[Senate Hearing 109-599]
[From the U.S. Government Printing Office]



                                                        S. Hrg. 109-599
 
 NATURALLY OCCURRING RETIREMENT COMMUNITIES: A MODEL FOR AGING IN PLACE

=======================================================================

                                HEARING

                               BEFORE THE

                SUBCOMMITTEE ON RETIREMENT SECURITY AND
                                 AGING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS
                          UNITED STATES SENATE

                       ONE HUNDRED NINTH CONGRESS

                             SECOND SESSION

                                   ON

 EXAMINING NATURALLY OCCURRING RETIREMENT COMMUNITIES AND WHAT IMPACT 
 THEY MAY HAVE ON THE ABILITY TO CREATE LIVABLE COMMUNITY OPTIONS FOR 
                             ALL AMERICANS

                               __________

                              MAY 16, 2006

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions


 Available via the World Wide Web: http://www.access.gpo.gov/congress/
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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                   MICHAEL B. ENZI, Wyoming, Chairman

JUDD GREGG, New Hampshire            EDWARD M. KENNEDY, Massachusetts
BILL FRIST, Tennessee                CHRISTOPHER J. DODD, Connecticut
LAMAR ALEXANDER, Tennessee           TOM HARKIN, Iowa
RICHARD BURR, North Carolina         BARBARA A. MIKULSKI, Maryland
JOHNNY ISAKSON, Georgia              JAMES M. JEFFORDS (I), Vermont
MIKE DeWINE, Ohio                    JEFF BINGAMAN, New Mexico
JOHN ENSIGN, Nevada                  PATTY MURRAY, Washington
ORRIN G. HATCH, Utah                 JACK REED, Rhode Island
JEFF SESSIONS, Alabama               HILLARY RODHAM CLINTON, New York
PAT ROBERTS, Kansas

               Katherine Brunett McGuire, Staff Director

      J. Michael Myers, Minority Staff Director and Chief Counsel

                                 ______

             Subcommittee on Retirement Security and Aging

                      MIKE DeWINE, Ohio, Chairman

JOHNNY ISAKSON, Georgia              BARBARA A. MIKULSKI, Maryland
ORRIN G. HATCH, Utah                 JAMES M. JEFFORDS (I), Vermont
JEFF SESSIONS, Alabama               JEFF BINGAMAN, New Mexico
PAT ROBERTS, Kansas                  HILLARY RODHAM CLINTON, New York
MICHAEL B. ENZI, Wyoming (ex         EDWARD M. KENNEDY, Massachusetts 
officio)                             (ex officio)

                   Karla L. Carpenter, Staff Director

              Ellen-Marie Whelan, Minority Staff Director

                                  (ii)

  




                            C O N T E N T S

                               __________

                               STATEMENTS

                         TUESDAY, MAY 16, 2006

                                                                   Page
DeWine, Hon. Mike, Chairman, Subcommittee on Retirement Security 
  and Aging, opening statement...................................     1
Mikulski, Hon. Barbara A., a U.S. Senator from the State of 
  Maryland, opening statement....................................     2
Ginzler, Elinor, Director of Livable Communities, AARP, 
  Washington, DC; and Fredda Vladeck, Director, Aging in Place 
  Initiative, United Hospital Fund, New York, New York...........     4
    Prepared statement of Fredda Vladeck.........................     7
Clinton, Hon. Hillary Rodham, a U.S. Senator from the State of 
  New York, opening statement....................................    12
    Prepared statement...........................................    15
Keller, Joyce Garver, Executive Director, Ohio Jewish 
  Communities, Columbus, Ohio; Ann Sutton Burke, Program Director 
  of Options Cincinnati, Senior Adult Services, Cincinnati Jewish 
  Family Services, Cincinnati, Ohio; Julia Pierson, Director of 
  Senior Home Services, Senior Friendly Neighborhoods/CHAI, 
  Baltimore, Maryland; and Beth Shapiro, Manager, Community 
  Partners, Jewish Federation of Greater Washington, Rockville, 
  Maryland.......................................................    18
    Prepared statements of:
        Ann Sutton Burke.........................................    23
        Julia Pierson............................................    27
        Beth Shapiro.............................................    34
Letter to Senator DeWine from Ann Sutton Burke...................    25

                                 (iii)

  

 
 NATURALLY OCCURRING RETIREMENT COMMUNITIES: A MODEL FOR AGING IN PLACE

                              ----------                              


                         TUESDAY, MAY 16, 2006

                                       U.S. Senate,
Subcommittee on Retirement Security and Aging, Committee on 
                    Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 10:39 a.m., in 
room SD-430, Dirksen Senate Office Building, Hon. Mike DeWine 
(chairman of the subcommittee) presiding.
    Present: Senators DeWine, Mikulski, and Clinton.

                  Opening Statement of Senator DeWine

    Senator DeWine. Good morning. We apologize for being late. 
The Senate had a vote that was originally scheduled at 10 
o'clock. Then it was scheduled at 10:15. Then it was scheduled 
at 10:20 and so here we are.
    We welcome all of you to the Subcommittee on Retirement 
Security and Aging's first hearing on the topic of naturally 
occurring retirement communities.
    Let me thank Senator Mikulski. She will be here in just a 
moment. Barbara and I just voted on the floor. I know that 
NORCs are of great interest to her and I have had many 
discussions with Senator Mikulski about this topic.
    They are a growing phenomenon really in the always evolving 
aging network. Older Americans are an important and rapidly 
growing segment of our population, so the issue of aging in 
place, in the home, becomes even more important.
    We know that over 36 million people living in the United 
States are over the age of 65, accounting for about 12 percent 
of the current population. The Census Bureau projects that 45 
years from now people 65 and older will number nearly 90 
million in the United States and comprise about 21 percent of 
the population.
    As Senator Mikulski and I work on the reauthorization of 
the Older Americans Act, we are continually reminded of the 
needs of the aging baby boomer population. We know that our 
current infrastructure will not be able to handle the magnitude 
of this growing population. That is why we need to look to new 
models which will allow older persons to thrive while remaining 
in their own homes.
    There are real, important issues that come with the aging 
of a population. We are all aware of the needs of older 
Americans, which includes adequate nutrition, medications, 
accessibility of doctors, transportation to those appointments, 
opportunities to take part in social activities, the ability to 
care for themselves and, if they cannot, the ability to have 
someone help them care for themselves.
    Naturally occurring retirement communities occur across our 
Nation and can be excellent models for aging in place. As 
people age together, it makes sense to provide services to help 
them remain in their homes for many reasons, the most important 
being that they usually want to remain in their own homes. 
Also, this arrangement is better because it is cost-effective 
and minimizes the disruption in their lives. We can all 
understand how an older person would want to remain in his or 
her home for as long as possible. Family members cannot always 
be there to make sure that you are taking your medication or 
have a nutritious meal, but the supportive services offered in 
many NORCs can do just that.
    I look forward to our testimony today and I want to thank 
those of you who have arrived from out of town, including two 
witnesses from Ohio who will be on our second panel.
    Let me now turn to Senator Mikulski for any opening 
comments that she would like to make.

                 Opening Statement of Senator Mikulski

    Senator Mikulski. Thank you very much, Mr. Chairman, for 
convening this very important hearing on something called 
NORCs, the naturally occurring retirement communities.
    I have really been excited about this hearing and I have 
been excited over the fact that since 2001 we have been really 
funding local social demonstration projects to see what are the 
best ideas and the best practices to help people who are aging 
in place. This hearing, I think, will tell us then what is it 
that we have learned? What can we do to be both socially 
responsible in this area, fiscally responsible? Do we need a 
national program? Or should we keep on doing it the way we are 
doing it and leave it to local flexibility and initiative?
    These programs have been very important in helping people 
remain in their own communities, the community of a lifetime, 
to remain in a community where they feel part of an extended 
family offering the very important service and social 
infrastructure needed.
    I first learned of NORCs when I was either the Chair or the 
Ranking Member of the VA HUD Appropriations Committee.
    Through HUD, we heard about in our housing programs in both 
Baltimore and in the Washington suburbs sponsored by the United 
Jewish Communities, whether it was the Associated Jewish 
Charities in Baltimore or the Federated, about this compelling 
human need, people aging in place, people living in the same 
ZIP code.
    But it is not so much where they live. It is how they live. 
And because they were part of a community, they wanted to stay 
part of that community, close to family, close to doctors, 
close to friends. And therefore, while they had their social 
and medical network, what they needed was a social 
infrastructure to support that.
    That is what the NORCs did, but before I get into some 
national program and let us spend a lot of money, I knew that 
by turning to the UJC--in my case the Associated and the 
Federation--this would be a way of coming up with what really 
works, what really helps people, and how can we do it in the 
most cost-effective kind of way.
    We knew that through turning to the considerable expertise, 
and I know that there are over 22 projects that are going on.
    Senator DeWine, my very able colleague, is outlined what 
are NORCs and I will not go into that, and why there are these 
supportive models around social work, services, health, 
transportation, and access to health as well as those other 
social issues.
    For me, it has been about what I have seen in Baltimore. 
Run by the Baltimore Associated Jewish Community, we served 
over 1,500 seniors in 22 apartment buildings but all are almost 
contiguous to each other, and have been able to provide core 
services from information and referral, health services and 
important transportation. Baltimore focuses on a warm house 
concept and we are going to be hearing about how a warm heart 
got translated into a warm house concept and what this means.
    Also, then, when we look to Silver Spring/Rockville they 
were again serving 800 seniors, helping them with their 
doctor's appointment, the shopping. And again, that was in, I 
think, about all 11 apartment buildings.
    But again, it is not about buildings and programs. It is 
about people. Because of this intervention, people were better 
off. They were in compliance for their medical appointments, 
very important to remaining independent. They were able to 
maintain that access to friends and to family, very important, 
because there is more than one way to help a heart to stay 
well.
    And number three, they could do it knowing that they were 
not alone and that we dealt with the issues of loneliness, 
depression and isolation, a leading impediment to good health.
    So we look forward to hearing from the people who actually 
did the hands-on and the helping hand and to learn from their 
experiences.
    I want to thank you for the hearing.
    Senator DeWine. We turn to our first panel. Elinor Ginzler 
is our first witness. She is the Director of Liveable 
Communities in the Office of Social Impact at AARP. She is 
responsible for the development of strategic plans to achieve 
social impact goals for AARP in the areas of mobility and 
housing.
    Since joining AARP in 1998, Ms. Ginzler has been 
instrumental in overseeing programmatic work in these areas. 
She has over 20 years experience in service delivery systems to 
the elderly and worked collaboratively with public, private, 
nonprofit, and community-based organizations. She is also an 
expert in long-term care issues and served on several boards 
and task forces.
    She also co-authored the book Caring For Your Parents: The 
Complete AARP Guide.
    Our second witness will be Fredda Vladeck, who is the 
Director of the United Hospital Fund's Aging in Place 
Initiative. This initiative works to further the development of 
new service delivery models that address the critical issues 
presented by the growing number of people who are aging in 
place.
    She has been a certified social worker for almost 30 years 
and an advocate for the needs of older people and other 
vulnerable populations. She was the founding Director of the 
first comprehensive NORC Supportive Service Program at Penn 
South and has worked with others to replicate the program. 
There are now 33 such programs in New York City.
    Let me now turn to Ms. Ginzler. Thank you very much for 
joining us.

STATEMENTS OF ELINOR GINZLER, DIRECTOR OF LIVABLE COMMUNITIES, 
 AARP, WASHINGTON, DC.; AND FREDDA VLADECK, DIRECTOR, AGING IN 
   PLACE INITIATIVE, UNITED HOSPITAL FUND, NEW YORK, NEW YORK

