execution. Having common areas inside and outside of the building help to facilitate the provision of services and provide a way for residents to come together when programs are offered and in their personal time as well. In some cases, community rooms feature a kitchen and other amenities to bring residents together. Lobbies can also serve this purpose. In addition, outside space can be used for gardening as well as physical and social activities, weather permitting. Properties with proper spatial infrastructure can offer varied programs, however those that lack designated spaces can also improvise as needed by, for instance, have residents host programs in their units or utilizing appropriate spaces within the community. Property management and maintenance practices can support or undermine services provided within the CoO model. Properly managed and maintained buildings and common areas serve the underlying purpose of encouraging livable environments that are conducive to health. The conditions of the buildings and interactions with maintenance and management staff are foundational to supporting a culture of health. A healthy building starts from the beginning in terms of architectural design and building materials, and is further sustained by long-term management and maintenance practices. Attention to property conditions and strong relationships between building staff and tenants is important for residential satisfaction. Outstanding repairs or safety concerns can strain relationships between tenants and building staff and discourage participation in programs that are intended to support health. Ensuring complementarity and consistency across the building ecosystem signals to residents that their health matters and, when the externalities are managed well, residents can focus on their health and well-being rather than gripes about housing conditions. Furthermore, a

Chapter 2 Background

healthy building allows the RSC to focus on programs rather than damage control from fallouts in building operations. However, RSCs can play a useful role as liaisons between residents and property management and maintenance staff and ensure proper communication of building service issues. Research and evaluation are the last key elements of the CoO model as they are rucial to planning programs and tracking impact. Relying on evidence-based programs ensures that residents benefit programming that has been previously tested and evaluated. Moreover, integrating research and evaluation to program delivery helps to document changes attributable to the programmatic offerings. The evaluation aspect is specific to the program aims and assesses shorter-term results. The research component is largely about following residents prospectively to track baseline metrics and changes over time. Ideally, there are quantitative and qualitative dimensions to the research approach that account for process and outcomes measures. In addition to resident outcomes, it is also important to examine the cost and cost-effectiveness of the model to justify future investments, inform policy and regulatory procedures and proper scaling of the model. CoO MODEL PROGRAMMATIC AREAS OF INTEREST AND IMPACT

In 2018, Jonathan Rose Companies’ launched a CoO toolkit with eight impact categories that serve as a menu of program areas that can be adapted at different sites based on needs and capacity. The core programmatic foci of the CoO model are as follows: 1) Safety, 2) Community Building and Recreation, 3) Food Security, 4) Healthy Living, 5) Financial Security, 6) Education, 7) Civic Engagement, 8) Green Initiatives, 9) Communication and Information Sharing, 10) Arts and Culture, and 11) Transportation. This CoO toolkit has been used to inform programs across their nationwide portfolio of multi-unit, affordable housing sites. Informed by our academic and grey literature reviews, we have refined and narrowed the programmatic content areas to include eight main categories while also offering several sub-categories. Below is a list of impact categories to promote health and well-being via the CoO model in affordable housing settings. 1.

Physical Health and Well-being •

Prevention: Nutrition, Healthy Eating, and Food

•

Injury Prevention: Trips and Falls for the Elderly

•

Chronic Disease Management: Asthma, Diabetes, Hypertension, Obesity

Stress, Mental Health and Well-being •

Meditation and Mindfulness

•

Physical Activity (including yoga)

•

Group Therapy and Trauma-Informed Practice

•

Substance Use Prevention and Intervention

Communities of Opportunity Study Design

Economic and Education •

Education and Academic Performance

•

Financial Security and Empowerment (Employment, Eviction Prevention, etc.)

•

Skills and Vocational Education and Training

Social Networks/Social Support and Community-Building

Safety and Violence Prevention •

Good Community Relations with the Police

Resident Engagement and Leadership •

Building Level: Tenant Association Creation, Participation, and Program Development

•

Community Level: Civic Engagement and Political Participation

Good Housekeeping Practices •

Energy and Water Conservation

•

Pest Management

•

Smoke-Free Living

•

Hoarding Prevention/Intervention

•

Prevention of Use of Harmful Chemicals

Community-Building and Recreation •

Gardens, Libraries, Game Rooms, Communal Kitchens

•

Arts, Culture, Music

This delineation of program areas is closely related to what the academic literature demonstrates as effective, though there are some, as indicated in the following section, that need more research and evidence (which our future study/intervention could provide).

Chapter 2 Background

Chapter 3 Academic Literature Review This review covers the design, focus, implementation, and results of affordable housing-based programming on a range of health and health-related outcomes as reported in peer-reviewed academic literature.

PREFACE This review covers the design, focus, implementation, and results of affordable housing-based programming on a range of health and health-related outcomes as reported in peer-reviewed academic literature. We include a description of the methods used to conduct this review, summary of results, analysis of rigor in the current evidence base, and a discussion of gaps in the literature and directions for future research. METHOD Using an organized search tracker and Covidence, the research team conducted searches in JSTOR, ProQuest, CINHAL and PubMed, through which we obtained over 15,476 results. We then sorted the results by theme and relevance, using a variety of search filters and limitations. The criteria for inclusion at this stage were: published after 2000; English-only; published in specific countries (US, UK, Canada, Australia, and New Zealand); and peer-reviewed. Search results were organized by systemdetermined relevancy, from which we selected up to 200 of the top results and/or scanned by title for potentially-relevant sources. A total of 1,494 results were then exported to a citation manager and imported into Covidence for title and abstract screening. During title and abstract screening, 832 sources were further deemed irrelevant because they did not fit the review criteria. The remaining 700 results were re-screened by title and abstract, and sorted into categories based on the following major programmatic themes: Targeted Health Programs; Economic and Educational Programs; Resident Engagement Programs, Empowerment and Leadership Programs; Social Network and Support Programs; Violence/Safety Programs, Resilience Programs, and Service Enrichment Programs. We then conducted a full text review of the remaining articles, scanned the reference lists/bibliographies of these articles for additional potentially relevant sources, and added newly identified results to the list. Rather than conducting a full systematic review of the literature using Cochrane guidelines, we have conducted an adaptation of a rapid, scoping review. Although we cannot guarantee to have captured every peer-reviewed, academic article fitting our criteria, we have comprehensively reviewed several databases using quality inclusion/exclusion criteria and search filters, resulting in a literature review that reached a saturation point with sufficient content to conclude our search process. Figure 1 graphically illustrates the method. RESULTS As noted, programs are classified into the following major areas of impact: Targeted Health Programs; Economic and Educational Programs; Resident Engagement Programs, Empowerment and Leadership Programs; Social Network and Support Programs; Violence/Safety Programs, Resilience Programs, and Service Enrichment Programs. Within each of these categories, we identified programs targeting specific populations/sub-populations, such as the elderly. Some programs are resident-led, -informed, and -engaged; some use community-based participatory research (CBPR) and needs assessment methodology; some engage community health workers and health advocates; and some employ other hybrid study designs and implementation methods. Measured health-related outcomes within the broad categories include chronic disease management, referrals to health, social services and care, smoking cessation, physical activity, nutrition and healthy eating, obesity prevention, asthma, resident empowerment, depression, anxiety, stress, substance use, skills development, pest management, employment, academic/educational performance, and social support/cohesion. Special populations were the focus of selected interventions are the elderly, youth, and African American communities.

Communities of Opportunity Study Design

1. TARGETED HEALTH PROGRAMS We identified 17 studies that met criteria, using a range of designs and methods of implementation. They are grouped according to the following outcomes and/or special populations: chronic disease management, screening, and referral (n=3); physical activity, nutrition and healthy eating (n=9); smoking cessation (n=3); integrated pest management (n=1); mental health and substance use (n=8); and programs designed to meet health needs for the elderly (n=17), including mental health programs (n=11). Chronic Disease Management, Screening and Referral In this category, we examine three studies that evaluate interventions aimed at chronic disease management, health screenings, and referrals to resources. All three interventions use community health workers (CHW) or health advocates (HA) to implement programming. In the first study, Lopez et al. (2017) used a needs assessment to inform their intervention, which was conducted with public housing residents, using other nearby housing developments as the comparison group. They conducted their needs assessment and subsequent intervention through discussions with community members, in this case, resident leaders and partner organizations. They recruited CHWs from intervention housing sites and the surrounding East Harlem community; CHWs were then hired and trained by a CBO in core competencies such as health education, goal setting, and facilitating referrals to care via the HAs. The HAs were hired and trained by a separate CBO in health insurance enrollment, issues surrounding access to care, and referrals to care. Though the CHWs and HAs were trained by their respective CBOs, they were trained jointly to learn the Harlem Health Advocacy Partnership referral and protocol process. All study participants received referrals to the HAs as necessary whether they were in the intervention or comparison group; those in the intervention

Chapter 3 Academic Literature Review

group received six (or more) support visits from a CHW. At follow-up, 90% of the intervention participations were highly satisfied with their CHW and 76% were highly satisfied with their HA; 97% of those who received HA support found those services helpful, but intervention participants were more likely to have received such support from an HA. The authors found that although the clinical outcomes measured did not improve for intervention participants when compared with the comparison group, intervention participants did have significantly greater physical activity improvements versus comparison participants (t=1.9; p=0.005). Additionally, intervention participants with hypertension experienced statistically significant improvements in blood pressure self-monitoring versus comparison participants (t=0.15; p=0.013). As a result of HA support, participants in the intervention group were more likely to report a change in their insurance status/ health insurance (11% vs. 4%; p=0.009) and doctor (14% vs. 6%; p=0.024) (Lopez et al., 2017). In the second study, the Boston Housing Authority (BHA) conducted a Resident Health Advocate training program through which it trains a cohort of resident applicants from BHA developments to become HAs for their communities (Bowen et al., 2015). They have conducted this program annually each year since 2004. Every year, flyers describing the program are distributed to family public housing developments, and eligible residents can apply at each management office. Applicants are required to be highly-motivated and interested in community outreach and health, and must provide three references, one from their development’s management and one of which must be from a tenant organization or community group. Once selected, the RHAs go through a 14-week training of weekly four-hour sessions led by various public health agencies and institutions. During training they received a small weekly stipend to offset transportation costs and learn about health conditions affecting their community, leadership, cultural competency, community organizing, and advocacy. RHAs also learn about local resources such as community health centers, and are provided with a resource manual. During the first 10 years of the program, RHAs who completed the training were automatically hired into the internship position in their housing developments, and were paid to work a maximum of six hours per week for six to eight months. In 2011, BHA decided to hire only two RHAs who would work 20 hours per week and work at multiple housing developments for six to eight months. The goal of the program is to provide training and job experience and help transfer people into the full-time workforce. RHAs maintain weekly activity logs, develop and implement workshops, distribute and collect health surveys, and invite health care providers/services to attend resident programming and promote their services and programs. RHAs have been integral in various health interventions at Boston public housing sites. For example, in the summers of 2007 and 2008, RHAs in four public housing developments in Boston helped recruit residents to participate in a mobile health unit screening for hypertension, high cholesterol, diabetes risk, and dental disease (Rorie et al., 2011). Intervention sites used RHAs to help with recruitment and control sites used recruitment flyers (Bowen et al., 2015). During the second summer, the control and intervention sites switched and Bowen et al. combined the data from both summers. They found that screening rates were 1.55 times higher among intervention participants versus the control participants and RHAs overall increased participation in health screenings and increased the rate of follow-up appointments among people who had screened positive (Bowen et al., 2015). The third study was conducted by the Healthy Families Brooklyn Program (HFB), a partnership between the Arthur Ashe Institute for Urban Health, Long Island College Hospital, Brownsville Multi Service Family Health Center, the New York City Housing Authority (NYCHA) and the New York City Department 24

Communities of Opportunity Study Design

of Health Office of Minority Health (Brown et al., 2011). HFB initiated the program through discussions among these institutions and the tenant association (TA) presidents at the two Brooklyn housing developments, who agreed the program would be beneficial; the TA presidents also helped inform the best ways to engage residents. The HFB advocates (HFAs) who implement the intervention were selected from the community to help residents access and navigate available social services and health care. The HFAs were volunteers, but received a small stipend for training and participating. Each HFA was recruited based on high community involvement, health knowledge, and two letters of recommendation. HFA training consisted of 30 hours of didactic classroom lessons about public health, prevention, detection, and management, community health empowerment, health access/outreach, and how to plan and conduct a health fair; HFAs also learned CPR and First Aid. It was important to HFB that they train the HFAs professionally and that they learn other important professional skills in addition to the core content. Such areas included cultural sensitivity and delivering culturally sensitive information, communication, counseling, advocacy, how to gather information, HIPAA and IRB competencies, disease-specific knowledge, procedures regarding referrals and follow-ups, and how to use reference guides. HFAs worked with one to five residents per month and were trained in tracking individual resident information so that they could more easily manage their residents’ needs. HFAs served a total of 172 unique residents through 222 visits and provided services including assistance accessing public benefits, offered health education, and facilitated connections to local hospitals. Brown et al. contend that HFAs are committed to assisting residents in improving their health knowledge and behaviors, and that HFAs are a useful way to engage communities and improve their healthcare access and disease screening, prevention, and treatment. Through pre- and post-test assessments, they found statistically significant improvements in individuals’ health knowledge in HFB’s main areas of focus: diabetes, asthma, and healthy eating. Breast-self exams were another area of improvement, such that 80% of women (compared to 50% at pre-test) knew that women ages 40-49 are recommended to have a mammogram every two years. At post-test, 80% of individuals could identify fatigue as a diabetes symptom, compared to 50% at pre-test, though there was still confusion about the difference between Type 1 and Type 2 diabetes at post-test (Brown et al., 2011). Physical Activity, Nutrition and Healthy Eating In this category, we identified nine relevant intervention studies, which can be further broken down into seven studies focused on physical activity programming and two focused on nutrition and healthy eating. High Point Walking for Health is a CBPR project in Seattle, Washington focused on increasing physical activity among residents in their public housing community (Krieger, Rabkin, Sharify, & Song, 2009). Through a partnership of residents, CBOs, the Seattle Housing Authority, university researchers, public health practitioners, and other institutions, this program used the CBPR approach to determine the goals of the project, determine its design, and oversee the implementation, evaluation, and results. Together they created community action teams of eight to ten adult and youth residents who discussed and assessed the community conditions, developed the project’s activities, and cultivated leadership and social capital. The team members engaged in qualitative interviews and researchers conducted door-to-door surveys and focus groups to learn about the perception of the community environment. The community action team also used photo voice to supplement this qualitative information, all of which culminated in the decision to make High Point a community that encourages walking. The community action team was directly involved in the grant application process to restore neglected staircases and identify a one-mile path for walking groups as a social strategy for promoting physical activity.

Chapter 3 Academic Literature Review

Residents engaged in organized advocacy through forums and rallies with the support of partnership staff and an advocacy organization for pedestrian safety and some were selected as walk leaders who encouraged participation in the walking groups. The youth community action team led the implementation of a marketing campaign and central kiosk for information about the walking program. The intervention was quite successful in that participants involved in the pretest-posttest evaluation of the impact of the project improvements significantly increased the amount of time spent walking per day for errands and exercise (from 65 to 109 minutes/day; p=0.001); the percentage of participants who met guidelines for moderate activity (at least 150 minutes/week) increased as well (62% to 81%; p=0.018). Additionally, participants reported general health improvements such that the average number of days (last 30 days) that their physical and mental health were not good decreased significantly (-4.9 days, p=0.001; -5.2 days, p=0.003). Residents also reported increased social connectedness such that the number of neighbors who said hello to each other increased by 4.3 (p=0.001). Other additional and unanticipated benefits were an increase in leadership skills and continued participation in the walking groups, even 18 months later (Krieger et al., 2009). Marinescu et al. (2013) developed the Be Active Together (BAT) initiative to expand upon the High Point Walking for Health initiative by Krieger et al. to increase physical activity among low-income, culturallydiverse women in nearby public housing communities in Seattle. In particular, this article focused on the BAT intervention for Muslim women at the Greenbridge public housing community in partnership with the Seattle Children’s Hospital. Other collaborative partners participating on the project steering committee were local organizations and residents including Neighborhood House, Public HealthSeattle & King County, Seattle Housing Authority, and King County Housing Authority. Half of the

Communities of Opportunity Study Design

members were a diverse group of public housing residents, and there was a subcommittee of researchers, representatives from the CBOs, and residents. The steering committee met monthly and eventually quarterly to make decisions about the program using a consensus method and CBPR principles to ensure community leadership and mutual respect. BAT began by reviewing results of a previous community assessment of local physical activity opportunities to update findings to better design and pilot community-informed, context-specific, culturally-appropriate physical activity interventions. The researchers conducted a community impact evaluation of BAT through interviewbased surveys and a process evaluation of BAT implementation through quantitative and qualitative methods, including focus groups, semi-structured interviews, structured surveys, participant attendance, participant observation, photographs, and meeting notes review. During the community assessment, Greenbridge was still in the process of redevelopment through HOPE VI funds and the New Urbanism model. The main communities in the development are women-headed Somali and Vietnamese households that had high intergroup, but low intragroup social cohesion. Through focus groups, the researchers learned that it was important to Somali women to have gender-segregated activity groups; but for the Vietnamese women, it was more important that the groups were segregated by age and community. All focus groups provided transportation as necessary, traditional ethnic food, and were scheduled at culturally-appropriate times. Although the Somali women’s focus group knew the importance of exercise, they did not engage in exercise frequently, in part because they believed it was inappropriate to exercise (even walking) around men. For this reason, it was important for these women to have not only gender-segregated time for physical activity, but also a safe, gender-segregated space. The women also expressed a desire to get to know each other better and increase their social cohesion. As a result, the researchers and BAT facilitated a Somali women’s group during which they could discuss common interests and shared struggles/concerns, build community, and have an opportunity to be heard by community service providers, allowing for trust-building and increased community engagement. Using the results of the community assessment, the researchers created a partnership with a local community center to provide the women with women-only exercise time in a designated room. Unfortunately, the distance from the housing development proved to be a barrier, as did the fact that the equipment was mostly weight-training and there was no trainer to address safety concerns, therefore participation continually decreased and resulted in the discontinuation of that intervention. Two other interventions were implemented with these barriers in mind and were more successful: 1) free gender-segregated exercise classes within their public housing communities; and 2) affordable gender-segregated swimming time at a rented public pool. Attendance at these programs demonstrated that other local women of various cultural and ethnic backgrounds who were not residents of these public housing communities, also took advantage of these women-only opportunities to exercise. Program success was due to the ease of location and bilingual, culturally appropriate recruitment, staff, organizers, and instructors. Women also enjoyed the fact that the exercise programming provided them with time to socialize and connect with other women and take time for themselves. Through the partnership with the local pool, the researchers learned that many participants did not know how to swim and wanted to learn, resulting in an adult swim lesson program that enjoys high demand and increasing participation every year. Overall, the BAT program was useful not only for identifying important cultural and logistical barriers to physical activity for female public housing residents, but also for learning the value and feasibility of addressing these barriers to implement such programming. Early program success can be attributed to the use of CBPR methodology and the needs assessment

Chapter 3 Academic Literature Review

which allowed for deeper understanding of these women and their cultural- and context-specific needs (Marinescu et al., 2013). Obesity and related health promotion activities such as physical activity and healthy eating are a common focus of intervention in affordable housing settings. One example is a program described by Lee et al. (2012), comprising an intervention in three different types of New York City high-rise buildings, including one 10-story affordable housing site, using stair prompts such as “Burn Calories, Not Electricity.” Long-term follow-up at the affordable housing site demonstrated sustained increases in stair use with a 42.7% increase (p<0.001) from baseline to nine months after posting the stair prompts. In addition to the prompts, the researchers conducted a health education event to increase awareness about the stair prompts and to provide information on obesity-related health issues. Although this event led to a minor increase in stair use, the change was not statistically significant. The researchers suggest that further study is necessary to demonstrate the impact of combined interventions on program uptake, awareness and sustained results. Active Design (AD), as defined by Tannis et al. (2019), is “an evidence-based approach to neighborhood development that uses architecture and urban planning to make daily physical activity (PA) and healthy foods more available and inviting.” The researchers used the New York City Department of Health and Mental Hygiene (DOHMH) and the Department of Design and Construction’s 2010 Active Design Guidelines as a manual and tool to describe features of AD buildings, such as inviting/well-lit stairwells, streets, and buildings, safe bike parking/storage, recreational courtyards, gardens, etc. They assessed how AD affordable housing affects physical activity levels among low-income residents living in a new

Communities of Opportunity Study Design

AD affordable housing complex, compared with low-income residents living in two non-AD apartment complexes in Brooklyn, NY. The new AD housing included five 6-story buildings with elevators, accessible and well-lit stairs, local artwork, community garden space, outdoor fitness space including a playground, and a fitness center. Participants were recruited and enrolled at the point of lease-signing, at which time researchers collected data on weight, BMI, waist to hip ratio, and physical activity. Additionally, anyone with a smartphone shared their data on average daily steps and flights of stairs climbed throughout the past month. Results showed that living in an AD building can positively affect stair usage, consistent with previous research. Self-reported physical activity was higher among AD residents compared to non-AD residents, although the difference was not statistically significant at either time point. Furthermore, BMI increased among AD residents and stayed the same for non-AD residents, potentially reflecting the multi-causality of physical activity and the limits of self-reported physical activity, which may be overestimated. This study demonstrates that while AD can have positive effects on behavior change, AD alone is not enough to improve health outcomes, suggesting that supplementary interventions may be necessary. The results also indicate that future research should potentially use more objective measures with which to identify strategies for supplemental interventions to improve and sustain higher levels of physical activity and greater overall health (Tannis et al., 2019). The GirlStars Program offers after-school programs focused on promoting physical activity and positive health behaviors among adolescent girls ages 9-13 years old in two public housing developments in Boston, Massachusetts (Strunin, Douyon, Chavez, Bunte, & Horsburgh, 2010). Through the GirlStars Program, girls had free access to a two-hour physical activity session and a two-hour health education

Chapter 3 Academic Literature Review

session each week for approximately three years. The sessions were led by the project coordinator and program assistants at centrally-located youth centers in the housing developments. Every session revolved around practical activities and group work around risk behaviors, self-efficacy, confidence, resilience, goal-setting, body image, self-esteem, and nutrition/healthy eating. Although the researchers intended to use a comparison group to better measure the effects of the intervention, participation was low; as a result, all girls were enrolled in the intervention group. The researchers wanted to understand the impact of the intervention on reducing high-risk behaviors. At the end of the three-year study, participants at both sites had increased levels of physical activity and improved knowledge of nutrition/ healthy eating, as reported in questionnaires. At program conclusion, the researchers conducted semi-structured, open-ended, individual interviews with participants (n=10) from housing site B to gather more information about reasons for joining the program, reasons for attendance at sessions, perceived benefits from participation, and any recommendations for future programming. Several challenges led to low participation in the GirlStars Program, including problems with recruitment and retention, staffing turnover and loss, funding difficulties, the perception that the GirlStars staff were “outsiders,” program location and safety concerns, interpersonal conflicts, low interest in physical activity, poor community support, and conflicting activity schedules. Strunin et al. (2010) noted that one way the program could be more successful in the future would be to hire staff members from the housing community, who could identify with and relate to the participants. Bowen, Quintiliani, Bhosrekar, Goodman, and Smith (2018) conducted the Boston Healthy Families study focused on obesity and related health behaviors. Through a cluster randomized trial within public housing developments, they selected 10 developments that were randomized evenly between the intervention and control conditions. The study focused on women and their daughters (ages 8-15) because over 80% of the households in the developments were headed by women, and because adolescent girls develop obesity during this age range. However, due to funding cuts, they were only able to complete the intervention with mothers. The intervention used HAs known as Healthy Living Advocates (HLAs) who were trained for 14 weeks through the same Resident Health Advocate training program as used in the earlier Bowen et al. (2015) study, but was supplemented with training specific to this study including intervention activity training, the research process, and information about weight management (Bowen et al., 2018). HLAs also received training about obesity-related risks, how to protect patient privacy, and health promotion tactics regarding weight-loss through diet and exercise behavioral changes. HLAs promoted, led, and attended a variety of activities as part of the intervention, including health screenings that linked public housing residents to the primary health care system, Fresh Trucks selling fruit and vegetables, weekly walking groups, cooking demonstrations and distributed recipes. Staff distributed maps of health and related resources at these events. They sought to test the effects of this multi-level, environmental intervention on obesity and obesity-related health behaviors over a 12-month period. The intervention found significant positive changes in weight reduction, increased healthy eating, and increased physical activity. Among intervention participants, average BMI was reduced by 1.5 points (from 30.6 to 29.1), whereas comparison participants experienced an increase in their BMI by 0.2 points (from 31.8 to 32.0). This difference was significant in both unadjusted and adjusted analyses. Additionally, intervention participants experienced significant improvements in four of five dietary and activity behaviors including: an increase in the mean number of fruits and vegetables eaten/day (+1.6 fruits and vegetables; p=0.03), a decrease in the percentage of those who eat fast food (-15%; p=0.04), a decrease in the percentage of those who are inactive (-30%; p=0.007), and an increase in the number of minutes spent walking in the neighborhood/day (+10.7 minutes; p=0.01) (Bowen et al., 2018).

Communities of Opportunity Study Design

Grier et al. (2015) used recommendations from Bowen and colleagues to conduct a mixed methods feasibility study of a theory-based community garden and nutrition education program for youth in two public housing developments using a CBPR approach in the Dan River region of Virginia. Each development was chosen based on having active youth programming on site led by site leaders, who were involved in the study and identified this programming as a priority initiative for their community. These site leaders also collaborated with the researchers on the grant funding process, the nutrition subcommittee, and recruiting youth. Additionally, site leaders were charged with planning, initiating, and maintaining the gardens after receiving training on using a scale and log book, maintenance techniques, and teaching the youth such techniques on non-program days. They modified the Junior Master Gardener curriculum using Social Cognitive Theory, to include more nutrition lessons, to improve cultural relevance to the youth. Each housing complex already had a garden (although one complex created a garden for this purpose), in which they delivered programming for 60 minutes every week. Some sessions focused on interactive gardening only and others were split evenly between nutrition, education and gardening. The researchers utilized a reward system to encourage goal-meeting and participation, and the program culminated in a graduation ceremony. Since the program was offered through the on-site youth centers, other youth, siblings, and parents often participated in the programming as well. Results of the feasibility study indicate that the program has high potential; youth, parents, and site leaders found it useful and suitable. Parents also indicated a desire to participate, prompting the need to incorporate parentspecific programming. In comparison to other studies of youth and community garden programming on fruit and vegetable intake and knowledge, this study showed mixed results, although a more rigorous experimental design may demonstrate different outcomes. In total, 53% of parents reported

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that their children had demonstrated new behavior and asked for fruits and vegetables or for new ways to prepare fruits and vegetables; 93% of parents also reported they had noticed an increase in their child’s gardening confidence and would let them participate in this programming again. Site leaders reported that among the participating youth, they observed many positive interactions, better social cohesion, and an increase in their willingness to eat fruits and vegetables during the program. Among youth participants, significant outcomes included: an increase in self efficacy for asking for fruit and vegetables in their diet (effect size (ES)=0.2; p=0.013); an increase in gardening knowledge (ES=0.33; p=0.01); an increase in knowledge of plant parts (ES=0.30; p=0.045); and an increase in knowledge of the MyPlate categories (ES=0.40; p=0.049) (Grier et al., 2015). The Live Well, Viva Bien intervention is the first multi-component, cluster RCT demonstrating the efficacy of year-round fruit and vegetable markets and nutrition education intervention for low-income adults, rather than examining the efficacy of individual educational programs, vouchers for use at farmer’s markets, and/or seasonal markets or using non-experimental designs (Gans et al., 2018). To better inform the development of the intervention, the researchers conducted focus groups with residents from non-study sites. Fifteen housing complexes in Rhode Island participated in the study; eight received the intervention and seven received a comparison intervention; the groups were matched based on being a family or elderly/disabled site, among other factors. They hired a resident from each site to be a Resident Assistant and help recruit participants and implement intervention activities. The intervention itself included fresh fruit and vegetable markets offering discounted prices, which involved a kickoff event, cooking demonstrations and taste-testing events, culturally-relevant and desired produce (determined during the focus groups and customer requests/comments). All

Communities of Opportunity Study Design

activities were held indoors at the elderly/ disabled sites. Based on initial participation, the investigators shifted the market to be held during the first two weeks of every month after residents received their monthly SNAP benefits. The educational component of the intervention included providing all intervention participants with an educational packet, a reusable shopping bag, an overview of the intervention, educational DVDs, recipes and recipe storage, and the first newsletter. Other educational components included motivational campaigns and continued distribution of educational materials. The researchers found that the year-round, mobile markets were effective in increasing fruit and vegetable consumption, that participation was high, and that there was a dose response relationship between higher participation in the markets and greater increases in the amount of fruit and vegetables eaten. Participants who attended all or most of the markets saw an increase in fruit and vegetable consumption of 2.1 and 0.86 cups respectively, whereas those who attended the markets less frequently saw increases of less than 0.5 cups (p<0.05). Participants in the intervention group increased their total fruit and vegetable consumption by 0.44 cups, whereas the intervention group participants decreased their consumption by 0.08 cups (p<0.02). Intervention participants also had a statistically significant increase in the frequency of fruit and vegetable consumption when compared with the control group participants (p<0.01). Participation in the educational component of the intervention was not as robust; only the DVDs, taste testing events, and recipe use were associated with increased consumption (Gans et al., 2018). Smoking Cessation Our search identified three interventions specifically focused on smoking cessation. The first, conducted by Andrews et al. (2012), began with the formation of a steering committee consisting of school officials, residents, and an academic researcher to conduct a community needs assessment and determine interest in an intervention. This steering committee developed into a larger community advisory board including two public housing tenants, two housing authority administrators, one health department staffer, one academic researcher, one pastor, and one school official. This board informed the pilot testing of this first ever CBPR multi-level intervention for smoking cessation in public housing neighborhoods. The phased approach of the intervention allowed for a participatory process, such that at each stage, the researchers disseminated their findings through forums, the local newspaper, and newsletters to the community. All CHWs, known in this intervention as coaches by community preference, were selected from the community to lead the intervention and were employed by the university, receiving 40 hours of protocol training as well as benefits. The intervention included one-toone contact with a coach, small group meetings with coaches and other participants, neighborhood level cessation strategies and events, nicotine patches (Nicotine Replacement Therapy (NRT)), and a Sister-to-Sister handbook of smoking cessation materials. Participants in the control group received a CDC manual on quitting smoking, additional mailed cessation materials, and an offer to participate in a delayed intervention (after data collection concluded) which consisted of an hour face-to-face meeting with a coach, personal contact from the coach, and an eight-week supply of NRT. Over the year-long intervention, Andrews et al. (2016) retained 92.2% of participants, with a smoking abstinence rate of 9% among intervention participants and 4.3% among control participants (p=0.05). In analyses that accounted for passive smoke exposure, the 12-month abstinence rates were still statistically significant, but in multivariate regression analyses the intervention effect did not remain significant. Among intervention participants, those who kept their visits with the CHW, attended the groups sessions, and used NRT were more likely to maintain smoking abstinence (Andrews et al. 2016).