    Ms. Ginzler. Good morning, Chairman DeWine and Ranking 
Member Mikulski.
    I am Elinor Ginzler, AARP's Director for Liveable 
Communities in the Office of Social Impact.
    On behalf of AARP, I thank you for the opportunity to 
discuss AARP's views regarding aging in place and what impact 
naturally occurring retirement communities may have on our own 
ability to create livable community options for the 50-plus 
population and all Americans.
    In AARP's landmark 2005 study, A Report to the Nation on 
Livable Communities: Creating Environments for Successful 
Aging, we define livable communities as having affordable and 
appropriate housing, supportive community features and 
services, and adequate mobility options, which together 
facilitate personal independence and the engagement of 
residents in civic and social life.
    Naturally occurring retirement communities were generally 
built many decades ago and originally served a mix of ages. 
Over time longtime residents grew older, fewer young families 
moved in. And except for age composition, there are few other 
defining characteristics of NORCs. They are frequently urban 
but they are also found in the suburbs. Many rural areas also 
have NORCs as younger residents have moved away for job 
opportunities and older residents have stayed.
    We know from AARP surveys that the vast majority of older 
adults want to stay in their homes and their communities. 
According to AARP's 2005 State of 50-plus America Survey, 89 
percent of those polled reported that they want to stay in 
their current residence for as long as possible and 85 percent 
want to stay in their community for as long as possible.
    And we also know, from Census data, that their behavior 
matches their words. Older persons move much less frequently 
than younger people. Only about 5 percent of people over age 55 
move in any given year, and about half of those move within the 
same county.
    AARP believes people should be able to age with 
independence, choice and control, and the ability to stay in 
their communities helps them do just that. NORCs offer a unique 
opportunity to develop service delivery methods that take 
advantage of efficiencies of scale. That is, providing services 
where concentrations of seniors are aging in place may make it 
possible to serve more older individuals at a lower cost, 
enhancing their ability to stay in their homes and avoiding 
expensive institutionalization.
    Also of interest, as a complement to supportive services, 
are programs that assist residents with maintaining the housing 
stock, including reauthorization and home repair. Preservation 
of this housing stock not only benefits current owners but 
helps assure a high-quality supply of housing for future 
residents.
    Understanding NORCs and the value of providing supportive 
services can help public and private policymakers plan more 
livable communities. When it comes to livability, most of our 
communities are now playing a frantic game of catch up and many 
others do not even realize what lies ahead.
    Expanding research on seniors living in NORCs should 
provide a broader picture of the significant contributions 
seniors make in their communities as volunteers, community 
leaders, mentors and teachers, and help demonstrate the many 
ways that intergene-
rational living enhances the community as a whole.
    Because NORC residents represent many types of people, 
research on NORCs should provide a more accurate picture of the 
status of healthy active seniors. This data could provide a 
valuable counterpoint to much of the current research which 
often focuses on the frail and homebound elders. The challenge 
then is to create livable communities with appropriate and 
affordable housing, adequate options for mobility, and the 
community features and services that can facilitate personal 
independence and continued engagement in civic and social life. 
The community-based services and NORC-related research grants 
funded by the Older Americans Act are critical to making this 
happen.
    But while increased resources are needed to explore the 
potential of NORCs and to better serve their residents, along 
with all older Americans, more money is not enough, and enough 
money is not likely to be made available in the current 
budgetary climate.
    In this light, AARP believes the enactment of S. 705, the 
Meeting the Housing and Service Needs of Seniors Act of 2005 is 
essential. As proposed, S. 705 would establish a Federal 
interagency council to not only coordinate service delivery but 
also monitor, evaluate and recommend improvements in existing 
programs and services that assist seniors in meeting their 
housing and service needs at the Federal, State and local 
level.
    We note for the record that the Senate passed this 
legislation by unanimous consent last November and we encourage 
you both to do all you can to encourage House passage before 
the end of this Congress.
    In sum, AARP applauds the Chairman and Ranking Member for 
their leadership regarding NORCs, as well as many other health, 
economic security and livable communities issues. We look 
forward to continuing to work together with you to ensure a 
healthy, secure and independent future for America's older 
population.
    Senator DeWine. Ms. Ginzler, thank you very much.
    Mrs. Vladeck.
    Mrs. Vladeck. Thank you, Mr. Chairman, Senator Clinton, 
Senator Mikulski. My name is Fredda Vladeck and I am the 
Director of the Aging in Place Initiative at the United 
Hospital Fund of New York.
    In 2005, there were more than 80 NORC supportive service 
contracts supported by funding. This is definitely a growing 
phenomenon. Approximately 43 contracts in 25 states were the 
result of congressional earmarks. And we are fortunate in New 
York to have a critical mass of program experience in both the 
housing-based model and the neighborhood-based model approach 
as a result of deliberate legislation and financing now at $10 
million enacted by both the city and the State. More than 
50,000 older adults live in multi-age communities served by New 
York's 43 NORC programs.
    I would like to emphasize three things that underlay the 
NORC supportive service program approach, distinguish them from 
other senior services, and make them a particularly important 
avenue of needed change to our system of service.
    The ultimate goal of NORC programs is, as we have said, to 
help transform communities into good places to grow old. 
Communities that support healthy, productive, successful aging 
and respond with calibrated supports as individual needs 
change. This means building these programs from the ground up 
so they are integral to the community and reflect not only the 
needs of residence which evolve over time but also their 
aspirations.
    Second, unlike many existing programs and services, 
eligibility for NORC program participation is on the basis of 
residential status, not on functional deficits or economic 
need. We know how to target a specific service to someone with 
a specific problem. I call it the one hip fracture at a time 
approach.
    But we are less good at shoring up the natural supports in 
a community, weaving and reweaving the social fabric or 
empowering older residents to take on positive roles in shaping 
the kind of community they think will be most supportive to 
them.
    Given these first two principles, successful programs must 
be partnerships that bring together the social capital, 
businesses and services in a community to effectively harness 
and target its resources to address the physical, social, 
emotional, health and environmental structural challenges faced 
by a community as it ages in. No single provider can do it all.
    In New York, these partnerships include at a minimum 
government, a housing entity where one exists, the residents, 
and health and social service providers. Often other leaders or 
community stakeholders are involved in the programs.
    As this committee deliberates ways to address the growing 
phenomenon of NORCs I offer the following recommendations. The 
term naturally occurring retirement community needs to be 
clearly defined and delineated for purposes of eligibility for 
funding. The original definition had some key elements that 
spoke to a geographic coherence, multiage or age-integrated 
buildings or neighborhoods, a specific density of older people 
in the community in order to achieve economies of scale. In New 
York, we define it both in terms of absolute numbers and 
percentages.
    New York State's legislation can be a starting point, but I 
think modifications will need to be made to reflect the density 
differences and types of communities found in other parts of 
the country.
    Second, we need to be clear about the purpose of a NORC 
supportive service program and how it differs from existing 
services. NORC funding should be value-added, not used for 
duplicating existing services or shoring up through a different 
funding stream our woefully underfinanced service systems. To 
be sure, they need money as well, but NORC programs are 
something entirely different.
    Third, we need to establish a set of standards that are 
enforceable and that get us to our goal of building community 
infrastructure to support aging in place. We should expect 
programs to produce improvements on a range of quality of life 
indicators for community dwelling seniors. Such things as level 
of connectedness to one another and to a program; improvement 
in key health indicators for older people; supporting new roles 
for older people; and establishing strong and consistent 
linkages with the primary health providers in a community are 
some important indicators of a community's ability to support 
aging in place.
    The Fund is working with the city of New York's Area Agency 
on Aging to develop a set of community health indicators for 
advancing healthy aging in place that will help us measure the 
program's impact and I would be happy to share the results once 
they are available.
    We need to also establish and fund a national research 
agenda that helps us understand the overall efficacy of this 
approach. Some have tried to claim that NORC programs prevent 
nursing home placement, as if nursing homes were the opposite 
of community living. But given the purpose of NORC programs, I 
think the lens through which we need to evaluate the NORC 
supportive service program approach is less about long-term 
care and much more about long-term living.
    I thank the members of this committee for the opportunity 
to testify and I am happy to answer any questions.
    Senator DeWine. We thank both of you very much.
    [The prepared statement of Mrs. Vladeck follows:]

                  Prepared Statement of Fredda Vladeck

    Mr. Chairman, members of the committee, my name is Fredda Vladeck. 
I am the director of the Aging in Place Initiative at the United 
Hospital Fund, a research, policy, and philanthropic organization 
focused on strategies to improve the delivery of services to vulnerable 
people in New York.
    It is a special pleasure to be here today. I have been involved 
with NORCS and the development of Supportive Service Programs since 
1985 when, along with UJA-Federation of New York, the residents of Penn 
South, and others, I developed and then directed the first NORC-
Supportive Service Program (NORC-SSPs). Since then, I have been 
involved in the evolution of NORC-SSPs in New York State and New York 
City, which together provides $8 million to support 42 public-private 
partnership programs in New York, with another $2 million in the works. 
I've also had the pleasure of working with the Administration on Aging 
and the Office of the Assistant Secretary for Planning and Evaluation 
as efforts have been made to disseminate this approach in other 
communities across the country. And with the support of the Daniels, 
the Weinberg, and the Samuels Foundations, we at the Fund are now 
working with program leaders and developers in seven states to 
establish a NORC Action Blueprint guide that will inform the future 
development of successful programs.
    In 2005, there were more than 80 NORC Supportive Service Programs 
receiving public funding. Approximately 43 programs in 25 states were 
the result of congressional earmarks. We are fortunate in New York to 
have a critical mass of program experience. There are 42 programs in 
New York State and New York City because beginning in 1995 and 1999, 
respectively, they each promulgated legislation and financing to 
support the development of NORC-SSPs. Today, $7.9 million in State and 
City tax levied dollars help support 33 classic (housing-based with a 
common ownership/management structure) NORC-SSPs and 9 neighborhood-
based programs in communities in which more than 50,000 older adults 
live.
    These programs reflect the city's range of low- and moderate-income 
housing and are located in 4 out of the 5 boroughs. Eight programs are 
in multi-family public housing developments; twenty (20) are in 
moderate income cooperatives; three are in moderate and low-income 
private rental developments; and two are in neighborhoods where there 
is no common housing ownership. NORC programs are in communities large 
and small--from a single building with 259 seniors among the residents, 
to a housing development with 8,000 seniors in 171 different buildings 
spread over a vast geographic area, and now in neighborhoods that are 
approximately 2 square miles.
    New York's NORC-SSPs are collaborative partnerships between 
government, housing, the residents, health care, and social service 
organizations. Participating organizations include 42 different housing 
developments, 15 different social service agencies, and 12 different 
healthcare organizations (including hospitals, homecare agencies, 
nursing homes, and an ambulatory care clinic).
    These programs are true public-private financial partnerships. Five 
million dollars in city awards to 33 programs annually leverages 
another $5 million in private support from philanthropy ($1.5 million); 
housing developments ($1 million); health provider partners ($1.5 
million in contributed nursing time); and in-kind contributions from 
housing entities of close to $1 million. (A good Place To Grow Old 
provides a detailed description of New York City's NORC Supportive 
Service Programs and can be accessed at www.uhfnyc.org)
    Inevitably, as models such as NORC Supportive Service Programs get 
broadly disseminated, underlying principles can become foggy. So in my 
testimony this morning, I would like to emphasize the 3 things that 
underlie the NORC-SSP approach, distinguish them from other senior 
services, and make them a particularly important avenue of needed 
change to our system of service to seniors.

    1. The ultimate goal of NORC Supportive Service Programs is to help 
transform communities into good places to grow old--communities that 
support healthy, productive, successful aging and respond with 
calibrated supports as individual needs change. This means building 
programs from the ground up so they are integral to the community 
(rather than being imposed from a distant office) and reflect not only 
the needs of residents--which evolve over time--but also their 
aspirations. Successful NORC-SSPs connect to the traditional range of 
services, but they must also develop other kinds of supports and 
services in order to be responsive to changes in their communities and 
their residents.
    2. Unlike many existing programs and services, eligibility for 
participation by seniors in NORC-SSPs is on the basis of residential 
status, not on functional deficits or economic status. We know how to 
target a specific service to someone with a specific problem (the one 
hip fracture at a time approach), but we are less good at shoring up 
the natural supports in a community, weaving/re-weaving the social 
fabric, and empowering older residents to take on positive roles in 
shaping the kind of community they think will be most supportive to 
them. In most communities in this country the older residents are a 
heterogeneous group, with 40 years between the oldest and the youngest 
and individuals experiencing oscillating, changing states of health as 
chronic conditions become acute and then get brought back under 
control. These realities necessitate a broad range of services and 
programming with an ability to respond flexibly to address the 
heterogeneity of the older population in a community.
    3. Given these first two principles, successful programs must be 
partnerships that bring together the social capital, businesses, and 
services in a community to effectively harness and target its resources 
to address the physical, social, emotional, health, and environmental/
structural challenges of a community as it ages in. No single provider 
can do it all. In New York, these partnerships include, at a minimum, 
government (the local Area Agency on Aging and the State Unit on 
Aging); a housing entity, where one exists; the residents; and health 
and social service providers. Often other leaders or community 
stakeholders are involved in the programs.

    For a generation, we have been preoccupied with specialized 
facilities or housing for the elderly--but in fact most older people 
want to and do remain in their long-time homes in communities not built 
for seniors. Many of these communities have or will evolve into NORCS. 
As this committee deliberates on how to address the growing phenomenon 
of NORCs, I offer the following recommendations:

    1. The term Naturally Occurring Retirement Community needs to be 
clearly defined and delineated for purposes of eligibility for funding. 
The original definition described an apartment building or buildings 
not built for seniors in which 50 percent of the heads of household 
were 60 years of age or older. Key elements of this definition are (a) 
geographic coherence; (b) buildings or neighborhoods that are multi-age 
or age integrated; (c) a specific density of older people in the 
community (which New York defines in both absolute numbers and 
percentages) to achieve economies of scale. New York State's 
legislation can be a starting point, but modifications will need to be 
made to reflect the density differences and types of communities found 
in other parts of the country.
    2. We need to be clear about the purpose of NORC-Supportive Service 
Programs and how they differ from existing services. NORC funding 
should be value added, not used for duplicating existing services or 
shoring up, through a different funding stream, our woefully 
underfinanced service systems. To be sure, some of our existing 
federally funded programs are in need of shoring up. But NORC-SSPs are 
something entirely different from what already exists.
    3. We need to establish a set of standards that are enforceable and 
that help get us to our goal of building community infrastructure to 
support aging in place. We should expect NORC-SSPs to produce 
improvements on a range of quality of life indicators for community-
dwelling seniors. Such things as level of connectedness to one another 
and to a program; improvement in key health indicators for older 
people; supporting new roles for older people as community leaders and 
doers; and strong and consistent linkages with the primary health 
providers in a community, are all important indicators of a community's 
ability to support aging in place.
    NORC-SSP contractors ought to be able to tell us what it is they 
expect to accomplish each year and how they plan on getting there, and 
then tell us what the outcome is. (For example, working with the city 
of New York's Area Agency on Aging, the Fund is developing a set of 
community health indicators for advancing healthy aging in place that 
will help programs measure their impact. I'd be happy to share the 
results with this committee once they are available).
    This is a fundamental change in the world of aging services, 
shifting from a units-of-service reporting system to one that is 
outcome-oriented. It will require new skill sets of a workforce that is 
by and large underpaid and undervalued.
    4. We need to establish and fund a national research agenda that 
helps us understand the overall efficacy of this approach. Some have 
tried to demonstrate that NORC programs prevent nursing home placement 
(as if nursing homes were the opposite of community living). But, given 
the purpose of NORC programs, the lens through which we need to 
evaluate the NORC-SSP approach is less about long-term care and much 
more about long-term living.

    I thank the members of this committee for the opportunity to 
testify. I'd be happy to answer any questions.