Chapter 3 Academic Literature Review

Jeffries, Choi, Butler, Harris, and Ahluwalia (2005) conducted the PATH trial in 20 public housing developments using a cluster-randomized clinical trial and community-based approach. The PATH trial aimed to examine the effectiveness of motivational interviewing and NRT on smoking cessation and educational materials to increase fruit and vegetable consumption by using community outreach resident (CORE) team members who were housing residents themselves. The CORE team members were hired to bridge the gap between the researchers and the housing community and to recruit residents to attend the PATH health fairs. The CORE members were identified by project directors, leaders from the housing authority, and members of the Public Housing Resident Council, and then asked for an on-site interview. The research team developed a training manual for the CORE members, and provided them with some financial compensation. In total, 813 residents (80% African American) were recruited and attended 20 PATH health fairs; attendance comprised approximately 21% of all residents (varying from 8% to 66% depending on the fair). In total, 273 were identified as smokers (33%) and 173 enrolled in the study (63%). Baseline results demonstrate that participants ate approximately two servings of fruit and vegetables per day and 49% smoked at least on some days. The investigators found that the health fairs were not only an effective method for data collection in preparation for the PATH trial, but also provided a needed resource to the community by including health promotion and educational resources at the health fair stations. Additionally, the health fairs were a social event and way for physicians and other medical providers to address residents’ medical concerns and establish their presence in the community (Jeffries et al., 2005). Brooks et al. (2018) conducted a smoking cessation intervention among public housing residents in Boston, implemented by residents trained as HAs known as tobacco treatment advocates (TTAs). Although this study did not include a needs assessment, members of the study team met with property management and tenant leaders before they began recruitment within each public housing development. At each development, two residents (other than the TTAs) were trained by the study staff to conduct recruitment and data collection. The four TTAs selected were current residents of the public housing developments and were diverse linguistically and racially/ethnically; three worked in the intervention group and one focused only on the control group. All TTAs received human subject and good research practice training from the project director and tobacco treatment training from a specialist. TTAs were also trained in motivational interviewing and practiced the intervention protocol with pilot participants before they were considered proficient. In their group’s randomized trial, the researchers used the TTAs to provide multiple visits consisting of motivational interviewing, smoking cessation counseling, and smoking cessation treatment navigation to the Smokers’ Quitline and other clinic-based programs for intervention participants; control participants received standard smoking cessation materials and one TTA visit consisting of basic counseling and smoking cessation resources. The researchers found that compared to control participants, intervention participants were more likely to use treatment programs (adjusted odds ratio (aOR)=2.15; 95% CI=0.93-4.91) and were more likely to maintain 7-day smoking abstinence (aOR=2.6; 95% CI=1.72-3.94) and 30-day (aOR=2.98; 95% CI=1.56-5.68). These results indicate that the intervention, as delivered by TTAs, significantly increased use of treatment programs and increased smoking abstinence as compared to standard smoking cessation interventions (Brooks et al., 2018). Integrated Pest Management We identified one intervention study focused on integrated pest management. In this communitybased participatory research (CBPR) and resident-led intervention, Scammell, Duro, Litonjua, Berry, 34

Communities of Opportunity Study Design

and Reid (2011) collaborated with the Boston Public Health Commission, BHA, the Committee for Boston Public Housing, Boston University School of Public Health, and the West Broadway Task Force (WBTF) to implement an integrated pest management program (IPM) at the West Broadway Development in South Boston. IPM is an alternative pest control tactic that aims to remove conditions in which various pests thrive or to modify the environment so that it is less attractive to such pests. Not only does IPM address the whole building at once instead of individual apartment infestations, but it also focuses on using pesticides as a last resort. The WBTF is the oldest resident leadership task force in the City of Boston, includes 11 residents who are elected by the housing development residents, and works to improve all residents’ quality of life. Much like the WBTF, the four community health advocates (CHAs) involved in implementing IPM at West Broadway worked constantly. WBTF hosted an information session about IPM and with the help of CHAs, knocked on doors, posted flyers, and recruited residents into the program. Initially, residents were suspicious of the CHAs knocking on their doors because they thought they were staff from the BHA looking to inspect and report them. CHAs quickly learned to explain that they were there to help people reduce pesticide use and infestations through tips and education. If willing, the CHAs would complete initial home visits for 30-45 minutes when residents opened their doors to them during which residents would complete a short survey and the CHAs would do a walk through to provide suggestions of how to prevent pests and demonstrate how to place pest monitoring devices. During the first visit, CHAs would also provide residents with Healthy Homes Kits that included maintenance materials for filling small holes, a mop, bucket, plastic food containers, glue traps, and sponges to help residents effectively clean, store food, dispose of trash, and monitor pests. On their second visit, CHAs would measure pest activity by checking these monitors. Since many residents did not use a lid to cover their trash, CHAs provided these residents with trash bins that had attached lids and discussed the importance of keeping it covered. CHAs also taught residents the importance of not leaving their pets’ food and water out overnight as a pest prevention method and discussed mold cleaning alternatives to bleach such as vinegar/water solutions. If residents were identified as asthmatic, CHAs would connect them with other available housing-based resources. CHAs also made referrals to local agencies with regularity. Two months after the program began, CHAs noticed that neighbors were discussing the program and providing each other with peer education, which led to much easier recruitment as the program continued. The CHAs were key to the program’s success, particularly because they brought with them years of experience; one had 15 years of experience as a tobacco treatment counselor and working for the WBTF on tobacco control programming. CHAs met people where they were by listening to residents’ concerns and interests, regardless of their direct relevance to the IPM program, and provided them with resources and support. CHAs participated in the BHA and tenant association-sponsored annual summer celebration to make themselves more approachable and connect with more residents. The CHAs also collaborated with the Boston Public Health Commission when they visited BHA developments monthly to offer screenings for blood pressure, cholesterol, and respiratory issues by providing residents attending the screening with IPM materials. As a result of the CHA-led IPM intervention, residents reported feeling more confident in themselves and more secure in their homes. The impacts were not limited to the residents receiving the intervention; CHAs greatly increased their skills, abilities, and knowledge and expressed a deep sense of pride and contentment with their work. CHAs also reported feeling more confident and were able to handle difficult situations with respect.

Chapter 3 Academic Literature Review

There were, however, some challenges related to being a CHA. It was a demanding position that required a lot of self-motivation and flexibility. The level of required documentation also became too much of a burden for some initial CHAs who did not have a high school education. Overall, the researchers found that the CHA-led IPM intervention was successful and led to the discovery of other pressing issues facing the residents. The intervention also built a sense of trust among residents, which has made a long-lasting impression and change to residents’ homes and overall quality of life (Scammell et al., 2011). Mental Health and Substance Use The bulk of the academic literature on mental health and substance use in affordable housing residents focuses on prevalence, correlates, mediators, and moderators of the relationships between the affordable housing setting and mental health and substance use outcomes (Casciano & Massey, 2012; Johnson, 2005; Nebbitt, Lombe, Yu, Tirmazi, & Alleyne-Green, 2014a; Nebbitt, Lombe, Yu, Vaughn, & Strokes, 2012; Nebbitt, Williams, Lombe, McCoy, & Stephens, 2014b). Some articles discuss mental health service use or community-level interventions (Windsor et al., 2018), but few studies implemented an intervention intended to impact mental health and substance use among affordable housing residents. We review here 15 studies of mental health and substance use among affordable housing residents, 14 of which are observational studies. Only one of three articles targeting mental health outcomes discusses programming focuses on mental health and well-being. Of the 15 studies, five focus on substance use among affordable housing residents, and these studies address the relationship between substance use and mental health outcomes. We first review three studies addressing the mental health of affordable housing residents, only one of which includes targeted programming. Shah et al. (2018) conducted a study of associations between pest infestations in public housing settings and mental health outcomes, to better inform potential interventions on pest infestations and/or depressive symptoms in public housing. Using a crosssectional study design, they randomly selected household units from 16 Boston Housing Authority developments and surveyed one adult from each unit about symptoms of depression, pest infestation, and pest management practices. Of those who completed the survey, 38% reported symptoms of depression, 15% reported current cockroach infestation, and 14% reported current mouse infestation. Results demonstrate that after adjusting for covariates, residents who had current cockroach infestation had three times the odds of high depressive symptoms as compared to those who did not have a current infestation. For those residents with a current mouse and cockroach infestation, after adjusting for covariates, the odds of high depressive symptoms were more than five times the odds of depressive symptoms among those who did not have a current infestation. The investigators did not find any evidence of effect modification when the relationship between pest infestation and depressive symptoms was stratified by pest management practices; i.e., there was no attenuation of the relationship between pest infestation and depression when adjusting for pest management practices, although self-reported use of pest control products modestly attenuated the relationship. Given the observed attenuation of the link between infestation and depression by product usage, it is possible that the act of dealing with the problem may increase the sense of control over the problem, thereby reducing depressive symptoms. Other potential explanations could be that pest infestations are a stressor contributing to depressive symptoms or social isolation for fear of inviting guests to their infested home. Although cross-sectional studies cannot assess the directionality of the association between pest infestations and mental health symptoms, results demonstrate that 36

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poor housing conditions do have an effect on mental health. This study also serves to demonstrate the high prevalence of depressive symptoms among public housing residents (Shah et al., 2018). Webb et al. (2017) conducted a study of residents’ depression symptomatology before and after relocation through HOPE VI from the Charlotte Housing Authority Boulevard Homes development to either another public housing development or private-market housing with a Housing Choice Voucher (HCV). Boulevard Homes had a variety of problems, including the neighborhood’s violent crime rate three times the citywide rate--one of the reasons it was selected for redevelopment through HOPE VI. Prior to relocating, only 53% of residents felt safe or very safe; only 12% felt very safe. Additionally, social support was very low, and 54% of residents had depressive symptom scores greater than or equal to 10 (average score around 11), indicating the high likelihood of clinical depression. After relocating to other affordable housing settings, more participants reported feeling safe or very safe, perception of crime decreased, depressive symptoms decreased, and the number of participants with high depressive symptom scores indicating clinical depression decreased. Results documented that 27% of households relocated to other public housing developments and 73% relocated using HCVs, though the majority of HCVs moved to other high violent crime areas. Those residents with higher depressive symptoms scores were more likely to relocate to other public housing developments rather than to market units using HCV. Interviews with case managers indicate that fear prevented residents from relocating to private-market rentals using HCV. Those with stronger social support prior to relocating had more depressive symptoms after relocating; those with stronger social support after relocating had fewer symptoms. Additionally, those respondents who reported higher crime rates in their neighborhood post-relocation had higher depressive symptom scores. This observed relationship of perceived neighborhood safety and social ties with less depressive symptoms is consistent with

Chapter 3 Academic Literature Review

prior research findings of links between neighborhood crime/disorganization and poorer mental health, and the role of social support in reducing depressive symptoms. The findings of high rates of depressive symptoms in Boulevard Homes pre-relocation and the relative economic deprivation and high crime in the housing development and surrounding neighborhood are consistent with rates of depressive symptoms reported in other studies of public housing (Webb et al., 2017). The intervention, Flash on my Neighborhood!, is a place-based intervention to reduce mental health disparities by focusing on improving person-environment congruence among residents in six public housing developments (n=1,009 households) in Quebec, Canada (Houle et al., 2017). According to researchers, this was the first study of a population health intervention that focuses on improving public housing residents’ mental health. They aimed to improve tenants’ control over decisions that affect their lives as well as their social capital by using a method known as collective empowerment. Collective empowerment is defined by Reininger et al. (as cited in Houle et al., 2017) as “a united and systematic effort by a group to gain control over and improve their aggregated lives by defining problems, assets, solutions, and the process by which change can occur, and by building individual and collective capacity that can energize the power and knowledge existing within the assembly.” Through this intervention, the investigators aimed to encourage residents to think critically about and assess their residential environment and how it impacts their well-being to develop, implement, and eventually evaluate an actionable plan to improve their situation, thereby promoting personenvironment congruence. Person-environment congruence is defined by Moser (as cited in Houle et al., 2017) as representing “the adequacy between their needs, capabilities, and aspirations on the one hand, and the residential environment’s resources, demands, and opportunities on the other.” To achieve this goal of developing control over what they perceive to be the most important changes, the investigators standardized the intervention process rather than its content. They implemented the intervention in three phases: strengths and needs assessment, development of the action plan, and the implementation and evaluation of the action plan. Since this is an ongoing, prospective case study, it will be several more years before outcomes are assessed and published (Houle et al., 2017). Next, we review five studies analyzing substance use among affordable housing residents, including the relationship between substance use and various mental health disorders in this population. Lombe, Yu, Nebbitt, and Earl (2011) conducted their study of African American youth and alcohol use in public housing developments in three cities across the U.S. The study found a 53.9% prevalence of ever using alcohol compared to 72.5% of all youth nationally (regardless of race) and 67.7% of African American youth nationally. Although lifetime prevalence was lower than national samples, they found that the current prevalence was higher than a different national sample. They also found a significant relationship between depressive symptoms and alcohol use, and that depressive symptoms are strong predictors of alcohol use among African American adolescents in public housing. Additionally, Lombe et al. (2011) report that alcohol use in the past year was related to delinquent behavior, and that exposure to peer delinquent behavior was also related to alcohol use, consistent with literature showing that exposure to peers who use substances is a strong predictor of early initiation of alcohol consumption. One study by Osypuk, Joshi, Schmidt, Glymour, and Nelson (2019) analyzed the effects of the Moving to Opportunity program (MTO), which relocated public housing residents using vouchers, on adolescent binge drinking compared to those who remained in public housing. They found that the prevalence of binge drinking was similar in both groups, but that the treatment effects were different 38

Communities of Opportunity Study Design

by gender. MTO reduced binge drinking among adolescent girls, but increased binge drinking among adolescent boys when compared to adolescents who remained in public housing. The researchers contend that there are three potential mechanisms that may have affected adolescent binge drinking within the treatment group: improved neighborhoods (quality and socioeconomic position); less easily available alcohol; and/or a shift in alcohol use norms. The researchers cite evidence that supports these potential pathways, but it’s unclear how they might affect each gender in opposite ways. Other analyses of MTO found that mental health outcomes followed similar gender patterns, and another study found that comorbid substance use and mental health outcomes partially mediated the effects of MTO on behavioral problems for boys, though binge drinking was not specifically measured (Osypuk et al., 2019; Schmidt, Glymour, & Osypuk, 2017). A study by Taylor (2015) also addresses substance use among adolescent public housing residents; however, this study focuses on African American youth and life stressors associated with such substance use. Taylor (2015) found that while all adolescents experience life stressors, some stressors are specific to and adversely affect African American adolescents who live in public housing, such as parent absenteeism, living in single-parent homes, childhood illness, unemployment, living in foster care, and family discord (family member with substance use disorder or fighting). Given the mental healthcare disparities that African Americans experience in the U.S., Simning, van Wijngaarden, and Conwell (2011) conducted a cross-sectional study to explore differences in African American subpopulations, specifically between public and non-public housing residents. Compared with non-public housing residents, they found that the 12-month prevalence of anxiety disorders was 1.8 times greater, mood disorders was 1.4 times greater, and substance use disorders was 2.2 times greater among public housing residents. These prevalence were still greater among public housing residents when the researchers controlled for sociodemographic factors and other chronic illnesses. Although there were no statistically significant differences in mental health service use between public and non-public housing residents, the point estimates were different; fewer public housing residents with a mood or substance use disorder within the past 12 months utilized mental health services than did non-public housing residents, though more public housing residents with an anxiety disorder within the last 12 months used services as compared to non-public housing residents. The mental health and substance use disparity among African American public housing residents is clear and the setting of public or affordable housing could be a key intervention point for improving detection and treatment of such disorders, though Simning et al. (2011) found that even in complexes with social workers or other comparable providers, residents do not receive or benefit from these opportunities for services and care. Williams and Adams-Campbell (2000) also researched African American public housing residents, and focused on the implications of their findings for interventions. They discuss the importance of acknowledging the sociocultural reality of public housing residents and how that may be affecting substance use and mental health (Simning et al., 2011; Williams & Adams-Campbell, 2000). Few studies discuss the association of cigarette smoking, alcohol use, and depression among public housing residents, but Williams and Adams-Campbell (2000) investigated how demographic factors, including socioeconomic status and ethnicity, influence these relationships in a sample of African American adult public housing residents in Washington, D.C. They found no association between substance use and symptoms of depression; however, among substance users, depression symptomology increased with higher alcohol consumption. Interestingly, they found no significant relationship between smoking and symptoms of depression, which is not consistent with prior research. However, previous studies

Chapter 3 Academic Literature Review

included predominantly White samples, suggesting that substance use and mood may vary by population and community, which could have implications for interventions, particularly within the affordable housing setting. The results regarding drinking and symptoms of depression in this study indicate that the chronic stressors African American public housing residents encounter, including poverty, discrimination, violence, etc., may increase their risk for depression and alcohol use. Further, alcohol use may be a coping mechanism for dealing with these stressors and symptoms of depression. Almost half of study participants reported that at some point in their lives, they believe they had a drinking problem and/or depression (Williams & Adams-Campbell, 2000). Elderly Health Within this category, we provide an overview of six studies. Castle and Resnick (2016) examined health outcomes, including nursing home placement and/or high use of emergency departments (EDs) and other medical services, for low-income elders in publicly subsidized buildings as a part of enhanced services provision through the Staying at Home (SAH) program in Pittsburgh. SAH was implemented in seven elderly high-rises compared with four high-rises that did not implement the SAH program. The SAH program implemented four basic programmatic elements: 1) care coordination; 2) advance planning; 3) medication management; and 4) a health care diary that were implemented by the intervention team, which included a social worker (care coordinator) and a nurse. The care coordinator jointly developed a care plan with each client, which involved coordinating health provider visits and assisting with care coordination between providers, encouragement for preventative care, connections to other community support services, and help with care transitions. Care coordinators also helped residents plan for housing needs, money management, and advance directives. SAH offered two levels of medication management: at level one, the care coordinator would update a resident’s medication list in their health care diary, review the list with the clinical coordinator/medical director, and assist the resident with getting refills; at level two, the nurse assisted residents with filling pill boxes, injections, and medication reconciliation at care transition. Every resident received help in maintaining a health care diary containing their critical health care information; clients were encouraged to update it, and health care providers and the care coordinator also updated it on a regular basis. The purpose of the diary was twofold: to engage residents in their health and health care, and to improve communication between residents’ health care providers. SAH also conducts health care outreach to all participating residents through monthly visits from the outreach nurse, who conducted blood pressure checks and health education sessions such as managing diabetes or high blood pressure. As predicted, those in the intervention group used health services more than those in the control group. Although both groups had positive health improvements, the improvements in the SAH group were larger. Additionally, individuals in the intervention group were half as likely to be transferred to a nursing home as compared to those in the control group. Both ER use and inpatient hospital admissions were lower in the SAH participants as compared to the control participants. Overall, SAH was highly beneficial to residents’ health, including cost savings. As a result, the health care provider who implemented the program continues to provide SAH to members and other interested groups (Castle & Resnick, 2016). The elderly population is known to be at high-risk for falls and various chronic diseases, which can result in expensive ED visits and 911 calls (Agarwal et al., 2015). In response to this, Agarwal et al. worked with a group of elderly housing-based health service delivery organizations to develop an intervention called the Community Health Assessment Program through Emergency Medical Service 40

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(CHAP-EMS). This intervention uses health promotion and prevention methods and connections to primary care for senior subsidized housing residents to reduce hypertension and diabetes, calls to EMS, and ED visits. CHAP-EMS is an expansion of a program focused on blood pressure and cardiovascular screening (Cardiovascular Health Awareness Program (CHAP)), and another program focused on diabetes (Community Health Awareness of Diabetes (CHAD)) that includes a fall prevention component. The intervention took place in a subsidized senior housing complex in Ontario with a high volume of calls to EMS. The free programming occurred weekly and was advertised through posters and flyers in four different languages. The intervention consisted of blood pressure, diabetes, and fall risk assessment, health education, promotion, and goal setting, identification of high-risk patients, and targeted referrals to primary care and community resources. The two paramedics who led the programming received a half-day training specifically developed for the intervention that included education on disease prevention and health promotion knowledge and skills, how to assess disease and fall risk, and information on local resources available to intervention participants. Participants were encouraged to attend the program sessions regularly, and health screenings were conducted in a semi-private space within the building’s common area. The pilot study showed that the program was feasible, low-cost, manageable, novel, and appealing; CHAP-EMS attracted one third of building residents in its pilot year alone (Agarwal et al., 2015). A follow-up study by Agarwal et al. (2017) found that of the 67% of participants who were at high risk of diabetes, 15% reduced their risk from high to moderate, and the 42% of participants with high blood pressure significantly decreased their systolic and diastolic blood pressure by the third and fifth visit respectively. The researchers also found that the number of EMS calls decreased by 25% over the course of the intervention. Later renamed the

Chapter 3 Academic Literature Review

Community Paramedicine at Clinic program (CP@clinic), the researchers built on the success of their previous studies, and implemented their first multi-site RCT of the program. At every time point, intervention buildings had lower mean numbers of EMS calls and there was a statistically significant difference in number of calls between the intervention and control buildings, resulting in a 19% relative reduction in EMS calls in intervention sites (Agarwal et al., 2019). Through a collaboration between senior public housing and a school of nursing, nursing students and their professor implemented the Wellness Program in the community room of an elderly public housing building (Aselton, 2011). Every semester, six to eight students conduct a needs assessment to determine the service and health education needs of the elders, and implement the programming four hours per week. Through a combination of tabling in the community room and making home visits to homebound elders, the nursing students asked residents to suggest topics and services they would like to see implemented, provide feedback on breakfast foods, and raise any other issue. The students also collected feedback from the program director and housing authority staff. From the needs assessment, students and the instructor determined feasibility and developed a plan. Over time, the program provided older residents with free breakfast, home visits, massage therapy, health screenings, various health promotion and education activities, and blood pressure clinics, among other activities. Health education topics included depression, diabetes, herbal medicine, men’s health, secondhand smoke, fall prevention, nutrition, and food safety. Nursing students have also offered gentle exercise classes, such as tai chi, relaxation therapy, meditation, and music therapy, including seated jazz dancing. Through home visits with homebound residents, students helped elders monitor their blood pressure, managed medication, changed dressings, conducted physical assessments, and provided necessary referrals to visiting nurse associations. In addition to the health-related activities conducted during home visits, students often took on the role of friendly visitor, with the benefit of learning residents’ illness narratives. Health screenings were also set up each week at a table in the common room during which student nurses monitored blood pressure, offered hand massages, encouraged conversation, assisted residents with learning how to use medical equipment, and helped residents communicate with their health care providers. Nursing students also provided education and tips for fall prevention, helped with “chaos control” and organization when residents presented with hoarding tendencies, and concluded the program each semester with a spa day. The nursing students also conducted a door-to-door survey and bi-annually evaluated and reviewed the program through critically appraising the needs assessment and program implementation to determine what worked well and what did not so that the program could continue to meet resident needs. This type of programming is relevant, useful, and fulfilling for both nursing students and elderly public housing residents and is an affordable alternative for community health promotion and care in the public housing setting (Aselton, 2011). There are also several quasi-experimental intervention studies that provide strong evidence of health benefits in service-enriched or housing-plus affordable housing settings for low-income elders (Golant, Parsons, & Boling, 2010). Golant et al. cite the Institute for the Future of Aging Services diverse list of housing-based service delivery approaches while noting that there has been very little research on how housing providers make decisions about what services to offer, service strengths and weakness, and the influence of these decisions and service-delivery approaches on health and health-related outcomes. Some of the services cited by Golant et al. (2010) include:

Communities of Opportunity Study Design

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Paid service coordinators

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Resident volunteers and trained, lay health educators

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Direct employment of health care providers

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Health clinics within housing sites operated by such providers

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Collaborations with local community health providers

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Collaborations with local academic health centers

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Co-location of health services in or adjacent to the property

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Including different types of residential care levels within one property

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Housing owned and managed licensed home health agency

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Partnerships with local home health agencies for more affordable rates

Service coordinators are often cited as a key element of housing-based care provision, but their job descriptions are varied and they are not universally used in such enhanced housing settings. In some settings, service coordinators’ sole purpose is to offer information to residents and to offer referrals to other service providers, whereas in other settings, they are more proactively involved in addressing resident needs (Golant et al., 2010). Elderly Mental Health Despite the paucity of studies on interventions to improve the mental health of elderly affordable housing residents, there were a number of prevalence studies and analyses of the correlates of mental health among elderly public or subsidized housing residents. This section reviews a collection of these articles (n=11), three of which discuss programming focused on mental health and social isolation, though not always within the affordable housing setting. Regardless, the programming related to mental health, perceived loneliness, and social isolation among the elderly explored here provide interesting opportunities for implementation in the affordable housing setting. The prevalence of mental health disorders is high among elders in public housing (Gonyea, Curley, Melekis, Levine, & Lee, 2016). Three separate studies of elderly public or subsidized housing residents demonstrated a depression prevalence higher than 25% in Portland, Oregon (29.5%; Cotrell & Carder, 2010), Connecticut (26%; Robison et al., 2009), and Delaware (31%; Shin, Sims, Bradley, Pohlig, & Harrison, 2014). Gonyea et al. (2016) found similar results in their study, such that 25% of elderly residents had clinically significant depressive symptoms. Among their study participants, they also found that greater levels of loneliness were correlated with higher amounts of depressive symptoms. Additionally, they found that health-related variables into their regression model explained 20% variance, perceived stress explained an additional 6% variance, and loneliness explained an additional 23% of the variance in depressive symptoms. Finally, the change in the amount of variance explained before and after adding loneliness into the model was statistically significant, demonstrating that perceived loneliness does contribute to symptoms of depression in elderly subsidized housing residents (Gonyea et al., 2016). According to Black et al. (as cited in Robbins et al., 2000), most elderly residents of public housing in need of mental health treatment do not receive it as a result of a multitude of barriers including stigma, decreased mobility, incorrect beliefs about the normality of mental health issues, and memory problems. Simning, van Wijngaarden, Fisher, Richardson, and Conwell (2012) found that 32% of older public housing residents in Rochester, New York needed mental health care, but the majority were not receiving it. For this reason, Robbins et al. (2000) developed the Psychogeriatric Assessment and

Chapter 3 Academic Literature Review

Treatment in City Housing, or PATCH model of care, as an outreach program for elderly public housing residents in Baltimore, Maryland. This model of care combines the following elements to address the barriers described previously: 1) focus on a high prevalence community; 2) seeks out and brings care to those in need; 3) uses a gatekeeper model of “indigenous” primary case finders; 4) psychiatric nurses conduct in-home assessments; and 5) educational programming centered around improving case finders’ skills and facilitating resident access to services. The PATCH program is a collaborative between Johns Hopkins Hospital and Bayview Medical Center’s departments of psychiatry and community psychiatry programs, the Baltimore Housing Authority, the mental health system of Baltimore, and the State government. The program used community guidance through a community advisory board made up of city council members, community and public housing residents, and staff from service organizations that work with the elderly mentally ill. The PATCH programming team is led by a senior geriatric psychiatrist who directs two psychiatric nurses (the primary providers) and two part-time psychiatrists (their supervisors). The program began with the nurses establishing themselves at a new site and initiating seven one-hour educational presentations/trainings for building staff to help them better recognize, understand, and refer residents who might need mental health care. At this point the nurses also presented the program and its free services to residents at a tenant council meeting. Typically, staff members and/or a building’s social service coordinator, community-based providers, or family members made referrals to the program, but residents were also encouraged to seek services of their own accord. Nurses were available one day per week and when residents were referred, that is when they would conduct an in-home psychiatric assessment. After the first visit, one of the psychiatrists would join the nurse for a

Communities of Opportunity Study Design

follow-up home visit to conduct a semi-structured psychiatric evaluation and develop a treatment plan, which would be proposed to the resident and relayed to the original person who referred them. As the case manager, the nurse provided direct care to willing residents, though if they were able (and willing) to go to traditional mental health care settings, they were referred to such services. The nurses’ persistence and continued follow-up were key to building trust and engaging residents in PATCH. PATCH is considered highly effective at significantly reducing elderly residents’ psychiatric symptoms and is a unique program in the mental health service world (Robbins et al., 2000). A prospective RCT assessed the effectiveness of the PATCH program compared to usual care and found that PATCH was significantly more effective than typical care in symptom reduction in those diagnosed with psychiatric disorders, even among those with high levels of psychiatric symptoms (Rabins et al., 2000). Not only are the reduction in symptoms significant, they are also clinically meaningful and comparable to other efficacy studies (Rabins et al., 2000). Eventually, the program was successfully integrated into every elderly public housing development in Baltimore (Robbins et al., 2000). Perceived loneliness and isolation are factors that contribute to poor mental and physical health among the elderly (Webster, Ajrouch, & Antonucci, 2013). Taylor, Herbers, Talisman, and MorrowHowell (2016) found that 26% of senior housing residents were socially isolated. A separate study by the same research team (Taylor, Wang, and Morrow-Howell, 2018) found that 69.3% of senior housing residents were moderately or severely lonely. Gray and Worlledge (2018) differentiate loneliness as a “subjective feeling” from isolation as “the objective features of an individual’s relationships or lack thereof.” Webster et al. (2013) describe objective indicators of isolation as “the size of one’s network and level of participation in community activities” and subjective indicators of isolation as “self-ratings of loneliness and support quality.” In their review paper, Gray and Worlledge (2018) analyzed 32 interventions in various settings, including various housing settings, focused on alleviating loneliness amongst the elderly. Although a majority of these interventions are not within the affordable housing setting, they are relevant to this review. The authors suggest that retirement housing should provide “something for everyone,” largely because men and women may enjoy different activities and retirement housing schemes tend to be predominantly female. From their review of the literature, they contend that book clubs, computer use, educational classes, lectures, and discussions, physical activity, problem-solving games, and arts and crafts may provide a good defense against memory loss and loneliness. Their review of these interventions also indicates that activities that truly foster emotional support and real friendship, which address the feeling of loneliness, are more effective than activities that just allow people to spend time together for shorter periods of time. The activities should be meaningful and create an atmosphere for generating peer support and mutual aid. Much like the resident-led programming discussed elsewhere, the researchers found the method of training residents to be volunteer leaders who engage other residents to have a positive effect on well-being and in creating new friendships. Numerous interventions analyzed by Gray and Worlledge (2018) demonstrate the importance of integrating the elderly with younger generations through mixed programming such as reading activities, gardening, history lessons, volunteer technology education, buddy clubs, etc., as opposed to solely age-segregated activities. They found that not only are younger people a great source of potential friendship and support, they also allow for engaging in activities based upon real interest rather than age. Another interesting finding was the review of studies demonstrating that internet use can lessen the psychological experience of isolation and loneliness. Cattan et al., as cited by Gray and Worlledge (2018), found in their review that group activities are more

Chapter 3 Academic Literature Review

effective than one-to-one visits when trying to create friendships and to rebuild social networks with the elderly who have withdrawn due to bereavement or crisis. Webster et al. (2013) discuss the importance of active and supportive communities in combating social isolation as people age. Though aging in place is often mentioned as the so-called “gold standard” of how best to age, they contend that it may actually promote social isolation. Practical and psychological reasons may create an isolating situation for an elder. For example, an elder might live somewhere where the neighborhood has “changed,” where community-based activities are no longer close or accessible, or their children do not live nearby (Webster et al., 2013). Antonucci and Kahn (as cited in Webster et al., 2013) have found that rather minor interventions in affordable housing can have an effect on social isolation and perceived loneliness among the elderly, particularly when they are in charge and are the ones identifying and achieving goals they set for themselves. An example of such a minor intervention is the return of a puzzle table requested by the residents, who stated it was an important gathering spot and contributed to a communal spirit. Once it returned, residents were more positive, engaged, and energetic. Similarly, Webster et al. (2013) discuss the importance of elderly affordable housing residents having a meaningful role in the community because feeling useful is linked to lower depression rates, among other health outcomes. They highlight this in particular because despite the documented relationship between having a meaningful role in a community and multiple health outcomes, older adults need more formal opportunities to do so and the affordable housing setting is a perfect place for this to occur. We found several studies evaluating the different types of social networks and social ties experienced by elderly residents in affordable housing settings, but few studies of interventions to improve social cohesion and social support. What follows is a review of two articles exploring the sources of social support among elderly affordable housing residents, one of which discusses programming. Cleak and Howe (2003) conducted a study of elderly public housing residents in two service-enriched housing developments in East Harlem that implemented services through Mount Sinai Medical Center and Union Settlement Association to better understand elders’ social networks and experiences of social support. Even though most of the residents of both housing developments had lived in the neighborhood for quite some time, overall, they scored quite low on a measure of social integration. They hypothesize that this could be indicative of the surrounding community deprivation, which can impact social networks, trust, and integration. They also found that residents of one of the housing developments had stronger social networks, used more informal supports, and had better mental health scores, supporting prior findings that social networks and informal social supports can be a conduit for the use of formal resources and services. The results also demonstrate that residents who used the most informal services also had the most robust social networks. One of the developments had a full-time, on-site social worker who provided elders with opportunities to interact with others and encouraged participation in building activities, which seemed to have an effect on the likelihood of whether or not residents would participate and if they would use informal supports when necessary. The second development lacked a full-time onsite social worker, had fewer activities and social integration, and used significantly more formal services than residents of the first development. Ultimately, they discovered that the more integrated the social network, the less formal services were used by residents, which in turn increases resident use of informal supports. This was also demonstrated by the level of service-enriched housing in each development; the more enriched the environment, the greater improvement in one’s social network and ultimately their well-being (Cleak & Howe, 2003). 46

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Webster, Antonucci, and Alexander (2019) conducted a study of elderly residents of HUD-subsidized affordable senior housing community to assess their social ties and levels of physical activity to assess the feasibility of using a social network approach to enhance interventions on physical activity. In their analysis, the researchers found that residents engaged in moderate physical activity about five times during a typical week and reported engaging in moderate to vigorous activity at least once per week over the past month. On average, residents named 12.5 people as members of their close social networks, of whom three were residents of their housing community. Additionally, residents reported that they knew about six other residents with whom they could link to another resident with certainty. They found that the study results supported their hypothesis that the use of a social network approach as part of a physical activity intervention in affordable housing settings with elderly residents is feasible, as demonstrated by their identification of physically active, socially engaged residents who could influence other less engaged or active residents to change their behavior. Overall, this study contributes to a body of literature that demonstrates how theoretical understanding of social networks and other social constructs can be implemented in context-specific behavioral interventions (Webster et al., 2019). In conclusion, the results of these targeted types of affordable housing-based health and healthrelated interventions indicate that the effect on resident health can be profound. Most of these programs had significant impact on and improvement in various health and health-related outcomes, including smoking abstinence, fruit and vegetable consumption, physical activity, referrals and use of local health services, etc. While their design and impact varied considerably, it is apparent that affordable housing is a useful, relevant, and important venue for targeted health programming. 2. ECONOMIC AND EDUCATIONAL PROGRAMS Much of the published literature in the affordable housing arena addresses economic and educational outcomes. Here we summarize five studies, three of which are intervention studies and mainly focus on after-school, skills development, and job-related programming. One example of an after-school program (ASP) focused on academic performance and school behavior in four public housing communities in Denver, Colorado (Jenson et al, 2018). Using a quasi-experimental study design, they compared school suspension and attendance, among other academic outcomes. The intervention consisted a variety of activities that participants could attend up to four days a week including the Read Well evidence-based curriculum (structured reading/literacy instruction), one-toone reading, math, science, and social science skills-based tutoring, and Second Step training groups for social and emotional skills. Participants in the comparison group received programming from the Bridge Project ASP or another ASP. Youth who received the intervention attended school at significantly higher rates and were significantly less likely to be suspended or expelled from school than youth in the comparison group (Jenson et al., 2018). Intervention children had greater increases in reading skills, and teacher ratings demonstrated a significant effect on proficiency in math (OR=1.75; p<0.05) and science (OR=2.12; p<0.01). Lang, Waterman, and Baker (2009) conducted an evaluation of Computeen, a novel prevention program based in strengthening protective factors to life stressors. Computeen is grounded in concepts of risk, resiliency, asset-building, self-efficacy, self-esteem, prosocial behavior, and psychosocial skills. The program integrates technology skills with psychosocial skills through psychoeducation, training participants to be computer/tech experts, building self-efficacy, self-

Chapter 3 Academic Literature Review

esteem, and competency--all supervised by a positive adult role model. The researchers used a randomized waitlist control design in four affordable housing developments in Los Angeles County to implement Computeen. Adolescents ages 12 to 16 were recruited through community meetings. Most participants knew about Microsoft Word and email, but much less about the other computer skills; 56% of participants had a computer in their home. The program was 16 weeks long; interviews were conducted at baseline, five months later, and three months after that. After the second interview, the waitlist controls began the Computeen program and followed the same interview pattern for the second and third interview; they completed the baseline interview with the immediate intervention participants before randomization occurred. Each week of the program, participants attended two-hour sessions that taught relevant computer skills and skills that could be used to complete coursework. Groups were led by two people, consisted of five to eleven participants, and every participant had their own computer to use during the workshop. Most groups had a male and female leader, at least one leader was a clinical psychology graduate student, and all leaders had weekly supervision from a licensed psychologist. Adolescents learned how to use all Microsoft Office programs, Front Page, Printshop, and the internet; they also gained hardware knowledge and skills in digital photography and networking. Group and individual projects focused on topics and skills relevant to low-income, at-risk youth and were designed to encourage positive interaction. Each week participants had “homework” to practice the skills, for which they earned points; they also earned points for attendance and participation. The intervention was overwhelmingly well-received by parents and participants and had 89% overall attendance. All participants had significant improvements from baseline to follow-up in self-esteem and externalizing behavior issues. At follow-up, participants felt they had learned new computers skills and were more confident in and capable of using a computer.