    Senator DeWine. Ms. Ginzler, you talked about the 
efficiency of scale. Mrs. Vladeck, you talked about the economy 
of scale. Would you both like to explain how that is achieved, 
and what kind of actual savings are we actually talking about?
    Ms. Ginzler. I will go first and then let my colleague fill 
in the blanks.
    You can easily get to an economy of scale notion when you 
think about the density issue that was described. You have a 
whole lot of older people who are in need of services in a 
close geographical area who do not need full-time services but 
need a few hours of care potentially on a daily basis.
    You can provide a series--one care worker, for example, 
could provide a full day's worth of work literally by walking 
down the hall of an apartment building and providing 2 hours to 
the resident on one floor, 2 hours to a resident who lives a 
few doors down. And in that way the actual scale is reached, 
the individual needs of several hours, a provider can give that 
care in an incredibly efficient way, cutting down on travel 
time, cutting down on overhead costs, and really meeting the 
needs of the individual where they are to the degree that they 
need.
    Mrs. Vladeck. I think that description applies both to 
social work services and case management services, as well as 
chronic care nursing services. Right now when these services 
are delivered in a traditional model, they are sent from a 
distant office. So you are really doing this one hip fracture 
at a time.
    But I think there is another piece to it, which is that 
when you are onsite in a community and you are building 
community infrastructure you are also looking for other 
resources in the community, the social capital. And it is 
amazing the kind of mutual support that goes on in a community 
that is hidden from us professionals.
    And so it is a real blending of both the revenue streams as 
well as the social capital to really build the support systems 
that you need in a more cost-effective way.
    Senator DeWine. Ms. Ginzler, the NORCs that I have seen in 
Ohio have demonstrated that density. And you can certainly see 
the efficiency of scale.
    But you mentioned that NORCs do occur or can occur in a 
rural setting. How does that work? And do you not lose that 
economy of scale when you get into a rural area?
    Ms. Ginzler. Certainly the dynamics are different in a 
rural setting. I think perhaps the most important feature to 
think about in those cases is that these are individuals who 
want to stay in their community and they have lived there most 
of their lives, if not all of their lives. And they are, to 
some degree, the backbone of those community settings.
    If we cannot provide them with the assistance that they 
need through the supportive services, they actually might be 
forced to leave their community and move out of that rural 
setting to potentially a facility in another location that 
would clearly be not supportive of their desire to age in 
place.
    Senator DeWine. Which is a very traumatic experience. I 
mean, they are totally gone from their community.
    Ms. Ginzler. Absolutely.
    Senator DeWine. Senator Mikulski.
    Senator Mikulski. Thank you very much.
    First, Ms. Ginzler, I want to be clear when I complimented 
the UJC, the important role the AARP has played. The UJC has 
actually run some of the demonstration projects. As a social 
worker, I have seen more of the hands-on. But we want to thank 
AARP for what they have done.
    And of course, Mrs. Vladeck, you are viewed as kind of the 
godmother of NORCs, and I think one of the original kind of 
social architects.
    Let me go first to AARP and then to you, Mrs. Vladeck.
    We have either one of three models to pursue. One, do 
nothing, say ``okay this is great to know.'' No. 2, to think 
about a new national program. Or to do a reformist model in 
existing programs and an incremental approach.
    You are talking, Ms. Ginzler, and I am going to ask you 
about reform and then also rural. You talk about S. 705 that 
Senator Sarbanes designed. I am a cosponsor, and it has passed. 
That is really an interagency coordinating model since it is no 
new money, no new services and so on.
    One of my questions would be: Is this just a new layer of 
bureaucracy that will not mean a ginger snap or a glass of 
Ensure to helping the senior population remain independent and 
happy about remaining independent?
    Ms. Ginzler. I do not think it is a ginger snap or a glass 
of Ensure. I think it is an important step. And I think the 
ability to coordinate, I do not think we can lose track of the 
importance of that and the reality that will be able to come 
about with this interagency council that will address this 
whole issue of duplication of services. If people across the 
spectrum at the Federal, State and local levels are doing a 
better job of knowing what each other are doing and dividing up 
the work that is going to be done and the purview that is 
needed. I think we are going to be better able to serve our 
elders. It does not take the place of supportive services 
available.
    Senator Mikulski. Along with kind of reforming and seeing 
where we go?
    Ms. Ginzler. Yes.
    Senator Mikulski. You also mentioned research and also Mrs. 
Vladeck mentioned it as well, and talk about how research 
focuses usually on the frail elderly or the homebound. Could 
you tell me where you think research ought to be done? In other 
words where, if we wanted to do that?
    Ms. Ginzler. I will go so far as to say that I think what 
we need to be continuously doing, and I know we are doing, is 
researching and evaluating those models that are on the ground 
now and figuring out the best way to assess them.
    Senator Mikulski. Where? Here is the question, is it at 
HUD? Is it at the Office of Aging at HHS? We have a National 
Institute of Aging at NIH. Where would you see this being done?
    Ms. Ginzler. I am actually not able to give you that kind 
of a direction at this point. I would be delighted to go back 
to my office and talk to our staff and be able to contribute 
back to you.
    Senator Mikulski. I think that would be good because what 
we are concerned about is--and each one will look at it from 
their perspective, as you know, and that determines the 
perspective of the research. But if you could ponder that, 
because I think we do need to know about these communities.
    Another question about the rurals. When I think of rural, I 
think of my Eastern Shore and my Western Maryland. And it is 
difficult than the way I think about NORCs. In NORCs I think 
about my urban and my suburban concentrations of elderly. You 
could actually see where they lived after World War II. Often 
it is where they moved first-generation into the suburbs. In my 
own community, inner beltway communities, etc. Then they moved. 
They downsized. They moved into apartment houses which became 
senior housing by proxy.
    But the rurals, my gosh, it is spread out, it is all over. 
How do you have a naturally occurring community when everybody 
lives 20 miles from each other?
    Ms. Ginzler. I think this absolutely speaks to what Mrs. 
Vladeck was referencing when we have to look at the issue of 
definition and come to some kind of congruence so that either 
density or population or percentage, so that we can use those 
definitions across. Because we are a wide country and we have 
so many different models to draw from.
    Senator Mikulski. But is it not true that the NORCs, as we 
talk about almost in the broad sense that we are using it now, 
are primarily an urban and suburban phenomenon?
    Ms. Ginzler. I am actually not able to give you a 
statistical analysis if you look across all the United States.
    Senator Mikulski. I am not asking you about statistics. I 
am asking about broad brush here.
    Ms. Ginzler. I think most of us, and I came out of the 
aging service delivery system before I came to AARP, and I 
agree with you 100 percent. I think all of us in the aging 
network, when you think NORC, we often go to the apartment 
complex where people have stayed and they have literally aged 
in place.
    Senator Mikulski. So the idea of the rural needs to be 
further dressed and conceptualize.
    Ms. Ginzler. Absolutely. It is out of sight, out of mind.
    Senator Mikulski. Thank you. Thank you very much. I see my 
little red light is on and I know it will be Senator Clinton's 
turn.
    Mrs. Vladeck, do you think that these programs are best run 
by faith-based organizations and nonprofits, as compared to 
State or essentially the local office on aging?
    Mrs. Vladeck. I think that our experience in New York is 
that----
    Senator Mikulski. Faith-based or a nonprofit.
    Mrs. Vladeck. These programs need to be part of the 
community. Faith-Based organizations are a major focus on a 
community. They need to reflect who that community is. Then 
that would make sense.
    The State units on aging, the Area Agencies on Aging, in 
our experience, are the administrative agencies for the public 
dollars. And the challenge is how to integrate the services 
provided through those agencies with the homegrown and building 
from the ground up services that you need to develop in a NORC 
program.
    Senator Mikulski. That is very interesting.
    My last question is should there be a new national program 
included in the Older Americans Act? Should we continue to do 
this through congressionally designated mandates and get more 
information? And what would be the key components?
    Mrs. Vladeck. I think there are those who say these are 
local efforts, this should be a locally driven process. But I 
think the issue of aging in place and NORCs is something that 
we are facing as a country. It looks different in different 
States, in different localities. But I think there needs to be 
some Federal policy that is driving the impetus or creating the 
impetus across the country to start rethinking and rebuilding 
communities to support aging in place and really key to NORCs 
in general.
    So I think it is broad brush policy. How that gets 
interpreted at the local level is really, I think, where the 
challenge is going to be.
    Senator Mikulski. Thank you, Mr. Chairman.
    Senator DeWine. Senator Clinton.
    Senator Clinton. Thank you very much, Mr. Chairman. I would 
ask consent to submit my entire opening statement to the 
record.
    Senator DeWine. Without objection.

                  Opening Statement of Senator Clinton

    Senator Clinton. Thank you.
    I want to thank Chairman DeWine and Ranking Member Mikulski 
for convening this hearing. I think this is one of the most 
important issues that we have to confront and the Subcommittee 
on Retirement Security and Aging is at the forefront of trying 
to help us do it.
    Of course, I am very proud of the pioneering role that New 
York has played in developing and expanding NORCs and NORC 
supportive service programs. As has already been pointed out, 
Fredda Vladeck is the godmother of NORC-SSPs. And Mrs. Vladeck 
and her husband have been wonderful citizens, not only of New 
York but of our country with the work they have done on behalf 
of health care and its expansion and the coverage of the 
uninsured and, of course, the work about the aging.
    I am also very pleased that we have with us Ron Saloway and 
Anita Altman from the United Jewish Appeal Federation of New 
York, the UJA Federation. They have made a great contribution 
in supporting the good work of New York's NORC supportive 
service programs and I wanted to thank them.
    The questions that have been asked really go to the heart 
of the issue. We know we have got to figure out how to deal 
with the aging of our population as the baby boomers turn 60 
this year and continue to age. The good news is it appears that 
people will be healthier. The not so good news is that they 
will be chronically ill longer. So the combination of that 
means that this effort to create aging in place and help to 
ease the cost of providing care to this growing group is 
absolutely essential.
    That is why I do think it is critical we include language 
in the Older Americans Act to make NORCs a permanent part of 
our strategy for helping older adults age with dignity.
    I think we have to have that Federal framework because, as 
Mrs. Vladeck said, one hip fracture at a time is just not going 
to be an acceptable strategy. We have to get smarter and we 
have to get out ahead of what is happening.
    I would like to ask Mrs. Vladeck, in your testimony you 
mention you are currently developing a set of community health 
indicators for the evaluation of NORC-SSPs. Can you talk more 
about the status of this? I know you will share it with us as 
it develops. But what are you looking at? What are the 
indicators? What are the lines of improvement that you are 
trying to catalog?
    Mrs. Vladeck. Drawing on much of the work done in Healthy 
People and the public health approach, the framework that we 
have devised says that in order for healthy aging or to advance 
healthy aging in a community, you have to have access to health 
care, you need to have promotion prevention and wellness, you 
need to address those issues. And you need to figure out what 
the health risks are in a community. You first have to get 
those baselines. And under each of those is a set of measures, 
indicators.
    What we are trying to do is establish some baseline data in 
all of the programs in New York City for each of these 
indicators. So for example for access, everyone needs a 
physician, should have a primary care physician. In one of our 
NORC programs in public housing, when it opened its doors, only 
30 percent of the residents, of the older adults, had a primary 
care physician. Today that number is over 90 percent.
    So those are the kinds of things that we need to be looking 
at and we need to be looking at it across how it relates to the 
city as well as nationally. Those benchmarks are around but we 
need to get the programs starting to work toward those 
benchmarks.
    Senator Clinton. I think that is very important because if 
we do move on this in the Older Americans Act I would hope we 
would have some sense of evaluative criteria, even if we are 
still in the process of developing them.
    You know, it has only really been in recent years that the 
concept of neighborhood NORCs had evolved. I know we talk about 
it being 40 years and that is, as I get older, very young. But 
the questions that both Senators DeWine and Mikulski asked 
really go to the heart of whether this can be a national 
program or not because they started in areas of great density. 
They have grown there. And New York City is particularly 
conducive to aging in place. I mean, people can get around 
easily. They can walk places. They have access to mass transit.
    So we have to think about how to create a model or several 
models that will take us to a point where suburbia and rural 
areas can also access that. And we have to think differently 
about it. We may need to do some demonstrations and try to 
figure out what works and what does not work.
    I also just wanted to ask both of you, just briefly, as I 
end my time here, how do we think about this concept of long-
term living instead of long-term care, Ms. Ginzler? I love that 
idea. And I think it is really important that we start re-
imagining what it is we are talking about when we talk about 
aging.
    And how would you both kind of give us advice here on this 
committee to sort of reconfigure our thinking, to move more 
toward long-term living as opposed to long-term care? Ms. 
Ginzler first and then Mrs. Vladeck.
    Ms. Ginzler. Thank you, Senator Clinton.
    Two things come to mind and it clearly is a reaction to 
your first observation. We are living longer and we will live 
with chronic conditions.
    So I think our whole notion of it is, at the very end of 
your life, that you need what we used to call long-term care, 
that notion is going to go away as people are going to live for 
decades with conditions that years ago would have severely 
compromised your ability to maintain engagement in the world 
around you. That is not going to happen anymore. We have 
delightful advances in pharmacology and people can live with 
disabling conditions with a much higher quality of life. And 
that is all going to contribute to the notion of long-term 
living, not long-term care.
    I think the other term that I think we might want to think 
about is the concept of independent living. Maybe we need to 
think about it as interdependent living and that is a phrase I 
think that fits all through life. We are all dependent upon and 
working with each other as we go through all of our life's 
phases. And as one is in the older age spectrum, it does not 
mean you are only receiving care, you are also giving back to 
the community. And this ability to think about it as long-term 
living also can then shed the light a lot better on the 
contributions that our older citizens make in their roles as 
volunteers, as engaged in their civic community on both a 
formal and informal basis.
    And then at the same time they are going to need some 
assistance as well, as is true all throughout life.
    So I love the concept of long-term living and I think we 
might want to think about interdependent living, as well.
    Senator Clinton. Mrs. Vladeck.
    Mrs. Vladeck. What I might add to that, I straddle several 
worlds, including the long-term care world. And I can tell you 
that our policies right now, when you look at Medicare, when 
you look at Medicaid, when you look at some of our services 
under the Older Americans Act, the focus is on providing a very 
specific service and then leaving. There is no focus. No one is 
responsible for re-integrating that person back into community.
    And given that people move in and out of acute states of 
health and dishealth, there is an unfinished piece of business 
that needs to be done. And often, the older person is left to 
do it on their own. Some succeed. But more often than not, they 
do not.
    Additionally, if you look at our homecare policy and the 
issue of homeboundedness, that homeboundedness means you are 
entombed, as one older woman put it, you are entombed behind 
your front door, behind your apartment door because you must be 
homebound in order to receive a Medicare homecare service. 
Which means that you are separated from the community at the 
very time that community is probably the most important thing 
to sustain you.
    So I think we need to start looking at some of those 
policies.
    The third piece that I would add is--this is the hardest 
thing in the world to do--is really sort of change a mindset 
about how we think about and deliver service. I say this very 
humbly, that for us professionals, we are used to thinking of 
the client as the dependent individual. And changing that 
mindset is really going to be a phenomenal challenge for us.
    Senator Clinton. Thank you very much.
    [The prepared statement of Senator Clinton follows:]

                 Prepared Statement of Senator Clinton

    First, I would like to thank Chairman DeWine and Ranking 
Member Mikulski for convening this important hearing on 
Naturally Occurring Retirement Communities (NORCs). As a strong 
supporter of NORCs over the years, I am very proud of the 
pioneering role New York has played in developing and expanding 
NORC Supportive Service Programs to help seniors successfully 
``age in place.''
    Let me also thank Fredda Vladeck, the founding Director of 
the first NORC Supportive Service Program (NORC-SSP) in New 
York City and the current Director of the Aging in Place 
Initiative at the United Hospital Fund, for coming here today 
to share her knowledge and experience. It is great to have you 
join us, Fredda. I am so grateful for your leadership and 
tireless work in this area.
    I also want to note that Ron Soloway and Anita Altman from 
United Jewish Appeal-Federation of New York (UJA-Federation) 
have made the trip down here today and are in the audience. 
Thank you for the critical role you have played in advancing 
the good work of New York's NORC Supportive Service Programs.
    This year marks the first year that the baby boom 
population turns 60. With a rapidly expanding older adult 
population, it is critical that we focus attention on the 
increasing needs of this elder boom and the demands placed on 
our local, State, and Federal health care and social services 
systems. NORC Supportive Service Programs play a significant 
role in helping to address this very real challenge.
    Since 1986, when Fredda Vladeck helped found the first 
professionally staffed NORC Supportive Service Program in the 
Penn South Houses in New York City, the number of publicly-
funded programs has grown to more than 40 in New York and 
approximately 80 across the Nation.
    NORC Supportive Service Programs have been invaluable in 
helping seniors stay in their homes where they have long 
resided and which many prefer. As I talk with seniors in New 
York and across the country, this is what I hear they most 
want.
    The NORC model of care not only respects seniors' 
overwhelming preference to age in place--to remain at home in 
the neighborhoods where they have lived for years--but also 
values their active participation in shaping their communities 
as ``good places to grow old.''
    This paradigm shift recognizes the importance of community 
for positive and healthy aging. For example, NORC-SSPs promote 
healthy aging by engaging seniors in preventative care before a 
health crisis occurs and by responding to their changing needs 
as they age over time. As a result, this approach helps prevent 
the premature or unnecessary institutionalization or 
hospitalization of seniors in short- and long-term care 
facilities. A cost savings to Medicaid and local taxpayers.
    Another important ingredient of NORC Supportive Service 
Programs is the partnerships they forge between the public and 
private sectors--uniting housing entities and their residents, 
health and social service providers, government agencies and 
philanthropic organizations. Through these partnerships, NORC 
Supportive Service Programs are able to offer a range of 
services--from social and health programs to educational, 
recreational and volunteer opportunities--that are diverse, 
flexible, and designed to engage as many community residents as 
possible.
    All these characteristics help support the residents of 
NORCs and benefit the communities in which they reside, 
reducing the overall burden on our health care and social 
service delivery system, saving money.
    As the baby boomers continue to age, our current 
infrastructure for delivering services needs to adjust to 
reflect the preference for aging in place and to help ease the 
cost of providing care to this burgeoning group. NORC 
Supportive Service Programs do just this.
    That is why I think it is so critical, and why I have made 
it a top priority to include language in the Older Americans 
Act . . . to make NORC's a permanent part of our strategy for 
helping older adults age with dignity. And I am hopeful that 
the work that is currently going on in this subcommittee . . . 
my efforts with Senator Mikulski, who has been a real champion 
for NORC's, and Chairman DeWine, will accomplish this goal.
    I am proud that New York has been such a leader on this 
issue and we need to give more communities in my State and 
around the Nation the opportunity to develop NORC-SSPs.
    As we face a long-term care crisis in our country resulting 
from the baby boom and the growing longevity of Americans, we 
must look for solutions to this mounting problem. A permanent 
grant program for NORC Supportive Service Programs in the Older 
Americans Act is a critical and common sense approach for 
investing in services and supports for our aging population.
    NORC Supportive Services Programs offer an exemplary model 
of care that respects our seniors' strong desire to remain in 
their homes and in their neighborhoods, values their strengths 
and contributions, and takes advantage of social networks and 
public-private partnerships to provide a myriad of cost-
effective services that foster positive aging.
    This innovative approach empowers older Americans to be 
actively engaged in a win-win solution to their long-term care 
needs. We owe it to our seniors to support these creative and 
invaluable programs.
    Again, I thank you for holding this hearing today and look 
forward to hearing from our witnesses and working with Chairman 
DeWine and Senator Mikulski to ensure inclusion of NORC 
language in our upcoming Older Americans Act reauthorization.
    Senator DeWine. Great panel. Thank you very much. We 
appreciate it. We appreciate your testimony.
    Let me invite our second panel to come up now, as I am 
introducing you.
    Joyce Garver Keller joins us today from Ohio where she has 
served for 16 years as Executive Director of the Ohio Jewish 
Communities. As head of the Ohio Jewish Communities, she has 
been at the center of efforts across the State to implement 
supportive services within NORCs.
    She has won numerous community service and civil rights 
awards. She has also been named by the Ohioan Magazine among 
the top five nice but effective lobbyists in Ohio. Joyce, that 
is quite interesting. I know you are nice and I know you are 
effective, so I guess that works.
    She has served on the Governor's Advisory Committee on 
Faith-Based and Community Initiatives, the Ohio FEMA Advisory 
Board and Chair of the Ohio Refugee and Immigration Advisory 
Committee of the Ohio Department of Job and Family Services.
    We are also joined today by Ann Sutton Burke from 
Cincinnati. She is currently the Program Director of Options 
Cincinnati, the supportive service program at Jewish Family 
Service.
    Ms. Sutton Burke also serves on the Best Practices 
Committee of the Ohio Valley Appalachia Regional Geriatric 
Education Center for the Office of Geriatric Medicine at the 
University of Cincinnati. She is Chairwoman of the Advisory 
Committee for Home Health Services for the city of Cincinnati's 
Health Department.
    She has over 25 years of experience working in the field of 
aging. Her background includes program planning and 
organization of senior centers, case management, home health, 
adult day care services and corporate elder care.
    Thank you both for joining us. Let me now turn to Senator 
Mikulski to introduce our other two panelists.
    Senator Mikulski. Thank you very much, Mr. Chairman.
    I too, have two Marylanders who have actually run hands-on 
with these NORC programs, of which I am very proud.
    I would like to present to the committee Ms. Julia Pierson, 
who is the Director of Senior Home Services at CHAI, which is 
our community housing association, which is part of the Jewish 
Federation of Washington. She is a graduate of the University 
of Maryland School of Social Work, my school of social work. 
She has worked as the Executive Director of Govans Ecumenical 
Services, a neighborhood corporation.
    She has over 20 years of experience in nonprofit management 
and now she is the Director of Senior Home Services at CHAI 
where she is coordinating its naturally occurring retirement 
project.
    And then we have Beth Shapiro. Beth is the Manager of the 
Community Partners Federation of Rockville. She has a masters 
degree of social work from the Shiva University, a graduate 
with a specialty in community organization, my field.
    For the past 6 years, Ms. Shapiro has been on the board of 
directors of a group called Grassroots Organization of Well-
Being for Seniors. Before taking her current position, she 
managed the Holy Cross Adult Day Care Center in Silver Spring 
and has now worked for over 20 years with developmentally 
disabled adults and seniors.
    Now she is heading up the Jewish Federation of Greater 
Washington's NORC supportive services in Rockville.
    Ms. Pierson is doing the job in Baltimore. Ms. Shapiro is 
doing the job in our Washington suburbs. I think, in doing the 
job, we are going to learn how better to do ours, and we 
welcome them enthusiastically.
    Senator DeWine. We thank all of you very much. We have a 5-
minute rule. We are going to have a vote apparently before 12 
o'clock, so we are going to run out of time here, so we are 
going to need you to keep right to your 5 minutes.
    Joyce, we will start with you.

  STATEMENTS OF JOYCE GARVER KELLER, EXECUTIVE DIRECTOR, OHIO 
 JEWISH COMMUNITIES, COLUMBUS, OHIO; ANN SUTTON BURKE, PROGRAM 
    DIRECTOR OF OPTIONS CINCINNATI, SENIOR ADULT SERVICES, 
  CINCINNATI JEWISH FAMILY SERVICES, CINCINNATI, OHIO; JULIA 
  PIERSON, DIRECTOR OF SENIOR HOME SERVICES, SENIOR FRIENDLY 
  NEIGHBORHOODS/CHAI, BALTIMORE, MARYLAND; AND BETH SHAPIRO, 
   MANAGER, COMMUNITY PARTNERS, JEWISH FEDERATION OF GREATER 
                WASHINGTON, ROCKVILLE, MARYLAND

    Ms. Keller. Good morning. I am Joyce Garver Keller, 
Executive Director of Ohio Jewish Communities. I want to thank 
Chairman DeWine and Ranking Member Mikulski and the Senate 
Subcommittee on Retirement Security and Aging for the 
invitation to participate in this hearing today.
    As this hearing coincides with the subcommittee's 
consideration of the Older Americans Act reauthorization, I 
commend you for the timeliness of today's hearing.
    The NORC movement in Ohio commenced specifically to assist 
seniors and aging baby boomers to maintain their lifestyles and 
social support networks without having to move out of their 
neighborhoods. The Jewish Community Federation of Cleveland has 
been in the forefront of seeking solutions to the looming 
crisis of caring for an ever-growing elderly population in 
Ohio.
    Today Ohio is home to more than 1.5 million residents 65 
years and older. Ohio, in fact, ranks 14th in the country for 
this aging population.
    Community Options, established in 1997, is one of the first 
NORC programs based outside New York State and it is the first 
program established in Ohio and one of the founding Older 
Americans Act Title IV demonstration projects that were 
commenced in 2002.
    Recognizing that loneliness and barriers to available 
services exist, Community Options was developed to better 
connect with seniors living independently and linking them to 
targeted community supports. The following are key factors to 
understanding the Community Options NORC supportive service 
model. The program is located in vertical NORC buildings at 
five sites in Cleveland's Mayfield Heights, University Heights, 
Beachwood and Lyndhurst neighborhoods and serves approximately 
700 residents a year. The typical NORC resident served by the 
program is female, widowed, in her early 80's, and has resided 
in her home for more than a decade. The program serves a 
diversity of ethnic and religious groups including Eastern 
European Jews, African-Americans, Italians, Protestants, 
Catholics, and Orthodox Jews.
    The Community Options program is structured around 
community organizing and senior empowerment. The seniors direct 
the program through advisory councils, volunteerism, cost-
sharing for the activities they participate in, and social 
service selection through a large referral system. A database 
of more than 1,400 providers is maintained and monitored 
frequently.
    Resource coordinators ensure a community infrastructure is 
in place through the development of partnerships with 
landlords, vendors, residents, and community service providers 
in many areas. Services and activities focus on health and 
wellness, education, recreation and, most importantly perhaps, 
transportation.
    The coordinators maintain a regular presence in the 
buildings and are recognized by the residents as the first line 
of support and only a phone call away. Unlike a housing complex 
with an employed service coordinator, the service activity 
developed by Community Options is consumer driven and based 
upon individual self-determined need and preference.
    The program operates on an annual budget of approximately 
$200,000 from income derived from the Jewish Community 
Federation of Cleveland, from their annual Campaign for Human 
Needs, other charitable contributions, landlords, activity fees 
and Federal grants.
    The seniors served by Community Options remain active, 
engaged and living at home longer. In 2004, the program was 
evaluated by Dr. Georgia Anetzberger, a renowned expert in the 
field of gerontology. Dr. Anetzberger's research found that as 
a result, Community Options participants are better able to 
control their lives and access assistance and activities. They 
are more connected to their neighbors. They feel that they have 
choices and are able to live independently with self-
confidence. In her report, Dr. Anetzberger wrote that Community 
Options fosters caring communities in which individual choice 
making is promoted and encourages seniors to thrive.
    In 2002, Community Options used its Older Americans Act 
Title IV demonstration grant to test the replicability of its 
NORC model in different Ohio regions. Through an RFP process it 
had four recipients selected for this demonstration. They 
included the Area Agency on Aging in Canton; Jewish Family 
Service in Cincinnati; the Western Reserve Area Agency on Aging 
in Cleveland; and Wexner Heritage Village in Columbus, a 
continuum of care campus with a 200 bed skilled nursing 
facility, two group homes for adults with developmental 
disabilities and mental retardation, subsidized housing for 164 
seniors, hospice care, end of life programming, and senior 
transportation and other supportive services.
    The four agencies launched 13 program sites and adhered to 
the consumer-directed community building empowerment model 
developed by Community Options in Cleveland.
    Internationally recognized Dr. Eva Kahana, Ph.D., Director 
of Elderly Care Research at Case Western Reserve University in 
Cleveland was contracted to assess the emerging programs within 
the demonstration project. Her report: Effects of Service 
Options Program in Naturally Occurring Retirement Communities 
articulated four central findings.
    Results support the value of Community Options' program's 
philosophy to give older adults a greater say in services to be 
marshaled.
    No. 2, significant improvements in reporting quality of 
life for residents of housing sites with newly instituted 
service and activity programs.
    No. 3, researchers propose that for populations with 
compromised access to basic services, tools should be developed 
that embrace a community model of empowerment rather than a 
clinical model of standardized assessments to determine 
comprehensive social and medical needs.
    And No. 4, the Community Options program has successfully 
developed social capital in the community by providing 
infrastructure to address the needs of community dwelling 
elders.
    Although the four participating agencies were able to 
successfully initiate programs, future sustainability of the 
NORC demonstrations became a significant challenge and only two 
of the programs--Cincinnati Jewish Family Service and Western 
Reserve Area Agency on Aging--were able to obtain funding 
beyond the grant period to continue operations in their 
respective regions.
    Cleveland's Community Options, whose Federal grants with 
HUD and AOA will soon be finished is in the process of 
assessing how it will address the funding shortfall of 
approximately $50,000 annually once these grant resources are 
terminated.
    While the Canton program could not continue, the experience 
provided an opportunity for the AAA to strategically target 
existing programs and resources in NORC locations and found 
that, as a result of the demonstration, residents are more 
connected to available community-based services in the area.
    The Columbus agency was the only one of four that chose to 
test the model in a horizontal setting, garden-type apartments. 
The visible impact of the program took longer to achieve than 
the others and, as a result, it was found that the landlords 
did not have sufficient time to become engaged in the program 
and receptive to making a long-term commitment. Should a 
favorable funding environment emerge, Wexner Heritage Village 
would pursue reestablishing a NORC program.
    Retaining familiarity of home remains an utmost priority 
for older adults. Yet for many seniors living alone with 
limited mobility and difficulty in assessing socialization, 
companionship and services become a major challenge to the 
quality of life and independence. The Community Options NORC 
supportive services program provides onsite activities, access 
to social service referrals, wellness activities and community 
building. The relationships developed through the resource 
coordinators enable seniors to trust more quickly, learn about 
and utilize community resources. Community Options' 
demonstration project found that replicability was possible, 
but sustainability was a significant challenge to fledgling 
programs.
    As supported by the findings of Drs. Anetzberger and 
Kahana, communities with high concentrations of older adults 
could gain tremendously if Congress were to establish a 
national NORC supportive service program through the Older 
Americans Act reauthorization process.
    On behalf of Ohio Jewish Communities, I want to thank the 
subcommittee for acknowledging the growing interest in NORC 
supportive service programs and for holding this hearing within 
the context of the Older Americans Act reauthorization.
    I personally appreciate the opportunity to come before the 
committee today and I would be happy to answer any questions.
    Senator DeWine. Thank you very much. Very good.
    Ms. Sutton Burke, thank you for joining us.
    Ms. Burke. Thank you for having me.
    I am pleased and honored to be here in my capacity as 
Program Director for Options Cincinnati, the Jewish Family 
Service NORC Supportive Services Program.
    With over 25 years of experience serving the aging network 
in community-based care, what I found innovative about the NORC 
Supportive Services Program is its preemptive nature. With most 
of the programs I have worked with, we wait for the phone to 
ring, we wait for a crisis to happen. With Options Cincinnati, 
we have turned that around with an approach that identifies 
clusters of seniors, NORCs, establishes a comfortable presence, 
engages residents in one-on-one and through programming, builds 
relationships and creates a sense of community.
    Through this program, we build trust with seniors and 
together we head off potential problems. NORC Supportive 
Services Programs like Options Cincinnati are responsive to 
trends in aging. We have already heard that today from the 
representatives, but research tells us that 9 in 10 of us want 
to age in place. And for those of us like myself that are over 
45, we also, a vast majority of us, want to age in place.
    NORC-SSP programs on a large-scale could help seniors 
throughout the country, perhaps up to one-third, receive 
services to successfully age in place.
    Locally, we have created a supportive environment to 
prevent situations from deteriorating to a point where a move 
out is the only option. In that vein, I want to share a story 
of a couple we work with. They have been married 58 years and 
are in their mid-80s. They live in a market rate apartment 
within a NORC building we serve. Bernice uses a walker and most 
of her care falls to Albert, her husband. All of their children 
reside at least a day's drive from Cincinnati.
    Bernice began attending programs that we would hold in her 
building and Albert would stop by our office onsite to make her 
reservations for the program. Over time, Albert started to stop 
in regularly to chat with our social worker. And in time, that 
developed into supportive counseling for him.
    That is important because Albert was injured and was 
confined to bed with a back injury. Although their privacy was 
very precious to them, Bernice and Albert allowed our social 
worker to come into their apartment and talk to them about what 
might be their next step.
    After completing an assessment, our social worker suggested 
homecare services and together they arranged those services. 
Albert recovered from his injury but, what was important was 
that their positive experience with Options Cincinnati 
continues to enrich their lives.
    Bernice, who relied completely on Albert for all of her 
transportation needs, now utilizes the services of one of our 
business partners to take her out to do her errands. This 
reprieve has greatly reduced the care giving burden on Albert 
and it has enhanced both his and Bernice's independence. Any 
worries about a need to move to a more restrictive setting are 
now nonexistent.
    Options Cincinnati operates in two NORC buildings, both are 
nondenominational programs, and one site is home to a 
significant African-American population, 22 percent. To date, 
the programs have served more than 200 residents combined.
    Property owners, CMC and Towne Properties in Cincinnati, 
welcomed our programs into their buildings. They understood the 
merits of our programs and the perspective of building 
stabilization. Emergencies are reduced and a caring network is 
in place. Both properties provided Options Cincinnati with 
donated space for our use as offices and also support us 
financially.
    The business community embraces our model, as well. 
Bethesda North and Good Samaritan Hospitals of the TriHealth 
System, Comfort Keepers, Mullaney's Pharmacy Plus Home Care and 
Arden Courts have helped support our local matching requirement 
in exchange for advertising and display space and opportunities 
to present programs to our residents. Despite no exclusivity 
for referral to their services, they have seen the benefit of 
such a private-public partnership.
    Scripps Gerontology Center at Miami University of Ohio is 
partnering with Options Cincinnati on program evaluation. Some 
of their project work has revealed that residents living in 
Options Cincinnati NORC sites were more likely to feel 
connected to their community, be age integrated, and have 
higher assessments of their health than residents living in 
similar buildings not served by the program.
    In Cincinnati we have a well-regarded aging network with a 
range of services thanks to our Jewish Federation, United Way, 
and Area Agency on Aging, Council on Aging of Southwestern 
Ohio. This great network has been made even better through the 
opportunity Senator DeWine has afforded us--the Options 
Cincinnati grant.
    Our project has shown that NORC Supportive Services 
Programs are a natural complement to services and providers 
already existing in our community.
    If NORC Supportive Service Programs were part of the Older 
Americans Act, it could significantly help reposition aging 
services to better serve those aging in place.
    I applaud Chairman DeWine and Ranking Member Mikulski and 
the subcommittee for holding this morning's hearing on 
innovative NORC Supportive Service Programs. As you fashion 
your reauthorization of the Older Americans Act, I hope you 
will provide an opportunity for further development of NORC 
Supportive Services Programs throughout the country.
    Thank you again for the opportunity to contribute to this 
discussion. And I look forward to answering any of your 
questions.
    Senator DeWine. Thank you very much. Very good.
    [The prepared statement of Ms. Burke follows:]