Communities of Opportunity Study Design

Parents also reported a significant decrease in adolescent internalizing behavioral problems, which was clinically meaningful among the subgroup of adolescents who were borderline and/or had clinically significant internalized behavior problems, supporting the hypothesis that the intervention reduces maladaptive behaviors. They also found that computer-use self-efficacy mediated the association between computer skills improvement and self-esteem. Additionally, Lang et al. (2009) found that overall, younger adolescents had greater improvement than older adolescents. An example of employment-related programming is the Jobs-Plus intervention implemented by HUD and other partners including MDRC (Bloom & Riccio, 2005). The Jobs-Plus intervention was a broad, comprehensive, and intensive community-centered, multi-component intervention for joblessness among public housing residents. The three components of intervention centered around: 1) support services and job-skills development such as conducting a job search, training and education, childcare assistance, and transportation; 2) financial incentives to reduce the amount that increased earnings would be offset by increases in rent; 3) and community support through building social capital, sharing information, and mutual aid/peer support. What is unique about this intervention is its effort to implement all three of these components for every working-age person living in the participating public housing developments. Seven cities participated in the demonstration including Baltimore, Chattanooga, Cleveland, Dayton, Los Angeles, St. Paul, and Seattle. The intervention was designed to include collaborative decision making, although this depended on the commitment of local housing authorities, partners, and project director. Resident engagement was important and complex; resident leaders played a critical role in identifying community needs and proposed services and service approaches to the project staff, which helped foster residents’ trust and willingness to participate in the project. To evaluate the impacts of the Jobs-Plus intervention, the investigators conducted site-level estimates through a comparative interrupted time-series analysis through multiple baseline observations before program launch and at least one follow-up after program launch to answer two questions: “To what extent was there an improvement in the experiences of residents at the program development?” and “To what extent did Jobs-Plus improve these experiences?” Results demonstrate that employment rates rose dramatically during baseline quarterly measurement periods for all groups, largely because employment rates were already higher than anticipated at program launch due to the continuous rising trend of employment rates for public housing residents during this period. Over the course of the follow-up period, results of the Jobs-Plus Intervention indicate that the number of employed residents increased steadily each year after the intervention was implemented. After the first year of the program, 54% of residents were employed, which continually increased through the fifth year of the intervention when 74% of residents were employed (Bloom & Riccio, 2005). Other studies have evaluated the role of transportation (cars and public transportation) in improving employment outcomes for affordable housing residents, including those who participated in the Moving to Opportunity (MTO) housing voucher program (Blumenberg & Pierce, 2014). The researchers found that transportation can play an important role for subsidized housing residents, helping them to improve and/or maintain positive employment outcomes more strongly than housing assistance alone. However, while moving to subsidized/affordable housing in a neighborhood with more public transit did not increase a resident’s likelihood of employment, it did help them to retain employment. Having a car increased the likelihood of employment, but other factors may have influenced this

Chapter 3 Academic Literature Review

relationship. The investigators also found that having a car made it easier for people to maintain longterm employment. Although this is not an intervention study focused on employment, results suggest that programming improving access to cars and/or public transit could increase employment among affordable housing residents. Other studies have analyzed the impact of work requirement policies for public housing residents. One such study was conducted in the Charlotte Housing Authority by Frescoln, Nguyen, Rohe, & Webb (2018). Although resident interviews suggested that overall stress level was reduced because of increases in household income, the researchers also found the policy had negative impacts. For example, in some cases, an increase in household income led to the elimination of or cuts in social welfare benefits such as Medicaid and SNAP. Therefore, while such policies could be beneficial, they can also create problems and challenges for affordable housing residents. Frescoln et al. (2018) urge practitioners, policymakers, and researchers to consider both positive and negative unintended effects when implementing such programming, and to evaluate the long-term consequences. 3. RESIDENT ENGAGEMENT, EMPOWERMENT, AND LEADERSHIP This section reviews studies that implement CBPR approaches, needs assessment methodolo-gies and/or focus on resident leadership, engagement, and participation. In this category, we identified nine articles addressing these topics and four of which evaluate programming relat-ed to the topics of resident engagement, empowerment, and leadership. What follows is an overview of these studies, their design, and impact on affordable housing residents. Wolff et al. (2001; 2004) developed a program called The Highland Park advocate program through a partnership between the Center for Healthy Communities (CHC) at the Medical Col-lege of Wisconsin, the Housing Authority of the City of Milwaukee, the Highland Park Resident Organization (which had received a Tenant Opportunity Program grant through the US Depart-ment of Housing and Urban Development [HUD] to cultivate resident leadership to address various health issues), other public housing tenants, and the Service, Empowerment and Trans-formation (S.E.T.) Ministry, Inc. These partners met regularly to identify and prioritize the resi-dents’ needs and to determine how best to address those needs. In these meetings, the partners discussed whether and how to implement such programming and jointly developed the goals, structure, and content of the program. The CHC partners developed a job description for the advocates and selection criteria (respected by residents, minimum a six month residency in building, trustworthy, committed to positive change, and enjoy working with people). The positions were advertised in the building and the buildings’ case management team also helped identify residents who demonstrated these leadership qualities. The training curriculum they utilized was a modification of Dayton, Ohio’s citywide CHA program curriculum and consisted of seven weekly one to one and a half hour sessions to strengthen and expand leadership skills. The training capitalized on expected input from residents to identify/ prioritize community concerns; the focus was how to leverage this information, develop strategies, and mobilize community participation and resources to resolve such concerns. The CHAs concluded the training with a graduation ceremony and were formally introduced to the CHC partners and the housing residents. The CHAs created groups and subcommittees to address tenant concerns such as the Tenant Patrol program to address safety, the spirituality group, the GED program, the health committee, and community-building activities (coffee club, discussion groups, and potlucks. CHAs also attended outsides series/forums on race and health, and invited prominent leaders to speak with the resident community such as local alderman and the Milwaukee Housing Authority director (Wolff et al., 2004). 50

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The Washington D.C. Housing Authority staff worked with public housing resident leaders to host health forums and discussions surrounding resident health and empowerment (Council et al., 2013). During these forums, residents viewed the seven-part PBC documentary Unnatural Causes and discussed how the film relates to their own lives. Attendees at these forums included a HUD official, representatives from the DC Department of Health, local universities, and senior officials from the DC Housing Authority. These forums led to a focus group of residents, which revealed that residents not only want to be more involved in planning future forums, but they also want to be involved in the decision-making process regarding health interventions. Regular meetings between resident leaders and staff from the DC Housing Authority and the other partners led to a decision to conduct a residentled community needs assessment. Ultimately, this led to a Citywide Advisory Board Health Planning Committee made up by elected leaders from every public housing development in DC. This Committee conducted a sur-vey of all DC public housing residents which demonstrated residents’ concern for their public safety, environment, asthma, and mental health (Council et al., 2013). Dahmann and Dennison (2013) conducted a case study of resident-led community organizing and community-building efforts focused on health issues in public housing in Los Angeles, sup-ported by the Los Angeles Human Right to Housing Collective (The Collective), composed of CBOs and individuals focused on community organizing, legal support services, and academic institutions. The Collective’s primary focus is resident engagement, leadership development, community organization, and coalition building. Central to this work is the concept that impacted residents are at the center of all decision making. The Collective defines their focus on community health as: (1) long-term housing stability without fear of displacement; (2) healthy conditions within and around homes; access to park space, grocery stores and fresh foods, health and mental health care, and other health-promoting resources; and (3) strong neighbor-hood social ties reflected by participation in community organizing and other clubs, activities, and events. The LA Human Right to Housing organizations have over 540 members who live in eight public housing communities from which more than 100 residents are active leaders in The Collective. Through their work, The Collective ensures sure that residents are actively involved in informing the process and engaged in decision making such that when a public housing community was identified for privatization, tenants were directly involved in organizing and responding. A resident committee at that housing developed designed and implemented a resident engagement survey to better inform future priorities of all residents, not just those involved in the committee or The Collective. Results of the resident-implemented survey demonstrated that residents’ top priorities were public housing preservation and access to high-quality fresh food and grocery stores. The Collective helped create and facilitate a voice among public housing residents that did not really exist previously; through group engagement, educational flyers, surveys, workshops, and community events, The Collective increased public housing residents’ capacity and impact. Some examples and successes of this work include: the prevention of public housing privatization and resident displacement, which positively impacted residents’ health and well-being; substantial improvements to the local housing authority’s maintenance procedures and fees, which positively impacted residents’ environment health; significant improvements to residents’ participation processes and involvement in the local housing authority’s annual planning process, which meant increased opportunity for more meaningful resident participation; and the reduction of monthly rent costs so that residents did not have to choose between paying for rent and fulfilling other urgent health or health-related needs.

Chapter 3 Academic Literature Review

As a result of the coalition infrastructure built by The Collective, thousands of public housing residents have been impacted and engaged in leadership and decision-making processes. Though there have been many successes, the researchers also note the many challenges of such broadly-representative, resident-led work, which includes the placement of important structures and great attention to the implementation various human rights principles; additionally, the time commitment and organizational capacity necessary for this level of engagement is significant. The researchers found that despite the challenges, such resident-engaged and -led work focusing on community organizing and coalition building can lead to increased long-term housing stability and social ties, which positively impact community health. Furthermore, Dahmann and Dennison (2013) have demonstrated that these processes, strategies, and methods (which are participatory and resident-driven) are effective community-level health interventions. Much of this work includes needs assessments and CBPR approaches, often with the purpose and goal of engaging residents, cultivating and implementing resident leadership, and encouraging resident engagement. Even when the conduct of needs assessments within the affordable housing setting does not include actual programming, this process can inform future implementation of programming based on resident perceptions, input, and voices (Lascher et al., 2013; Rogers, Johnson, Nueslein, Edmunds, & Valdez, 2018; Wells et al., 2019). Such engage-ment of residents also seeks to identify and overcome barriers to resident participation to fur-ther encourage meaningful participation in such programming and services (Ciro & Smith, 2015; Cotter et al., 2016; Wells et al., 2019). Engagement Studies with Elderly Populations This category provides a summary of nine studies, five of which discuss programming. The studies are resident-centered, informed, engaged, or led. As mentioned previously, CBPR methodology is, by definition, inclusive of participants, which explains why it is an important tool for implementing resident-centered and engaged programming in housing settings. This holds true for the elderly or senior population in affordable housing as well. In addition to studies and interventions using CBPR principles and methodology, this section highlights other programs and services that are residentfocused, include resident voices, and/or use needs assessments to inform future interventions. Barnes et al. (2012) conducted five focus groups with elderly residents in four extra-care housing schemes throughout England to learn about residents’ views and concerns regarding the physical design of the buildings in which they live. While not an intervention, this study still focused on the viewpoints of the most important stakeholders in the context of the “housing-plus” setting—the residents. The two big themes that emerged from data analysis were: how the design of the building affects its usability and how it supports residents’ lifestyles. Residents with disabilities, who are quite prevalent among the elderly population, found that lack of access to amenities and activities often prohibited participation, particularly because elements of the building did not accommodate reduced physical abilities. For example, moving around the buildings, doing laundry, and use of the kitchen were restricted due to physical barriers. Ultimately, use of such services and amenities, including access to outdoor space, met the needs of physically fit and healthy residents, but not the needs of residents who had physical or cognitive impairments (Barnes et al., 2012). Lindley, Wallace, and Milligan (as cited in Canham et al., 2018) also note that elderly residents often live in housing settings that are not matched to their place-based needs, which results in isolation and marginalization. Senior residents who live in affordable housing settings have identified the importance of communal spaces for programming, social interaction, and meaningful activity (Leviten-Reid & Lake (2016) and Fang et al. 52

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(2016) as cited in Canham et al., 2018; Gray & Worlledge, 2018). Canham et al. (2018) therefore developed a longitudinal, collaborative, CBPR project in a senior affordable housing development in Western Canada focused on these issues. Rosewood Gardens, the site of the study by Canham et al. (2018), includes units for two full-time, live-in caretakers who are multilingual and serve a variety of purposes including ensuring a safe/secure environment, supporting building maintenance needs, and implementing bylaws; they do not, however, implement social programming. Communal spaces on the property include centralized community spaces such as a multipurpose room (with a kitchen), a board room, an arts and crafts room, a game room, a salon/spa, lobbies with seating areas, a secure outdoor courtyard with walking paths and a garden, and courtyard-level lounges with connecting laundry rooms. Following CBPR principles, the project began in consultation with the housing authority and municipal government, which continued to provide input and collaborate on decision-making throughout the study. Before seniors moved into the buildings, they initiated deliberative dialogue workshops, a unique method of discussion aimed at creating a platform for generating collective thought toward potential solutions for a common purpose (Kingston, 2005). Participants of these workshops were key stakeholders from the housing authority, property management, and the municipal government, including service providers. The goal of the workshops was to identify the ways in which services and supports could be delivered sustainably to residents, while facilitating inclusive, accessible, and supportive environments. Ultimately, the study aimed to collaboratively design solutions for how best to use the communal spaces, to connect residents to services and programs, and to provide opportunities to develop and continue building collaborative and effective senior housing-based

Chapter 3 Academic Literature Review

service delivery. On-site programming recommendations varied; participants stated that services and programming should change as needs change and should not assume tenants’ needs without engaging in collaborative exchanges. Participants emphasized the need for available and proximate local senior programming offsite, as well as the need for these outside organizations to become a network and offer support collaboratively for senior independence. Additionally, participants acknowledged the importance of letting residents know of the various options available to them through presentations, resource guides, etc., and to understand the communication styles and needs of residents to best relay this information. Stakeholders also emphasized the need for an on-site program coordinator separate from the building manager and caretakers (Canham et al., 2018). Another report by Sixsmith et al. (2017) describes the inclusion of residents’ voices in the planning process of Rosewood Gardens. Continuing to use a CBPR approach, Sixsmith et al. (2017) used photovoice to capture residents’ needs regarding sense of place and Fang et al. (2016) conducted participatory mapping workshops with residents and service providers to envision age-friendly community and homes. In addition, resident stories from the photovoice project and interviews were shared and everyone took walks together to map the communal spaces in the buildings during these workshops (Fang et al., 2016; Sixsmith et al., 2017). These workshops also included discussions about aging in place and how that could be incorporated in the new housing setting (Fang et al., 2016; Sixsmith et al., 2017). Each workshop had a different purpose for generating ideas/solutions through audio, visual, and other sensory methods (Fang et al., 2016). Participants led and retained collaborative ownership of the maps and results of the workshops (Fang et al., 2016). Results from this project indicated that residents needed access to grocery stores, health services, and transportation, in addition to more time to cross the nearby streets (Sixsmith et al., 2017). As a result, new traffic lights with longer timing were installed, transportation links were made, and the housing provider and local government promoted and raised awareness around local services. Residents also expressed concern about the higher rent, even though service providers and developers facilitated access to welfare support for rent payment. Additionally, residents expressed a need for pets to be permitted, places for relatives to stay, and consciousness of cultural sensitivity issues and language differences. The collaborative process facilitated a gradual reduction in the “us versus them” mentality that was pervasive at the beginning of the projects. Importantly, residents also felt a sense of ownership of the outcomes of the project due to their participation in the decision making (Sixsmith et al., 2017). In 2000, the Angelus Plaza was the largest federally subsidized, affordable senior housing complex in the United States with a diverse and aging population (Cohn, Lyons, Fink, & Marker, 2000). They conducted a needs assessment with Angelus Plaza residents to learn about preferences and conditions of housing-based services to improve planning and delivery, in addition to improving the social fabric, communication, and sense of community between residents, staff, and service providers. The needs assessment was conducted in a culturally responsive manner with the approval of resident leaders and focused on the use of the senior activity center, frailty and need for help, mobility, and safety. During the first phase of the study, investigators met with housing administration staff, department heads, senior center staff, and key resident leaders, including those from resident clubs/councils to determine and refine the study purposes and preferences through individual and group discussions. During phase two, they administered surveys to the residents which was informed by the first phase of the study. The group and individual discussions provided information to improve selection, design and delivery of programs and services, but also provided relevant contextual information about culturallyspecific needs, the facilities, and safety. From the survey, they learned that 34% of respondents have 54

Communities of Opportunity Study Design

someone assist them with personal care, though there were dramatic differences between the language groups (Chinese, Spanish, English, and Korean) as to who provided the assistance (family member, in home caregiver, a friend, or someone else). Additionally, almost 50% of responding residents needed help with housekeeping and shopping and 33% needed help with laundry, preparing meals, and paying bills. A quarter of responding residents said they needed someone to check on them daily and 20% said they needed help with bathing, dressing, or other personal care activities. Interestingly, 70% of respondents said they have no problem getting around and only about 4% reported being homebound, though 18%-35% of respondents reported using a cane or walker at least sometimes. The researchers state that the housing administration and staff used the results of the survey as a blueprint for action, such that the administration applied for and was granted a three-year HUD grant to pay for an additional service coordinator who is bilingual and can assist with the concerns raised in the needs assessment. The results also led to building manager training sessions on elders’ needs, cultural sensitivity, and crisis intervention, given that many residents go to them for help. Another tangible impact of the needs assessment was the creation and hiring of a Health Center Supervisor and Personal Care Planner, who would increase case management capacity and assist with early identification of frailty. Additionally, efforts and commitments were made to incorporate more culturally sensitive approaches to service provision, including use of translation equipment, hiring more staff who speak resident languages, culturally relevant food at events, and hiring healthcare providers who speak languages other than English (Cohn et al., 2000). In their survey of elderly housing development managers, Gray and Worlledge (2018) found that manager support for activities and programming was critical for expanding services and programs beyond coffee times and bingo. In fact, manager support and encouragement of residents organizing programming resulted in an increase in the variety and frequency of activities. Additionally, they found that the likelihood of having weekly programming in an elderly housing setting increased by 60.7% if there was a common room, and 29.6% if there was a resident or tenant group. Residents’ groups were also more likely to exist if there was a common room for meeting. The existence of a resident or tenant association had an equal effect on managers’ helping organize programming and on residentorganized programming. The range and quality of activities were more influenced by manager help than was program frequency. When outside partnerships with local organizations existed, it was rare that resident associations coordinated these activities alone; manager efforts were crucial. It is clear that housing staff played an important role in coordinating and sustaining programming, especially in settings lacking a common room space. Finally, housing staff and managers are more likely to support housing-based programming when there are resident associations with whom they can collaborate, whether formally or informally (Gray & Worlledge, 2018). Other peer-reviewed articles that focus on resident-centered programming use current services, such as a food pantry or community gardens, as opportunities for determining residents’ interest in other community-based programming (Petroka, Campbell-Bussiere, Dychtwald, & Milliron, 2017). Similar to other studies, researchers have used needs assessment to inform interventions for elderly residents (Cotrell & Carder, 2010; Sanders, Stone, Meador, & Parker, 2010). Through CBPR approaches and other methods, researchers have evaluated a variety of housing-based programming that is residentcentered, -engaged, and -informed.

Chapter 3 Academic Literature Review

4. SOCIAL NETWORKS AND SOCIAL SUPPORT This section of the review addresses the related concepts of social networks and social support in the affordable housing setting. In this category, we found six observational studies, but no true program evaluations. We focus on social integration and cohesion as outcomes related to social networks, social support, and social ties. The effects of social networks, social support, and social integration on health outcomes have been well-established in the sociological and public health literatures (e.g., Keene & Geronimus, 2011). The ethnographic literature suggests that social support and the pooling of resources across a social network serve as survival strategies in the face of serious socioeconomic pressures and limited opportunity for those in low-income communities (Keene & Geronimus, 2011). Although few studies in affordable housing settings have formally evaluated the impact of interventions utilizing social networks, support, cohesion, and ties among affordable housing residents, we reviewed some studies that characterize the nature of social ties among residents. These include descriptions of the ways in which social ties and networks are formed, the type, quality and density of these relationships, and the level of social cohesion. Most of these studies described public housing relocation programs such as HOPE VI and Moving to Opportunity. As such, they involved comparison of pre- and post-relocation experiences by residents with respect to social networks, support, cohesion, and ties while living in public or affordable multi-unit housing settings. Keene and Geronimus (2011) describe previous research showing that the role of social support is particularly impactful among low-income black Americans. They conducted a study of black adults who received rental assistance, focusing on public housing residents to explore associations with various kinds of community-based social supports. Compared to those receiving other forms of rental assistance, residents of public housing developments were more likely to have self-reported access to several different types of social support. The self-reported types of social support included: 1) “count on each other;” 2) “watch each other’s children;” 3) “trust each other to intervene;” 4) “get help from family nearby;” and 5) and “get help from friends nearby”. This study only explored ethnographic accounts of associations between residence in public housing and social support, and did not explore the mechanisms underlying the connections. The authors discussed some of the reasons underlying these associations, hypothesizing that the stability of public housing as compared to other rent-assisted housing might mediate the relationship. They also suggest that the observed association between residing in public housing and social support might explain why programs like HOPE VI and Moving to Opportunity have not been as successful in producing positive health effects across the board. Specifically, the loss of social supports may offset the benefits of moving into improved housing. Although this study suggests that social support may be strong among public housing residents, these housing settings do require revitalization and additional community-based support services and programming. Results suggest that social ties and networks among public housing residents are important coping mechanisms, particularly in areas of economic deprivation, high crime and violence. These findings indicate the need for more programs and services to strengthen social ties, support, and networks among residents in other multi-unit rentassisted/affordable housing settings (Keene & Geronimus, 2011). Gaumer, Jacobowitz, and Brooks-Gunn (2014) studied social ties and networks among people who had moved into a newly-built affordable housing complex three and a half years prior to being interviewed. The researchers linked secondary data describing the population’s pre-move demographics to other premove baseline data to determine housing eligibility. The buildings had elevators, a small lobby, and no community room or outdoor space encouraging social interaction except for a laundry room connecting 56

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the buildings. Gaumer et al. measured the following types of social networks among residents: 1) overall social network regardless of where those social ties live (core network); 2) relationships with people who live in the neighborhood; and 3) relationships with people living in their building. Using the following methods, the researchers sought to understand the value use of these relationships by asking residents to name up to three people who fit the following categories: 1) those with whom they discuss important personal matters (in the last six months); 2) those of whom they have asked small favors (in the last two months); 3) those whom they have asked for advice/information (in the last 12 months); 4) those in the neighborhood with whom they engage/ interact most often; 5) any others in the neighborhood not yet named whom they have asked for advice/information; and 6) any others in the neighborhood not yet named to whom they have given advice/information. The first three categories were used to define residents’ core network and the last three categories were used to define social ties with neighbors, considered local ties (i.e. living in the same building or elsewhere in the neighborhood). They also measured the density of core ties as share of total social ties. On average, residents had an overall network size of almost six unique individuals, with whom the average frequency of contact was two to three times per week. As for local ties, on average they made up 54% of the average overall social network; residents communicated with them about one to two times per week. They found that local ties have relatively low density such that only 31% regularly interact or engage with each other. Additionally, they found that ties within the building interact with each other at half the rate of social ties with people who live elsewhere in the neighborhood, but the density of the networks are greater within the building than elsewhere in the neighborhood. On average, 25% of within-building ties and 75% of other neighborhood ties were named as members of residents’ core networks. The most common response to how many building ties was considered to be close friends was zero. Furthermore, a majority of people did not rely on building-level neighbors as essential resources. Results corroborate the results of prior studies focused on relocated public housing residents. In particular, the affordable housing residents in this study did not have the level of density and locally-situated social networks that ethnographic and quantitative studies have typically found in low-income households. This may indicate the need for building-level programming that supports the growth of social networks and deep-personal ties to cultivate a stronger sense of within-building social support for affordable housing residents (Gaumer et al., 2014). Pollack et al. (2014) sought to understand how the type of public housing affects residents’ social networks by focusing on perceived health and health behaviors of residents and members of their social networks. They expanded upon previous research indicating that the type of public housing arrangement, either clustered or scattered units, can affect the quality of support and level of emotional intimacy in the social networks of public housing residents. Unlike recent studies on the effects of relocation of public housing residents from high-poverty neighborhoods to lower-poverty neighborhoods through programs like Moving to Opportunity, this study focused on public housing residents living in a low-poverty neighborhood within the highly-affluent Montgomery County suburbs of Maryland. Two thirds of the study sample lived in scattered public housing units among market rate apartments, and one third lived in clustered public housing developments, although there were no statistically significant differences in these residents’ sociodemographic characteristics. The researchers measured social networks through a naming strategy and density in a manner similar to those used by Gaumer et al. (2014). They found social density, on average, to be relatively low; the level of density did not vary significantly by housing type. Most social network health-related characteristics did not differ significantly by housing type, but the health composition of a resident’s social network was associated with personal health behaviors, especially

Chapter 3 Academic Literature Review

smoking. In general, smoking rates were higher than the national average, and smoking within a resident’s social network was significantly related to whether or not that resident smoked. Additionally, residents’ perception of exercise among their social networks was 10% higher among scattered housing residents when compared with clustered housing residents, indicating that perception of exercise among public housing residents’ social networks may contribute to those health outcomes impacted by exercise. These results demonstrate that public housing residents’ social networks can in fact influence health behaviors (Pollack et al., 2014). Smith, Kwon, Mason, and Sheehan (2018) sought to understand the role of social support among low-income mothers living in a high-density public housing development, Cabrini Green, on the Near North Side of Chicago. Although this study described how these support networks and ties changed after the dismemberment of a public housing development, we focus on results related to how these two generations of former Cabrini Green residents experienced social support while living in public housing. Through qualitative, in-depth interviews, the researchers categorized social support as follows: support from family including the fathers of their children and the fathers’ families; support from the community; and support from institutions. The first-generation mothers who raised their children in Cabrini Green, cited a mix of neighborly and familial support as being trusted resources and assisting with childcare. Most mothers, regardless of generation, had little or only intermittent support from their children’s fathers, although sometimes the fathers’ families or the father of the youngest child would act as a source of support for the entire family. Mothers viewed the Cabrini Green community as an extended family that provided emotional and tangible support through community parenting, mutual accountability, childcare, groceries, employment resources, transportation, and general advice. Cabrini Green fostered deeply emotional and supportive social ties providing instrumental social support to residents that was greatly missed when residents were forced to move elsewhere. The mothers also cited the institutional sources of support at Cabrini Green through service and on-site programming, which provided them with tangible resources and facilitated connections to each other and other sources of support. Despite the violence, safety issues, and other environmental issues within and surrounding the Cabrini Green site, residents found solace in each other through this sense of the community as “family” and their provision of emotional and instrumental support to each other. Residents also cited the importance of these social supports as integral to their ability to parent, particularly when fathers were not involved (Smith et al., 2018). Using a focus group study of African American public housing residents living in a low-socioeconomic, cluster, low-rise housing development, Hayward et al. (2015) sought to understand how the social and built environment are perceived by residents, and how they perceived these environments as affecting their health and well-being. The investigators used the approach developed by the World Bank for assessing community social capital to inform a semi-structured focus group guide. This included open-ended questions and probes covering themes such as health, quality of community attributes, neighborhood resources and social structure, and interpersonal relationships. The questions and probes used to determine the structure of social support included: •

“Who are the important people in your community? What do they do and where are they located? Are there important people who do not have *official titles* in the community?”

•

“Is there a strong sense of community where you live?”

•

“Do neighbors look out for one another? Help each other out?”

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•

“How has the community worked together in the past to solve a problem? Or have members in the community ever helped you with a problem?”

In contrast to the results from other studies on social support in public housing communities, participants reported mixed feelings about relationships with neighbors and community members. Some participants referenced times in which the community rallied together to help them through difficulties, while others stated that they are skeptical of the trustworthiness of neighbors and do not form trusting friendships for fear of gossip. Overall, this resulted in a sense of social isolation among the social network at this public housing development. The housing development was split into geographic courts, and some court communities were more cohesive than others. In more cohesive courts, residents mentioned helping each other after the death of someone close to them, tending for each other’s children, and working together to eradicate pests. In the less cohesive courts, residents had more negative opinions of their neighbors, and only “stuck together” with other residents who had lived in the community for as long as they had, perceiving new residents as outsiders. Some participants attributed the lack of social cohesion to the lack of a unifying voice to advocate for change and cohesiveness despite having a resident council representing their needs. Other participants thought this lack of cohesion was due to residents’ non-participation in the community meetings, events, and council, and wished for more collective action to improve their social network and quality of life. Overall, participants perceived connections between the physical environment and their own health and well-being, despite the lack of social cohesion and community action. Although most studies of social cohesion and support in public housing developments have found that social support and ties are strong within their communities, the results of this study differed. Further qualitative and quantitative study is needed to further explore the reasons for inconsistent findings, potentially leading to interventions that could improve residents’ social environment and influence their health and well-being. Tester, Ruel, Anderson, Reitzes, and Oakley (2011) conducted a study of Atlanta public housing residents prior to their relocation to other living environments through HOPE VI, using vouchers to understand their sense of place, community attachment, and social support. Using a prospective, longitudinal, quantitative design, the researchers surveyed public housing residents from six different communities, including two senior/disability developments. They found that on average, residents felt a sense of place, although this was stronger among senior residents than other residents. Their findings also confirmed previous research reporting that more social control is associated with stronger community identification among public housing residents. Results demonstrated that social support and collective efficacy were positively related to a stronger sense of place, that social support is associated with place (neighborhood) and community attachment, and that collective efficacy is associated with community attachment. Although results were mixed, Tester et al. (2011) concluded that residents of public housing feel that social ties and support are important and are created within public housing developments. Overall, this review found that social support, ties, networks, and cohesion are typically strong among public and affordable housing residents, with few exceptions. Although methods varied, articles primarily focused on public housing residents and their experiences of these social environments in the context of public housing relocation. Given the importance of these social factors to affordable housing residents, interventions in such settings could build upon these networks and use this knowledge to better design and implement interventions that are appropriate for the community they intend to serve.

Chapter 3 Academic Literature Review

5. VIOLENCE AND SAFETY There is a significant amount of research regarding neighborhood level violence and safety, although very few studies have addressed violence at the building level, much less in affordable housing. Most of the peer-reviewed literature addresses the prevalence of violence at the neighborhood level, constructs that may be mediators or moderators of violence at the neighborhood level, and/or how elements of the social environment such as social cohesion and support, impact violence, safety, and crime. In this category, we found two studies addressing violence, fear, crime, safety, and coping with such issues in public housing, but they do not include interventions to eliminate violence or maintain safety. Our search for studies evaluating programming intended to reduce violence in affordable housing settings yielded only one such peer-reviewed article (Coggan, Saunders, & Grenot, 2008). A case study of the largest public housing development in Sydney, Australia conducted by Coggan et al. (2008) shows how a collaborative community development approach resulted in the first WHOdesignated Safe Community. Prior to the intervention, the Northcott Housing Estate community was traumatized by the high prevalence of violent crime, murder, and suicide and an unspoken “shuttered door” policy. Starting in 1992, a social-change organization focused on art, Big hART Inc., had been working with marginalized, isolated groups much like the residents of Northcott. Big hART began talks with Northcott about collaboration on a cross-government, cross-portfolio strategy to build community strength, create understanding, and cultivate a stronger sense of community identity. Through Big hART’s programming it became apparent that Northcott needed structures for sustainability of program achievements, which led to the concept of Safe Communities (Coggan et al., 2008). Safe Communities were developed out of a community-based injury project in Sweden in the early 70’s, drawing on the

Communities of Opportunity Study Design

idea that communities themselves are best equipped to develop and implement solutions for their own risk factors, in collaboration with other local, community organizations and stakeholders. The researchers describe the criteria for Safe Community designation as: 1.

Infrastructure based on partnership and collaborations, governed by a crosssectional group responsible for safety promotion in the community;

Long-term sustainable programs covering genders and all ages, environments and situations;

Programs that target high-risk groups and environments and that promote safety for vulnerable groups;

Programs that document the frequency and cause of injuries;

Evaluation measures to assess programs, processes and effects of changes;

Ongoing participation in national and international Safe Communities networks.

The most important element of the Safe Communities initiative is community leadership. Through collaboration between the Big hART artist and creative team, a community development worker from the New South Wales Department of Housing, a crime prevention officer from the Surry Hills Police, and a volunteer tenant committee, tenant activities were organized to cultivate social support and community engagement, while reducing tenant isolation. A larger partnership called the Neighborhood Advisory Board included representatives from the Department of Housing, St. Vincent’s Mental Health, City of Sydney Council, Surry Hills Police, Department of Aging, Disability, and Home Care, Department of Community Services, Surry Hills Neighborhood Centre, Central Sydney Community Transport, Big hART, and Northcott tenants. Through this partnership, residents could report issues and concerns they felt regarding safety and well-being in their community in an open forum. As a result of these collaborations, approximately 30 different organizations, government departments, businesses, and individual people worked together to create opportunities for Northcott residents and to help residents identify and address their needs. This activity ultimately generated increased pride and confidence among the tenants. As a result of these collaborations and art-based programming and activities (including theater performances, portrait exhibitions, film screenings, etc.), violent crime and vandalism decreased significantly, leading to a community-level decrease in stigma associated with the Northcott Estate and public housing. Results suggest that collaborations focusing on social connectedness, relationships, agency (individual and community level), a functional physical environment, physical/emotional well-being, and a positive community image contributed to significant change in perceived and actual safety of the Northcott community. Coggan et al. (2008) found that a concept of safety that included individual and community ownership, leadership, empowerment, and capacity-building also facilitated the project’s success, not to mention the important role played by art-based programming in regenerating disadvantaged and deprived communities. Kilewer (2013) conducted a study to determine associations between residence in public or Section 8 housing, fear of crime, neighborhood collective efficacy, and caregiver coping suggestions. The study was conducted in low-income neighborhoods characterized by moderate to high levels of violence. Forty one percent of the participants were residents of public or Section 8 housing; the rest lived elsewhere within these neighborhoods. The researchers found that living in public or Section 8 housing was associated with significantly lower collective efficacy and greater fear of crime. Living in public or Section 8 housing was also associated with more suggestions to use aggression as a coping mechanism and fewer suggestions to seek support as a coping mechanism during violent neighborhood situations.

Chapter 3 Academic Literature Review

Kilewer’s (2013) findings corroborate past research that residents and caregivers who live in public or Section 8 housing report greater fear of crime and less collective efficacy. Howard, Kaljee, Rachuba, and Cross (2003) conducted qualitative research with predominantly African American public housing residents in Baltimore (parents of adolescents) to learn more about their views on violence prevention. Through focus group discussions with 38 parents from four public housing developments, the researchers learned that drug trafficking was the most prevalent concern, in addition to fear regarding accessibility of guns, chronic gunfire exposure, and publicly seeing dead bodies. The study found that parents were in a constant state of hypervigilance about the surrounding neighborhood and used various coping methods such as taking their kids away for the summer or bringing them to less dangerous neighborhoods, putting bars on windows, or leaving sticks or “weapons” by their doors to deal with their fear. Many of the parents discussed using their social networks and supports as coping methods for dealing with violence, but reported ambivalence around the effectiveness of “support agencies,” public housing staff, community police officers, and other resources. There was a lot of distrust and conflict among the parents with regard to the police in particular (Howard et al., 2003). A great deal of literature focuses on violence and safety at the neighborhood level, particularly with regard to area-level deprivation, social cohesion, and collective efficacy. Unfortunately, although many affordable housing communities are situated in violent, high crime neighborhoods, there is a lack of peer-reviewed studies of interventions to address such issues at the building level or within affordable housing settings. 6. RESILIENCE This review found very few studies addressing the concept of resilience, including disaster and emergency preparedness, in multi-unit affordable housing settings. The available literature discusses how individuals and communities respond to natural disasters and climate change. We reviewed interventions, programs, and services in affordable housing settings that aimed to prepare residents for emergencies and to encourage/cultivate resilience. We found 5 articles addressing resilience at the community and affordable housing level, including systematic reviews, concept papers, and observational studies. None of these articles included program evaluation in affordable housing settings. As described by Vale, Shamsuddin, Gray, and Bertumen (2014), the concept of resilience is imprecise, raising many questions about definition and intention. As applied to cities, the Massachusetts Institute of Technology (MIT) Resilient Cities Housing Initiative (RCHI) has developed criteria to facilitate measurement. One of the core elements is the lens of equity—a particularly important perspective given that low-income populations and communities are often the hardest hit by socioeconomic, political, and environmental disasters. Vale et al. invoke the concept of critical resilience--the willingness to seek ways to bounce forward, not merely bounce back. They make a distinction between resilient housing and housing for resilient cities. They define resilient housing as being specific to a building’s architectural design, tectonics, and structure; they define housing for resilient cities as being inclusive of the greater urban context. Applying the RCHI framework’s four criteria to affordable housing settings could be a basis for a variety of housing-based interventions to promote resilience. These criteria include: supporting residents’ social and economic livelihoods, reducing residents’ vulnerability to environmental threats, enhancing residents’ personal security, and empowering residents in shared governance. Hernández et al. (2018) suggest that resources at the community-level (including social capital, social support, economic development, and collective efficacy) are key factors 62

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in promoting pre- and post-disaster resilience. Further, the reduction of inequities related to these concepts, in combination with the facilitation of connections to organizations and trusted resources, may help to build community-level resilience to such disasters. Hernández et al. (2018) initiated the first-known qualitative study of the impact of a natural disaster, Hurricane Sandy, on high-rise, high-density, multi-unit public housing by examining the setting as a unique risk environment. Overall, the storm impacted 400 public housing buildings in 33 developments, affecting approximately 80,000 residents, making it the most powerful natural disaster to ever hit New York City public housing residents. The researchers used an original conceptual framework to contextualize the results of their study, known as the “resilience reserve.” This framework explains how socioeconomically, medically, geographically, and physically vulnerable populations use resilience to confront chronic hardships. Low resilience reserve leaves a population without sufficient capacity to take protective action in the face of acute adverse experiences, such as a natural disaster, resulting in “delayed recovery.” Many of the public housing residents affected by Hurricane Sandy lived in New York City Housing Association (NYCHA) buildings less than a mile from the coastline and therefore experienced flooding, outages of electricity, hot water, heat, and running water, damaged equipment, etc. as a result of the storm surge. Working with community and governmental partners, Hernandez et al. conducted 8 focus groups with 74 public housing residents in Far Rockaway, Coney Island, and Red Hook. Topics included: 1) experiences and impact of Sandy; 2) response/recovery efforts; 3) decisions about evacuation; 4) social communities within the buildings; 5) resident engagement pre- and post-storm; and 6) implications for future disaster preparedness. The researchers found that Sandy created a level of acute adversity informed by various pre-existing cumulative individual and community vulnerabilities, which limited residents’ responses and resilience, and delayed their recovery. They corroborated the findings from previous research showing that the ongoing socioeconomic conditions of people’s everyday lives impact their vulnerability to disasters. This study also found that while some research has looked at the larger concept of resilience to disaster, the everyday strengths that individuals use to deal with chronic stressors and hardships are often overlooked. The researchers created the concept of ‘resilience reserve’ to describe that inventory of potential capacity to confront unanticipated challenges, on which vulnerable populations often rely. Such a reserve may become depleted. The researchers contend that shifting interventions toward socioeconomic security by connecting people to larger resources such as community health/ mental health services, improved housing and education, and other pathways to encourage selfsufficiency, could alleviate this depletion, allowing populations to be better prepared for both daily and acute hardships. Public housing is a potential vehicle for enhancing resilience by empowering, informing, and engaging residents, improving social cohesion, creating better protocols for coordination among city agencies involved in emergency response/recovery, and conducting practice drills with attention to vulnerable residents’ needs. Hernández et al. (2018) suggest the following actions to increase institutional and building level resilience: 1) enhancement of human resources; 2) implementation of technological innovations; 3) investment in facility upgrades using weather-proof design; and 4) embracing sustainable practices that promote resident health and reduce operating costs and emissions. A study by Kraushar and Rosenberg (2015) also focuses on resilience, mitigation, and response to disasters in the context of Hurricane Sandy. Red Hook, Brooklyn, an area hit hard by Sandy, is home to one of the largest public housing developments in the borough. The study addresses the impact of

Chapter 3 Academic Literature Review

structural devastation on essential services (heat, water, electricity, internet, and phones), as well as access to ambulatory medical services (e.g., clinics, home health agencies, pharmacies, etc.). Two types of groups were organized to provide disaster relief: a community center and grassroots activist groups. The groups worked closely with other community groups and institutions, including small business owners, the NY Police Department, clergy, homeowners, and other community members, to create makeshift support and provide disaster relief to people isolated from necessary medical services. Through these efforts, volunteers created a strategy by which to identify, assess, manage, and monitor those individuals who were medically fragile and reliant on systems damaged by the storm, including access to EMS, reliable 911 service, home health aides, visiting nurses, regular hospital care, and oxygen. Using a knock and check strategy, over 100 volunteers deployed a survey to rapidly assess a person’s status, screening public housing residents twice because there was such a density of potentially vulnerable senior citizens, chronic disease, and infrastructure damage. Additionally, through word of mouth and intermittent internet and cell phone service, these volunteers were able to recruit a small cohort of medically-trained individuals who volunteered to help those in need. In total, 15 doctors, 5 nurses, 3 physician assistants, 3 paramedics, 3 medical students, 2 social workers, and 3 nursing students helped in the relief effort by using a spare room at a local community center as medical dispatch. During initial checks, volunteers found elderly, medically-fragile public housing residents huddled together in steam-filled units wearing winter jackets soaked in water condensation from water they had been boiling to stay warm. Using intake forms based on the rapid survey results, these medical volunteers triaged people as high- or low-priority and managed such data with oversight from a doctor. Supervised by a doctor, they made home visits to provide preventative care, calling in necessary prescriptions, monitoring patients, and mobilized more support when necessary. The main focus of their efforts was to reconnect people to necessary preexisting medical resources; however, due to the severe infrastructural damage, this was often not possible. In this case, the medical teams provided supplies and activated other medical services as necessary (e.g., emergency services). They monitored existing diseases, blood sugar, vital signs, and signs of worsening disease; additionally, they assessed availability of individual’s medications and other medical goods, phone access, and family support systems. Medical team records showed that the most prevalent, high-need conditions were respiratory disorders that required nebulizer treatment and/or supplemental oxygen, diabetes that required insulin, and hypertension/congestive heart disease requiring frequent treatment--all highly-susceptible to stressors in disaster contexts. Other increased risks during this disaster period included those related to pregnancy and mental health, such as emerging conditions (e.g., PTSD and depression) and exacerbation of existing chronic mental health disorders. New York City Housing Authority (NYCHA) residents made up 83% of the residents evaluated through the medical teams’ grassroots efforts. Most people received two or more visits, although some received as many as 10 visits. About 90% of individuals required monitoring of exacerbated disease or medical conditions, 34% required medication refills/delivery, and 31% need durable medical goods. A lack of heat and power were likely causes of exacerbated disease states and residents also mentioned concerns regarding food, water, and phone access. Such utilities were out for over a month and government agencies were generally unresponsive, so that displaced doctors, paramedics, and social workers continued to provide care and follow-up, particularly for extremely high-risk residents. Of note, public housing residents were forced to use a single stairwell to travel in the building and the other was used as a toilet since there were none functioning in the building. 64

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Overall, Sandy demonstrated the severe lack of comprehensive emergency plans and services in lowincome, urban communities, particularly for vulnerable individuals. What was needed (and unavailable) included a resiliency plan, on-going maintenance, a focus on preventative measures, lists of vulnerable residents, a medical reserve corps, and training for medical response efforts (Kraushar & Rosenberg, 2015). Red Hook was particularly vulnerable to the storm since it is a peninsula and is isolated from the rest of the borough. Schmeltz et al. (2013), much like Kraushar and Rosenberg (2015), found that social capital, strong social networks, and high social cohesion were key factors in the resiliency of this community following the hurricane. Despite the lack of a consistent definition of community resilience, Patel, Rogers, Amlôt, and Rubin (2017), have identified some core elements in the face of adversity, emergencies, and disaster. In a systematic review of 80 relevant articles discussing resilience, they identified 9 core elements of community resilience: 1) local knowledge; 2) community networks and relationships; 3) communication; 4) health; 5) governance and leadership; 6) resources; 7) economic investment; 8) preparedness; and 9) mental outlook. They found that long- and short-term disaster effects could be ameliorated if local communities have knowledge of pre-existing vulnerabilities. Some sub-categories of local knowledge include: factual knowledge, training and education, and collective efficacy and empowerment. Patel et al. also found that the level of social connectivity, cohesion, and capital in a community can create positive effects in the face of a crisis through building trust, shared values, and connectedness. Another important element of community resilience, is effective communication, including risk communication (pre- and post-disaster), and crisis communication during disaster and relief efforts. Physical and mental health and health service delivery are key to community resilience. The ability to address health vulnerabilities both pre- and post-disaster, particularly with regard to health service delivery, can mitigate long-term negative impacts. As noted by Hernández et al. (2018), Schmeltz et al. (2013), and Kraushar and Rosenberg (2015) in their studies of Hurricane Sandy’s impact in Brooklyn, Patel et al. (2017) cite governance and leadership as key to shaping communities’ ability to handle crises and disasters. Addressing the post-crisis economic situation is important to mitigate long-term disastrous effects by distributing financial resources, ensuring the cost-effectiveness of economic interventions and programming, and diversifying economic resources. Individual, government, family, and community-level preparedness are key to building resilience pre- and post-disaster. Specific activities, such as risk assessments, disaster preparedness and response plans, practice drills, and other mitigation strategies are critical. Finally, Patel et al. (2017) note that attitudes, feelings, and perceptions of uncertainty in the face of disaster can be important leverage points for building resilience and coping mechanisms such as adaptability and hope. While many researchers discuss similar resiliency strategies used by communities both pre- and post-disaster, there is a lack of consensus on the definition of a culture of resilience at the community level, let alone at the level of affordable housing (Patel et al., 2017). DISCUSSION This review of the academic literature on affordable housing-based programming yielded large numbers of studies with promising results and directions for future research. Several studies included in this review discuss programming involving the use of CHWs and HAs and other forms of resident leadership, both within the broader literature on affordable housing and in the literature on elderly affordable housing residents. There was also quite a bit of literature regarding other types of service provision within public and affordable housing, mainly focused on health and health care outcomes, with fewer studies addressing social determinants of health or health-related economic or educational

Chapter 3 Academic Literature Review

outcomes such as academic performance or employment. Additionally, the academic literature is lacking in evaluation of adult academic or skills-based education or vocational training programming, which future research could address. Despite the high prevalence of mental health disorders and substance use among affordable housing residents, our review of the literature identified few programs or interventions targeting these issues. Additionally, the focus of the literature seems to be on youth, African Americans, and alcohol use. Although several studies focus on smoking cessation, there are few studies targeting other types of substance use, including alcohol, opioids, marijuana, and/or other drugs. Overall, a major gap in the published academic literature concerns interventions that address mental health disorders and substance use among a broader group of affordable housing residents. A larger body of literature addresses the theme of social networks/supports/cohesion among affordable housing residents, although, again, the number of intervention studies is limited. Within the observational (non-intervention) literature, several studies have addressed associations between resident-informed, -engaged, and -led programming and measures of social networks/supports/ cohesion. Overall, there is evidence that resident engagement fosters increased social participation, with measurable impacts on social cohesion and perception of social support. Future research is needed to further explore how such engagement of residents in the implementation of programming and services impacts residents’ perceptions of social cohesion, social support, and social networks and which methods are the most successful. With respect to the theme of violence/safety, only one study included an intervention on violence and safety within affordable housing. However, much of the literature regarding mental health, substance use, social cohesion, and social networks discussed the relationship between these conditions/ outcomes and violence and safety. There is a vast amount of literature discussing the violence and safety of neighborhood communities, including interventions at the community level, but a lack of academic research regarding programming within the affordable housing setting. This is a major gap since many of these properties are situated within these violent, high crime neighborhoods. More studies are needed to determine how interventions within affordable housing impact violence and perception of safety, and how interventions within the wider community affect affordable housing residents. In light of some tensions between disadvantaged communities and police, it would be important to evaluate how interventions in the affordable housing setting might affect these community-level tensions. Resilience remains a largely unexplored area within the affordable housing literature. While the theme of resilience has been explored at the broader community level, particularly with respect to emergency and disaster preparedness and response, there is a notable gap within the context of affordable housing in general. There are also few studies that evaluate the impact of social cohesion on community, building-level, or resident-level resilience. While some work relates to the theme of resilience in the face of heat waves and power outages, few programs address the consequences of and response to other natural events, conflicts, and disasters. While several observational studies suggest that residence in senior or elderly affordable housing provides an opportunity for social cohesion and social support, intervention studies are lacking. Similarly, although mental health disorders, social isolation, and loneliness are commonly reported by elderly housing residents, only one intervention study addressed these issues in the affordable 66

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housing setting. The literature on aging in place, regardless of income-based housing, does discuss programming, services, and interventions targeting mental health, social isolation, and loneliness, with implications for elderly affordable housing residents. Future studies would need to adapt these interventions and test their efficacy within these different contexts and communities. The literature reviewed here typically has a singular focus on one health/health-related outcome or set of outcomes; few studies include multiple outcomes. There was also an over-representation of public housing. Future research could benefit from broader analysis and use of multi-faceted interventions that seek to improve multiple areas of health and well-being, acknowledging a broader set of pathways, barriers, and facilitators. For example, several studies have individually measured the impact of social cohesion, violence, and collective efficacy on mental health, but there is a lack of work addressing multiple elements. Other directions for evaluation could include how programming related to energy conservation and energy literacy could promote energy security (which we know is true in other settings from work by Hernández and others) and reduce residents’ personal costs and building-level operational costs; similarly, programming focused on water conservation could also offset operational costs. There is little information on how these offsets to operational and maintenance costs could be used to divert funding towards other additional programming for affordable housing residents. METHODOLOGICAL ISSUES Methodologically, there is wide variation in how studies are designed and implemented to assess the impact of programming within affordable housing. CBPR is clearly a common approach, as is the use of needs assessments to inform interventions. Importantly, many intervention studies do include a comparison group rather than only providing some residents with a potentially beneficial service. In some cases, after the study period and after the conclusion of data collection, researchers have offered services to all residents, regardless of groups, largely for ethical reasons. The academic literature does include some comprehensive research designs, but many programs evaluate program implementation only, rather than including rigorous measurement of well-defined outcomes. Again, different implementation strategies are rarely compared with each other for the purpose of measuring efficacy or uptake in different populations and settings. Furthermore, it would be useful to determine the degree of uptake under different conditions in the community. Many studies and articles mentioned previously in this review utilize a community-based participatory research approach and/or needs assessments to inform and implement programming in affordable housing settings. Community health workers (CHWs) and health advocates (HAs) are shown to be effective means for implementing housing-based programming. Importantly, the use of CBPR approaches and selecting CHWs and HAs from the local communities are important strategies to create more sustainable impacts on health and well-being. Furthermore, CHWs and HAs are most commonly used when programming is focused on chronic disease management or in smoking cessation programs. In addition, several studies do address resident leadership, engagement, and participation as methods for informing and/or implementing programming. In addition to using CBPR approaches and needs assessments, there are many other ways in which housing-based programming seeks to engage residents to lead and inform programming. This engagement and leadership takes several forms, either through focus groups, feedback on programming, or the use of intervention methodology such as photovoice.

Chapter 3 Academic Literature Review

Much of the program and evaluation work depends upon available grant funding, so that interventions are implemented for the length of the grant study period only. If successful, they may be sustained by other sources of funding, but this is not commonly reported. The result is that most interventions are time-limited; rarely do we see longitudinal or cohort study designs, and even less commonly long-term integration of results into public policy. To assess and categorize the programming and interventions summarized in this review, we came up with a set of evaluation criteria based on the included intervention studies. We propose that affordable housing programming be evaluated based on the following criteria and answered with three choices— yes, no, or partially. The evaluation criteria are as follows: 1.

Does the study have a comparison group?

Does the study use a pre/post design?

Does the programming have multiple components?

Does the programming consider the community and neighborhood context?

Does the programming consider the building context?

Is the analysis of the programming descriptive?

Is the programming analyzed using multivariate statistical tests? Meaning, is the programming evaluated using complex statistical analysis?

Is the programming resident-informed, does it utilize a CBPR approach, and/or does it utilize a needs assessment? Meaning, is there a level of resident engagement or co-creation?

A table of studies that discuss and evaluate programming and interventions in affordable housing can be found in the appendix. In this table, we utilize those eight criteria to evaluate such programming. ADMINISTRATIVE ISSUES Many of the articles reviewed in this paper discussed a variety of challenges and limitations in their implementation of various programming within affordable housing, though not all focused on administrative and logistical hurdles so much as they focused on study and design limitations. Many resident- and CHW- or HA-led programming encountered difficulty regarding funding such positions. Most of the time, these positions were funded through academic/research grants as a part of the study; it was rare that such leaders and intervention implementers were actually employed and paid through a housing development or authority as a full-time, permanent position because it raised issues of sustainability, trust, power, and promise-fulfillment. Additionally, much of this programming was implemented through pilot or one-off studies, meaning they were not planned for sustainability necessarily, perhaps due to funding, but also due to lack of evidence. Space was another issue mentioned in a few studies. Not all affordable housing settings have common space for programming and sometimes isolation and trust prevent congregation and or desire to participate in such programming or common spaces. Many of the interventions that used door-to-door or on-site recruitment methods faced major issues of trust; residents seemed fearful in many situations that the people recruiting them were representatives of the housing authority or management. Issues of low participation and safety concerns were also significant challenges, but studies that placed an emphasis on trust-building exercises prior to beginning a study, were more successful in this area, even though it was a time consuming and intentional process.

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It is clear from the review of the literature, that affordable housing programming impacts residents in several areas including their physical and mental health and well-being through a variety of different pathways and methods. Programming focused on singular issues and even those focused on a single issue using multiple intervention components, have had a positive impact, so it could be hypothesized that a combination of multidimensional programming focused on many outcomes could have a dose response effect on residents’ health and well-being. It is clear from results that impacts are greater when residents are engaged in, help inform, and lead programming that is centered on their needs and wants. Though there are many positives attributable to this “housing-plus” or “service-enriched” housing model, there are some drawbacks. The horizon for impact is much longer than a single evaluation, research study, or intervention can achieve. Programs and services that simply deal with a problem or support people through dealing with a problem rather than addressing the root cause of the problem will ultimately not make a great enough difference. This model of enhanced housing certainly cannot address root causes of socioeconomic disparities, racism, discrimination, and other systems of oppression on a large scale because that is bigger than a single institution such as housing can provide in an entire system of institutions and related problems. This model of enhanced housing does however have great potential to address some of the root causes of stress and poor health and well-being through skills development and other programming or services that invest in residents’ abilities, potential, power, and capacity for change.

CONCLUSION The academic, peer-reviewed literature on affordable housing programming was larger than originally anticipated. Programming covers a wide swath of themes and outcomes from chronic disease to well-being to other social determinants of health beyond housing itself. The elderly are a special category of interest and have a vast amount of literature dedicated to their experiences and programming related to their specific needs as the aging population in affordable housing continues to grow. CBPR methodology/principles and needs assessments are powerful tools used to implement and inform service delivery within the affordable context, often to support resident voices in order to offer more relevant and residentinformed programming. Resident leadership is another key method of program delivery, as are outside CHWs and HAs. Some of these most progressive interventions have been conducted outside the U.S. and/or with governmental (e.g., HUD) support. Several gaps in the academic literature are noticeable, particularly around mental health, substance use, social support/ networks, violence and safety, and resilience. While plenty of literature discusses and explores these topics, few, if any, evaluate programs or services intervening upon these issues, despite their high prevalence in affordable housing populations and communities. Future research should address the topics and perhaps look to more comprehensive/holistic interventions informed by residents’ voices to fully encapsulate a service-enriched or housingplus model beyond single, one-off interventions. Future research, including ours, could expand on how interventions focused on such categories of impact could result in improved resident outcomes, quality of life, and satisfaction.

Chapter 3 Academic Literature Review

Chapter 4 Gray Literature Review By using housing as a platform for interventions and programming, housing providers can address the range of challenges that affordable housing residents experience to improve health and its social determinants

INTRODUCTION Non-profit affordable housing providers have elevated their focus beyond the provision of safe and adequate housing by using more holistic approaches toward improving health and housing (Ladha & Thompson, 2014). By using housing as a platform for interventions and programming, housing providers can address the range of challenges that affordable housing residents experience to improve health and its social determinants (Ladha & Thompson, 2014). The concept of “service-enriched housing” originated as a way to describe integrating and coordinating services within affordable housing and low-income community settings (Tull & Cohen, 2013). The overall goal of such housinglinked services or service-enriched housing is “to help stabilize and support vulnerable families and individuals, while at the same time promoting the well-being and improved quality of life for all residents” (Partnering for Change, 2015). As a result, there is a rich history of health and social determinants of health programs and interventions that have emerged in the affordable housing setting, sometimes through community partnerships and/or through the use of resident coordinators. Historically, the difference between service-enriched housing and traditional affordable housing is the role of a services coordinator (Tull & Cohen, 2013). The term ‘services coordinator’ is often used to broadly describe services linked to low-income housing, also referred to as housing-based services coordination (Partnering for Change, 2015). Service-enriched housing further differentiates affordable rental housing that provides community, support, and services for all people from supportive housing and special needs housing specific to certain needs or risks (Beyond Shelter & Partnering for Change, 2011). As Ladha and Thompson (2014) contend, “affordable housing property managers are often cornerstones of their communities, working and collaborating alongside other high-demand service providers.” It is common for housing providers to recognize the structure of the community and to foster relationships with members of the community to efficiently implement these interventions, prioritizing residents’ well-being (Brennan et. al., 2017; Freeman et. al., 2018). Housing property managers, community partners, and housing providers have been instrumental in building a body of practice and evidence in this field, frequently outside of traditional academic and commercial dissemination channels (“grey” literature). This review explores service-enriched housing and housing-based services by providing examples of such programs, services, interventions, and community partnerships in the affordable housing setting. The format is similar to the academic, peer-reviewed review. We begin with the key components of affordable housing-based programming, namely the role of resident service coordinators and community partnerships. Next, we address health and healthcare programming and its various focuses including healthcare services, food, nutrition, and physical activity, mental health and trauma, followed by a discussion of the various economic and educational programs offered in affordable housing settings. We conclude by summarizing the types of community partnerships that occur in these settings. As in the academic literature, the grey literature details the experiences of service-enriched housing and housing-based services and programming. What follows is a review of this programming. We begin with the key components of housing-based programming, including the role of the resident service coordinators and community partnerships. We then discuss health and healthcare programming. Finally, we describe economic and educational programming within the affordable housing setting. RESIDENT SERVICE COORDINATORS Resident service coordinators (RSCs) play a unique and important role in affordable housing and housing-based interventions by linking residents’ needs with possible services offered (Stewards of 72

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Affordable Housing for the Future (SAHF), 2018b). RSCs act as a support system, engage residents in programs and services, ensure programs are established and well-coordinated, participate in housing decisions, and promote resident satisfaction (Freeman, McDaniel, & Despard, 2018; Nardone, Roan, & Trowbridge, 2013; SAHF, 2018a, 2018b; The Urban Institute, 2014). SAHF define RSCs as, “the staff person(s) responsible for the implementation of programs/services either directly or through partners at a property. This staff person may be hired through a property management company, but is not a property manager and has a distinct scope of work and hours dedicated to resident services coordination” (SAHF, 2018b). Evaluations have demonstrated that residents are much less likely to follow-up on meetings or deadlines for programming in the absence of a resident coordinator to reach out to them (Hood, McMiller, & Barkley, 2015). Based on interviews with residents in upgraded housing in New Orleans, Freeman et al. (2018) found that friendly staff and coordinators in their housing development enhance resident comfort. The residents also reported their appreciation for programs held by resident coordinators in their housing development, mentioning games, food, and entertainment at “Stop the Crime Night” as examples. Since resident service coordinators have firsthand experiences with residents, they are well-equipped to mediate interpersonal issues, act as advocates for resident needs, and understand gaps in care and services—a truly multidimensional process (Stewards of Affordable Housing for the Future (SAHF), 2018b).

Chapter 4 Gray Literature Review

COMMUNITY PARTNERSHIPS Community partners are vital to the world of housing-based health and social determinants of health programs and interventions. Community partnerships are based on combined service-provision between housing developments, community organizations, government entities, academic institutions, and increasingly, through public-private partnerships. This review found that successful housing-based programs collaborate with the surrounding community to ensure access to resources and services like schools, grocery stores, and job opportunities (Braveman, Dekker, Egerter, Sadegh-Nobari, & Pollack, 2011; Center for Promise, 2014; Ladha & Thompson, 2014; Maqbool, Viveiros, & Ault, 2015; Rumi, 2017). Successful community partnerships and housing-based programming embrace the concept that the community and surrounding neighborhood significantly impact resident health (Rumi, 2017). This section discusses strategies for developing new programs versus incorporating existing programs through community partnerships. We also explore the various ways in which community partnerships benefit housing developments, their residents, and the overall community, in addition to providing examples of these partnerships and programs. Ensuring that a community has proper resources and services is instrumental when developing programs within affordable housing (SAHF, 2018b). It is especially important to understand the context in which these programs are developed, because different communities have different needs (Ladha & Thompson, 2014; Nardone et al., 2013; SAHF, 2018b). It is also imperative to know what resources, programs, and services already exist within the community, so that new programs can strengthen their work, rather competing with or duplicating effort. SAHF (2018) emphasizes the importance of conducting community needs assessments in order to determine which resident

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services exist prior to implementing new programs. For example, it is possible that a community may not need assistance with healthy food access, but is lacking in job opportunities, so that resident programs focusing on building jobs and networks may be more effective in that specific community. Only after understanding community needs can program implementation successfully proceed, including designing interventions, establishing partnerships, securing services, and prioritizing needs (SAHF, 2018b). Financial constraints are another reason it is important to understand what services and resources are already exist in a community. Such constraints often make it difficult for housing programs to afford comprehensive interventions (Ladha & Thompson, 2014). If housing providers are able to incorporate existing neighborhood institutions, they are better able to ensure their financial sustainability and meet future community needs (Weinstein, BRIDGE Housing Corporation, & Harder + Company, 2018). Many resident services programs partner with existing organizations, such as the YMCA, to bring their services on-site, particularly when intervening with youth (Ladha & Thompson, 2014; The Urban Institute, 2014). Bringing existing programs and institutions into housing developments alleviates the burden of massive start-up financial and training costs. Beyond the financial benefits, community partnerships also help to establish lasting links between community members and organizations (Roan, Wood, Nardone, Fitzgerald, & Kelly, 2017). Healthcare institutions/community health programs are another key partner for housing-based programs (Nardone et al., 2013). Programs and services provided through community partnerships with healthcare institutions include direct provision of healthcare within housing complexes, health fairs and community events, health education programs, health-monitoring services, and nutrition and exercise programs. Healthcare and Healthcare-Related Services and Interventions As is the case in the academic literature, the grey literature describes many types of health and healthcare programming in affordable housing settings. In this section, we discuss the various types of health and healthcare programming available to affordable housing residents, including healthcare services provision and intervention, nutrition, food, and physical activity programming, mental health and trauma-informed programming. Stewards of Affordable Housing for the Future (SAHF), an affordable housing syndicate, provides a directory of healthcare-related support services, the type and intensity of which are affected by staff resources, the availability of community partners willing to participate, special funding or grants for services, and residents’ needs and demands (Nardone et al., 2013). For this reason, there is no one set of core common services in affordable housing settings. SAHF contends that a common directory of core services would be useful when trying to engage healthcare partnerships. Often, such programs and services are the result of individual collaborations with local community partners and are funded as special projects through time-limited funding streams. SAHF states that stable and secure ongoing funding is necessary to establish long-term, continuous, and consistent service provision. Nardone et al. (2013) provide a list of services common to all SAHF members: assistance with accessing healthcare benefits, assistance with accessing healthcare services, coordination of activities of daily living, monitoring and assessing community services, care coordination, health education programming, health fairs and community events, onsite screenings, assessments and services (provided by the program or through a community partner), nutrition and exercise, and personal care and attendant care services.