              Prepared Statement of Ann Sutton Burke, MPA

    I am pleased and honored to be here in my capacity as Program 
Director for ``Options Cincinnati'', the Jewish Family Service of 
Cincinnati's NORC Supportive Service Program.
    I have 25 years of experience serving the aging network, with the 
vast majority of that time focused on community-based care. From this 
perspective, I have embraced the NORCs service concept for its 
innovative preemptive nature in community-based supportive services. 
The vast majority of programs serving older adults are ones where we 
wait for the phone to ring. We wait for a crisis. With Options 
Cincinnati we've turned this around by developing an approach that:

     Identifies clusters of seniors: NORCs.
     Establishes a comfortable presence.
     Engages residents one-on-one and through programming.
     Builds relationships.
     Creates a sense of community.

    Through this program, we have built a trust with the older adults, 
who now turn to us to head off developing problems together.
    NORC Supportive Service Programs, like Options Cincinnati, are 
responsive to the trends in aging--research tells us that older adults 
want to age in place (9-in-10, according to AARP). This trend is not 
fleeting, as AARP research also indicates that the vast majority of the 
45 and older population wants to age in place and receive the services 
that will allow them to do so. NORC programs, on a large scale, could 
help a great many older adults throughout the country, perhaps as many 
as one-third of the senior population, according to the research. In 
our local experience, we have created a supportive environment to 
prevent situations from deteriorating to a point where a move out is 
the only choice left.
    In this vein, I want to share with you a story of a couple we work 
with, Bernice and Albert Kaplan. They have been married 58 years and 
are both in their mid-80's. They live independently in a market rate 
apartment within a NORC building we service. Bernice uses a walker and 
most of their care falls to Albert to provide. All of their adult 
children reside at least a day's drive from Cincinnati.
    The Kaplan's established their relationship with Options Cincinnati 
when Bernice began to attend events we would hold in their building and 
Albert would stop by our office, located on the premises, to sign her 
up for programs. Albert then began to drop by on a regular basis simply 
to ``chat'' with our social worker. These visits over time became 
supportive counseling for Albert. This relationship became critical 
after Albert injured his back and was confined to bed. Although their 
privacy was precious to them, the Kaplan's allowed our social worker 
into their home to help them figure out what they were going to do 
next.
    After completing an assessment our social worker recommended 
homecare and she worked with the Kaplans to arrange the services. 
Albert has since recovered from his injury, but the positive experience 
with Options Cincinnati continues to enrich the Kaplan's lives in other 
ways. Bernice, who previously relied on Albert for all of her 
transportation needs, now utilizes services of one of our business 
partners to run errands and outings outside of the building. This 
reprieve has greatly reduced Albert's caregiver burdens and enhanced 
both his and Bernice's independence. Any worries about Albert and 
Bernice's need to move to a more restrictive setting are now 
nonexistent.
    Currently JFS operates in two NORC buildings. Both are non-
denominational programs, and one site is home to a significant African-
American population (22 percent). To date, the programs serve more than 
200 residents combined.
    Property owners, CMC and Towne Properties, both openly welcomed 
locating our programs in their buildings. They understood the merits or 
our program from the perspective of building stabilization (rents get 
paid, apartments are safe and accessible, emergencies are reduced and 
crises avoided, and a caring network is in place). For their part, both 
properties provide Options Cincinnati with donated space (converted 
apartments) for our use as offices. They also contribute financial 
support.
    The business community has also embraced our model. Businesses that 
cater to older adults, such as Bethesda North and Good Samaritan 
Hospitals (TriHealth), Comfort Keepers, Mullaney's Pharmacy, Home Care, 
and Arden Courts, have helped support our local matching requirement in 
exchange for advertising space, display space and opportunities to 
present programs to our residents. Despite there being no exclusivity 
for referral to their services they have seen the benefit of such a 
private-public partnership.
    Additionally, the Scripps Gerontology Center at Miami University of 
Ohio is partnering with Options Cincinnati on program evaluation. Some 
of their project work has revealed that residents living in the Options 
Cincinnati NORC sites were ``more likely to feel connected to their 
community, be age-integrated, and have higher assessments of their 
health,'' than seniors living in similar buildings not served by the 
program.
    If there was an opportunity to expand the NORC-SSP model, Options 
Cincinnati has received interest about collaboration from several 
community partners in our aging network, including Clermont Senior 
Services (whose interest is a rural NORC in Felicity, Ohio), Community 
Services West in western Hamilton County and Senior Citizens, Inc. 
about the African-American community in Hamilton, Ohio. JFS and the 
Jewish Federation is looking at how to use the NORC-SSP model to better 
serve resettled New Americans.
    If NORC Supportive Service Programs were to become a part of the 
Older Americans Act, it could significantly help reposition aging 
services to better serve those aging in place. As the NORC model has a 
flexible approach to programming and service development--in order to 
respond to the specific wants, as much as perceived needs of the 
service recipients--the model is adaptable and well suited for the 
changing continuum of care required as older adults age in the 
community. Additionally, the model promotes choice, as the older adults 
contribute to the direction services and activities take and foster the 
program through their engagement. With so many independent minded baby 
boomers on the cusp of retirement, NORC Supportive Service Programs 
that foster their empowerment and self-determination would add to their 
well-being and quality of life.
    In Cincinnati we have a well-regarded aging network with a range of 
services available thanks in large part to support by our Jewish 
Federation, United Way and our area agency on aging: Council on Aging 
of Southwestern Ohio. This great network has been made even better 
through the opportunity Senator DeWine has afforded us with, the 
Options Cincinnati grant. Our demonstration project has shown that NORC 
Supportive Services Programs are a natural compliment to services and 
providers already existing in our community. It has also shown that a 
program designed to be proactive, rather than reactive, can help reduce 
the burden on limited resources and improve the health and social 
outcomes of the seniors served.
    I applaud Chairman DeWine, Ranking Member Mikulski and the 
subcommittee for holding this morning's hearing on innovative NORC 
Supportive Service Programs. As you work to fashion your 
reauthorization of the Older Americans Act, I hope you will provide an 
opportunity for further development of NORC Supportive Service Programs 
throughout the country.
    Thank you, again, for this opportunity to contribute to this 
discussion, and I look forward to answering any questions you may have.

    [Editor's Note--Due to the high cost of printing, previously 
published material submitted by witnesses may be found on the Program's 
website at www.jfscinti.org.

             Council on Aging of Southwestern Ohio,
                                            Cincinnati, OH,
                                                      May 10, 2006.
Hon. Mike DeWine, Chairman,
Subcommittee on Retirement Security and Aging,
United States Senate,
Room 140, Russell Senate Building,
Washington, D.C. 20510.
    Dear Senator DeWine: As the Area Agency on Aging that serves the 
five county region in Southwestern Ohio, we appreciate the partnership 
and work with Jewish Family Services on their NORC project ``Options 
Cincinnati.'' They are an important link in the system of services 
available to seniors that provide low-cost options for their long-term 
care needs.
    Part of our new Strategic Plan for Southwestern Ohio is to enhance 
service options and supports to prepare for the rapidly growing 
population of older adults. Most older Americans want to remain in 
their homes and communities where they are familiar, and lead a good 
quality of life. Developing a network of services and options that 
allows seniors to remain independent is good for families, and makes 
prudent use of limited long-term care resources.
    If you have any questions about naturally occurring retirement 
communities, or programs and services available to seniors, please feel 
free to contact me at 513-345-8616.
            Sincerely,
                                             Suzanne Burke,
                                           Chief Executive Officer.
                                 ______
                                 
    Senator DeWine. Ms. Pierson, thank you.
    Ms. Pierson. Thank you. Thank you, Chairman DeWine and 
Ranking Member Mikulski.
    First of all, Senator Mikulski, I want to thank you on 
behalf of the Associated and CHAI for continuing to fund our 
programs over several years.
    Senior Friendly Neighborhoods operates in the Northwest 
section of Baltimore. It is a low- and moderate-income post-
World War II urban area and there are seniors living in market 
rate and subsidized apartments, in condos, in single-family 
houses and in duplexes.
    I am going to keep my remarks short in the interest of 
time. A lot of the themes said by my colleagues are similar in 
Baltimore.
    What I really want to focus my testimony on are four 
characteristics that make a NORC program distinctive and more 
effective than other senior programs. First of all, we offer 
programs and services where people live. For example, instead 
of having a case manager in a central office, our social worker 
has an office in apartment buildings where seniors live. This 
allows staff to see how people are functioning in their home 
environments and foster stronger relationships, which is so 
key.
    That leads to our second characteristic, which is having a 
prevention focus. When you establish a high level of trust, 
then people are more likely to accept help and ask for it. Our 
staff suggests changes to help remedy a problem before it 
becomes a crisis. This is key. It is a safety net of 
information and support essential to the NORC paradigm.
    The third characteristic that I want to point out is that 
Senior Friendly and other NORC programs are collaborative 
partnerships. All too often, agencies work independently 
without the knowledge of others who also provide services to an 
older adult. At Senior Friendly, we have brought together all 
of the major community partners into our--all of the community 
providers into our partnership. We hold regular 
interdisciplinary team meetings. We provide cross training so 
all staff know how to identify at-risk seniors and what to do 
about it. As a result, we are able to avoid overlapping, 
duplicative and less effective services.
    The fourth characteristic is we have a community 
orientation. You have heard it again and again. NORCs are 
programs that start in the neighborhood and in the communities. 
Our participants are key players in determining what services 
are offered, how they look, and how they are delivered. We 
conduct a community assessment before we start working in a 
building. We conduct regular open forums to solicit feedback 
from our clients. Consequently, we have a high attendance and 
utilization rate because we provide what people want.
    Now I am going to talk about warm houses, which the Senator 
had asked us about before. One of the biggest challenges for 
NORC programs are to reach people who would normally be 
isolated because they live in single-family houses or they live 
in an apartment building where there are not many seniors, or 
they live in a rural area, frankly. So our Warm House 
Initiative is a cost-effective way to reach these populations.
    For instance, we have brought together eight homeowners in 
a two-block area who did not really know each other well. We 
have also brought together an intergenerational warm house in 
an apartment building that has seniors and college students so 
that the college students get cookies but the seniors also have 
someone looking out for them.
    Another warm house meets in a small apartment building 
where there are about seven seniors and most of them are frail 
and isolated. These warm houses meet monthly for a social 
activity in a senior's homes. The participants develop a 
network of neighbors that become a new support system for them. 
It really works. They also develop a relationship with a staff 
person who can connect them to services that they may not need 
this month but they may need next year.
    I wanted to finish my testimony by speaking from the voice 
of one of our participants. I thought that was really important 
because of this woman, Mary, who lives in an apartment 
building. Maybe about half of the people in the building are 
seniors. She is wheelchair-bound. Before Senior Friendly, she 
spent 2 years--she did get out of her apartment for 2 years. 
This is what she writes:

          For someone who depends on a wheelchair to get around, Senior 
        Friendly Neighborhoods is a true blessing. Every Friday, Senior 
        Friendly provides me with a shuttle bus with a ramp which 
        allows me to go to the Meyerberg Senior Center for lunch and 
        then to shop for groceries and go to the bank.

    Ms. Pierson. She makes three stops.

          Aside from a good inexpensive meal, I eat with a group of 
        seniors who also have become my friends.
          At my apartment building, we are also fortunate to have two 
        eating together meals a week.
          I have been there. People are enjoying themselves and they 
        are actually very hungry. This meal is very important to them.

    Ms. Pierson. As she says, she has developed special 
friendships as well as having a good meal.

          Both a nurse and a social worker visits regularly and are a 
        great help. Without Senior Friendly, I would be confined to my 
        apartment and would not have such a productive existence.