Chapter 4 Gray Literature Review

Most SAHF members implement services with coordination by Resident Service Coordinators (RSCs), who implement a wide array of programming. RSCs have first-hand knowledge of local resources to which they connect residents, are seen by residents as trusted resources, have the capacity to engage residents, and often have backgrounds in social work/human services. Although most SAHF members track their service and program provision in databases, Nardone et al. (2013) found that staff compliance with the maintenance of up-to-date records and data repositories was lacking. The authors contend that SAHF member organizations should provide services and outcomes measures that align with the standard, and emerging, outcome measures used by healthcare payers, based on the three overall Center for Medicaid Services (CMS) healthcare outcome goals/criteria: 1) Improve the Health of Populations; 2) Improve the Patient Experience of Care; and 3) Reduce or Control Costs. Measurement of such outcomes could be conducted using the Healthcare Effectiveness Data and Information Set (HEDIS®), the Consumer Assessment of Healthcare Providers and Systems (CAHPS®), the Star Ratings program for Medicare Advantage Plans, the Medical Loss Ratio (MLR) and Administrative Loss Ratio (ALR), hospital re-admission penalties, and enrollment churn rates. The authors identified six areas on which SAHF member organizations should focus for high-value service provision, that align with current service provision by these organizations and current outcomes measured by healthcare plans. These high-value service areas include: 1) maintaining health coverage; 2) care coordination and navigation; 3) health education/risk reduction/outreach; 4) care transitions support; 5) healthcare services onsite; and 6) access to stable, affordable housing. Nardone et al. (2013) also classify the level of service provision which may vary from property to property into three levels: (1) low intensity properties (have no staff members dedicated to services, might be managed by a single property manager/leasing agent, interventions might be limited to existing interactions with residents, interventions might include informing residents about external resources/services); (2) medium intensity properties (have staff such as a RSC dedicated to resident services who coordinate programming across areas including health and wellness [activities might include one-to-one discussions with RSCs about healthcare needs, facilitated connections to and follow-up on referrals to external resources, organized healthcare programs onsite targeted to resident needs (e.g., walking clubs, support groups, nutrition classes, etc.); (3) high intensity properties (have dedicated staff who provide health and related support services and service coordination, case management staff help residents access healthcare services, healthcare professionals might be employed by the housing provider/a community partner to provide onsite direct healthcare provision [activities might include interdisciplinary care teams made up of housing staff, availability of on-site clinical services staff, direct skilled services provision (e.g., home health care and attendant care), aging in place]). This classification is useful for: (a) identifying the many types of health and health-related programming offered in affordable housing settings; (b) providing a ranking of intensity; and, (c) providing a metric for potentially comparing the effectiveness of the services. A report published by Enterprise Community Partners and the Center for Outcomes Research and Education (CORE) in 2016 outlines the importance of incorporating healthcare services directly into housing to promote health (Wright et al., 2016). In this report, the authors evaluated the efficacy and potential cost-savings of interventions that pair healthcare and affordable housing using national health and healthcare reform metrics including: “better connection to primary care, fewer emergency department (ED) visits, improved access to and quality of care, and lower costs”. They used Medicaid claims data and survey data to measure changes in healthcare use and cost post moving into affordable housing and to measure healthcare quality and access, respectively. The study focused on 76

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three different types of affordable housing: family housing (FAM), housing for seniors and people living with disabilities (SPD), and permanent supportive housing (PSH) for people covered by Medicaid who moved into one of 145 of these affordable housing properties in and around Portland, Oregon. The researchers used a retrospective, descriptive, pre-post, longitudinal cohort study design to address two key study objectives regarding the impact of affordable housing and health services on health- and healthcare-related outcomes: (1) to assess the impact of affordable housing on health care outcomes among low-income people who have experienced housing instability; and (2) to assess the role that discrete integrated services play in driving changes in health care expenditures and quality outcomes. Wright et al. (2016) conducted several kinds of statistical analyses including: paired t-tests to describe and compare healthcare utilization and expenditures pre- and post-move-in; difference-indifferences analyses to assess whether the pre/post change seen among clients in properties that offer a given service is different from the pre/post change seen among clients in properties without that service; and outcomes modeling using multivariate regression models to assess the effect of affordable housing and integrated services while controlling for the influence of other variables (e.g., race, gender, age, etc.). Additionally, they used a property-assessment tool, completed by RSCs or other staff, to describe the availability of services staff and services across the participating housing properties. Types of available staff on-site included: RSCs; activities coordinators; community health workers (CHWs) or health navigators; doctors, nurses, or nurse practitioners; social workers; and other health professionals. They categorized the focus of available services as: food resources; medical resources; mental and behavioral health; insurance assistance; nutrition and cooking; fitness; transportation; dental resources; and other. Key study findings are as follows:

Chapter 4 Gray Literature Review

Healthcare systems’ costs decreased by 12% or $936,000 the year after people moved into affordable housing when compared to the year prior (though this was only significant for PSH and SPD residents). •

Implication: Having access to affordable housing likely will decrease costs to the healthcare system

After move-in, primary care visits increased by 20% and ED visits decreased by 18% compared to the year prior. •

Implication: Major health and healthcare reform metrics can be met with the help of affordable housing

After move-in, 40% of residents reported improved access to and quality of care despite reduced expenditures, though mental health and dental health continued to be unmet needs. •

Implication: The differences in healthcare expenditures and utilization between preand post-move-in did not come at the expense of healthcare access or quality

The presence of integrated health services and staff was a key driver of improved healthcare outcomes (e.g., reduced healthcare expenditures and ED use), but this association did not hold for integrated social/wellness services. Additionally, the greater a resident’s health needs upon move-in, the stronger the effect of affordable housing on their health. •

Implication: Increasing the use of integrated health services could result in even greater cost differences than were found in this study

Notably, this study did not use a comparison group of similar low-income people, precluding causal assertions. Despite this limitation, the study provides promising evidence that the combination of affordable housing and integrated health and healthcare services may help to optimize the type of healthcare utilization and effectively lower healthcare costs. PHYSICAL ACTIVITY, NUTRITION, AND HEALTHY EATING Physical activity, nutrition, and healthy eating are key targets of health programs, services, and interventions in the affordable housing context. Some housing providers have promoted walking and biking because they are reliable modes of transportation with significant health benefits for communities. These modes of transportation provide a great form of exercise, are emission free, and can be incorporated into the built environment through various interventions (Urban Land Institute (ULI), 2015). Efforts to prioritize walkability can reduce the amount of land for parking and therefore can minimize pedestrian exposure to active driveways and parking lots. In fact, housingbased interventions that prioritize walking and biking encourage residents to engage in more physical activities, positively influencing resident health. The University of California at Davis (UC Davis) West Village neighborhood housing complex was designed to be the largest zero-net-energy community within the United States. There are numerous parks, paths, and gardens within the area surrounding UC Davis West Village that UC faculty, staff, students, and West Village residents are encouraged to, and do, utilize to increase their walking and physical exercise. The goal of this intervention in West Village was to decrease residents’ reliance on cars by consolidating parking along the eastern edge of the development so that pedestrian and bike paths take priority. To encourage residents to rely on walking and biking as their dominant form of transportation, UC Davis West Village developed a neighborhood bike train, bike parking, and bike repair facilities to further encourage UC faculty, staff, students, and West Village residents to utilize these services instead of single occupancy vehicles as their dominant mode of transportation.

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Interactive internal staircases, such as those implemented by Mariposa, an affordable housing project that was redeveloped by the Denver Housing Authority (DHA) in Colorado, is another example of an innovative way to engage housing residents with the built environment and encourage them to make healthy choices. The DHA was determined to prioritize physical activity, so they designed this interactive internal staircase so that residents would feel more comfortable moving through and taking the stairs. They also redeveloped the Mariposa so that the thoughtful design would encourage physical activity through active transportation options, such as a bike-sharing program, and through supportive classes. Other housing-based programs focus on issues such as nutrition and healthy food access by partnering with local community groups and resources. To combat barriers to healthy food access often experienced by those with low socioeconomic status, many affordable housing providers have connected with community institutions to create programs, such as Mercy Housing’s Cultivating Healthy Communities program, that focus on teaching nutrition and healthy cooking classes and to provide access to healthy foods thereby reducing food insecurity (Ladha & Thompson, 2014; Roan et al., 2017). The focus on food insecurity and providing opportunity for access to healthy foods is integral to the success of these programs. Without access to these foods, residents would be unable to put the educational components of the program into practice and no behavioral changes would occur (Roan et al., 2017). Another program run by Mercy Housing involving nutrition education and food security focuses on wellness and community strength by providing other opportunities for healthier lifestyles, including partnering with local churches and schools to encourage exercise by combining resources and improving outreach (Nardone et al., 2013; Roan et al., 2017). Community gardens provide

Chapter 4 Gray Literature Review

an additional platform utilizing the built environment to influence resident health through housingbased interventions (ULI, 2015). Community gardens are described as shared plots of land utilized by a collective group of people typically exclusive to residents who live in a particular housing area. In recent years, community gardens have become popular places for communal activities. In these collaborative community gardens, residents of all ages have an opportunity to work within the space to grow fresh produce, learn healthy eating habits, increase their outside activity, and enjoy the green space with their fellow residents. One food-based program, Banana Kelly Gardens, in East Harlem, NY, aims to address the root causes of food inequity through collaborative programs that focus on empowering residents with tools and knowledge (ULI, 2015). Banana Kelly Gardens, once a simple resident gardening project, grew into an urban agriculture share program and community garden in the backyard of the Banana Kelly affordable housing development. In this program, volunteers teach new housing residents gardening skills and also conduct culinary and nutrition workshops using the produce grown in the garden. In addition to providing healthy food and cooking skills, other support services such as health screenings and health care enrollment are available to participants and residents through the program. Via Verde in New York City’s South Bronx neighborhood, is another community garden program that provides garden amenities and facilities located throughout the housing development. Via Verde’s amenities include a courtyard garden at ground level, a fruit tree orchard, a fitness garden, and a community garden located on the fifth floor of the building. A local non-profit organization, GrowNYC, helps manage the Via Verde community garden with help from Via Verde residents (ULI, 2015). GrowNYC also provides access to organic heirloom herbs, vegetables, and edible flowers. Residents at Via Verde, much like at Banana Kelly, can participate in food nutrition programs and workshops to learn how to prepare the fresh produce they have access to and other food. Mental Health and Trauma Informed Community Building Mental health is another critical issue affecting affordable housing residents that is included in the grey literature. In this section, we review the various programs and services offered to affordable housing residents to address mental and behavioral health issues. In a series of profiles, Wood (n.d.) describes strategies to support the mental and behavioral health of residents at SAHF properties. Wood discusses the various factors that influence mental and behavioral health among affordable housing residents. For some, there is no access to emotional/social safety nets and no family nearby. Seniors may suffer from social isolation, while children and families may be experiencing exposure to trauma and toxic stress from community and domestic violence, food insecurity, housing instability, racism, and discrimination. Based on the results of a resident survey demonstrating the serious stressors faced by children and youth, Mercy Housing formed a partnership with an elementary school and an on-site mental health navigator to expand the capacity of the property to address the needs of children/youth and their families and connect them to mental health services. Mercy Housing also implemented the Parent Teacher Home Visit Project in which teachers, accompanied by the mental health navigator, informed parents about mental health programming available at the community center, thereby helping to destigmatize care (Wood, n.d.). Weinstein, BRIDGE Housing Corporation, and Harder+Company (2018) created a report outlining the Trauma Informed Community Building (TICB) model. This model “was developed as a holistic approach to community engagement that recognizes the impacts of community trauma on residents’ lives because it hampers participation in traditional community building and limits the impacts of broader 80

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community development efforts. The TICB model is proactive and assumes that communities require a set of common experiences and conditions to participate fully in community building and benefit from sustained community development (Weinstein et al., 2018). The TICB model uses strategies that help to de-escalate chaos and stress, build social cohesion, and foster community resiliency to support a community’s long-term health and well-being. Many low-income communities and residents of affordable housing are subject to pervasive community trauma as a result of structural and historic racism, isolation, exclusion, and the current chronic, daily stressors and trauma of exposure to community violence and concentrated poverty. The TICB model has four key principles that guide all TICB programs, activities, and strategies: 1) do no harm; 2) acceptance; 3) community empowerment; and 4) reflective process (Weinstein et al., 2018). ‘Do no harm’ means the programming is guided by awareness of past and current trauma such that it avoids re-traumatizing people (Weinstein et al., 2018). ‘Acceptance’ contends that programming meets residents where they are by accepting their realities and setting appropriate expectations. ‘Community empowerment recognizes the importance of participants’ self-determination. Finally, ‘reflective process’ engages an ongoing reflective practice such that it responds to changes and knowledge by adjusting to meet community needs and a community’s vision. These principles guide TICB’s intentional strategies: 1) individual strategies; 2) interpersonal strategies; 3) community strategies; and 4) systemic and institutional strategies. Individual activities should provide an antidote to the daily stresses of poverty that often overwhelm residents in trauma impacted communities that should be scheduled consistently, encourage and maintain participation, provide residents with some sense of reward, allow them to meet goals, be open and inclusive, and transparent with clear expectations. Interpersonal strategies should help build interpersonal relationships, create communication, build social cohesion, and increase/create social supports through activities that are low-intensity opportunities during which interpersonal interactions, relationship development, and mutual sharing can occur. Interpersonal strategies should provide residents with a sense of pride, shared experience, connectedness, and interdependence through social interactions that they can lean on to combat everyday personal traumas and triggers. Community strategies encourage the creation of community-level norms by addressing community trauma through culturally competent, consistent, and regular communication that builds inclusivity, awareness, and community. Community strategies should help cultivate community-level ownership and infrastructure for sustainability and implement both formal and informal activities that encourage leadership, skill building, and recognition across socioeconomic levels and racial groups to provide opportunities to create new, shared community norms. Finally, systemic and institutional strategies build on community strategies and capacity to create sustained community development through “the incubation and promotion of a backbone entity to manage and guide all community building and community development efforts towards a long-term vision in which residents are at the center.” This backbone should help to build strategic partnerships, ensure coordination between programs and partners, be trauma-informed, and capable/accountable for meeting community needs (Weinstein et al., 2018). Economic and Educational Programming In this section, we provide examples of economic and educational programming within the affordable housing setting. We explore the various financial education, capability, and empowerment programs, in addition to educational and academic programming. Economic programming covers issues including

Chapter 4 Gray Literature Review

empowerment, eviction prevention, employment, and budgeting. Educational programming focuses on children’s academic and developmental outcomes. Financial Education, Capability, and Empowerment Programming Many affordable housing programs recognize residents’ need for financial health including and beyond financial education, on which resident services have long focused (Ladha & Thompson, 2014). Financial empowerment programs and services have been incorporated into housing to improve the financial well-being of residents, often by focusing on long-term financial stability, as opposed to short- term support. Such programs include teaching day-to-day budgeting to secure a functioning financial system, financial resilience or the ability to withstand potential financial setbacks, and the ability to take part in opportunities that can lead to financial mobility. Some housing providers also offer financial products such as loans, rental assistance, and matched saving programs to their residents. The authors contend that establishing and maintaining financial health (as necessary as physical health) requires individual persistence, a supportive economic environment, availability of robust social services, and access to high-quality financial products and services. The authors outline the three core elements of financial health: (1) well-functioning financial life on a daily basis; (2) resilience as a tool for handling the positive and negative aspects of life; and (3) the capacity to take advantage of opportunities for financial mobility. In 2014, The Stewards of Affordable Housing for the Future (SAHF) published a report with the Center for Financial Services Innovation (CFSI) about using housing as a platform for improving people’s financial capability by outlining programming that enables residents to save for the future by improving

Communities of Opportunity Study Design

consumer financial health. Additionally, Ladha and Thompson (2014) highlight evidence that there has been a significant shift away from financial education/literacy programs toward client-/residentcentric financial behavioral change programming. In CFSI’s scan of the literature on financial education, interviews with practitioners and stakeholders, and exploration of interventions, they found that the most effective financial health interventions aim to be relevant, timely, actionable, and ongoing. Relevant interventions aim to address program participants’ specific financial situations and concerns. Timely interventions aim to coincide with participants’ key life events or decisions to provide feedback immediately. Actionable interventions enable participants to put new knowledge to use immediately to improve their financial situation. Finally, ongoing interventions promote long-term relationship with participants that provide support, instill accountability, and track progress. Ladha and Thompson (2014) identified several strategies for improving affordable housing residents’ financial health and capability. One strategy is leveraging teachable moments as opportunities for education and behavioral change. This often occurs in conjunction with key life events and financial decisions such as receiving a first paycheck, making a rent payment, resident eligibility recertification, and tax season. The researchers contend that to capitalize on such key teachable moments, residents and affordable housing organizations need on-going access to financial advice and information. Forming partnerships is another key strategy suggested for improving residents’ financial health. Either as single service offerings or in combination, the authors discuss the importance of embedding financial capability services within other affordable housing services and programming, referring residents to outside services, and/ or forming partnerships with outsides services at the local, regional, or national level to expand their services to residents. By forming partnerships with existing services, housing providers are able to prioritize their capacity to deal with other operational, maintenance, and/or physical security challenges their residents face. Co-location of these services within housing enables partners to set up “micro branches” within the housing complexes, allowing residents to connect with these services directly on site, thereby reducing attrition and increasing capacity. Finally, Ladha and Thompson (2014) outline the importance of providing generationally- and culturallyappropriate financial services and using technology to scale program provision. They also discuss other financial funding models that do not fit within the resident financial health and capability framework, but are nonetheless important and gaining traction. These include the use of Social Impact Bonds and Pay-for-Success models. Pay-for- Success quantifies the amount of public money saved by implementing a specific social intervention with the use of private capital; if the program is successful at achieving pre-determined outcomes, government funding will pay the original private funders with a return on their investment using the money saved by the intervention. SAHF contends that long-term financial planning promotes future housing ownership, housing stability, improved wellness, and empowerment, because research has shown that budget management is the key to preventing loss of housing. The SAHF strategy employs programs such as on-site financial education and a system of off-site referral if needed. They also provide financial assistance through loans and matching savings programs. The authors found that even without an increased income, financial health programs in-residence lead to better financial health through promotion of healthier financial behaviors. Since 2014, programs within the SAHF framework have evolved to promote financial stability for entire communities, showing that the health of a neighborhood or community is closely linked to the health of residents in a specific complex (The Democracy Collaborative, 2013). The Cleveland Model, created

Chapter 4 Gray Literature Review

by Community-Wealth, is a great example of financial empowerment programs that have evolved from short-term financial assistance programs to foster systems-level, community-oriented financial stability. The Cleveland Model aids struggling communities via worker-ownership such that anchor institutions (stable economic powerhouses of the community) invest in local businesses to grow community wealth. Workers also own businesses, much like a co-operative model, promoting job and financial security (The Democracy Collaborative, 2013). Another example of services aimed at financial well-being and management is eviction prevention programs (EPP). Eviction is not only bad for residents, but also for property owners, managers, and affordable housing providers. Non-profit affordable housing providers realize that the economic issue is about more than the money; rather, it addresses the underlying challenges that drive nonpayment of rent to begin with, often through resident services (Hood, McMiller, and Barkley, 2015). EPPs are effective at supporting residents’ needs, as evidenced by Enterprise Community Partners’ and Mercy Housing’s 2007 study, and Community Housing Partners’ and NeighborWorks America’s 2008 study about property performance and resident services (Hood et al., 2015). EPPs are enriched housing services that directly benefit residents most at risk for losing their housing by identifying them and averting evictions through targeted interventions, thereby increasing housing stability and income. EPPs also benefit housing providers by stabilizing the inflow of rent and reducing costs associated with eviction, vacancy losses, and debts. Residents are identified when they violate a lease, often through rent nonpayment, and are then referred to the EPP. Although there are several different ways in which EPPs are run and services provided, they generally include similar services, such as payment plans; financial capability services; and community services referrals (Hood et al., 2015). In consultation with Community Properties of Ohio (CPO), NeighborWorks America conducted a best-practice review of six affordable housing organizations with EPPs to describe current EPP best practices, the metrics used to manage EPPs’ success, conditions under which EPPs are advantageous, how EPPs align with financial capability standards, and the training needs related to EPPs. The affordable housing organizations involved in the evaluation were Community Housing Partners (CHP), Community Housing Works (CHW), Community Properties of Ohio (CPO), Mercy Housing (MH), REACH Community Development (REACH), and Urban Edge (UE). NeighborWorks America identified the organizations, and CPO conducted the telephone interviews with at least one resident services representative and at least one property management representative at each site. Other data collected from each organization included EPP forms, protocols, procedures, and policies (Hood et al., 2015). Hood et al. (2015) found that the organizations offered EPP at varying levels of capacity, often attributed to their resident services staff capacity and the characteristics of the resident population. Three of the organizations offered a varied level of EPP services: REACH, MH, and CHP. All REACH properties had EPP except a single residential care facility; MH implemented EPP at supportive housing properties via case managers and at other sites with resident services; and CHP provided some basic EPP at all properties, but higher-level EPP at eight of their properties. All but one of the organizations used a resident services staff member, typically as Resident Services Coordinator (RSC) with many duties, to implement EPP; the other organization had a staff person who was solely dedicated to EPP services. Additionally, a few of the organizations used specialized teams of financial coaches or adult asset coordinators, who provide a deeper level of services. All six organizations emphasized the importance of team-wide participation and communication between staff from property management, resident services, maintenance, and other teams via written protocols, meeting agendas, referral 84

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forms, written resident action plans, automated data sharing tools, and other web-based management tools, to coordinate and deliver effective and efficient EPPs. The housing provider organizations also emphasized the importance of delineating roles and responsibilities among staff and making that clear to residents. All the organizations have a standard protocol to refer residents to their EPP, but their implementation and engagement policies were often organization specific and unique to individual sites. For example, sites that had capacity and resident services staff at every site, would follow up after first notices, but sites without resident services staff had very low resident participation in EPP services. Hood et al. (2015) summarized all the organizations’ standard protocols for EPP intervention into seven steps: 1.

Clarify the lease compliance issue with resident and help them understand which behaviors contributed to receiving a notice of lease incompliance

Identify options for the resident to access emergency assistance funds for issues with rent nonpayment and facilitate the appropriate referrals

Provide resident with access to services for basic budgeting and money management (sometimes this step is referred out to other providers at sites with less capacity)

Screen the resident for benefits (e.g., Supplemental Nutrition Assistance Program (SNAP), WIC (Women, Infants, Children), utility and/or energy assistance, childcare assistance (as relevant), and/or cash assistance)

Propose payment plans to the resident with the guidance of property management staff

Assess other relevant life issues (sometimes via a structured assessment)

Refer the resident to other relevant resources (e.g., employment services)

In addition to these core financial capability services, 75% of housing organizations provide referrals to outside professional financial planners for tax preparation, among other services. Other financial capability programs included employment services, such as job coaching and training, connections to local employment agencies, information on how to get a GED, and linkages to community colleges (Hood et al., 2015). Hood et al. (2015) also found that organizations are making the effort to strengthen their ability to track data and metrics regarding the impact and outcomes of their EPPs. Some organizations have outlined short- and medium-term outcomes they hope to achieve, but few have measured long-term outcomes of EPPs, and the availability of real-time data was limited. For example, many of the organizations track evictions prevented as the number of residents issued eviction notices who were not evicted as a result of that notice, but the measurement is vague and there is no tracking formula. Others measure the number of households referred to EPP that remained stable through the end of the intervention. Despite reporting that they track various EPP-related outcomes, these data were not readily available. In evaluating these metrics, Hood et al. (2015) compared the success of various EPPs, and identified one EPP cost-saving formula for potential future use by other housing programs, saving about $38 dollars per unit per year. EPP outcomes differ based on housing type, number of properties, and the depth of the services offered (Hood et al., 2015). This review found that the most successful EPPs have clearly defined roles and duties for residents and property managers, on-going close communication between program teams and residents, and a standard protocol for timely referrals to the program. After evaluating these EPPs at six affordable housing organizations, Hood et al. (2015) outlined several opportunities for improvement by honing EPPs so that they are can be more easily compared across organizations in future evaluations. Recommendations include: standard definition of EPP; additional study of

Chapter 4 Gray Literature Review

funding; additional scaling of programming; use of a common set of metrics for analyzing data; and availability of such data across affordable housing organizations to better understand the benefits (Hood et al., 2015). Another way in which public and affordable housing providers help residents secure stronger financial futures is through career assistance and development programming for adult residents. Riccio (2010) contends these programs came about in response to a high rate of joblessness in the 1990s in communities that were already economically deprived. These programs aimed not only to assist adult residents with finding jobs, but also to increase their income and housing stability. An example is the Jobs-Plus program, an intervention operating in public housing developments from 1998 to 2003. This program aimed to assist residents with long-term job security, increased earnings, and use of housing as a platform to support job-seeking activities. The Jobs-Plus program centered around three main elements: employment-related services, financial incentives, and community support for employment (Riccio, 2010). The employment-related services included on-site job centers, referral and education programs, job search assistance, and support services for the families of those looking for jobs (e.g., child care and transportation assistance). The financial incentives segment included switching residents from paying 30% of their income for rent to flat rent, thereby incentivizing residents to increase their earnings without being penalized with increasing rent costs. Lastly, community support for work aimed to strengthen relationships between neighbors, and increase social capital by encouraging residents to share job opportunities.

Communities of Opportunity Study Design

A 2005 report comparing the outcomes from the Jobs-Plus program with outcomes of residents from non-program housing developments found that, across all six sites, residents’ average earnings from the program increased by 6%, although this varied site by site because the program was not always fully implemented (Riccio, 2010). The sites where the Jobs-Plus program was fully and sustainably implemented were Dayton, Los Angeles, and St. Paul. These sites had a combined increase in earnings of 14% compared to non-program sites. Additionally, the impact of the program steadily increased over the study period and by the final year of the program, earnings increased by 20%. These sites also had increased quarterly employment rates, although these increases were smaller and more inconsistent than earnings increases. Riccio (2010) found evidence suggesting that the rent incentives aspect of the Jobs-Plus program was an important explanation for overall earnings increases because sites that did not fully implement rent incentives (but had other program elements) did not experience any increase in earnings. Additionally, they found that implementing the full range of program elements was key to better outcomes. Longer-term analyses demonstrate that the program effects were long-lasting, sustained, and large; in the year after the program, there was a 19% increase in earnings compared to non-program sites and there was a 16% increase during the entire follow-up period (seven years). Despite the variation in quarterly employment rates, the impacts of Jobs-Plus on employment across some subgroups was statistically significant, including for Hispanic men in LA and Southeast Asian women in St. Paul. Both groups experienced average quarterly employment rates that were 11% higher than their comparison site counterparts. Riccio (2010) concludes that the affordable housing setting, in conjunction with institutional partners, offers an effective venue for increasing low-income resident earnings. When the Jobs-Plus program is properly implemented, Riccio (2010) contends that it offers a feasible and effective way for the nation’s public housing system to take on another important role: serving as a platform for work. Educational and Academic Programming Many affordable housing developments provide educational and academic performance programs and interventions for children residing in their buildings. To support the healthy academic development of children in affordable housing properties, some housing providers have implemented afterschool programs (Brennan, 2007; East Lake - A Model for Successful Community Revitalization, 2007; Rumi, 2017; Stewards of Affordable Housing for the Future (SAHF), 2018a). Mercy Housing, a national affordable housing organization, implemented a housing-based program aimed at improving academic achievement, AfterSchool KidzLit™, within their Out of School Time program in selected Mercy Housing properties in California (Mercy Housing, 2015). Children from families with extremely low incomes were eligible. The program provided children ages 5 to 16 with homework support and tutoring, opportunities for community service, cultural enrichment such as field trips to museums, and on-site educational programs on health, nutrition, and other important health-related topics. In their pilot test of AfterSchool KidzLit™, Mercy Housing used a pretest-posttest nonequivalent group evaluation design to assess the impact of the AfterSchool KidzLit™ curricula on educational habits and behaviors, as compared to their regular Out of School Time programming. Eleven KidzLit™ building sites and 11 comparison building sites for a total of 250 children participated in program. Using a 13-item assessment on a three-point Likert scale (“very little enjoyment or skill” to “high levels of enjoyment or skill”), they created composite scores to evaluate program effects. The KidzLit™ intervention group (109 participants) completed both pre- and post-test assessments on 12 out of 13 questions on the assessment. The intervention group mean composite change scores over time were statistically significant. Additionally, a greater percentage of children in the KidzLit™ group experienced positive improvement over time compared to the Out of School Time group. The KidzLit™ group also

Chapter 4 Gray Literature Review

experienced more positive change in composite scores over time when compared to the Out of School Time group (Mercy Housing, 2015). Overall, there was an increase in children’s confidence in reading, writing, and listening skills, which were most improved in the youngest age group targeting children 5-7 years of age, but positive outcomes were seen in all age groups (Mercy Housing, 2015). AHC Inc., an affordable housing provider in the Washington, D.C., Virginia, Maryland metro area, works with NeighborWorks America to implement age-appropriate student programs that support the needs of elementary through high school students (AHC Inc. & NeighborWorks America, 2018). AHC aims to provide an environment for growth and academic achievement. For elementary school students, this happens through after-school programs using a multi-pronged approach including reading and literacy support, and educational and cultural activities. Through their programming, 90% of students showed reading level improvement of at least one grade. For middle and high school students, AHC interventions aim to maximize student options for the future through tutoring, college visits, SAT prep, and additional enrichment experiences (AHC Inc. & NeighborWorks America, 2018). Nearly all participants in the teen tutoring program continue their education to college. Based on these results, AHC created a college and career readiness program matching students with adult mentors for a full year, and providing these participants with college preparation assistance. AHC also runs a summer camp that aims to prevent summer learning loss through educational and cultural enrichment experiences. As a result of this program, 94% of program participants maintained their reading level when school started again at the end of the summer (AHC Inc. & NeighborWorks America, 2018). Connecting with the local school system is another way in which housing developments can collaborate with surrounding community organizations and systems to address the needs of youth in particular (Abravanel, Smith, & Cove, 2006). The East Lake Foundation targeted youth residing in a large public housing community (East Lake) to address their needs (Center for Promise, 2014). East Lake used the Community Comprehensive Initiative (CCI) model to improve the extremely low educational outcomes, to bring down the high poverty rates, to reduce unemployment and crime rates, and to redress poorly maintained housing (Center for Promise, 2014). CCI is a collaborative approach across institutions that promotes diverse partnerships through well-structured governance geared toward systems- and institutional-level community improvement. Based on this idea, the East Lake Foundation coordinated efforts with other community institutions to open the Drew School, an elementary school offering enrichment programs to East Lake youth. The educational outcomes of the youth improved as a result of this effort (Center for Promise, 2014). In addition to transforming school opportunities for youth, the East Lake Foundation used the CCI to implement the Resident and Community Support Program (RCSP), which provided financial literacy and career workshops in the complex to promote long-term housing security and social wellness. East Lake is a model for the success of this strategy for improving resident wellness through structured community collaborations, and improving neighborhood institutions to build social capital for their low-income residents (Center for Promise, 2014). The Urban Institute conducted a literature review to examine connections between affordable housing and child/youth outcomes, focusing on educational and academic outcomes (The Urban Institute, 2014). In this report, they surveyed SAHF member organizations about their education-related services, programs, and outcome measures. In their review of the literature, the Urban Institute (2014) came up with three major findings: 1) housing impacts child/youth development directly and indirectly; 2) the research discussing such relationships is still in the early stages and therefore the effects are difficult to interpret (correlation versus causation); and 3) the research lacks clear understanding of how different subsidy programs differentially affect child/youth well-being (e.g., the different types of housing and 88

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rental assistance). Ultimately, the Urban Institute contends that housing support and services are important for child/ youth development and well-being, particularly among struggling families. Of the eight SAHF member organizations surveyed, 40% of the total properties were family properties; 30% of these family properties had a service coordinator, and 40% provided or connected family property residents to services and supports (Urban Institute, 2014). Although the types of child/youth services vary by SAHF member organization and property site, linkages to mentoring and tutoring programs and services are the most common services (Urban Institute, 2014). Some organizations with dedicated staff have on-site programs; others have created formal partnerships with external organizations (e.g., the YMCA) that come on-site and provide services and programming so that properties are not responsible for staffing or planning such programming (Urban Institute, 2014).

CONCLUSION This review of the grey literature provides a great deal of information about promising interventions and successful approaches. It covers many of the same themes addressed in the academic review. Although we found some rigorous program evaluations, most of these results have been disseminated as reports from think tanks, non-profit housing providers, and non-academically affiliated researchers, rather than appearing in the peer-reviewed academic literature. In the grey literature, we found that the health and healthcare programming addresses them and problems that are similar to those in the academic literature, namely healthy eating, nutrition, and physical activity. The grey literature also included reports of programming focused on mental health and behavioral interventions—an area that has received less attention in the academic literature. The grey literature also provides additional information regarding health cost savings as a result of on-site health services. The economic and educational programming followed themes similar to the academic literature, such as job support and children’s academic and developmental outcomes. However, we also discovered other types of financial programming, such as eviction prevention programming, that was largely absent from the academic literature. This review provides us with a great deal of programmatic and field-based practice evidence that dovetails nicely with the academic literature findings.