    Ms. Pierson. So there are Marys all over America. They are 
unhappy, they are isolated, they are inactive, and they have 
chronic conditions. And they need and deserve long-term living, 
as Fredda said. They deserve joy, friends, and a healthy and 
productive existence.
    So I think that the national NORC program would be very 
helpful for people all over the United States. And I hope that 
we are able to find a way to implement that.
    Thank you.
    Senator DeWine. Thank you very much.
    [The prepared statement of Ms. Pierson follows:]

                  Prepared Statement of Julia Pierson

    Thank you Chairman DeWine, Ranking Member Mikulski, and 
subcommittee members for this opportunity to raise awareness on an 
innovative and important paradigm of community-based services, 
Naturally Occurring Retirement Communities (NORC). The NORC program I 
represent is called Senior Friendly Neighborhoods (SFN). The Senior 
Friendly Neighborhoods program is exactly what its name implies--it 
provides services that make a neighborhood a friendly place for seniors 
to live in. SFN is targeted to older adults living in the Naturally 
Occurring Retirement Communities in the Upper Park Heights and Milbrook 
neighborhoods of Baltimore. Our goal is to enable older adults to ``age 
in place'' in their own homes. The program is operated by a partnership 
of agencies with Comprehensive Housing Assistance, Inc. (CHAI) as the 
lead agency. I am the director of the SFN program.
    CHAI did not set out to create a NORC supportive service program. 
As community development corporation, CHAI set out to stabilize and 
revitalize an area of Northwest Baltimore in order to make it a viable 
and attractive community for its residents. As the agency began to 
renovate and develop housing, what it found was a large number of older 
adults who were aging in place, often vulnerable, and having difficulty 
maintaining their residences. The area of Baltimore City and County 
that we serve has:

     A total population of 12,490 of whom 62 percent are 
Caucasian, 33 percent African-American, 2 percent are Latino, and 3 
percent are other races.
     Of this population, over 2,600 are older adults.
     35 percent of the households are headed by an older adult, 
and
     30 percent of the households headed by people over age 65 
live below the poverty level.

    Services for seniors existed in this community of private homes, 
condominiums, and garden style and high-rise rental apartments. There 
was an assortment of services through the city and county Area Agencies 
on Aging, a local Senior Center, a Jewish Community Center, a local 
medical complex with a hospital, nursing home, and out-patient 
services, and a Jewish Family Services agency with an older adult 
division. But, older residents were not necessarily making optimal use 
of these services, nor were these agencies working together to serve 
the older residents.
    The Federal demonstration grants provided to CHAI beginning in 
2002, and secured for us by Senator Mikulski, allowed CHAI to create 
Senior Friendly Neighborhoods, to test out a new approach to providing 
services in this Naturally Occurring Retirement Community. We chose not 
to begin a new agency, but rather to draw together some of the existing 
community service providers into a collaborative. SFN is a partnership 
of the seniors themselves, the apartment building owners and managers, 
CHAI, the Jewish Community Center, Jewish Family Services, LifeBridge 
Health Systems, and the Edward A. Myerberg Senior Center. The project 
could not work with one agency. We needed to bring together the 
talents, expertise and resources from many agencies to provide the 
comprehensive services we currently offer. Each month we work with 
about 1,000 seniors. Services are provided to everyone over age 62 in 
the catchment, but are concentrated in several apartment buildings and 
in ``warm houses''--where groups of homeowners gather together for 
socialization.

     We sponsor activities and programs like trips, art 
classes, exercise, games, movies, speakers, music and social events, 
and ``Eating Together'' meals. Over 1,000 activities were offered last 
year in 2 hubs and 8 apartment buildings.
     We have created a program we call ``Warm Houses,'' which 
are monthly gatherings of culturally similar residents who live in 
close proximity to each other and meet in each other's homes. There are 
9 such programs currently serving 140 individuals.
     We offer health education about medical issues that affect 
older adults. This includes taking blood pressures, clarifying 
medication directions, and having workshops about preventing falls. 
Additionally, the nurse follows up individually with people who have 
multiple and complex medical needs. She monitors their conditions, 
provides individualized education, and acts as a liaison with their 
medical providers.
     We offer social work services that help older adults 
connect to the services they need such as: energy assistance to help 
with fuel bills, homecare, and a volunteer to take them to the doctor. 
We offer support groups for issues like living with low vision, 
caregiver support, and coping with grief.
     We provide transportation to shopping centers, medical 
appointments, and recreational activities.
     We help older adults with minor and major home repairs as 
well as home adaptations like installing grab bars. More than 500 home 
repair services were provided last year.
     And we provide a safety net of information and support 
when our members need help.

    The services that are offered by SFN are not unique or 
revolutionary. Health education, social service assistance, activity 
programs, and transportation programs for seniors have been in 
existence for years. What is unique is the delivery system created to 
bring these services into the community. It's a delivery system that is 
effective and efficient in getting people the help that they need.
    There are four main ways that SFN, and NORC supportive service 
programs are different from the existing service delivery system for 
seniors. These differences are: a community orientation, a 
collaborative partnership, services onsite where people live, and a 
focus on prevention.

                         COMMUNITY ORIENTATION

    When planning services for older adults, sometimes professionals 
are paternalistic; they sit down in a room and presume to decide what 
is best for the seniors. The NORC supportive service program, instead, 
presumes that it is critical for residents to design and take ownership 
of the program themselves. The older adults should be key players in 
determining what services are offered, how they look, and how they are 
delivered.
    Since the SFN service area is so large and culturally diverse, 
multiple approaches to empowerment have been implemented to gain 
community input. When we first started, we did community assessments. 
This included doing an inventory of the services that were already 
available in the area. We also did assessments of smaller areas where 
we considered providing services, i.e., apartment buildings and 
neighborhoods. We talked with resident leaders, apartment managers, and 
other key community members. We conducted formal written surveys and 
focus groups with residents, as well as canvassing them informally--we 
came to their activities, we knocked on doors and we sat in their 
lobbies and chatted. The Upper Park Heights neighborhood is 
multilingual. Key to conducting outreach in a multicultural community 
is having bi-lingual staff available and translating materials into 
other languages. In our case, a large proportion of our older adult 
population is recent immigrants from the former Soviet Union.
    Once programs are established in a building, activity participants 
routinely help determine the substance and programming for their 
meetings. Activity programs, since the residents themselves determine 
their content, often reflect the cultural diversity of the community. 
For example we sponsored a trip to the newly opened Reginald R. Lewis 
Museum of Maryland African American History and Culture, a concert 
featuring Russian music and dance, and a celebration for Israeli 
Independence Day. Also, ``Open Forum'' meetings are held in 8 of the 
apartment buildings. These are meetings where participants can share 
feedback on existing services and suggest ideas for new programs. 
Forums occur several times a year in each building, depending on the 
building's size.
    The open forum process then feeds into a formal Advisory Council. 
The SFN Advisory Council is a group of volunteers who help guide the 
SFN staff in making decisions about the future of the program. The 
Council currently has 20 members who meet every other month to discuss 
current issues of concern for SFN. A chairperson and a steering 
committee of four members guide the group.
    Council membership is designed to represent the diversity of the 
community. Members are representatives from the SFN apartment 
buildings, condominium residents, warm house participants, and 
homeowners. Additionally there are individuals on the Council who are 
not necessarily SFN participants, but who represent other community 
organizations and stakeholders.
    One project of the Advisory Council was a community-wide conference 
held in June 2004, when SFN was undergoing a strategic planning 
process. The conference was an effort to include the older adults in 
the planning process. About 100 older adults participated with staff in 
small group sessions to learn the participants' priorities.
    One of the priorities that came out of this conference was an 
interest in creating a ``caring community'' where residents look out 
for each other. Basically, residents were concerned about having a 
medical emergency in their apartment, and being unable to call for 
help. SFN staff researched various strategies to address this concern, 
presented them to residents, and the residents decided which one to 
pursue.
    The residents decided to create a door tag system to check on each 
other. The way this works is participating apartments are issued a 
brightly colored tag that hangs on the handle of their apartment door 
entrance. The residents place their tags on the outside handle of their 
front doors each morning, and take it inside in the evening. A floor 
captain checks to make sure the tags are out. If a tag has not been put 
out or taken in, the floor captain knocks at the resident's door. If 
they do not answer the door, then the floor captain calls the 
individual. If there is still no response, then the floor captain 
contacts a program coordinator or building manager. The building 
management then enters the apartment to check on the resident and 
arrange for help, if necessary.
    This system has allowed the residents in participating buildings a 
low-cost means to address their fears. Initially, the process required 
staff involvement to implement, but is now run solely by resident 
volunteers. In the process, residents have gotten to know each other 
better and created more connections and involvement among themselves.

                       COLLABORATIVE PARTNERSHIP

    The second concept critical to the NORC supportive services model 
is the provision of services in a collaborative partnership. All too 
often in the existing system of services for older adults, agencies 
work independently without the knowledge of the others to provide 
services to a client. This often leads to overlapping or duplicative 
service provision. Also, when a worker from a single agency assesses a 
client, the worker often creates a one-dimensional evaluation of the 
client. This can lead to a very narrow response or solution to the 
problem.
    A NORC collaborative partnership allows a program to avoid these 
pitfalls. Different agencies, and the workers within them, who come 
from different educational backgrounds, offer a unique perspective on 
the individual's circumstances. These perspectives come together to 
form an interdisciplinary team that guides the service for the older 
adults. In SFN our team members consist of a nurse, four social service 
staff, three activity workers, an outreach worker, the coordinator of 
our Senior Home Repair Program, and our transportation/membership 
coordinator.
    Typically, it is the activity worker who first becomes aware of an 
individual who may need extra assistance. In SFN the activity programs 
are designed to be the public face of the program and then to make a 
connection to the greatest number of people possible. Residents are far 
more likely to connect to SFN through an exercise class, party, or a 
trip out to dinner than by entering the social worker's office to 
acknowledge that they have a problem and need help. The activity 
workers are the eyes and ears of the program, and they bring their 
concerns back to the social service and nursing staff.
    For example, an activity worker staffing an arts program may notice 
an individual who is no longer caring for their appearance and hygiene 
properly and who forgets what time to come for the program. She brings 
this to the attention of the nurse or social worker, who then stops in 
at the next class to meet the individual. The activity worker, whom the 
resident is already comfortable with, facilitates the introduction of 
the new team member. The connection to the clinical services is much 
smoother and occurs more readily because the activity worker has 
already established a trusting relationship.
    In the existing service delivery system, an activity worker might 
not know whom to go to ask for help with this individual. Even if she 
did, the social service worker may not be able to come if the client 
did not request the meeting herself. Certainly, the worker would not be 
able to come to the activity program and receive such a facilitated 
connection to the client. The worker would be a stranger calling on the 
phone and offering assistance--an offer that is then likely to be 
refused.
    The SFN team members work together to provide a coordinated service 
plan for the residents. This work happens on an informal basis in the 
office and during a formal Interdisciplinary Team meeting each month. 
The meetings are facilitated by a clinical social worker. We discuss 
situations that require guidance from the whole team's perspective. At 
a recent meeting we discuss a frail depressed woman that many of the 
staff had interacted with and were concerned about. Because so many 
people were present, we were able to get a more complete picture of her 
circumstances, and decided on a strategy to get her help. We have found 
that Interdisciplinary Teams:

     Give staff the tools they need to handle difficult and 
complex cases,
     Improve service delivery,
     Provide cross-training for staff, and
     Help us replicate best practices in working with seniors.

    In addition to the managing partners involved in SFN, the program 
is always looking to work collaboratively with governmental and other 
community service providers around short- and long-term issues. We 
regularly hold meetings, dialogues, and informational sessions with 
both Baltimore City and County agency representatives in the 
departments of aging, social services, housing, planning, and police 
around issues facing the older adults in our community. These 
collaborations often ultimately enhance CHAI's larger goal of 
stabilizing and enhancing the entire neighborhood. Finally, there are 
numerous projects where SFN engages with other agencies to enhance 
specific services for seniors. For example, SFN has worked 
collaboratively with the University of Maryland School of Pharmacy to 
provide medication screenings, a local bank and a Catholic Charities 
youth group to provide volunteers for a Senior Home Repair Day, and a 
Russian membership organization to offer a special event honoring 
immigrants who recently became U.S. citizens.
    At SFN we have found that the team approach is an invaluable one 
that offers a tremendous enhancement to the service provision to our 
clients. It should be noted, however, that partnering and collaborative 
work can be a time consuming effort. Like a marriage, inter-agency 
partnering takes nurturing and hard work. Bringing together multiple 
interests and viewpoints is critical, but adequate staff time needs to 
be allocated to bring these viewpoints together.

                            ONSITE SERVICES

    The third unique difference about SFN, and NORC supportive service 
programs in general, is that they are offered right onsite where people 
live. Instead of having a case manager in a central office, the NORC 
social worker's office is right in the buildings where people live. The 
social worker can schedule formal office or home visits, but they also 
have the opportunity to monitor residents in an informal way--riding 
the elevator, getting their mail, sitting in the lobby, attending an 
activity--like the case detailed above. The primary benefit of this 
close contact is that it can result in a high level of trust between 
workers and clients.
    A second benefit of the onsite location of staff is an economy of 
scale. The nurse may have a home visit scheduled in a particular 
building. She may use the time before and after this visit to check on 
other individuals she is concerned about, or stop and sit in the lobby 
for a moment to converse with residents there. In this way more people 
get to know her and become familiar with what she does. This leads to a 
third benefit, which is that residents begin to be familiar with the 
entirety of the SFN's services, even before they may need them.
    Once residents trust staff and have seen what they can do, we find 
that residents share concerns about themselves and their neighbors more 
readily. For example, residents in one SFN building became more and 
more concerned about Mrs. B., an 83-year-old widow whom they had seen 
wandering in the neighborhood at odd hours. Mrs. B. also began knocking 
on doors saying that she was hungry. One neighbor, who had been helped 
by the SFN nurse, introduced the nurse to Mrs. B. The nurse was able to 
readily establish a relationship with Mrs. B. to evaluate her needs. 
The nurse arranged for a system to help her remember to take her 
medications. The nurse also brought in the SFN social worker, who saw a 
need for Meals on Wheels and homecare services. The social worker 
worked with Mrs. B. and her family to arrange for these services so the 
client could remain at home safely and have her needs met.
    The fourth benefit to being onsite is that it is easier to access 
and assist residents who are more frail and isolated. There is no need 
to transport frail and mobility-impaired individuals out of the 
building, because services are right there. Such individuals might only 
be able get out of their buildings with great assistance, and thus only 
venture out for large occasions or medical appointments. In SFN 
activities are created right in the building, making transportation a 
nonissue.
    One 91-year-old SFN member lives in a small apartment building 
where there is no community space to gather. Mrs. D. has Parkinson's 
disease, which severely limits her mobility. She requires a walker and 
even with this device she has great difficulty walking long distances 
or getting in and out of a car. SFN created a ``warm house'' where 
programs occur in the building by rotating them in different resident's 
apartments. Without these programs offered right in her building, Mrs. 
D. would remain isolated and without regular social connections. One 
other senior said, ``My house is like a prison. I have just myself, and 
these walls. I would love to have others come to my house.'' We were 
able to start a warm house for her and her neighbors that met in her 
house.

                            PREVENTION FOCUS

    NORC programs have a major focus on prevention. When you establish 
a high level of trust with residents, you can often catch problems 
early on, and suggest changes to remedy problems before they become a 
crisis. The regular onsite contact allows staff to observe changes in 
residents over time, and suggest services that can prevent an emergency 
from happening. And finally, even when crises do occur, residents are 
getting help from people who know them.
    Let's use the example of an older man who develops hypertension. If 
he does not come into contact with a health care establishment or 
social service provider early, he may become dizzy and fall. The fall 
may result in a hip fracture, leading to hospitalization, surgery, and 
a lengthy rehabilitation from which he may or may not return home.
    When the SFN nurse discovered a similar situation the results were 
quite different. The SFN social service staff learned from neighbors 
that a participant's wife had recently died. Mr. G., an 80-year-old 
recent immigrant from the former Soviet Union, had multiple medical 
problems and his wife had always managed his care. The social worker 
assessed the situation along with the nurse. When the nurse found Mr. 
G's blood pressure unusually high, she helped him contact his doctor 
who then ordered the proper hypertension medications. The blood 
pressure stabilized and Mr. G. was connected to services to help him 
with his meals and personal care. The nurse continues to monitor his 
condition due to his multiple medical needs and because he has no 
family nearby to assist. This approach allowed Mr. G. to remain at home 
safely and averted a potential further medical complication.
    SFN also offers a significant number of preventative health 
programs. The nurse conducts regular health education programs in many 
of the buildings. These efforts focus on offering and encouraging 
preventative health care tips, and offer the nurse a means to get to 
know the residents in the buildings in a non-threatening fashion. 
Additionally, the nurse is always looking to bring in representatives 
from other disciplines to augment the SFN interdisciplinary team. Last 
year, SFN engaged in a partnership with the University of Maryland 
School of Pharmacy. A pharmacy professor and her students conducted 
outreach programs in SFN buildings that caught a number of crises 
before they happened. Mrs. J., a 78-year-old African-American resident, 
brought medication down to the pharmacist. She handed the pharmacist a 
bottle and proudly said that she took only one pill a day. When the 
pharmacist opened the bottle out spilled medications of every different 
sort. The pharmacist and nurse immediately contacted her physician, who 
resolved the medication error and now monitors his patient much more 
closely.

                               EVALUATION

    Evaluation in order to document our success and best practices is 
an important part of this demonstration grant. SFN commissioned from 
University of Maryland Baltimore County, a study to find out the impact 
of SFN's services to its members. We did a baseline sample of 108 SFN 
members, and then reinterviewed people the following year. This study 
measured our success--we had made improvements in people's lives in 
almost every area studied:

     90 percent of members turn to SFN to learn about services 
that they need, up from 69 percent in the first survey; only 11 percent 
reported that there are services they need but cannot get, down from 35 
percent in the first survey.
     Respondents reported an increase in social involvement; 83 
percent-89 percent got together and/or talked on the telephone with 
friends, neighbors and/or family in the 2 weeks prior to the interview, 
up from 65 percent-72 percent in the first survey.
     77 percent of respondents feel more involved in their 
building or neighborhood since becoming a member of SFN, up from 56 
percent in the first survey.
     Only 2 percent of respondents said they have no one to 
help them if they were sick or disabled, down from 9 percent in the 
first survey.
     Only 2 percent of respondents said that there were health 
services that they needed, but could not get, down from 13 percent in 
the initial survey.
     50 percent of respondents are participating in on-site 
preventative health services, up from 19 percent in the initial survey.
     SFN transportation services are used by 74 percent of 
survey participants, up from 51 percent in the first survey.
     99 percent of members responded that they are satisfied or 
very satisfied with the SFN program.

    With results from surveys like these, SFN can proudly say that we 
have assisted people to know where to go for help, decreased social 
isolation, increase resident's connections to their neighbors, helped 
facilitate access to health service, gotten people where they wanted to 
go, and helped them age in place.
    There are many additional evaluation efforts we would like to 
undertake at SFN. We see daily anecdotal examples of the positive 
impact that SFN is having on our community, but it is difficult and 
expensive to regularly undertake the kind of extensive evaluation that 
we conducted with the initial Federal demonstration grant. We recognize 
that further work into demonstrating the measurable outcomes that NORC 
supportive service programs make is needed to better document our 
critical work.
    In closing, the story of Mrs. L. demonstrates the true benefits 
that SFN has been able to achieve. Mrs. L. was a 75-year-old African-
American widow who was a founding member of an SFN warm house. After 
participating for several months, Mrs. L. had to bury her last living 
son. Several weeks after her son's death, the warm house activity 
coordinator met Mrs. L. who was reluctant to attend that month's warm 
house on a cold snowy winter day. Despite her hesitations, Mrs. L. 
decided to come. Once inside, all the members offered their 
condolences. Mrs. L. lamented, ``What will I do now?'' This was the son 
who shoveled my walk for me and took me shopping.'' Immediately, the 
other participants came to her aide. One woman said that her husband 
would help shovel the walk. Another woman who still drove offered to 
take her shopping on a regular basis.
    The SFN professional staff stepped in to offer support to Mrs. L. 
as well, but this help pales compared to the generous offers made by 
her neighbors. The connections between neighbors never would have 
existed without the groundwork laid through the SFN program. We do not 
simply provide services to seniors, we partner with them. We bring them 
together to create their own safety net for each other, which allows 
them to age in place with a greater sense of security and well being.
    What is left now is to keep critical programs like SFN sustainable 
into the future. Other communities should have the opportunity to 
develop their own programs. We believe that NORC supportive service 
programs should be included in the Older Americans Act. This would be a 
tremendous step in helping to sustain existing programs, like SFN, and 
in assisting other communities in developing similar resources for 
their communities.
    Thank you to all the committee members for convening this hearing 
on NORC supportive service programs, and for inviting me to share the 
experiences of SFN with all of you. I welcome the opportunity to answer 
any questions you may have.

    Senator DeWine. Ms. Shapiro, thank you for joining us.
    Ms. Shapiro. Thank you.
    Good morning, Chairman DeWine, Ranking Member Mikulski.
    Senator DeWine. You need to turn that on.
    Ms. Shapiro. Is that better?
    Senator DeWine. That is good.
    Ms. Shapiro. Good morning, Chairman DeWine and Senator 
Mikulski. It is a true honor to testify before you today.
    My name is Beth Shapiro. I am the Director of Community 
Partners, CP, for the Jewish Federation of Greater Washington's 
NORC demonstration project in Montgomery County, Maryland. On 
behalf of the 800 seniors whose lives Community Partners has 
touched, I want to express my sincere appreciation to Senator 
Mikulski for her well-established commitment and support of 
Maryland seniors and for sponsoring Community Partners.
    Community Partners provides over 100 programs a month in 
the NORCs that we serve. We are testing transitioning from a 
facility-based model where the client must go out to receive 
services, to a community-based model where staff provide 
services where seniors live. We have found NORC supportive 
service programming to be an effective public-private 
partnership that successfully leverages expertise and 
resources.
    We have collaborated with seven agencies to provide four 
cornerstone services: recreation, transportation, social work 
and health. We come together in support of seniors' 
overwhelming desire to age in place by simplifying their access 
to services. Our program invests in keeping seniors healthy and 
active by offering services that prevent and delay disability 
and disease. We provide professional intervention before, 
during and after and preempt isolation with active physical, 
intellectual and socially focused programming.
    It is critical that NORC service models like Community 
Partners be tested now in order to successfully serve seniors. 
The benefits of CP's NORC model include extending the length of 
time a person can live in their community, helping seniors 
apply for public and private services for which they were 
eligible, such as Medicare Part D and getting new wheelchairs, 
serving resident's adult children by providing them a peace of 
mind, supporting building managers and front desk staff with 
difficult or at risk seniors and residents.
    The diversity of our program partnerships include 
successful public-private partnerships with county, State and 
Federal Governments, philanthropic foundations, the seniors 
themselves, and a growing number of their families, building 
management and staff, a social work agency, a recreation 
partner, a home health agency, a transportation partner, a 
research partner and an information and referral partner.
    Sustainability is a challenge. This is why we are testing 
an individual membership model. Later we will expand membership 
to include adult children and the business community. In our 
preliminary baseline survey of senior's needs and interests, 
transportation ranked high. However, seniors are not 
enthusiastic with a one-schedule-fits-all model. As a result, 
we are currently testing a ride coordination service which 
would customize rides to the individual's needs.
    We have learned a great deal from the NORC demonstration 
experience. The most critical is the importance of working 
proactively instead of reactively to support seniors to age in 
place.
    The following examples illustrate the supportive nature of 
Community Partners.
    After a NORC resident was involved in a car accident, 
Community Partners reacted by providing social work services, 
thus decreasing the woman's anxiety and that of her husband and 
adult children.
    After another NORC resident fell, she was very resistant to 
getting medical treatment. A CP social worker talked to her 
about the importance of medical treatment. Because the woman 
was a CP program participant and had an established 
relationship with the social worker, she agreed to speak to our 
CP nurse, who was actually in the building that same morning. 
The nurse assessed her and successfully encouraged her to go to 
the emergency room.
    Many seniors tell us that before Community Partners came to 
their building, they dealt with daily isolation and loneliness. 
This is what some have told us:

          ``CP has helped me alleviate the loneliness that comes with 
        living in a big apartment complex.''
          ``CP helped me stay in my apartment during my building's 
        conversion to a condominium. I went from being told by the 
        condominium management that I did not qualify for an extended 
        residency to receiving a 2-year extension.''

    There are significant challenges facing today's seniors and 
the providers who serve them. Seniors have limited information 
about services. Many experience transportation barriers when 
accessing services. Many face caregiving and aging issues 
without available support. And many lack basic access to 
socialization and recreational opportunities.
    Our demonstration has been an overwhelmingly positive 
experience for the older adults it serves and for the 
partnering agencies who, without this grant, would not have had 
the impetus to provide services in this manner.
    In this context, I hope that my experience and those 
related by my fellow panelists provide you with an 
understanding of new ways to serve the country's aging 
population.
    I look forward to answering your questions. Thank you very 
much.
    Senator DeWine. We appreciate your testimony. All of you 
have been very, very helpful.
    [The prepared statement of Ms. Shapiro follows:]

                 Prepared Statement of Beth K. Shapiro

    Good morning Chairman DeWine, Ranking Member Mikulski and respected 
members of the committee. It is a true honor and privilege to testify 
before you today. My name is Beth Shapiro. I am the director of 
Community Partners (CP), the Jewish Federation of Greater Washington's 
naturally occurring retirement communities demonstration project in 
Montgomery County, Maryland.
    On behalf of the 800 seniors whose lives Community Partners has 
touched, I want to express my sincere appreciation to Senator Mikulski 
for her well-established commitment to and support of Maryland's 
seniors and sponsoring Community Partners.
    CP brings services and programs to seniors living in NORCs. 
Frontline staff are in the buildings we serve providing 1:1 support, 
interesting social programs, blood pressure clinics and health 
education programs. Community Partners provides over 100 programs a 
month in the NORCs. This is our way of transitioning from a facility-
based model--where the client must go out to receive needed services, 
to a community-based model where staff provide services where the 
senior lives. We like to think of ourselves as the ``advance team'' 
providing support based on strong trusted relationships.
    We have found NORC Supportive Service Programming to be an 
effective public-private partnership to successfully leverage community 
expertise and resources. To make this possible in our own catchment 
area, Community Partners has created a successful collaboration of 
seven agencies providing four cornerstone services that include 
recreation, transportation, social work and health services. County and 
State governments have joined us in this endeavor along with two 
philanthropic foundations, the managements of 5 apartment and 
condominium properties, (with a waiting list of 4 more), and other 
critical community partners. We have all come together in support of 
seniors' overwhelming desire to age in place by bringing a variety of 
professional services to NORC's thus, logistically simplifying access 
to the services they want and need.

                    ASSESSMENT & PROGRAM DEVELOPMENT

    Our program invests in keeping seniors healthy and active. It is 
critical that NORC service models like Community Partners' be tested 
now in order to successfully serve the future demographic of seniors. 
We spent the first few months of our grant completing 268 in-depth, 1:1 
surveys with seniors to determine their interests and needs. The top 
services requested were:

     Educational programs;
     Memory improvement programs;
     Onsite medical services;
     Exercise activities;
     24-hour emergency call service for medical needs;
     Coordination of services;
     Curb to curb transportation;
     Volunteering to help operate this program; and
     Recreational activities and events.

    As the result of critical partnerships including with the seniors 
themselves, we are now providing all of these services.

                      A PREVENTION-BASED APPROACH

    These programs and services comprise a pro-active system designed 
to prevent and delay disability and disease. As such, our programs and 
services strive to:

     Eliminate and prevent isolation by aggressively pre-
empting it with active physical, intellectual and socially focused 
programs;
     Provide emotional support;
     Provide new avenues for conversation that promote respect 
by family and friends;
     Provide health services such as blood pressure checks and 
24-hour emergency alert services (many are using this service because 
it was recommended by one of our staff whom they know and trust); and
     Provide professionals that are there before, during and 
after a crisis.

               THE COMMUNITY BENEFITS OF CP'S NORC MODEL

     Making it possible for greater numbers of seniors to age 
in place;
     Supporting building managers with difficult or at risk 
residents;
     Directly and indirectly serving resident's adult children 
by reducing stress and improving family relationships;
     Extending the length of time a person can live in their 
community;
     Maintaining community in a resident's building for an 
extended time thus supporting longer-lasting friendships and more 
physically and mentally active lives; and
     Helping seniors understand and apply for the government 
services for which they are eligible to receive, such as the new 
Medicare Part-D program.

                 THE DIVERSITY OF PROGRAM PARTNERSHIPS

     Our successful public-private partnership is one in which 
funding is supported by all 7 agency partners, the local county 
government, the State Government, the Federal Government, and 
philanthropic foundations.
     Currently we have active partnerships with the seniors, 
building managements, a social work agency partner, a recreation 
partner, a home health partner, a transportation partner, a research 
partner, and an information and referral partner.
     We are actively working on partnering with a local 
hospital, a grocery delivery service, a prescription delivery service 
and we are developing a shelter-in-place program with Montgomery 
County.