Chapter 4 Gray Literature Review

Chapter 5 Field Scan Understanding Resident Engagement and Health Outcomes in Affordable Housing: A Summary of Interviews with Nonprofit Resident Service Providers

PREFACE The purpose of this field scan is to inform the study team for the COO project, a partnership among Columbia University and practice-based partners Jonathan Rose Companies, Success Measures at NeighborWorks America and Enterprise Community Partners. It complements the review of the peerreviewed literature completed by Columbia University. SECTION 1. INTRODUCTION AND SUMMARY Housing has long been recognized within the field of community development as a platform for delivering services. Multi-family affordable housing providers have offered services for residents since the late 1980s and early 1990s. More recent interest in adding or expanding resident services stems in part, from a growing recognition of the importance of social determinants in building healthy communities, and continuing increases in the costs for Medicare and Medicaid. The field of housing with services is changing rapidly. Intermediary organizations such as Stewards of Affordable Housing for the Future (SAHF), NeighborWorks America and Enterprise Community Partners are leaders in establishing communities of practice to help multi-family housing providers improve the effectiveness and efficiency of services, to meaningfully engage residents in determining what services are needed and the most effective methods of delivery, and to document the impact of services on the lives of individuals and families. Government agencies, including the Centers for Medicare and Medicaid Services (CMS) and Housing and Urban Development (HUD) are supporting innovative systems and approaches to reduce the rate of increase in government health care expenditures and improve overall health. Underlying efforts to reshape the delivery of health services are questions of funding and sustainability. Governments and organizations are also developing innovative solutions in this space as well. This report synthesizes perspectives from structured conversations with key informants from housing intermediaries and multi-family providers. A fundamental value in community development the empowerment of individuals and groups to make decisions or take action on issues that are important in their lives. While research and practice support the inherent value of marrying housing with services, a community development perspective also considers the level to which residents are truly engaged in identifying, designing, and delivering services since resident agency is important to building a healthy community. The role and importance of trust-building, the degree of resident engagement, and the value resident voice all figured prominently in conversations with informants. METHODOLOGY Staff from Success Measures, Enterprise, and Columbia University conducted the telephone interviews in January and February 2019, following a scripted list of questions developed by the research team. The research team selected participating organizations to reflect a balance in size, number of properties, and geography. The result is a mix of large multi-state housing providers; community-based housing providers committed to providing resident services; national intermediaries providing support to multi-family housing providers; and individuals and organizations with special knowledge and experience in resident services, with an emphasis on health services.

Communities of Opportunity Study Design

The team first identified leading organizations in the field and then used a snowball sampling process where interviewees were asked to recommend additional organizations that use unique or cuttingedge approaches in resident services to fill out the interview list. Fourteen organizations participated in the interviews. Generally, the informants have corporate level (Vice President or similar title) responsibility for resident services, including program development, staff training, and implementation of service protocols for rental properties in the portfolio. In some cases, research and evaluation staff also participated in the interview. The one-hour interview focused on best practices and challenges in determining service offerings; funding models; the level of resident engagement in the design and delivery of services; and measures of success, evaluation methods, and results. Interviews were recorded and analyzed by identifying key themes, as is customary in qualitative research, and examples that illustrate different approaches in the design, delivery, funding, support, and evaluation of resident services. The results reflect the practices of participating organizations as described above, and were not intended to represent a random sample of the industry as a whole. DESCRIPTION OF ORGANIZATIONS INTERVIEWED Table 1 describes the participating organizations, types of properties, number of properties and units, and geographic scope. A list of interviewees by organization and the interview questions are included in the Appendix. Collectively, the direct housing providers interviewed represent approximately 119,000 affordable units. In addition, we interviewed two of the large intermediaries, NeighborWorks and SAHF, whose combined members have a total of approximately 303,000 affordable units. Because we also interviewed several SAHF and NeighborWorks member organizations, some of the latter units are included in the direct housing provider total above. The range in the number of units owned by the individual direct housing providers is 1,200 units to 30,000 units. The mix of populations served varies by provider, and include senior, family and supportive housing.1 The focus of this summary is on affordable housing for family and senior populations. The geographic scope of operations also varies. Foundation Communities serves Austin and Dallas, TX; 2Life Communities has properties in three communities. At the other end of the spectrum, Volunteers of America owns properties in 46 states and Puerto Rico.

Chapter 5 Field Scan

TABLE 1. DESCRIPTION OF INTERVIEWEE ORGANIZATIONS Name of Organization

Type Of Organization

2Life Communities (JCHE)

Community 9 properties based provider (4 campuses)

AHC, Inc.

# properties, # units # units

Geographic locations

Properties with services

Types of services

# (%) residents receiving services annually

How services and programming determined

1,261

3 Cities

9/9 (100%)

Information and referral; crisis intervention; tenancy issues; social engagement; health; volunteer opportunities

~1500

Input from resident councils, annual survey question: what is unique or special about where you live?

Community 50 properties based provider

7,400

MD, VA (4 cities, 1 county)

9/50 (18%) excluding limited case mgmt

Education; resident engagement; health and wellness; housing and financial stability

~ 3000

Varies by property, some do surveys, focus groups, interest assessment

BRIDGE Housing

Multi-state provider

10,000

WA, OR, CA

87%

Common Bond Communities

Community 142 based provider properties (101 owned; 41 managed)

6,063 owned, 7,549 overall

57 cities in MN, WI, IA

101/101 (100%) of owned sites

Health and wellness; housing stability; employment; after-school and youth

~7800 (75%)

Informal staff engagement with residents/ participants; residents at one property developed program to help residents from different cultures build a common understanding

Community Housing Partners

Large multistate provider

6,500

VA, NC, SC, MD, KY, FL

40/115 (35%)

Education; health and wellness; financial stability; resident engagement

3,700-3,900 Recently, begin with assessing broader community needs through County Health Rankings, Opportunity 360 etc. and informal conversations with residents

3,106

3 cities, 2 counties

28/43 (65%)

Next generation (after-school and teens); health and wellness; financial wellbeing; resident engagement

Not available

110 affordable properties

115

Community Community 43 Housing Works based provider

Communities of Opportunity Study Design

Review broader community data – do an environmental scan to identify needs and potential partners. Use residents as volunteers and strategies to empower

TABLE 1. DESCRIPTION OF INTERVIEWEE ORGANIZATIONS (CONTINUED) Name of Organization

Type Of Organization

# properties, # units # units

Geographic locations

Properties with services

Types of services

# (%) residents receiving services annually

How services and programming determined

Community Partners Development Corporation

Large multistate provider

9,000

3 states, 11 cities

22/35 (63%)

Education; economics; environment; health and wellness; resident engagement

Not available

Intensive Relationship building between property staff and residents, identify needs and gaps and resources

Foundation Communities

Community 23 based provider

3,400

Austin and Dallas, TX

23/23 (100%)

Education; health and wellness; financial stability

~4000 (60%)

Informal staff engagement, interest assessment form, resident councils, outreach and engagement

Mercy Housing

Large multistate provider

344

25,082

23 states2

73%

Community participation; health and wellness; housing stability; financial stability; events

19,822 (2017)

Varies across regions. Current model is informing and consulting; future goal is to move to consulting and engaging.

National Church Residences

Large multistate provider

>3001

25,00030,000

26 states and Puerto Rico

66%

Health and wellness and other areas depending on community needs

~20,000 (goal is 80%)

Resident council, individual assessments and annual satisfaction survey

NeighborWorks National America intermediary

130 organizations report MF > 100 units; ~3000 properties

165,000 50 states, DC 60-75 and Puerto estimate Rico

Varies

Varies, resident engagement is part of the network culture and brand

Stewards of Affordable Housing (SAHF)

National intermediary

1900 total across 13 member organizations

138,000 49 states, DC, Puerto Rico and Virgin Is.

58%, but varies by member

Education; community engagement; housing stability/ eviction prevention; financial stability; and asset building

Do not collect this from members

VOA

Large multistate provider

500

20,000

158/200 (79%) senior properties only

Emphasis on health, vulnerability,

8,652 (90% at rticipating properties)

42 states and Puerto Rico

Individual assessments – ADL and Vulnerable Elder

1 Multi-family affordable properties only. Does not include market-rate or permanent supportive housing. 2 From https://www.mercyhousing.org/propertylocations accessed February 14, 2019. Bridge Housing, Community Housing Partners, Common Bond, Mercy Housing, National Church Residences, and Volunteers of America are members of SAHF. AHC, Inc., Community Housing Partners, Foundation Communities are NeighborWorks chartered organizations.

Chapter 5 Field Scan

SUMMARY OF KEY THEMES Housing providers have a deep commitment to providing services to residents and continue to develop strategies to broaden and deepen services to meet resident needs. There is no ‘one size fits all’ approach; with types of services and delivery models determined by the resident population and its needs, the funding model for the property, community resources and partnership opportunities, and corporate organizational goals. Most providers truly aspire to engage residents more deeply in planning and decisions related to the provision of services. Engagement is resource-intensive and a long-term investment. For some housing communities and provider organizations, it requires a significant change in culture. Organizations are moving towards increasing resident engagement, but at different paces and in different ways. Service areas and models •

Most organizations identify general service areas at the corporate level, and individual properties then create programs based on resident needs, budget, and local partnership opportunities.

•

Common services areas are health and wellness, youth and education, community engagement, jobs and financial stability, and housing stability.

•

SAHF created a step-by-step framework for providers seeking to add or expand resident services within their portfolio. SAHF also offers certification for organizations that demonstrate a robust commitment, competency, and capacity in coordinating resident services in affordable multi-family housing. Designation as a Certified Organization in Resident and Engagement Services (CORES) is a requirement for eligibility for financing under Fannie Mae’s Healthy Housing Rewards initiative.

Staffing •

The level of corporate staff coordination and support for resident services varies among organizations, based in part, on the degree to which services are a major component of the corporate brand.

•

The standard and general practice for determining property-level resident services staff is 1 full-time equivalent (FTE) resident service coordinator per 100 units. It is common for smaller properties to share a service coordinator. Additional program level staff, particularly for after school and youth programming, are determined by program participation levels and needs.

•

Properties with populations with special needs may have a smaller ratio of staff per unit.

•

All organizations recognize the important role of staff in building trust with residents. Some organizations emphasize a team approach, where resident services and property management staff work together to create a climate that encourages a high level of service and respect.

Health and wellness services •

Organizations are actively seeking opportunities to expand and improve health and wellness services for residents.

•

The most common health services include on-site health education and prevention seminars; food access; and exercise and physical fitness classes. Other health services include blood

Communities of Opportunity Study Design

pressure and blood sugar monitoring; assistance with insurance enrollment and government benefits; referrals to healthcare providers; and more individualized case or care management. •

Health programs and services are generally delivered through 3rd party partnerships developed at the community or property level.

•

Some organizations provide corporate staff support for health and wellness programs.

•

Several housing providers are currently participating in pilot projects supported by universities, CMS, HUD, and private insurers to investigate the impact of newer service delivery models on health outcomes and costs.

•

One of the most innovative new programs is Support and Services at Home (SASH), a program piloted in Vermont and now offered statewide with support from USDA Rural Development, LIHTC, HUD, and the State of Vermont. Participation is open to residents of affordable multifamily properties operated by 20 affordable housing providers. A robust evaluation of the program pilot demonstrated cost and health benefits from place-based service delivery.

•

IWISH, a replica of the SASH model, is described by proponents as a system change approach to health and housing. One of the biggest challenges for SASH and WELLCARE, the organization that developed the model, is funding, which requires coordination among multiple payers.

Resident engagement •

Engaging residents in the design and delivery of services has multiple benefits, including strengthening resident connections; developing leadership and advocacy skills; increasing participation in programs and activities; meeting resident needs more effectively; and building trust among residents and staff.

•

A few organizations still view engagement rather narrowly as marketing activities designed to increase participation in services. However, most interviewees recognize that residents must be more deeply engaged in decision-making to build a healthy community. For many, deeper engagement is the ultimate objective.

•

Most organizations rely on informal conversations with residents, end-ofprogram participant surveys, and questions on more general resident surveys to “inform” or “consult” with residents about services needs and delivery.

•

One organization has worked extensively to engage residents at its larger properties. Residents have become the voice of the community and lead efforts to develop solutions to community issues, reflecting ownership and empowerment. Engagement, strategies are part of this organization’s overall community development approach and were not designed to focus solely on engagement in services decisions. Nevertheless, it is an example of the high level of engagement that is possible in a multi-family community.

•

SAHF currently has a grant from the Kresge Foundation to redefine its resident engagement framework to more deeply inspire resident power, voice, and agency. Through a series of focus groups across the country, SAHF hopes to better understand resident experiences and the deeper context so that services can be delivered in a way that lead to greater effectiveness.

•

Several organizations are developing survey-based measures of resident engagement patterned after a generally accepted continuum used in the field.

•

Several organizations use a process to more deeply engage residents at newly acquired properties to build trust and identify service needs.

Chapter 5 Field Scan

Funding resident services •

Funding resident services is an ongoing challenge. Providers use a mix of resources, including property operations budget, corporate support, and philanthropy (fund-raising and grants). The exact mix for a property depends on the type of property and eligibility for government support.

•

Long standing properties in a portfolio may have more resources for services in the property budget based on the original funding package compared to those properties more recently acquired. In the current market, interviewees’ experience is that funders are more reluctant to budget for services in the financing package.

•

Government funding for senior housing (HUD 202 Supportive Housing for the Elderly program) includes services support, but some interviewees expressed concern about future uncertainties in this funding stream.

•

Partnering with local providers is one strategy to leverage property assets, bring program experts on site, and manage costs.

•

The newest models for delivering health and wellness services (SASH and IWISH) use all-payer funding pools that include private, third-parties and governments.

Evaluation and outcomes •

All interviewees recognize the importance of tracking outcomes from resident services. Most agree that evaluation, like resident engagement, is an area where their organization needs to improve. In practice, the extent and capacity for outcome evaluation varies across organizations.

•

Fewer than half of participants in the interviews said their organization asks residents to complete an annual survey.

•

Several have developed models that identify short-term, intermediate and long-term outcomes from services, and specify indicators and measures for outcomes.

•

SAHF has a comprehensive outcomes framework and aggregates, analyzes and reports the results from data that its member organizations submit voluntarily.

•

Success Measures at NeighborWorks has outcome tools, including measures for health and wellness, and an online data collection, analysis, and reporting system for evaluations.

•

Some organizations collect outcome data through partnerships, particularly in the areas of K-12 education and health services.

•

A few participants described conducting advanced analysis on outcome data. An example is the relationship between participation in wellness programs and reduction in emergency room visits or unnecessary hospitalization or increased use of primary care providers.

•

Barriers to increasing capacity for evaluating resident service outcomes include the complexities and costs of integrating technology platforms; lack of staff with evaluation and analytics expertise; and limited corporate recognition of the importance and benefits from evaluation.

Communities of Opportunity Study Design

SECTION 2. DETAILED FINDINGS Scope and types of services All the organizations interviewed offer resident services, with most offering services at 50% or more of their properties (see Table 1 for more detail). SAHF estimates that 58% of properties owned by its members offer some type of resident services, although the percentage varies widely across the member organizations. Organizations use different categories to describe the types of services for residents. Generally, services cluster into the following areas: health and wellness; youth and education; community engagement; employment; financial stability; and housing stability. Table 2 is an example of the categories and types of services offered by SAHF member organizations responding to recent member survey. Again, the mix and extent of services varies by member, with some organizations offering services in one or two areas, while others provide services in all the areas listed. Organizations participating in the interviews use categorization schemes similar to Table 2.

TABLE 2. RESIDENT SERVICE CATEGORIES AND OFFERINGS Service Category

Types Of Services

Health and wellness

Nutrition, food access, health assessments, preventative health education, exercise programming, health fairs, connecting to health benefit providers, referrals to practitioners and programs, blood pressure and blood sugar monitoring, some on-site health services, case management.

Youth and education

After school programming (on-site), technology access, summer camps, summer lunch program, post-secondary education planning, parenting classes, youth employment assistance and training, youth leadership.

Community engagement

Resident-led programming, social and recreational programs and events, volunteer opportunities, community councils and leadership, community organizing, safety initiatives.

Work, employment, and financial stability

ESL assistance, computer courses, job readiness training, GED programs, career advancement, financial capabilities classes, coaching, connecting to banking and savings options, tax preparation assistance.

Adapted from Resident service programs provided by SAHF members or partners at SAHF member properties 8.9.17.

Resident demographics determine the mix of services available at a property. Senior properties emphasize health and wellness and opportunities to meet and engage with other residents. Family families focus on after school and youth programming; family social activities; and housing and family stability.

Chapter 5 Field Scan

RESIDENT SERVICE FRAMEWORKS AND APPROACHES SAHF’s Framework and Guidelines for the System of Resident Services Coordination is intended for use by practitioners, providers, policy makers, funders and partners in making services decisions. The framework identifies decisions that are generally made at the corporate or regional level and those that might be made at the property level, recognizing that organizations will develop an approach that best fits their business model and culture. At the corporate level, decisions include: •

Establishing organizational goals for resident outcomes

•

Identifying community needs, resources, and providers

•

Whether to offer services at a specific property

For senior properties, examples of organizational goals include helping residents age in place as long as possible; promoting resident health and well-being; or improving access to healthcare services. For family properties, the overall goal might be to improve family stability. Interviewees use various tools to assess community needs. For example, when acquiring a property in Hopewell, VA, Community Housing Partners (CHP) gathered information about the community and its needs before beginning property rehabilitation, a practice that SAHF also recommends. Of particular importance in helping CHP identify needed services were the county’s ranking on health outcomes, which is near the bottom of all Virginia counties according to County Health Rankings and Roadmaps (www.countyhealthrankings.org) and the lack of accredited elementary or middle schools in the community. CHP Vice President of Resident Services Angie Roberts-Dobbins notes that prior to 2016, CHP would acquire property, do the lease up, and then develop services and programming. Now the organization begins identifying community needs and potential partners before beginning any physical improvements or developing programs and services, which Roberts-Dobbins describes as an organizational best practice. Other interview participants echo the importance of understanding community needs prior to developing a service plan. Community Housing Works completes an environmental scan to understand the locality and its needs, a practice it describes as a critical piece of its geographic expansion strategy. SAHF’s framework recommends that organizations re-evaluate community needs on a regular basis. Mercy Housing requires local property management to reassess resident services at the beginning of each year based on resident demographics, service utilization data, an annual survey of resident health and Opportunity 360. Mercy Housing provides additional tools to help properties develop and revise their plans. BRIDGE Housing describes an approach that includes assessing the context of both the resident community and the larger community and its resources. Services at a property in a ‘high functioning may focus on building community among residents and helping them to access high-quality services that are already available. In a neighborhood where there is more isolation and trauma, and maybe some gentrification with people are feeling ‘shut out,’ the focus would be on more services to stabilize families, such as educational programming for kids.

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CORPORATE-LEVEL SERVICES STRATEGIES Francie Ferguson, Vice President of National Real Estate Programs with NeighborWorks America, emphasizes the strategic importance of resident service decisions at the corporate level. For some providers, the resident service strategy is a major brand component. Ferguson observes that organizations choosing this strategy, particularly those with many properties and a large geographic footprint, need to be cognizant of the commitment of resources necessary to provide a consistent and sustained level of services across all properties, while still meeting future goals for growth and expansion. If an organization elects to include resident services as a brand component, Ferguson suggests identifying a basic level of services that can be offered across all properties to maintain brand consistency and integrity. Ferguson cites Foundation Communities, which owns 23 properties in two cities, as a prime example of developing a brand around resident services using a deep services strategy. Foundation Communities’ family properties offer services in education, health, and financial stability. Classes in financial stability, financial coaching, and savings programs are open to both tenants and others in the surrounding community. Thirteen learning centers provide after-school programming in partnership with local schools. Adult education includes English as a Second Language and technology skill development; another program, College Hub, helps adults navigate the process of college admission and enrollment. Foundation Communities’ array of health and wellness programs include prevention and nutrition; physical fitness; food pantry; blood pressure and other routine health monitoring; vaccinations; care coordination; and a social work clinic offered through the learning centers that uses a trauma-informed care model with children with behavior issues. Foundation Communities’ deep service strategy is successful, says Ferguson, in part because of its focus in two cities where the organization is deeply embedded with local partners and the donor community. Foundation Communities also has high brand recognition and is outcomes-focused.

“The Foundation Communities model is awesome, really, really awesome and also expensive! If your markets are spread all over the country and you want services to be a part of your brand, you really need to think about the level of services you can offer and sustain at all of your properties.” — Francie Ferguson, NeighborWorks America 2Life Communities (formerly Jewish Community Housing for the Elderly) is another example of a deep service model. 2Life Communities serves a low-income senior population with four campuses in three communities. The average age of residents is 83 years. 2Life provides services at all its properties and considers services as “the core of what we do and who we are,” according to Lizbeth Hayer, Chief of Real Estate and Innovation. Services focus primarily on health and wellness, and social connectedness. In contrast, a tiered services strategy allows organizations to focus on basic services at all properties and deeper services at some properties where feasible. Common Bond uses this approach at the 101 properties it owns in 57 cities in Minnesota, Wisconsin, and Iowa.

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At the basic services level, property managers at all Common Bond locations connect residents to core services that include food support and emergency financial assistance. If an individual needs support beyond the capabilities or resources of the property staff, the property manager reaches out to corporate staff for additional assistance. At the enhanced services level, a service coordinator is on site twice a week to help residents solve housing stability issues and support senior independence. Common Bond properties with comprehensive services – the highest level - have staff on site three to five days a week and offer more comprehensive employment services, mentoring, and case management. A tiered services strategy gives organizations the flexibility to offer more comprehensive services at properties that are most in need, and in communities where there are qualified local partners. Regardless of the approach an organization ultimately selects, Ferguson says that it is important for the strategy to fit the organization’s business model. In her experience, a longer-term commitment to a basic set of services produces better outcomes than a shorter commitment to a deeper set of services. NeighborWorks America recommends that network organizations wanting to establish services begin by offering financial capabilities and eviction prevention programs at family properties. Improving financial well-being and housing stability benefits both residents and the property, says Ferguson. Programming for children and youth can be added next, because of the benefits for kids, families, and the property from engaging young people in positive activities. In Ferguson’s experience, initial services are generally funded by the property. As services establish a foothold, other needs and opportunities usually follow; however, at some point, the property will need additional sources of funding or support because budget limitations eventually kick in. With all services, according to Ferguson, community building and resident engagement are critical. Once good management starts to build strong connections with and among residents, service programs become more impactful. Some services are more difficult to provide or fund, according to interviewees, including mental health services; job programs, which require strong partnerships with employers; after-school programs; and food pantries. Looking at innovative solutions As housing providers anticipate demographic changes over the next 20 years and plan for future investment and expansion, services figure prominently for many in the equation. One organization that is very committed to helping residents age in place is in the process of expanding its portfolio and an important consideration for the future is meeting the affordability needs of baby boomers who do qualify for housing support, but still cannot afford market rates. The organization is looking at financial models that allow them to continue to provide services to residents in affordable properties and meet the needs of this new group of seniors. They are finding that in their geographic market, people are turning to nursing homes because of the high cost of housing alternatives. This has led to thinking more creatively about how the organization can partner with health care institutions to unlock dollars to provide support.

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RESIDENT ENGAGEMENT IN SERVICES DECISIONS While a few organizations still view engagement rather narrowly as marketing activities designed to increase participation in services, most interviewees recognize that engagement must include residents in decision-making at a higher level to build a healthy community.

“The ultimate goal of housing with services is to support and stabilize individuals and families. You can’t really achieve this with a top-down approach -- you need to include the resident voice and opportunities for participating in decision-making in order to be successful.” — Alexandra Nassau-Brownstone, SAHF In practice, most interviewees describe engagement activities that inform residents of programs or consult with or ask for input or feedback from residents after decisions have already been made. Some organizations rely on informal conversations between staff and residents to gather feedback about programs and services, others conduct surveys. Regardless of the method used to gather information, the step that is usually missing or incomplete is sharing feedback or survey results with residents. Overall, interviewees agree that their organizations need to do more to engage residents in service decisions. Two interviewees from different organizations said their goal is to move from informing and consulting with residents about services to more consulting and involving and residents in decision-making.

“Resident engagement is the weakest link in our services programming. Maybe if residents played a bigger role in (program and service) design they would have more ownership and would participate more. We are currently looking at strategies to address this barrier.” — Donna Thurmond, Volunteers of America Engaging residents of newly acquired properties Community Development Partners Corporation (CPDC) has a structure for building relationships with residents, particularly after acquiring a new property. Staff from all areas of management (Resident Services, Property Management, Maintenance, and Real Estate Development) participate in monthly gatherings to acquaint residents with the role and staff of each functional area and generally engage in conversations. Service suggestions emerge from these meetings, and trust between management and residents increases over time, resulting in increased sharing of needs and concerns. The time it takes to develop trust can vary from as little as several months to four years or more, according to CPDC. CPDC describes the strategy as resource heavy, but very worthwhile. One result of relationship building is that residents first contact Community Impact Services (CIS) before going to Property Management when they have trouble paying their rent. This gives CIS an opportunity to make a referral or mediate the issues.

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Other engagement models 2Life Communities relies on residents to develop and shape the programs it offers. All properties have resident councils, and some are more involved than others in developing and implementing programming. Some properties with significant language diversity have multiple councils to insure representation of non-English speaking residents. Community Housing Works (CHW) has a volunteer community leadership program that supports and trains residents in leadership and advocacy skills. As part of the program, residents can participate in actual service delivery. Program goals include resident empowerment and service sustainability. BRIDGE Housing has elected not to engage residents in service design across all its 100 properties. “As much as we value the resident voice, it is a scale issue: we just don’t have the staff and it is not something you can contract out because a contractor cannot represent the resident voice,” says Damon Harris, BRIDGE Vice President of Community Development. BRIDGE does have a strong emphasis on community building at two large former public housing properties where funding for engagement is what Harris describes as ‘solid’. “We rely on residents to help decide how programs will be rolled out to the community and how services can be improved,” says Harris. BRIDGE serves as the backbone for processes and projects where the goal is for residents to be able to step forward and assume more responsibility.

“We have to think about sustainability and authentic resident engagement is backbreaking work. It is hard for residents and for the organization. The organization has to open up for discussion its operational culture, the way we look at risk and the way we manage for the long term. These sites are living social labs for us to engage in community and see how far we are willing to go, but it is not feasible to do this at 100 properties and it may not deliver meaningful results at some properties. “ — Damon Harris, BRIDGE Housing SAHF engagement initiative SAHF is developing a more robust resident engagement component to its resident service community of practice framework referenced earlier, which reflects agreement among members that engagement needs to be operationalized more systematically. Currently, SAHF member organizations vary widely in their views and approaches to resident engagement; but do agree that more attention needs to be focused on strategies that give residents a voice and foster agency, which is much different from increasing participation in events designed for socialization.

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Benefits from engagement Interviewees cited the following benefits from resident engagement: •

Builds resident connections.

•

Builds resident leadership and advocacy skills.

•

Helps to increase inclusiveness.

•

Builds trust and community.

•

Increases resident participation in activities.

•

Improves decisions about partnerships, minimizing partner turnover.

•

Helps to target fundraising efforts.

STAFFING Integration of services and property management Organizations with strong resident services programs recognize that social stability is greatly dependent on property management stability. Some organizations use a team approach, where property management and resident services staff work in close collaboration to build relationships and meet resident needs, both individually and collectively. One organization describes how site representatives are trained to respond when residents use the pull chord at night, resulting in 92% of all calls being handled internally rather than by emergency (911) services. One interviewee describes collaboration between resident services and property management as “a pain point, but also the crux of success.” Organizations that have been able to integrate resident services with property and asset management and have developed strong partnerships between these two areas, both at the property and regional or corporate levels, have been most successful in the service arena, according to the interviewee. “This is because of access to data, and because property managers are the eyes and ears when there are problems, so they can make or break the success of a program through sharing what they know.” Another interviewee addressing the services-property management relationship went one step further by asking whether property and asset managers should also bear some accountability for resident outcomes. Staffing ratios Staffing models for resident services depend on the type of property (senior, family, supportive housing or other special population); the types of services that are offered; the level of funding for the property; and the organization’s management structure. •

Most organizations use HUD’s recommended ratio of 1 fulltime staff position for every 100 units as a guideline.

•

BRIDGE Housing uses 1:150 for its family properties.

•

Properties with residents with special needs, including frail elderly, transitioning homeless, veterans, or a population with significant mental health or substance abuse needs may have ratios of 1:30 – 1:50.

•

The average staff ratio across all SAHF member organizations that offer resident services is .8 FTE per property.

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105

•

It is common to split a resident services coordinator position between multiple properties in close proximity.

Staff roles •

A resident service coordinator is the most common position responsible for resident services.

•

Larger properties are more likely to employ specialized staff, such as Youth Coordinators, Peer Support Specialist (behavioral support for kids), or After-school Program Coordinators.

•

Case managers conduct individual assessments of resident needs and develop a package of services. Case managers may or may not be located on site, although having case managers office on the property is an important component of the IWISH health services model described on page 25.

Third-party contracts versus organizational staff Organizations use a mix of organizational staff and third-party contracts for service delivery. Mercy Housing explains that the decision depends on the availability and quality of community resources and the skill set of the resident services coordinator. For example, Mercy Housing staff usually perform after school programs and community events; whereas health education and other health services are contracted through third parties. The property context is also a determining factor in contract vs. staff decisions. For example, large urban areas offer a variety of qualified partners; in rural areas, Mercy Housing provides most of the services directly. Other staffing strategies Organizations describe a variety of other staffing strategies to provide quality services to residents. •

Corporate staff may support property-level services, usually in specialized areas such as health and wellness. Foundation Communities uses corporate staff to provide health and wellness and financial capabilities services on site, but its geographic footprint is small. Organizations with larger footprints use corporate staff more for program development and training.

•

Several organizations use resident and non-resident volunteers as a strategy to provide programs.

•

Properties provide space to partners for programming in exchange for giving enrollment preference to residents.

•

Another type of in-kind relationship is BRIDGE Housing’s agreement with the city and county to set aside a certain number of units for residents transitioning from homelessness. Under the agreement, the city and county agree to pay a specific amount for a set number of hours of case management and mental health services. BRIDGE contracts with the same case management provider for additional service hours for other residents needing similar services.

•

2Life Communities with its deeper service approach operates a staff training institute that is open to other providers in the community.

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FUNDING FOR SERVICES There is no standard or sustainable approach to funding resident services. Providers generally use a mix of property operating funds, philanthropy, corporate budget, and government grants. The mix depends on the type of property (HUD-202, Section 8, Tax Credit, or private affordable) and the terms of the financing for the project. Using operating funds is the preferred approach; however, the budget for services is often determined by the financing agreement when the property is first purchased. In today’s market, interviewees agree that some financial institutions are less willing to incorporate resident services into new or re-negotiated financing packages. According to SAHF, some organizations set an internal goal or threshold for funding resident services, such as a minimum of 30% must come from property operations. This is not an industry standard, although SAHF would like to see the industry move in this direction. There is statutory authority for HUD to support resident service coordinators. The reality is that many properties have not been able to get approval from local HUD officers for rent adjustments to cover increases in costs or additional services. Federal funding for service coordination is also uncertain. HUD demonstration projects, particularly in the senior housing space, provide opportunities, but are unreliable because of the federal budget climate according to some interviewees. Some organizations collect ‘community development program fees’ or ‘property fees,’ which become part of the operating budget and are used for resident services. Another source of funding is corporate revenues. A significant number of SAHF member organizations channel corporate funds back into the provision of resident services, primarily for staff salaries or technology systems at the property level. Philanthropy is a strategy that many organizations rely on to fund a portion of the cost of services. CDPC has a dedicated fundraiser for resident services. BRIDGE, on the other hand, wants to make sure that a sustainable funding source is in place early on because it prefers to use fundraising for newer projects, and not for continued support of existing ones. As noted in the previous section, organizations indirectly augment funding by seeking partners willing to provide specific programs onsite, with the property providing the space and coordination support. FOCUS ON HOUSING AND HEALTH Almost all of the affordable housing providers interviewed for this project provide some type of health and wellness services on-site for residents at one or more of their properties, either through their own service coordinators or through third-party partners or a combination of both. More providers target senior properties for health and wellness services because of the greater need and the recognition that health is important to aging in place. Several organizations have set ‘aging in place’ as a corporate goal. The mix of health and wellness services is most often customized to individual properties because of the need to match resident needs to service partnerships and available resources. The degree of customization and the need for partnerships with local service and healthcare providers means that arranging and providing services at several locations is very time intensive. One organization specifically seeks to build relationships with larger, multi-state service providers to achieve efficiencies. Organizations that have chosen to make health and wellness services a key part of their brand have invested in centralized systems for data collection and care management, staff training, and quality assurance processes.

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Types of health and wellness services Health and wellness services can be grouped into several categories, with some programs or services requiring more specialized staff (ex. nursing, social work, community health worker, or other health professional). •

Health and wellness promotion and programming – may include nutrition classes; food access; fall prevention; exercise/physical activities on site; stress management; kids health programs; and diabetes prevention and education.

•

Health navigation – includes assistance with insurance enrollment, including prescription coverage; finding a primary care provider; access to government benefits and other services for low-income families and seniors; referrals for mental health, substance abuse, or specialist care; and transitioning from hospital to a home setting.

•

On-site health care and wellness services – blood pressure checks; BMI; blood sugar monitoring; emergency assistance; and flu shots.

•

Individual health assessments and plans – most often for seniors, may vary in depth and in extent of goal-setting and follow-up.

•

Individualized care management or case management.

SAHF conducted a member survey around resident services, gathering information about the types of services member organizations offer. In the health and wellness category (Table 3), all 12 organizations responding to the survey offer prevention and education programs; 11 offer food access, connections to government health benefits and referrals to health care providers; 10 have on-site exercise classes and health fairs; and 10 offer on-site blood pressure checks, blood sugar, and BMI testing.

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TABLE 3. HEALTH AND WELLNESS PROGRAM OFFERED BY SAHF MEMBERS

Number of organizations offering

Preventative classes/workshops provided by health professionals (i.e. Diabetes prevention, sexual health, pregnancy prevention, healthy eating)

Food Access (Food Pantry, Meals on Wheels, summer meals for youth)

Connecting Residents with Government health benefits, such as Medicaid, Medicare, WIC, SNAP

Referrals to Off-site Health Providers, such as mental health professionals and specialists

Health Fairs with various community vendors/healthcare providers

On-site fitness programs (Zumba, yoga, walking program)

Community Gardening Programs

Annual Health Screenings

Providing transportation to off-site health services

Annual Health & Wellness Interviews/Assessments

ADL screenings and support for seniors

Monitoring coverage of health benefits and utilization of health services

Community Violence Prevention

Community Health Worker Program/Partnership

Communities of Opportunity Study Design

TABLE 3. HEALTH AND WELLNESS PROGRAM OFFERED BY SAHF MEMBERS

Number of organizations offering

Preventative classes/workshops provided by health professionals (i.e. Diabetes prevention, sexual health, pregnancy prevention, healthy eating)

Food Access (Food Pantry, Meals on Wheels, summer meals for youth)

Connecting Residents with Government health benefits, such as Medicaid, Medicare, WIC, SNAP

Referrals to Off-site Health Providers, such as mental health professionals and specialists

Health Fairs with various community vendors/healthcare providers

On-site fitness programs (Zumba, yoga, walking program)

Community Gardening Programs

Annual Health Screenings

Providing transportation to off-site health services

Annual Health & Wellness Interviews/Assessments

ADL screenings and support for seniors

Monitoring coverage of health benefits and utilization of health services

Community Violence Prevention

Community Health Worker Program/Partnership

Domestic Violence Support

Transition planning to assisted-living and nursing facilities

Other -- Please specify:

On Site Services provided by health professionals: Vision Screenings

Dental Exams

Eye Exams

Flu Shots

Blood Pressure, blood sugar, BMI checks

Other (Please Specify): Medication Checks

Other (Please Specify): Mammograms

Other (Please Specify): Pregnancy tests/Prenatal care

Source: SAHF member survey, 8.09.2017.

The remainder of this section highlights additional examples of health and wellness services and innovative service models developed by organizations interviewed for this project. The remainder of this section highlights additional examples of health and wellness services and innovative service models developed by organizations interviewed for this project.

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MERCY HOUSING – OUTCOME FOCUS Mercy Housing offers services at 73% of its 344 properties. All properties with services offer services in health and wellness, as Mercy Housing requires that properties with services must incorporate all service areas. Properties for seniors have a heavier emphasis on health, with on-site programs and services almost always delivered by a third party. Mercy has a robust evaluation program. Outcome goals for health include ‘reduced use of the emergency department’ and ‘fewer hospital stays’ for seniors, and ‘improved overall health’ for families. Mercy collects data on program participation, provider utilization, health status, housing stability, and social connectedness and analyzes differences in health outcomes at individual properties, by region, and in the aggregate. Results demonstrate improvements in health outcomes after the first two years in stable housing, and a positive association between social connectedness and health outcomes. NATIONAL CHURCH RESIDENCES – PROPRIETARY CARE GUIDE DATA SYSTEM National Church Residences (NCR) has more than 300 affordable communities in 26 states and Puerto Rico. Three-fourths of the communities offer resident services. Much of the funding for services comes from HUD 202 support for senior properties. Within NCR, the Support Services unit provides quality assurance for all NCR-owned properties with services and for other (contracted) client organizations. Support Services develops guidelines for selecting and managing services and supports 250 internal service coordinators and a similar number of external clients. NCR developed Care Guide, a data collection and reporting system for its properties. Service coordinators enter assessment and participation data into the system, which can generate reports for an individual resident, a property, and in the aggregate. Care Guide has given NCR a more complete picture of its residents – for example, 20-25% of residents with chronic conditions were not seeing a primary care provider on an annual basis. With monitoring and follow-up protocols in place, this percentage has dropped to 2%. BRIDGE HOUSING AND FOUNDATION COMMUNITIES - TRAUMA-INFORMED APPROACH BRIDGE Housing and Foundation Communities have incorporated a trauma-informed care approach in health and community engagement. Trauma-informed care “is an approach to engaging people with histories of trauma that recognizes the presence of trauma symptoms and acknowledges the role that trauma has played in their lives.” Stressful or traumatic events (Adverse Childhood Events or ACEs) are associated with abuse, poverty, and neglect and are strongly related to risky behaviors and significant health issues. Both individuals and communities can be affected by trauma. Trauma-informed care and its adaptation to community building and engagement emphasizes listening and acknowledging people’s lifetime experiences and empowering them through engagement and control in decision making. A trauma-informed approach can directly benefit individual and community health. As a community engagement approach, it provides a pathway to empowering residents through decision making in many areas, included the design and delivery of resident services.

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“In order to be effective with the rebuild at Jordan and Potrero (former public housing projects), we needed to acknowledge that these properties displaced people from their historic communities. So, for both of these communities our goals are to create communities of opportunity for all residents (both new and historic). We realized early on that we needed to recognize the social dynamics around trauma and distress and the ways that systems including housing has failed these communities. The result is intensive strategies to build trust.” — Damon Harris, BRIDGE Housing WELL HOME (SASH AND IWISH) – SYSTEMS CHANGE Well Home is a consulting organization in the field of affordable housing and health care services founded by Nancy Eldridge. Eldridge was the CEO of Cathedral Housing Corporation in Vermont and is one of the architects of the Support and Services at Home (SASH), a groundbreaking effort to coordinate support services to help residents in HUD and Low-Income Housing Tax Credit (LITC) properties age in place. SASH is a significant step in health systems change because: •

It is one of the first projects in the housing and health services space to provide robust results on the impact of place-based health services on care utilization and costs. Results from a five-year review and evaluation demonstrated slower growth in expenses for hospitalization, emergency department use, and specialty physician care for resident in urban settings (current recommendation is for cities larger than 160,000 population). Other benefits are higher patient functionality and better medication management.

•

The foundation of the approach is deep resident engagement. Says Eldridge, “SASH was designed to engage residents directly and was shaped by what residents told us.”

•

SASH has expanded after the successful pilot and is now offered statewide to residents of properties operated by 20 affordable housing providers in Vermont, with funding from USDA Rural Development, LIHTC, HUD, and the State of Vermont.

•

An almost identical program, IWISH, is in the pilot stage at 40 senior (HUD-202) properties in seven states.

•

Both SASH and IWISH represent a systems change approach to health and wellness services for seniors because of the emphasis on deep engagement with the resident to determine service needs, and then linking residents and communities with primary care practices and clinics to meet those needs. (See sidebar)

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“IWISH is a systems change model. It is not a program where we provide transportation assistance, nutrition, and medication management. It is about having a deep conversation with each resident and each site about what motivates them, what is purposeful, what they care about, and whether and how they want to age in place. It is a system of providing whatever services people need by linking primary care practices to housing sites and then to clinical sites and replaces the current system of various ‘programs.’” — Nancy Eldridge, National Well Home Network IWISH components include a standardized individual assessment; individual and community plans; resident engagement; a centralization data collection platform; an emphasis on local partnerships; and evidence-based strategies. Each participating property has a full-time resident wellness director and a .5 FTE nurse. The SASH pilot included a .25 FTE nurse, which participants agreed was not enough to meet resident needs. One goal of the person-centered, in-depth interview and assessment is to begin to build trust between staff and the resident. Interviewers are trained in trauma-informed techniques. Eldridge emphasizes that this may be a totally new approach for housing staff, who are trained to implement certain rules or protocols and not necessarily to act as advocates for residents. The approach also requires a highlevel commitment and engagement by all property staff. For example, the nurse is embedded into the community with an office on-site and is also an employee. All staff receive training in how to engage residents and the importance of doing so. Eldridge describes the value-add from this level of engagement as ‘huge.’ Benefits derive from the increased level of trust, which leads to greater participation in the community; improved relationships among different ethnic groups; and, ultimately reduced eviction rates and improved health and housing stability. The biggest challenge with the IWISH approach is developing the funding stream, where collaboration among payers is essential. Eldridge says that states will need to create multipayer pools, and since the funding streams into the pool will differ depending on the resident mix in the state, this is a customized, state-by-state process. Another more general challenge in providing health services, particularly in less populated areas, is the quality of internet connectivity. With many healthcare systems moving to telehealth services, internet speeds need improving for telehealth to be feasible. EVALUATION All interviewees recognize the importance of demonstrating the impact of resident services and housing-based support on resident health and well-being. Most characterized evaluation and outcomes measurement as an area where their organization needs to build capacity. Evaluation concepts This subsection provides a basic description of outcomes and evaluation for readers who may not be familiar with the concepts. Outcomes frameworks are roadmaps that identify changes in attitudes,

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behaviors, or circumstances that are expected to occur from a particular service or intervention. Mercy Housing shared the outcomes frameworks that it uses to describe the intended impacts of resident service programs offered at its properties. The example below is for housing stability programs at family properties. Essential activities are the program components or ‘interventions.’ ‘Outputs’ are what is produced as a result of the programming; in the example below, outputs reflect participation in the various activities. ‘Impacts’ are changes in attitudes, behaviors, or circumstances that are expected to occur as a result of participation and are reflected in time as short-term, intermediate, and long-term. For example, looking at Figure 1., residents attending classes and coaching sessions will in the shortterm, pay rent on time, resolve issues that might affect housing stability (seeking help if they cannot make a rent payment on time), and be knowledgeable about lease obligations and rights. FIGURE 1. EXAMPLE OF AN OUTCOMES FRAMEWORK OR LOGIC MODEL OF RESIDENT SERVICES Mercy Housing Resident Services Family Program Model PriorityPRIORITY Components COMPONENTS

Impacts

ESSENTIAL ACTIVITIES

OUTPUTS

SHORT-TERM

INTERMEDIATE

LONG-TERM

Average length of residence at property (property level outcome) Proportion of households with timely rent payment (property level).

Households have continuous safe, and stable housing and are renters in good standing

Priority Programs Priority Components Economic Development

Housing Stability

•

Eviction prevention coaching

•

Lease education

•

Housing options

•

% of residents and households participating in: -

Housing inspections

eviction prevention coaching

•

Linkage with financial resources

lease education

housing options

•

Referral & verification

housing inspections

linkage with financial assistance

housing stability referrals

Participating households demonstrate: -

timely rent payment

successful resolution of housing stability issues

Participating residents demonstrate: -

knowledge of lease obligations & rights

Source: Mercy Housing 2019 copyrighted

Indicators are the measures that will be used to represent the outcome of interest. SAHF has developed a list of recommended outcomes and indicators for five resident service program areas, which is included in the Appendix. An example of outcomes and indicators for housing stability is shown in Table 4. “Move out reason” would be captured during an exit interview or survey.

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TABLE 4. EXAMPLE OF OUTCOMES AND INDICATORS FOR HOUSING STABILITY PROGRAM AREA

Housing Stability

OUTCOME

INDICATOR

Median duration of residence

Move in Date/Move Out Date

% of household who moved out because of nonpayment of rent

Move Out Reason

% of household who moved out because of poor health

Move Out Reason

% of household who moved out because of home purchase

Move Out Reason

% of household who moved out because of death

Move Out Reason

% of household who moved out because they no longer need this level of subsidy/financial assistance

Move Out Reason

Source: Excerpt from SAHF Outcomes Initiative: Housing as a Platform for Services, updated 2018

Evaluation practices Organizations use a variety of approaches and practices for capturing and analyzing resident data to demonstrate outcomes. Mercy Housing has developed evaluation frameworks, such as the example shown above, and a full slate of outcomes and indicators for all resident service categories. Mercy collects information through an annual resident survey and a biennial household census at all its properties. Mercy uses the aggregated results to track changes in indicators such as food insecurity; number of visits to the emergency department in the last year; inpatient stays; and social connectedness and reliance on others within the community for help or support. Reports are shared at various levels of the organization and compare results across regions and types of properties to identify needs and assess change. CPDC also conducts an annual resident survey to measure outcomes in each of its five service areas and uses the information to describe resident characteristics and demonstrate needs to potential partners. National Church Residences uses its aggregated satisfaction survey results to measure progress against corporate goals, while individualized assessment tools track resident needs and progress. Annual resident surveys are not the norm among the organizations participating in the interviews. Some organizations that do survey their residents annually do not measure outcomes per se; but focus more issues that can be addressed by property management such as resident satisfaction or the resident experience. In some cases, the survey is conducted by the management company, which gives corporate staff less control over the content or the process. Program approaches Several organizations track outcomes at the program level. For example, CHW uses Success Measures health and financial capabilities tools and iReady for tracking reading readiness and changes in skill level. Other providers, such as 2Life Communities, partner with insurers, healthcare service providers, and universities on specific projects. These kinds of projects may involve a limited number of properties or be a mix of properties from different organizations. Partner organizations (specifically, educational institutions) usually conduct the formal evaluation.

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While some organizations have developed logic models and are using evaluation results as internal metric, others engage in evaluation to provide information required by funders. According to one interviewee, “right now our evaluation is funder-driven, and the approach is piecemeal (by program). We would need to develop more capacity, such as perhaps an evaluation director, in order to use data for decision making at the organizational level and there is some interest in doing so.” Strong support from leading organizations Leaders in the field of multi-family housing, such as SAHF and NeighborWorks America, provide support to member and network organizations for outcome evaluation. In addition to the list of measures and indicators, SAHF created a community of practice around outcome evaluation where members share best practices and problem solve around challenges. SAHF also collects, aggregates, and reports outcome data from member organizations that elect to participate in sharing. NeighborWorks America provides a list of outcomes and measures, with periodic updates, for network organizations that are multi-family housing providers. Success Measures offers tools, evaluation planning, and technical assistance to both network and non-network organizations, including those with multi-family properties with services. The Success Measures Data System is an on-line platform for evaluation planning, data collection, and analysis. Success Measures comprehensive tools include, but are not limited to, health outcomes, resident experience, social capital, and financial capabilities. HUD, as a leading funder and national collaborator in multi-family housing, continues to demonstrate an interest in health outcomes in particular, and may be moving towards adopting common outcomes and tools, according to one interviewee. Evaluation challenges Evaluation is complex and organizations face technological, cultural, and practical challenges including some of those described below. •

Property management and resident services data systems are not integrated, making data sharing cumbersome or not possible. The good news is that leading property management software providers are recognizing the importance of address data needs and systems compatibility in their products.

•

Different areas and fields have different perspectives and approaches on information gathering and feedback. Property management and corporate research staff may focus on satisfaction, property upkeep, and amenities, and may not fully understand or appreciate the importance of outcome measurement and resident needs.

•

Corporate resident services staff lack training in outcomes measurement and analysis.

•

Organizations have difficulty recognized when they need outside assistance with evaluation and complex analytics and some have faced challenges in finding qualified, outside evaluators.

•

Executive leadership does not recognize the value from outcomes measurement and evaluation.

•

Housing and health sectors have different standards, expectations, and lexicons relating to measurement and outcomes, making conversations and collaboration challenging.

•

There is a need for data visualization tools and expertise in communicating results in a way that is meaningful and interesting to all audiences.

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•

As accountability for resident results is pushed to the property level and property staff are able to generate reports from a centralized system, organizations must train and motivate staff to seek out and use the results.

Organizations are addressing some of these challenges and are taking steps towards improving evaluation capacity by: •

Expanding analytical capabilities.

•

Developing new measures of resident engagement and social connectedness.

•

Seeking projects and partners, particularly in health care, where the partner brings skills and/or technical assistance in outcomes and analysis.

Topics of future interest to interviewees include: •

Using an equity lens in analysis to determine where inequities exist

•

Developing more effective tools and processes for resident feedback, such as Net Promoter Score or Listen4Good.

SECTION 3. CONCLUSIONS The housing providers and intermediary organizations interviewed as part of this project are very proactively seeking opportunities to improve the quality of life for residents. Resident engagement is one area where organizations are beginning to identify strategies to include residents in decisions relating to services. Some providers are asking questions about what resident engagement truly means in the context a multi-family portfolio and are having internal conversations about how to define and measure engagement and what ‘increased engagement’ looks like. Providers also recognize the importance of consistency among staffing and operations models and engagement and service strategies. Leading organizations train all property staff to engage and build relationships with residents as part of their job and have bi-lingual or multi-lingual staff available to communicate with non-English speaking residents. Given the aspirations of individual providers and the current work of SAHF and NeighborWorks America to support activities in the engagement space, we expect to see an increasing focus on deepening resident engagement, particularly around the provision of services.

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In addition to engaging residents in decision-making regarding types of services and delivery, the results of the interviews suggest that multi-family housing providers that aspire to be leaders in the field must also: •

Develop a robust process that includes resident input, for identifying community needs for newly acquired properties.

•

Recognize the value of investing in strategies and practices that build trust with residents.

•

Become more sophisticated in defining outcomes and collecting outcome information across properties to demonstrate impact and inform strategy development.

•

Dedicate resources for data systems to capture and share resident and outcome information.

•

Build partnerships within the broader community to meet the needs of residents, provide opportunities, and leverage resources.

•

In the healthcare space, seek opportunities to partner with healthcare organizations, particularly for providing services to the senior population.

•

Support innovative approaches to funding healthcare services.

•

Recognize the importance of making investments that build a healthy community, where all residents are respected have a strong voice in decisions that affect their lives and well-being.

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Chapter 6 Case Study: Grace West Manor This case study paints a picture of the full implementation of the Communities of Opportunity Model at JRCo’s Grace West Manor, a 429-unit, affordable housing complex in Newark, NJ that houses 788 low-income seniors and families.

THE COMMUNITIES OF OPPORTUNITY MODEL The Communities of Opportunity (CoO) Model was developed by Jonathan Rose Companies (JRCo) and the Community Opportunity Fund (COF). This Model embodies the philosophy of aligning the often siloed medical, public health, and social service sectors within the affordable housing sphere with the goal of creating opportunities for affordable housing residents to live healthier, happier, and more connected lives. (COF, 2019; (JRCo, 2019a). The CoO Model seeks to increase positive health, educational, and socioeconomic outcomes by using housing—itself a most critical social service—as a primary vector that connects individuals to each other and to broader resources, through external partnerships and linkages to a variety of medical and social services and public health programs (COF, 2019; JRCo, 2019a). This case study paints a picture of the full implementation of the CoO Model at JRCo’s Grace West Manor, a 429-unit, affordable housing complex in Newark, NJ that houses 788 low-income seniors and families (JRCo, 2019b). At Grace West, a constellation of medical, public health, and social services align and are fully integrated to meet residents’ multifaceted needs and interes; it is an exemplary example of the CoO Model in action (JRCo, 2019b). JRCo, a nationally-recognized affordable housing provider, acquired Grace West in June 2013. At Grace West, and across its expansive portfolio of over 15,000 affordable housing units in 18 states, JRCo has begun to implement the CoO model which: 1.

Provides services and positive exposures to affordable housing residents in opportunity-deprived areas

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Adopts a regional, system-level, and asset-based approach that connects affordable housing residents to existing opportunity structures within and about their communities (COF, 2019; JRCo, 2019a).

The CoO model further purports that affordable housing can produce additional benefits for residents when complemented by: 1.

Resident-centered programs and services

Physical features such as computer rooms, community centers, fitness facilities, community gardens, safe outdoor spaces, etc.

Linkage to health resources and social services via the collocation of community health centers, healthy food provision, and other health-related services.

Green building and maintenance practices that minimize toxic exposures (i.e., use of low/ no VOC paints and carpets, integrated pest management, etc.), reduce carbon emissions, and lower operational costs through energy efficiency and energy conservation methods.

The model is guided by the philosophy of system alignment and housing as the core delivery mechanism, with a vision of housing that extends beyond the mere provision of a residence. As such, the CoO approach views housing as a primary vector that connects individuals to each other and to broader resources. In this model, affordable housing—itself a critical social service—is coupled with medical services through external partnerships, public health programming and social service linkages to:

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Improve socioeconomic, health, and educational outcomes for residents

Spur positive housing system results

Provide the evidence needed to influence structural changes in the subsidized/ affordable housing sector (COF, 2019; JRCo, 2019a & 2019b).

Utilizing affordable housing as the alignment mechanism of these three sectors through the CoO model allows for improved access to people, community, and place, thereby better meeting residents’ complex needs, reducing barriers to participation (i.e., time and logistics), and creating facilitators to meeting those needs (i.e., convenience of onsite wraparound services) (Swope & Hernández, 2019; Wright et al., 2016). The CoO model is a novel solution to connecting vulnerable populations with highquality, high-priority, necessary medical care, social services, and public health programming (COF, 2019; Cohn et al., 2000; Freeman et al., 2018; Golant et al., 2010; Hood et al., 2015; JRCo, 2019a; Nardone et al., 2013; Rabins et al., 2000; Robbins et al., 2000; Stewards of Affordable Housing for the Future, 2018a & 2018b; Urban Institute, 2014; Wright et al., 2016). Resident Services Coordinators (RSC) are a key component of this model. At Grace West, there are two full-time and one part time RSCs. Across the country, funding for RSCs comes from two funding streams: properties’ operating budgets and/or “grants provided by HUD through the Service Coordinators in Multifamily Housing grant program” (U.S. Department of Housing and Urban Development, 2019; American Association of Service Coordinators, 2016). Generally, and at Grace West in particular, resident services are not that expensive since many services are provided through community partnerships (Braveman et al., 2011; Center for Promise, 2014; Ladha & Thompson, 2014; Maqbool et al., 2015; Nardone et al., 2013; Roan et al., 2017; Rumi, 2017; SAHF, 2018b; The Urban Institute, 2014). The incremental expenditures specifically associated with resident services in affordable housing consists of a couple of staff helping to make the connection between available services and resident needs, such as the RSCs or community managers. SIGNIFICANCE What is learned from this case study will help establish the evidence for the scaling of the CoO Model to affordable housing sites across the country, of which there were approximately 4,355,000 occupied public housing and Section 8 project-based units and Housing Choice Vouchers used in 2018 (Joint Center for Housing Studies of Harvard University, 2019). By leveraging housing as a platform of system alignment, we envision a future in which residents enjoy stable, affordable, safe, connected and healthy housing while also linking to medical care services and public health programs within residential contexts. Additionally, this case study will provide us with guidance while we plan largerscale studies implementing and evaluating the CoO Model at JRCo properties across the country. METHOD Description of the Site: Grace West As stated previously, the CoO Model has been fully implemented at Grace West, making it an exemplary site that integrates programming and services across the medical, public health, and social service sectors to meet residents’ various needs and interests. Given the anecdotal success of the CoO Model at Grace West, it seemed the perfect place to conduct a case study of the Model in action. Grace West is a 429-unit, affordable housing complex in Newark, New Jersey that houses low-income seniors and families (n = 788 residents). The Grace West housing complex consists of a 12-story tower 122

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with 325 units designated for senior citizens and 21 town homes with 104 units designated for families. Grace West is located at the southern edge of Newark’s central business district, affording its residents easy access to transit, services, and downtown amenities through the several bus lines that serve the property and surrounding area. Newark City Hall, Newark Symphony Hall, Lincoln Park, the Prudential center, and Broad Street—a major retail corridor in downtown Newark) are all within walking distance. The main train station in Newark—Penn Station—has access to commuter and Amtrak train service and is just over a mile north of Grace West. Since the initial purchase, JRCo has conducted various capital improvement plans to improve the energy efficiency and resiliency of the building and to increase the quality of life for residents. Between 2013 and 2018 approximately $4 million in upgrades were undertaken, including modernizing elevators in the senior tower, new energy efficient boilers in the townhomes and a new community center. In October 2018, the property was refinanced using Low Income Housing Tax Credits, enabling further capital improvements supporting $18 million of upgrades that are currently underway, including improvements to bathrooms, kitchens, windows, and to increase accessibility for disabled residents in the units and building mechanical systems such as the ventilation and apartment-level thermostatic controls. The scope of this improvement project also includes the provision of a gym for seniors, a medical exam room and an all-season multi-purpose room—an extension to the community room serving the senior tower. Upon completion, the project will achieve Enterprise Green Communities certification (JRCo, 2019a & 2019b).

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As an affordable Section 8 housing development, Grace West is a social service in and of itself and also offers medical care, public health programming, and other social services, This affordable housing site is also a venue where various public financing systems together, including federal housing subsidies (Section 8), Medicare and Medicaid, and local public health dollars to support health promotion and to address the social determinants of health. In this case, Grace West, as an affordable housing property, serves as the direct basis and venue connecting and aligning services and programming across the medical, public health, and social service sectors and systems. This sector alignment also allows providers to most directly address a variety of the social determinants of health at once and from multiple angles. All 429 households earn less than 50% of the area median income and 100% have household incomes below $10,000. As of October 2019, 96% of Grace West 324 senior and 104 family units are occupied. Of the 788 residents, more than 50% are age 50 or older and about 20% are age 18 or below. Based on available data, 17% of tenants identify as Hispanic/Latino, 76% as non-Hispanic Blacks, and 7% did not specify. A majority of residents are female and single heads of household. Methodology of the Case Study Grace West was chosen as the site for the case study as a part of the planning year grant funded by the JPB Foundation because it is a JRCo site that is fully-implementing the CoO Model. To collect data on the site, how it runs, and what the CoO Model looks like in action, we utilized a variety of qualitative methods and administrative data. Qualitative methods employed to conduct this case study include, semi-structured, in-depth interviews with RSCs and the community manager at Grace West; participatory observation; and, a conversation with a member of the tenant association board. All interviews were recorded using a digital recording app on a researcher’s password-protected iPhone XR. Additionally, we collected and took pictures of flyers and informational materials around the site and took photographs of programming in action and the site itself. Finally, members of the research team on this grant from JRCo and the community manager at Grace West provided us with various administrative information, including rent rolls, programming and services, attendance, and other building-level data. SERVICES AND PROGRAMS AT GRACE WEST Staff Grace West employs 2 full-time Resident Service Coordinators (RSCs), 1 part-time RSC, and a community manager, who coordinate and manage partnerships with community organizations, social service, public health, and medical care providers to deliver programming and services on-site and liaise between management and tenants. RSCs leverage these relationships, network, and seek out services and programming to provide to residents at no-cost and provide elements of service provision themselves, such as assisting with housing and social benefit re-certification, providing job search support, and making necessary or requested referrals to the relevant social, public health, and medical providers. The RSCs regularly plan programming for the month ahead, though often times opportunities for outside community partners to provide programming and services happen on an ad-hoc basis and they “can’t pass up on something good,” even if it means a change to the planned programming schedule. The RSCs stated that the programs happen “whenever they can get them.” One of the full-time RSCs focuses on coordinating programs and services for senior residents in the tower and the other full-time RSC focuses on such coordination for those residents living in the tower, though they often work collaboratively to implement programming at Grace West. The part-time RSC was hired to help coordinate and run the Telehealth Intervention Program for Seniors (TIPS) offered at Grace West (to be described in detail 124

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later). The full-time RSCs are funded through the operating budget and the part-time RSC is funded through the aforementioned telehealth initiative. The official job description for the Senior RSC states that the Senior RSC: •

Assumes responsibility for developing and coordinating programs and services to help residents maintain a good quality of life and age in place

•

Works closely with the Director of Social Services to develop, promote, monitor, and evaluate the effectiveness of social and health programs by liaising with community agencies, networking with community service providers, seeking out new services, and identifying low-cost service providers

•

Engages and builds rapport with all residents to identify areas of need, make referrals to community agencies when necessary, and help to build informal support networks with other residents, family, and friends

The Family RSC has similar duties and responsibilities, including: •

Coordinates programs and services for children and families ₀

Learning events, pre-school, after-school, graduation preparation, summer

₀

Career development events/planning, job skills development, workforce preparation

camp, and other programming for children ages 3 - 18 years old and planning, and career advancement for adults ages 18 - 40 years old, including identifying training venues, resume development, interview preparation, etc.

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₀

Family and parenting events for all populations, including providing education and locating resources that reduce family displacement due to eviction for non-payment or other breaches of lease

•

Works with community management and as a conduit with at-risk households to prevent eviction and track program effectiveness

Finally, the part-time RSC working on the telehealth program is primarily responsible for overseeing its implementation and wraparound services and assisting in measuring its effectiveness. The part-time RSC also: •

Serves as a liaison between partner organizations to ensure the smooth coordination of the telehealth program, networks with community service providers, and seeks out new wraparound services available to residents

•

Assists residents in acquiring and utilizing desired and necessary community and health services (i.e., housekeeping, meals, transportation, primary care referrals, personal service, financial assistance, day care, counseling, etc.)

The community manager at Grace West has related duties, including supervision of the RSC, and in addition:

126

•

Handles work orders

•

Re-certifies residents annually for lease-renewal

Communities of Opportunity Study Design

•

Helps to manage the on-site construction

•

Manages the database for Grace West on OneSite RealPage

•

Tracks and facilitates unit transfers and changes (e.g., for disability status, moving in and out of building)

•

Bridges gaps between residents and management

•

Builds trust with residents

•

Launches the resident portal

•

Integrates the family townhome residents better

•

Launches the display of information on digital boards in the lobby (e.g., transit info, emergency information, etc.)

•

Utilizes appropriate documentation systems to track all work done with residents, especially as it relates to contract-required deliverables

•

Completes care plans and quarterly monitoring with residents needing referrals and follows up on all services at and after implementation

Services and Programming Grace West has designated areas on-site that serve as physical spaces where services and programming occur. For example, the community room and soon-to-be-completed multipurpose room in the Tower and the Club House, basketball court, playground, green spaces, and garden near the townhomes serve as physical spaces where programming and services across these three sectors align and are delivered cohesively, holistically, and synergistically. Medical care programs and services provided at Grace West include the telehealth program, podiatry, HIV testing, vision checks, colon

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screening, flu shots, and other chronic disease management and preventative health services. Soon, Grace West will have an on-site consultation room for medical services, such as podiatry, though mostly services are implemented in the Tower’s community room and the club house. The medical care offered at Grace West aim to “keep individuals healthy in their homes and communities” to lower individual and health care, housing, and social service system-level costs. On-site medical services at Grace West are unique in that they provide a direct mechanism for aligning preventative medical care with wraparound public health and social services within affordable housing. The variety of wraparound health and wellness programs provided by community organizations and organized by RSCs make up the public health programming offered at Grace West. Such programs include health education, fitness, (i.e., Zumba, yoga), and culture (i.e., crafts, chorus, drumming), mindfulness, and after-school programming (including academic support and enrichment, safe and supervised playtime, etc.), summer camps for youth, and more. The public health programming plays an important role in providing relevant and needed services and programs to support resident health and wellbeing other than through direct medical care provision. Public health programming at Grace West aims to ameliorate toxic stress, provide opportunities for social cohesion, community empowerment, and collective efficacy, and to create enriching experiences and recreational activities such as academic, arts, athletic, and cultural activities free of charge. These public health efforts enable residents to enjoy stable, affordable, safe, connected, and healthy housing. Social services at Grace West, including those provided by the RSCs and community manager, include linking residents to health and material benefits, such as SNAP (food stamps), Medicaid, Medicare, subsidized phones, access to food and transportation, energy bill assistance, and job placement

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support. Grace West functions as a social service hub linking medical care, public health, and other social services by serving as a central location for separate services and programs to come together. Providing comprehensive services in an affordable housing setting allows for aligned care provision and the opportunity to meet the multifaceted needs of residents. Leveraging housing as a venue for connecting these systems and services also reduces access barriers for residents thereby increasing efficiency (i.e., time, costs, recruitment, and travel) for residents and service providers alike. There are numerous key institutions, collaborators, and community partners that provide medical, public health, and social services and programs at Grace West, which are outlined in table 1. Programming and services happen all year-round and attendance often depends on the day, the topic or focus of the programming, and if there is food served at the program. Typically, about 15 residents show up to a program and it is often a core group of the same residents. Lately, there have been a lot more new residents and the RSCs are employing the method of having everyone bring a neighbor to a program and to pass the word around to get more Grace West community members involved. The RSCs also use newsletters, bulletin boards, floor captains, flyers, and monthly meetings to convey programming opportunities to residents. Depending how residents feel about a certain program or service, RSCs will attempt to find more opportunities to work with a certain community partner to continue providing the service. One example of this is that the residents have liked a certain Zumba instructor and an art class for seniors that lasted for 8 weeks such that the RSCs have continued to have the same instructor and offer the art class again. RSCs state that it’s “50-50 whether or not a resident will tell them if they’re having a problem or a neighbor will let them know,” otherwise RSCs will know by their behavior or mood or because management or the community manager told the

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RSCs that they were late on rent or some other resident-issue. Additionally, RSCs report that a lot of referrals to them come from security or maintenance telling them about the condition of their home/ unit, the company the residents are keeping, visitors they are having, what they were like when they came in through the tower (e.g., drunk etc.). The RSCs find that its harder to follow-up with residents of the townhomes because they are often quiet during the day and they are more spread out; if they hear about an issue it is usually by word of mouth that “a parent isn’t home or the kid was outside until late.” RSCs have also created a health ambassador program where the resident floor captains are ambassadors to engage and enroll other residents in health programming on-site, such as the telehealth program. SUMMER CAMP AND AFTER-SCHOOL PROGRAMMING FOR CHILDREN AND YOUTH Other important programming that happens on-site includes the after-school program and summer camp programming for children and youth that is driven by the full-time RSC who focuses mostly on the townhome and family residents. The summer program incorporates programming through outside partnerships with some of the organizations mentioned in the table in addition to programming that the RSC plans. The programming occurs at the Club House on-site, which has common space, a room set up with a classroom, a full kitchen, two bathrooms, a computer lab, front desk, and the Family RSC’s office. Each day starts with free, nutritious breakfast at 8am and programming starts at 9am. They also provide the children with lunch at 12pm and the kids are dismissed at 2pm. Breakfast and lunch are delivered daily and always come with fruit, 100% juice, milk, and a nutritious snack. After lunch, they typically have some quiet time, movies, a power hour of “homework” to keep the kids academically sound over the summer, do arts and crafts, and have mindfulness activities like animal yoga or

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meditation. The summer program is open to all kids at Grace West as well as kids from the surrounding community. The entire program is free. The majority of the kids who are in 3rd grade or are younger, have a grandparent or family member or friends on-site who they go home with after programming. The kids in 4th grade are able to walk home after the programming if they have a signed permission slip or they too will go home with friends on-site for playdates. Often the older kids stick around after programming and play on the playground with the other kids for the rest of the afternoon. This past summer, through the City of Newark, there was a Newark Summer Employment Program for youth through which high school students got paid to work and assist at the camp. One of these helpers was a youth who used to live at Grace West and still came back to visit family. Additionally, there are 4 seniors on-site who volunteer to assist with the summer programming. The after-school programming is similar in nature to the summer camp programming and usually involves homework help, time for arts and crafts, free time on the computers, and other activities. The after-school program typically has about 15-20 kids at a time. Programming and Services for Adults and Seniors One example of services and programming for adults and seniors at Grace West is the Telehealth Intervention Program for Seniors (TIPS) offered on-site through funding from Fannie Mae to support a collaborative partnership between the Community Opportunity Fund, Pace University, the, Westchester County Department of Senior Programs and Services (DSPS), Vital Care Services (VCS), and Columbia University Mailman School of Public Health. Through TIPS, HIPAA-trained Telehealth Technical Assistants (TTAs) measure residents’ blood pressure, blood oxygen levels, weight, and pulse rate and ask them a series of health status questions. The information is entered into a tablet and is instantly transmitted through a dashboard/ database system to a telehealth nurse. As opposed to telemedicine, TIPS is a remote patient monitoring platform whereby a telehealth nurse receives the screening data and makes appropriate recommendations. If a participant’s readings trigger an alert based on pre-programmed alert criteria, the telehealth nurse will call the participant and often a primary care provider or caregiver (if they have consented to this). If necessary, participants will be referred to visit a medical provider or go to the emergency department. Implementing TIPS at Grace West calls for the required alignment of wraparound social services with preventative healthcare further solidifying the alignment of medical, public health, and social services within affordable housing. For example, the RSCs attend and are involved during the twice-weekly provision of TIPS on Tuesday and Friday afternoons (1pm to 4pm) for seniors and evenings (5pm to 7pm) for families, such that they can provide social support services, including making sure participants have cell phones so that the telehealth nurse can call them and connecting them with other necessary referrals and social benefits as needed. Additionally, the RSCs coordinate concurrent services and programming, so that TIPS participants can, for example, also receive vision checks or participate in fall prevention programs (Larkin, 2018; Price & Whitacre, 2016). On an average TIPS program day, which started in mid-September, approximately 30 seniors will come to the Community Room and approximately 5 or so of the family residents will go to the Club House to participate in the program. Overall, at the time of data collection, 110 seniors and 35 adult family residents were participating in TIPS, but it is not necessarily the same people who come each program day. The senior residents in particular seem to really love TIPS, according to the RSCs and will show up at 8am to sign up to be the first in line to get checked. Seniors are excited to get their weekly checks and to tell the RSC and everyone they see that “their numbers [BP, heart rate, etc.]