                     PROGRAM CHALLENGES EXPERIENCED

    Sustainability is a particular challenge to launching new 
programming. This is why part of our demonstration will be geared 
toward testing a Membership (``fee-for-service'') model this summer. 
The model will include program subsidies based on an assessment of 
ability to pay. Moving forward, CP services will be available only to 
the NORC residents through a ``membership program.'' Later, we will 
expand the concept to incorporate a ``family membership'' program for 
adult children to support their parents through CP services. We also 
plan to develop a program to engage the business community in financial 
support of the program.
    Devising a workable transportation program has also been a 
challenge we are working toward rectifying. Transportation ranked very 
high in our baseline survey with the older adults, but ridership 
associated with our initial transportation model was low. This model 
was premised on a set route according to a set schedule. Through 
evaluation of the program, we found that the seniors were not 
enthusiastic with a one-size-fits-all transportation model that did not 
allow for deviation. We are now testing a ride coordination service we 
call Smooth Riding, which arranges rides for participants to medical 
and social appointments for a nominal fee. So far, we have found the 
service to be attractive to seniors because all arrangements for their 
rides are made for them, they get a reminder call, and providers are 
matched with the passenger's needs such as access to an escort or 
wheelchair lift. Seniors are thrilled to let the program staff handle 
issues such as rides that do not show up and paying the bill for them 
from their Smooth Riding account. In the future we will be looking at 
providing subsidies for medical appointments as this can be a proactive 
way of supporting aging in place. Transportation is very expensive and 
a frequent necessity for seniors with numerous medical appointments and 
limited access to transportation options.

         LESSONS LEARNED FROM THE NORC DEMONSTRATION EXPERIENCE

    In this process we have learned many things along the way. The most 
important thing we have learned is the importance of working 
proactively instead of reactively. Of course we respond to the 
immediate and more obvious needs of NORC residents. However, our focus 
is on building ``pre-existing professional friendships.'' These are 
relationships that are established and maintained between a 
professional senior service staff member and a NORC resident. Such 
relationships allow for a different kind of intervention that creates 
opportunities for prevention. The following three examples illustrate 
the supportive nature of the CP program.

     CP has played an important role in helping several women 
after they lost their husbands. One woman lost her husband this past 
winter. Her life was directly affected as the result of CP staff making 
regular visits to her apartment the week following her husband's death. 
As a result of this relationship, although she had not regularly 
participated in CP programs previously, the woman now attends almost 
EVERY event. We believe her participation provides vital stability and 
structure in her life, especially during the difficult transition to 
living alone after 50-plus years of marriage.
     CP recently provided social work support after a NORC 
resident had a car accident. CP staff coordinated support services with 
her husband and adult children, visited her in the hospital and 
assisted with arranging for rehabilitation. This process went very 
smoothly because this woman and her husband had an existing 
relationship with CP staff. They had attended social excursions, 
discussion groups and health programs in their building. The couple 
felt comfortable and trusted the CP staff and, as a result, so did 
their children. In this case the entire family was able to benefit from 
the pre-existing relationship.
     One participant fell at the grocery store and made her way 
home alone. A CP staff member happened to run into her later that 
morning in her building. The woman was resistant to getting medical 
treatment but because she knew and trusted the staff member, she agreed 
to see one of our nurses who happen to also be in the building. The 
nurse did an assessment and convinced her to go to the Emergency Room, 
which she did. At the ER the woman received information about how to 
care for the bruising on her face. Had she been more seriously injured, 
the trip to the hospital would have been even more critical.

                       PROGRAM'S GREATEST BENEFIT

    Many seniors express they feel forgotten by the communities in 
which they were once actively involved. Seniors tell us that before 
Community Partners came to their building, they had to deal with daily 
isolation and loneliness. In combating isolation, this is what some 
have told us:

     ``The in-building discussion groups have helped. I was 
severely depressed about 6-8 months ago. Then I saw the big CP monthly 
calendar and attended a discussion group. I enjoyed it and started 
attending regularly because they significantly lifted my spirits and 
enabled me to become friends with more neighbors. I now attend almost 
all of CP's activities each month.''
     ``CP has helped me alleviate the loneliness that comes 
with living alone in a big apartment complex. The program has really 
helped transform my life and I am so thankful to CP. I go on every 
museum trip and to every lecture and to the social work groups. I love 
volunteering to help with the monthly mailing because it helps the CP 
program and gives me a chance to talk with a circle of friends as we 
work together.''
     ``CP helped me stay in my apartment during my building's 
conversion to a condominium by connecting me to the right person in the 
County who could help me. I went from being told by the condo 
management that I did not qualify for an extended residency, to 
receiving a 2-year extension!''

                               CONCLUSION

    There are significant challenges facing today's seniors and the 
providers who serve them:

     Seniors have limited information about services and other 
helping organizations;
     Many experience barriers in accessing existing programs 
because of distance and transportation issues;
     Many face caregiving and aging issues without support and 
guidance; and
     Many lack basic accessibility to socialization and 
recreational opportunities.

    NORCs are a national aging phenomenon that are the manifestation of 
the desires or consequence of the fact that the majority of older 
adults want, or by necessity, will age in place, even as they grow 
frail. Our demonstration has been an overwhelmingly positive experience 
for the older adults it serves and for the partnering providers, who, 
without this grant, would not have had the means or impetus to approach 
community services in such an innovative way. In this context, I hope 
that my experience and those relayed by my fellow panelists have 
provided you with insight and understanding into what I believe is an 
incredibly important model to serve the country's aging population. I 
look forward to answering any questions you may have regarding my 
testimony, Community Partners, or NORC Supportive Services.
    Thank you.

    Senator DeWine. Let me ask all of you this question. How do 
you coordinate with the Area Agencies on Aging? How does that 
work? Are you able to cooperate with them? Do they cooperate 
with you? What is the coordination? How do you deal with any 
kind of duplication of services? Anyone want to jump in, just 
go.
    Ms. Burke. I will be glad to start.
    The Council on Aging of Southwestern Ohio, which is our 
Area Agency on Aging, is really a cornerstone in our community 
when it comes to aging services. And we are working with them 
right now to educate them further about the NORC concept and 
see how it can work well with their services they already 
offer.
    We have local tax levies in Hamilton County and our 
surrounding counties that help support aging services. And that 
makes, I think, our program even more crucial because we can 
help direct the right person to the right program.
    Senator DeWine. Anybody else?
    Ms. Pierson. Actually I sit on the Baltimore City 
Commission on Aging, which is our AAA. So we have a close 
relationship with them. I also straddle Baltimore County and we 
have a good relationship with that AAA.
    For instance with Medicare Part D, they were very involved 
in coming to our sites and we coordinated with them to have 
their SHIP counselors explain Medicare Part D.
    So AAA has a lot of services that our clients can partake 
in but they do not get involved in the day-to-day local 
community programs that we offer.
    Senator DeWine. Anybody else?
    Senator Mikulski? We are running out of time so I want to 
give you a chance to question.
    Senator Mikulski. Know that I am suspicious of national 
programs. That might come as a surprise, oh big Democrat, big 
Government. But my observation of national social programs are 
this: money goes to the State. A chunk out of that for State 
overhead. Then money goes to local, chunk out of that for 
overhead, two layers of bureaucracy to apply. Third, there is 
always research and then training. And then when it comes to 
the service, it is usually the fifth thing.
    What has been so great about what has been done here is 
money went directly to the locals, in coordination with the 
Offices on Aging, etc.
    If you were doing a national program, how could we avoid 
the trickle-down but be able to do kind of the freshness, 
creativity, dedication that obviously was in each one of these 
programs that have been described?
    This is not about programs. It is what you said, it is 
about people. And the effectiveness has obviously been because 
small amounts of money were leveraged for more money. But most 
of all, leveraged volunteerism, other things. It was not a lot 
of overhead.
    Could you offer your thoughts? Ms. Pierson, you have worked 
for a variety of nonprofits and so on.
    Ms. Pierson. I am sitting here thinking, and thinking about 
the Older Americans Act and senior centers. As you went through 
the trickle-down I saw the money going like this, and I know 
how hard it is in Baltimore City for senior centers. So I 
really have to think about that.
    I had not thought that you would have that viewpoint but I 
think you are absolutely right, that programs end up getting 
very structured over time. And this program has to be very 
fluid to be able to react to a neighborhood.
    Maybe it is more like community development block grants, 
where jurisdictions have some leeway in how they provide the 
money to the local entity.
    Senator Mikulski. Let me suggest a model and get the 
reaction, No. 1, for those who would want to do a NORC. Not 
everybody wants to and everybody has the social or 
administrative capability to do it. There are a variety of 
reasons to do something in the Older Americans Act, maybe even 
under the demonstration program. I am not sure, again I look 
for advice.
    But where money is applied for for a local NORC, rather 
than going through a lot of administrative arms. And then to 
meeting certain Federal standards around exactly what you said, 
prevention, community-based, local partners in both providing 
service and additional funds, etc.
    But would allow for the creativity and the flexibility to 
handle the wide geographic and other profiles that you 
presented to the committee.
    Ms. Keller, Ms. Burke, do you think about that?
    Ms. Keller. I appreciate how you laid out----
    Senator Mikulski. And maybe you think I am wrong.
    Ms. Keller. No, I think you are right, it is disturbing to 
us. We understand that the State does need some administrative 
money and the county or city needs some administrative money, 
and obviously the agency whose administering the program needs 
some administrative money. But obviously, at the end of that 
stream, there is less money available to deliver programming to 
the people who really need it.
    The other side of what we have now is a hit and miss 
situation where starting a program means putting some money in 
the front end to create it and then having to come back to 
generous and forward thinking Senators like both of you.
    Senator Mikulski. We cannot keep doing this on earmarks. It 
is too unpredictable.
    Ms. Keller. Exactly, and what happened last, of course, it 
was unpredictable or perhaps predictable. But all of us who 
were looking forward to that money and that commitment ended up 
sitting empty-handed and having to figure out how they could 
stretch money or find some short-term funds. And now sit again 
this year and hope for the possibility of continuing their 
programs.
    What a designated funding stream would mean is better 
ability to plan for a program, to do some real strategic 
planning, to be able to get past that front end. And I would 
support something that would set up a designated funding stream 
for these programs.
    Senator Mikulski. I am going to offer another model. You 
know, we have 202 housing programs at HUD. And recalling when I 
was a HUD appropriator and I believe Senator DeWine, I do not 
know if you were on housing and banking, I seem to feel you 
were.
    But organizations apply to do 202. It does not come through 
a lot of layers at HUD. And then often it is done through 
nonprofits like your Govans Ecumenical. It was the churches 
coming together for that wonderful new stadium place endeavor 
that is underway, Ms. Pierson.
    Often it is the Associated. Very often it is faith-based 
that know programs, know how to do it, etc.
    But the money to do the 202 housing does not go through a 
lot of organization, a lot of layers.
    And I wonder if that is something that is a model?
    Ms. Burke. I think definitely that is a possibility. I 
think the Older Americans Act, in a lot of ways, is a natural 
place for this program.
    Senator Mikulski. Oh no, we would not put it at HUD. No, 
no, because HUD does what HUD does and they have their own, the 
housing for the elderly. And I have a feeling Ohio is a lot 
like Maryland. A lot of that housing for the elderly were built 
in the 1970s and the 1980s. That, in and of itself, the 
buildings are aging. That is a whole another issue.
    Ms. Burke. I think though in our case what you are saying 
is the idea is how it is structured, to keep that flexibility 
and be true to the original principles of the NORC movement. A 
big part of that is that it is driven by the older adults that 
are in these NORCs.
    In our case, I know the early speakers, there was some talk 
on the first panel about rural NORCs. In our community, we have 
been collaborating with other agencies such as ourselves, 
Claremont Senior Services, about Felicity, Ohio and Senior 
Citizens Incorporated about the African-American community in 
Hamilton, Ohio. And although their NORCs would look very 
different, I think that is the key to structure so that people 
can have that flexibility.
    Senator Mikulski. See, that is what we want. I know one of 
the things that Senator DeWine and I share, which is big 
outcome, not necessarily big government. And then also a look 
to use the nonprofit and faith-based networks, who seem to know 
how to leverage other money and other resources and often deal 
with suspicion.
    A lot of what you have talked about is people letting them 
in homes. Certainly we see that in the rural areas. In the 
rural parts of my State, people will work with an ecumenical 
housing effort where they would never work with a Government 
effort. They would shun it.
    And so that is what we are looking for, big outcome, not 
necessarily big government. I think you have given us some 
ideas.
    Can I just ask this, and this is my last question. It was 
about lessons learned and best practices. But out of what you 
did, what was your biggest surprise about what worked and what 
might not have worked? Mrs. Shapiro?
    Ms. Shapiro. What was our biggest surprise?
    Senator Mikulski. Yes, when you actually ran the program 
now for a couple of years, about what worked from your regional 
conceptual model to what maybe did not work?
    Ms. Shapiro. I think what worked the most and the way we 
are influencing people's lives on a daily basis is bringing 
people together and we do a building model. And they are now 
getting to know their neighbors that they have lived with for 
20 years and never really knew except for going up and down the 
elevator and sitting in the lobby and passing by. Now they 
really know them. They know their names. They know their 
hobbies. They know their interests. They know about their 
families.
    And when there is a crisis, they have an existing community 
that really was not there before.
    Senator Mikulski. So it will be neighbor helping neighbor 
because neighbor now knows neighbor.
    Ms. Shapiro. Yes, absolutely. Absolutely.
    Ms. Pierson. One of the biggest surprises I had recently, I 
looked at demographics and 30 percent of the people in our area 
have incomes below $7,500 a year. Seniors are living on just 
SSI and poverty. I think one of our biggest successes is 
providing those people with joy and good living within their 
means. That is no small achievement for that group of people.
    Senator Mikulski. No.
    Ms. Burke. We have had similar experiences, but I would say 
the biggest surprise to me is how open our property managers 
were to us. These are people----
    Senator Mikulski. The private sector.
    Ms. Burke [continuing]. In the business community. They 
want to keep their apartment buildings or condominium 
complexes, whatever it is they own, full. This is an 
alternative to them to help them do that. They welcomed us with 
open arms.
    Ms. Keller. And I will end on the biggest challenge, and 
that is a secure funding stream.
    Senator Mikulski. We were surprised that the money got 
canceled last year.
    Ms. Keller. I think that has been the greatest difficulty. 
The successes are there. I think the program speaks for itself. 
Nobody opposes it. But we need to find some sustainability to 
the funding to move forward.
    Ms. Shapiro. Can I make one very quick comment, in just the 
time? One sentence.
    What was very surprising to us was when we went to approach 
building managers and board of directors of condominiums. At 
first, many were very resistant and they turned us down. And 
others jumped on board right away and were willing to play 
guinea pig, if you will.
    Those folks that turned us down are now banging down our 
door, please come serve us. The word-of-mouth is out there. I 
have got people from other States calling me, saying, ``Can you 
come?'' ``When are you coming?''
    I think that was a very telling surprise to us.
    Senator Mikulski. Thank you.
    There is a saying, all politics is local. But truly, all 
social services is. We have come up with some new language 
here.
    But many people talk about assisted living. You have 
obviously taken hard to reach populations and you have helped 
them with assistance with living. So we are very proud of what 
you have done and you have given us a lot to ponder.
    Thank you very much for your dedication and creativity and 
resourcefulness.
    Senator DeWine. Let me thank all of you very much. I want 
to thank both panels. Very good testimony, very helpful. We 
really, really appreciate you all coming in. It has been, I 
think, a very informative hearing for this committee. And you 
can tell that Senator Mikulski and I are both very interested 
in this subject.
    Thank you very much.

    [Whereupon, at 12:05 p.m., the subcommitee was adjourned.]