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are better!” The TIPS RSC has noticed even though the Senior RSC has many programming and service opportunities for the seniors, she has noticed that many of the senior residents do not have primary care providers and when something is wrong they go to the ER or urgent care because they do not have a regular healthcare provider. That is now a wraparound service connected to the TIPS program that the RSCs are trying to coordinate and support residents in finding primary care providers. An issue that arose during programming was that many residents, seniors in particular, did not have phones in order for the nurse to call and check-in on participants. The RSCs have arranged to get residents free cell phones that include free minutes based on whether someone has Medicaid, Medicare, both, income level, and or food stamps. The Tenant Association The tenant association is a 501(c)(3) organized by residents at Grace West. All residents can be duespaying participants and there is a tenant association board. The board includes the President, Vice President, Secretary, Chaplain, and Sargent of Arms. The monthly dues are minimal, but they allow the

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Association to put on programs such as an annual barbeque, and also to provide monetary assistance and support to sick and/or bereaving residents who are in the hospital or who have lost someone close to them. Additionally, they hold fundraisers and trips, such as a bus ride to Atlantic City. They also work with the RSCs to plan thanksgiving and mother’s and Father’s Day events. The tenant association also serves as an advocacy group for the rest of the residents on behalf of their tenant rights. According to the Senior RSC, when the residents have any concerns, they usually bring it to the Association President and the board will then put it in writing and take it back to management. If it is something that management cannot solve, the Association will bring it to City Hall. For example, when there was construction on the community room, it was still open to the residents. The workers were given masks to wear to protect them from the dust, but the residents were not and so they took that issue to the city. According to the community manager, the building is majorly tenant-driven, as evidenced by the Tenant Association and program participation. Residents just want to be involved and included in everything, which is partly why the tenant association functions so well at this site. Interestingly, city officials and community police are very involved in the building, regularly come to the tenant association meetings, and residents think this is great.

IMPACT OF THE COO MODEL AT GRACE WEST The RSCs report that from what they have heard from residents and families, is that this housing complex and the community has been changed for the better. Residents talk to them about how Grace West used to be and how dangerous it felt and how much better the community and environment is now. Residents say that all the seedy people have been weeded out, that they are gone, and that Grace West is a safer, happier place. The RSCs think that this is a result of multiple factors, but that JRCo’s acquisition of Grace West and the implementation of the CoO Model are major reasons why this is the case. The construction has made apartment have a brand new feel. The gates and key fobs have given residents an even greater sense of community and environment. There is more of a positive community feel because of the playground, community rooms, basketball court, and club house. The playground is central, enabling residents to see children playing after school. The basketball court, according to the RSCs, gives residents a positive feeling, drawing people out and into the space. The RSCs are grateful for these spaces that facilitate engagement. The long-standing Grace West residents who have been living there for 20, 30 years can truly attest to the positive changes that have been made. Additionally, they care about the community, which inspires residents to take pride in the community and get involved. The community manager told the research team that she has worked in many different affordable housing sites, and she has “never seen anything like the massive level of participation at Grace West.”

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Chapter 7 Proposed Research Design The proposed project aims to determine the effects of the CoO Model on resident health and well-being by developing, piloting, and validating a new scale that measures the attributes of affordable housing related to these outcomes.

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ABSTRACT Members of the research team from the Dartmouth Institute for Health Policy & Clinical Practice, Enterprise Community Partners, Harvard University T.H. Chan School of Public Health, JRCo, and Success Measures at NeighborWorks America, alongside Columbia, researched and collected information to develop the aims, research questions, research design, data collection methods, data sources, statistical analyses, hypotheses, limitations, sample size, and power of a future study rigorously evaluating the CoO Model as implemented in JRCo affordable housing properties. The proposed project aims to determine the effects of the CoO Model on resident health and well-being by developing, piloting, and validating a new scale that measures the attributes of affordable housing related to these outcomes. The long-term goal of this project is to generate sufficient evidence to support systems-level change and implement the CoO Model across the affordable housing and community development fields. The project will be a natural experiment of JRCo properties across the country, including a mix of senior and family housing, old and new construction, and pre- and postreconstruction buildings. Data collection will come from a variety of sources and methods, including annual resident surveys, JRCo administrative data, primary data on environmental conditions, and neighborhood contextual factors using Opportunity360. The primary outcome will be the SF-12 component score averaged across all residents at a property at baseline and follow-up; all analyses will be conducted at the property level. Secondary outcomes include resident satisfaction. Properties will be characterized at baseline and follow-up based on building conditions and resident services, creating four comparison groups. We hypothesis that 1. Residents of properties in the treatment groups will have better health and well-being than those in the control group at baseline; 2. Residents of properties with favorable surrounding community conditions will have better health and well-being at baseline and interactions between these factors and model compliance will have a dose-response relationship with regard to outcomes; 3. Residents of properties that undergo improvements in coo model scores will have corresponding improvements in generic and population specific scales from baseline to follow-up; and, 4. Resident services will improve residents’ health and well-being and costs of providing these services will be offset by increased occupancy and rent collection and reduced evictions and maintenance costs. METHOD Narrative Theory of Change Researchers across the collaborative team compiled information from the Knowledge Landscape to create a narrative theory of change for the CoO Model. This narrative theory of change incorporates a vision for the future of the CoO Model, which ultimately aims to create systems-level change across the affordable housing and community development fields such that the Model is implemented widely across these fields affording all people the opportunity to be happy, healthy, and connected. Figure 1. (see pages xxx/xxx????) lays out this theory of change starting with the drivers that inform the CoO Model, the activities and strategies that will accomplish its implementation, the expected short-, mid-, and long-term outcomes of implementing the Model, and the goal and vision for the CoO Model. Though this vision and theory of change could not be accomplished in a single study or intervention, this is what we, as a research team, aspire to accomplish through validating, implementing, evaluating, and disseminating the CoO Model over time.

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Aims We aim to determine the effects of the Communities of Opportunity (CoO) Model on resident health and well-being by developing, piloting, and validating a new scale for measuring the attributes of affordable housing that are related to these outcomes. Our long-term goal is to generate sufficient evidence to support changes at the systems-level to provide incentives for widespread implementation of the CoO Model across the community development and affordable housing fields. Research Questions 1.

What are the resident health-related outcomes (including self-efficacy) associated with full adoption of the CoO Model, as implemented in selected affordable housing settings and defined by a quantifiable CoO-rating scale?

What effect does the CoO Model have on outcomes related to the health of residents of JRCo properties? Do these effects vary depending on the CoO scale rating?

How do surrounding community conditions influence the uptake and health-related impact of the CoO Model?

What is the relative cost-effectiveness of CoO model implementation in affordable housing settings?

Research Design The design for this research is a natural experiment which capitalizes on a large, geographically diverse portfolio of multi-family affordable housing at various stages of improvement. These properties include a mix of elderly and family housing, old and new construction, and pre- and postreconstruction buildings, from throughout the United States providing a rich substrate for evaluating the COO Model under different conditions. Data Collection This research will rely on data collected from a variety of sources and methods. Residents will be surveyed annually to gather information regarding demographic characteristics, generic and population-specific health and well-being, and health-related resource use and costs. JRCo administrative data systems will be used to measure building characteristics, operations, and improvements. Community managers will be surveyed to collect data about resident services offered. Primary data on environmental conditions in the buildings will be gathered as described in the data sources section below. Data regarding neighborhood contextual factors will be measured using Opportunity 360, which is a national database that compiles information from the census and other national sources that is available at the ZIPCODE level. The annual survey of residents will be conducted through use of best practices for data collection in communities including helping residents understand the value of the survey process and how the data will be used, as well as integrating the data collection effort as seamlessly as possible into residents’ ongoing contacts with either property management staff or resident services staff, partners or volunteers. Success Measures at NeighborWorks America, an evaluation resource technical assistance and data collection tool provider will support the JRCo staff and academic research team in tailoring the survey process for the specific conditions in each affordable housing property. As a leading expert in evaluation of housing and community development outcomes, Success Measures has supported more than 900 community development organizations to conduct evaluations of a broad range of housing,

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resident services and community development initiatives. In these efforts, Success Measures has assisted organizations in ensuring quality data collection to achieve desired response rates through outreach and implementation processes that are clear, transparent and build trust. Success Measures would guide the overall process and train the staff or volunteers who will be responsible for survey administration at each property. The following describes a range of best practices that the team will employ to administer the survey with residents of affordable housing properties: •

Tailor the overall data collection process for the specific community culture and history of relationships in each property, including the conditions in the property and surrounding community at the time of the survey, the level of trust that has been established in the property, whether or not there is a resident service coordinator and set of resident service programs operating, other existing relationships among residents and property staff and other opportunities for resident engagement.

•

Ensure good, engaging, clear upfront communication about the purpose of the survey, including making sure residents understand how the information will be used by the JRCO and the research team and how residents will be able to be engaged, if possible, to help make use of information from the survey to benefit the community of residents living at the property.

•

Identify ways residents can support the data collection process by spreading the word, creating a fun kick-off event or helping determine the best type of incentives for residents who complete the survey.

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Ensure privacy for individually administered surveys by methods that are most appropriate to the population – via interview, email, paper take away/return. Ensure that the survey is translated into all necessary languages if email or paper based, or that that appropriate translators are available if interviews are being conducted.

•

Time the survey effort to ensure it works well for both the property and the residents and that supports, such as childcare, are provided as needed. Also ensure that any special needs that residents have related to survey administration are met. For example, if interviews are used, offer to conduct them over multiple weeks, times of day and days of week to allow for various work and childcare responsibilities. If email or paper administration is used, plan for multiple follow-up rounds that are in keeping with how residents receive information from the property or that work best given language, literacy and other factors.

•

Ensure good communication of aggregate survey results in ways that are meaningful to residents. This includes using posters, social media, resident meetings or other engaging methods to share preliminary results so that the survey process enhances the overall Community of Opportunity model to strengthen resident engagement, leadership and agency.

DATA SOURCES Building Conditions and Resident Services To pilot our methods for collecting data on building conditions, we conducted a case study at Grace West Manor, a JRCo property in Newark, NJ. Data was collected from JRCo internal databases and from field interviews with key property staff. To gain a robust understanding of Grace West Manor, we sought to collect data on building operations, building management, general polices, resident demographics, on site social services, and planned capital improvements to the building. We expected much of this data to be easily accessible via RealPage (property management software). Challenges arose around staff’s understanding on how to run these reports, and accuracy of data in JRCo’s systems. Of specific concern is the accuracy of the resident demographic data collected. 138

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Resident demographics are collected after a resident’s application has been accepted, and thus are not compulsory for residents to complete. Properties may not be well enough staffed to collect this information, and residents may opt not to give this information. JRCo is taking steps to improve the consistency and accuracy of demographic data collection. Researchers aimed to collect data about staffing structure, building policies, HUD guidelines being followed at Grace West, subsidies used by residents, capital improvements, and overall building characteristics. Building characteristics, such as number and type of units, square footage, number of stories, and general capital improvement plans were available via the project profile on Jonathan Rose Companies’ Website. The current full scope of work, which outlines all improvements to be made and the financing plan, was requested from JRCO’s acquisitions team; researchers were asked to sign a NonDisclosure Agreement before it could be released to them. To expedite the process, researchers agreed to use only publicly available information. If this data was required for properties across the portfolio, sharing of confidential information could become a larger challenge. It could be that, with clarification of the level and detail of information required, an NDA may not be necessary, but this would need to be resolved prior to the rolling out of this process to the rest of the portfolio. Current building conditions were ascertained by observation, building data, and field interviews. Data about work orders and general policies were gathered through interviews with the on-site Property Manager. The Property Manager was able to answer what type of work orders are most common, processes for tracking orders, and how they are prioritized. Service request and work order information is also tracked in RealPage. A RealPage report can be run for this information, but the ease and speed with which this report can be produced depends greatly on a Community Manager’s familiarity and comfort level with the database. Property managers can answer general questions such as “what work order are most common,” and “how quickly are work orders typically complete” anecdotally, but to get hard numbers are dependent on running a report. A recent process improvement at the property level could improve maintenance data accessibility. Maintenance staff are now equipped with Ipads or other handheld technology to record maintenance orders, action and completions. Demographical information for each of JRCO’s properties is housed in RealPage. Reports can be run per property, or on a portfolio-wide basis. Theoretically, these reports can be easily pulled. In practice, the ease of gathering this information varies greatly on the technical skills of each property’s Community Manager. Additionally, across JRCo’s portfolio, demographic data on residents is thought to be unreliable due to the optional nature of this data request, as well as confusion in the way questions are posed and the fields available to residents to choose from. As stated above, work is currently being undertaken by JRCo to improve the collection of this information. The research team sought to collect data on categories of programming provided at Grace West, participation numbers, how programming is delivered, and community partners. Data on types of programming and participation numbers was gained through reports from Jonathan Rose Companies’ Social Impact team and field interviews with Social Service staff. Jonathan Rose Companies utilizes a customized tool created by Success Measures to collect output data from all properties on types of resident services offered, participation numbers, as well as which programs are resident led or supported by resident volunteers. This data is routinely collected on a monthly basis; if this data were needed for properties across the portfolio, it would be easy to gather and share. Additional information about resident services was gathered by interviews with the three on-site Resident Service

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Coordinators (RSCs) at Grace West. Two of the three RSCs are full time employees, and one is part time and dedicated to the on-site telehealth program at Grace West. Through these interviews, researchers were able to gain a fuller understanding of the breadth of community partners, and how programming is delivered on site. Challenges in collecting data arose concerning confidentiality and usage of JRCo’s databases. Additionally, much of the sought-after data was only accessible by field interviews with property staff, which could pose a challenge if data was required on a portfolio-wide scale. Gathering this data would require staff time, and reliability of the data would be dependent upon staff narrative and understanding of operations and resident services. Overall, researchers were able to gather the data requested, though some barriers presented. Being that this data was required just for one property, additional challenges may present themselves if researchers were to seek data on a larger scale. Existing databases can be refined for increased ease of use, and with property training for staff, these databases can be utilized to provide researchers with almost all the data requested. Environmental Conditions Many potential approaches can help to identify, quantify and track building conditions that may be associated with occupant health. We propose that existing data sources (e.g., work orders, maintenance records, energy usage, capital improvements) and the collection of data directly from residents or site managers and staff can all provide useful information to measure the extent to which building sites minimize environment health risk. Resident Surveys and Inspections Several approaches have been employed for understanding environmental exposures and health risk including both individual indicators (e.g., secondhand smoke risk) and summary measures that encompasses several domains (e.g. a summed index for household exposures which includes mold, combustion by-products, secondhand smoke, chemicals, pests, and inadequate ventilation). For the proposed project, we plan to build upon our previous household-level studies to develop tools that utilize existing administrative data to create similar benchmarks. Screening tools and short resident surveys will be used to identify those conditions variables which best indicate environmental exposure risk. Properly conducted resident focus groups can also provide valuable information on resident priorities, concerns, in-unit conditions, and process-related issues. Work orders Provide insight into various elements of building performance and occupant experiences directly relevant for environmental exposures. Tenant-initiated work orders tend to highlight issues of highest importance for occupant comfort, satisfaction and safety. In our prior work, we categorized a database of individual Work Orders into broad categories that could be related to occupant health, comfort and satisfaction. These categories were: appliances, mold/flaking paint, pests, plastering/tiles, plumbing, heating, windows, lighting, and toilets. All remaining records were placed in an “other” category. Building-level data and reports Third-party rating systems can also be used to define building conditions or system attributes in ways that are useful to our proposed model. For example, the Enterprise Green Communities Criteria specifically defines properties by degree of rehabilitation. While qualitative, this categorization can be useful in site comparisons at baseline and throughout an intervention. For example, Enterprise defines 140

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moderate rehabilitation as, “a project that does not fully expose the structure and envelope of the building and/or does not include replacement or improvement of two or more major systems of the building, yet is still able to comply with the energy performance requirements of at least one iteration of Criterion 5.1.” Substantial rehabilitation is defined as, “a project that includes the replacement and/ or improvement of at least two major systems of the building, including its envelope. Major building systems include roof structures, wall or floor structures, foundations, plumbing, heating and air conditioning, and electrical systems. The building envelope is defined as the air barrier and thermal barrier separating exterior from interior space.” Many common building improvements have been shown to positively affect indoor environmental quality. Residents Health and Well-Being i.) Generic Health Status and Well-Being The Medical Outcomes Study Short Form (SF-12) will be used to measure health-related quality of life. The SF-12 measures eight attributes of health status: physical functioning, role limitations attributable to physical health, bodily pain, general health, vitality, social functioning, role limitations resulting from emotional issues, and mental health (psychological distress and well-being) which can be summarized into physical and mental component summary scales. The SF-12 was chosen for its brevity and because it has been shown to be valid and reliable for use in low-literacy and low socioeconomic populations. In addition, the SF-12 has been mapped to preference-based health states, scored from 0.0 (worst health state) to 1.0 (best health state), which are required for the assessment of quality-adjusted life years (QALYs) in analysis of the cost-effectiveness of interventions. ii.) Demographics and Population-Specific Health Status and Well-Being The study team will develop a custom health status and well-being survey, similar to the Healthy Housing Outcomes Survey (Enterprise Community Partners & Success Measures at NeighborWorks America, 2019; https://www.buildhealthyplaces.org/content/uploads/2018/12/Enterprise-HealthyHousing-Outcomes-Survey.pdf). This survey was developed by Enterprise Community Partners and Success Measures to assess the impact of stable, healthy housing within properties supported through Enterprise’s investment funds. It is comprised of questions from the Success Measures Health Outcome Tools, a set of 65 measurement tools that were specifically designed to measure the health outcomes of housing and community development programs (Mulcahy, 2017; www. successmeasures. org/healthtools). These tools were most recently used and re-validated through the national Health Outcomes Demonstration Project, a collaboration between Enterprise and Success Measures supported by the Robert Wood Johnson, Kresge and Hearst Foundations, in which 20 housing organizations across the country evaluated their residents’ health outcomes and behaviors. The project’s final report outlines this 3-year effort (De Scisciolo, S., et al., 2019; www.successmeasures. org/healthoutcomes). In addition, to ensure that all aspects of the CoO model are covered through the survey, the study team will draw on other Success Measures tools that assess outcomes of community engagement, resident service, financial capability and resident leadership programs, among others. The Success Measures’ library of 350+ data collection tools reflect an approach that is grounded in the realities of low-wealth communities and is inclusive and respectful of diverse cultural norms. https://successmeasures. org/ measurement-tools. These surveys and other tools have been very broadly used in the community development field to understand social connectedness, resident satisfaction, perceptions of safety

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and community engagement in several large, longitudinal evaluation efforts. For example, over the last 13 years, 70+ community-based grantees in the Wells Fargo Regional Foundation’s neighborhood revitalization funding programs for Eastern Pennsylvania, Delaware and New Jersey have used these tools to conduct neighborhood quality of life surveys at five-year intervals to demonstrate outcomes from the Foundation’s investments in resident-led neighborhood initiatives. Similarly, NeighborWorks America has used these tools in its Community Impact Measurement Project, one of the largest multi-site evaluations of housing and community development outcomes. Since 2013, 190 of the housing and community development nonprofits that receive grant funds and other support as members of the national NeighborWorks Network, have followed a common evaluation protocol at three-year intervals to conduct random sample surveys of neighborhood quality of life, social capital and related community engagement and revitalization outcomes. Through this effort, the local organizations demonstrate outcomes meaningful at the local level and NeighborWorks America can look across its portfolio to document its community level impacts. The study team will use the Success Measures Data System (SMDS) to administer the custom health status and well-being survey. SMDS is a specialized web-platform that provides access to the Success Measures tools and a secure, user-friendly and efficient way to collect, analyze and manage outcome data over time. Resource Utilization and Costs i.) Healthcare Cost Measures We will use utilization events, (e.g., MD visits, ambulance use, ED visits, hospital admissions, hospital readmissions) as well as out of pocket costs (e.g. prescription drugs) to serve as proxy measures of healthcare costs. Validated self-report measures of utilization have been widely used in major research studies when claims data are not readily available. The investigators have extensive experience in using both self-reported utilization as well as claims data for major national research projects. ii.) Property Owner Costs JRCo administrative data will be used to measure resource utilization and costs before and after implementation of resident services. Costs will include those related to resident services staffing, occupancy, maintenance, and evictions (lost rent, eviction service fees, moving/storage fees, court filing costs, and cleaning/repairs). Neighborhood Attributes Neighborhood attributes will be evaluated and documented using both primary and secondary data sources. As a first step, the study team will use Opportunity360 to gain a comprehensive view of neighborhood conditions along five key dimensions of opportunity: housing stability, education, health and well-being, economic security and mobility. Opportunity360, developed by Enterprise Community Partners in 2017, is an inclusive approach to understanding and addressing community challenges by identifying the pathways to greater opportunities using cross-sector data, community engagement, and measurement tools. Opportunity360 brings together over 150 data indicators from 37 different data sources to provide an in-depth assessment of community conditions at the census tract level (Enterprise Community Partners, 2019; https://www.enterprisecommunity.org/ opportunity360). Data from Opportunity360 will be augmented by other secondary data sources, such as the 500 Cities Project sponsored by the Centers for Disease Control and Prevention and the Robert Wood Johnson Foundation (CDC, 2017; https://www.cdc.gov/features/500-cities-project/index. 142

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html) and the Opportunity Atlas (Opportunity Insights at Harvard University, Darkhorse Analytics, & United States Census Bureau, 2019; https://opportunityatlas.org/), a tool based on the work of Raj Chetty, which focuses on economic mobility, as well as any local data sets, that will provide additional information about neighborhood conditions. While secondary data can provide a general assessment of a neighborhood’s attributes, it cannot replace the insights of those living in the community. The study team will engage in primary data collection methods, such as story mapping; interviews and focus groups of community groups, residents, and business owners; ethnographic observations; and windshield surveys. Records of community meetings, visioning exercises, etc. will also be reviewed. This primary data collection effort will provide a rich and multi-layered community assessment to gain important insight on how the residents of JRCo properties perceive and interact with the broader community. STATISTICAL ANALYSIS All analyses will be done at the property level. The primary outcome variable will be the SF-12 physical (PCS) or mental (MCS) component score averaged across all residents of a given property at baseline or follow-up. Secondary outcomes will include resident satisfaction with various aspects of their housing. Properties will be characterized at baseline and follow-up to the extent to which each conforms with the CoO model along two dimensions: building conditions and resident services. These dimensions will be used to form four comparison groups which will serve as the primary exposure variable of interest. a.) Hypothesis 1 Hypothesis 1: Residents of properties in the treatment groups will have better health and well-being (as measured by SF-12 PCS and MCS) than those in the control group at baseline. For analyzing our primary outcomes, we will use maximum likelihood estimation for longitudinal mixed-effects models (a type of statistical model that contains both fixed effects and random effects). These models are particularly useful in settings where repeated measurements made on the same subjects over time, or where measurements are made on clusters of related statistical units (residents within properties in this case). These models will include the SF-12 PCS or MCS as the outcome variable, treatment group as the primary exposure variable, and resident demographic characteristics as covariates. For secondary outcomes (e.g. resident satisfaction with various aspects of property), longitudinal logistic regression models will be fitted using generalized estimating equations as implemented in the PROC GENMOD program of SAS (SAS Institute Inc., Cary, NC). These models are commonly used in large epidemiological studies, especially multi-site cohort studies, because they can handle many types of unmeasured dependence between outcomes. Treatment effects will be estimated as differences in the estimated proportions in the 4 treatment groups. P<.05 (2-sided) will be used to establish statistical significance. For the primary outcomes, 95% confidence intervals (CIs) for mean treatment effects will be calculated at each designated time point. Global tests of the joint hypothesis of no treatment effect at any of the designated periods will be performed using Wald tests as implemented in SAS. These tests account for the intraindividual correlation due to repeated measurements over time.

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b.) Hypothesis 2 Hypothesis 2: Residents of properties with favorable surrounding community conditions will have better health and well-being at baseline and interactions between these factors and model compliance will have a doseresponse relationship in regards to outcomes. Interaction terms will be included in the models described above to evaluate the effects of surrounding community conditions (as measured by Opportunity 360) on the relationship between treatment group and outcomes. Neighborhood attributes measured by Opportunity 360 include: housing stability, education, health/well-being, economic security, and mobility. c.) Hypothesis 3 Hypothesis 3: Residents of properties that undergo improvements in COO Model scores (due to building reconstruction and/or resident services upgrades) will have corresponding improvements in generic and population specific scales from baseline to follow-up. Predetermined end points for the study will include results at baseline, and every 6 months for 3 years. To adjust for the possible effect of missing data on the study results, the analysis of mean changes for continuous outcomes (SF-12 PCS and MCS) will be performed using maximum likelihood estimation for longitudinal mixed-effects models under “missing at random” assumptions and including a term for JRCo property. Comparative analyses will be performed using the single imputation methods of baseline value carried forward and last value carried forward, as well as a longitudinal mixed model controlling for covariates associated with missed follow-ups. d.) Hypothesis 4 Hypothesis 4: Resident services will improve residents’ health and well-being and costs of providing these services will be offset by increased occupancy and rent collection and reduced evictions and maintenance costs. Resident Services Coordinators typically assess residents’ needs, identify available services, and match residents to services tailored to meet their goals. While the resident services coordinators are typically employed by property owners, the services themselves are typically funded through a mix of public agencies and private/charitable sources. For this reason, our cost-effectiveness analysis will take a property owner perspective. The primary endpoint for the cost-effectiveness analysis will be the incremental cost-effectiveness ratio (ICER). To estimate the ICER, average total costs and average quality adjusted life years (QALYs) from baseline to 2-years will be estimated for each treatment group. The ICER is defined as the difference in mean total costs between treatment groups, divided by the difference in mean QALYs as follows in Figure 2. Our measure of intervention effectiveness will be the QALY as derived from the SF-12. We chose this measure for its brevity and because its proven valid and reliable as a health status measure for low literacy and low socioeconomic status populations. Furthermore, the SF-12 has been mapped to 144

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preference-based health states, scored from 0.0 (worst health state) to 1.0 (best health state), which are required for the assessment of QALYs. JRCo administrative data will be used to measure resource utilization and costs before and after implementation of resident services at intervention and control sites. Costs will include those related to resident services staffing, occupancy, maintenance, and evictions (lost rent, eviction service fees, moving/storage fees, court filing costs, and cleaning/repairs). Since health-related resident services are aimed at increasing use of preventative care and decreasing use of emergency/acute care, we will also measure resident health resource utilization by surveying residents about out of pocket medication costs, physicians’ visits, emergency department visits, and hospitalizations. Separate models will be fit for QALYs and costs. We will use maximum likelihood estimation for longitudinal mixed-effects models (a type of statistical model that contains both fixed effects and random effects). These models are particularly useful in settings where repeated measurements made on the same subjects over time, or where measurements are made on clusters of related statistical units (residents within properties in this case). These models will include the mean QALYs or mean change in costs as the outcome variable, treatment group (intervention versus control) as the primary exposure variable, and resident demographic characteristics and neighborhood contextual variables as covariates. Limitations. Our study design is a natural experiment. The greatest threat to the validity of these types of studies are uncontrolled confounding. In a randomized, controlled experiment, in contrast, both known and unknown confounders are assumed to be equally distributed among treatment groups by random assignment of the intervention. Fortunately, we will have a rich database that will allow adjustments for important determinants of health including resident demographics and socioeconomic characteristics as well as neighborhood contextual variables. Another limitation of our study design is the inability of investigators to control the timing of intervention. Funding streams for building greening and resident services and other housing related policy changes are complicated and beyond the purview of researchers. However, the JRCo portfolio of affordable housing properties is large and diverse and undergoing perpetual improvements providing a rich variety of conditions for study. Sample Size and Power. These calculations assume that every individual is measured at baseline and follow-up and the resulting difference in the SF-12 summary scale scores have a standard deviation of 4. To the extent that the standard deviation of the difference is smaller than 4, the sample-size calculations will be conservative (i.e., an over-estimate of what we will need). Conversely, to the extent that different people are sampled at baseline and follow-up the sample calculations will likely be anti-conservative (i.e., an under-estimate of what we will need). In fact, we expect that there will be some turnover of residents between baseline and follow-up but not complete turnover. So, these numbers are a guide. For example, if the ICC is 0 (no clustering by site) we only need 25 residents per site (i.e., for each of the sites). If ICC is 0.05 then we need 54 residents per site (sampled at baseline and follow-up; See table 3.). For our cost-effectiveness analysis, we will rely on utilities derived from the SF-12, known as the SF-6D. For these analyses, we will compare two groups, sites that have CoO model aligned resident services and those that do not. Figure 2. shows the sample size required per treatment group under two scenarios, one where the utility values are normally distributed (Method 1) and one where it is not, and

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non-parametric methods are required (Method 2). This graph shows that with 150 or more subjects per group, our power would be exceed 80% under either assumption.

ENDNOTES 1. Supportive housing is housing that is designated for a specific population, usually families transitioning from homelessness, individuals with long term disabilities, and returning veterans. Supportive housing includes a suite of wrap-around services that help individuals and families become more self-sufficient. Supportive housing is not included in this scan. 2. Framework and Guidelines for the System of Resident Services Coordination, Stewards of Affordable Housing for the Future (2018), Accessed at https://www.sahfnet.org/rscframework Accessed February 20, 2019. 3. Certified Organization for Resident Engagement and Services, Stewards of Affordable Housing for the Future (date unknown), also see https://coresonline.org. 4. Framework and Guidelines for the System of Resident Services Coordination, Stewards of Affordable Housing for the Future (2018), Accessed at https://www.sahfnet.org/rscframework Accessed February 20, 2019. 5. Substance Abuse and Mental Health Services Administration. Retrieved May 15, 2018 from http://www.samhsa.gov/nctic. 6. Listen4Good is an initiative to help nonprofits create client feedback loops. https://www.fundforsharedinsight.org/ listen4good/. Net Promoter Score is a management tool for tracking customer loyalty and is different from evaluation

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