ARCHIVED - Searchable Database of Supportive Housing for Seniors in Canada: Final Report

Prepared by Social Data Research
For Health Canada
April 15, 2005

Abstract

This report describes the results of a study undertaken as part of an important new initiative, Searchable Database of Supportive Housing Options for Seniors in Canada. The main purpose of the study was to identify and survey supportive housing projects for seniors age 65+ across Canada and to create an unpublished electronic test database with information on each of these projects. The report describes the range of projects in the database and identifies selected examples of innovative projects. The report also identifies issues related to the supply and quality of supportive housing for seniors including benefits, limitations, barriers and gaps, and describes the most current public policies and guidelines applicable to supportive housing in Canada. The database will be helpful to researchers and policy makers as well as organizations with an interest in seniors housing across Canada. It will also be useful as a model for inventories of housing options for other special needs populations such as persons with disabilities.

Executive Summary

Introduction

The purpose of this study, prepared for Health Canada in cooperation with Canada Mortgage and Housing Corporation (CMHC), was to identify and survey supportive housing ¹ projects for seniors (age 65+) across Canada and to create an unpublished electronic test database with information on each of these projects. The published report for this study discusses the range of projects surveyed and describes selected examples of innovative projects. It also identifies issues related to the supply and quality of supportive housing for seniors including benefits, limitations, barriers and gaps, and describes current public policies and guidelines applicable to supportive housing.

Terminology

"Supportive housing is a term used to describe a range of housing options designed to accommodate the needs of seniors through design features, housing management, and access to support services. At one end of the range, supportive housing refers to congregate housing with supportive features and services such as monitoring and emergency response, meals, housekeeping, laundry and recreational activities. At the other end of the range (referred to in most North American jurisdictions as "assisted living") personal care services are also provided for frailer seniors with more significant support needs. Professional services may be provided on a home-care basis in a supportive housing setting as they would be if the resident were living in a different kind of (non-supportive) residential setting. Supportive housing may be provided by either the public or the private sector, for profit or not for profit. In some cases, one provider will be responsible for delivering the whole supportive housing package (services plus housing). In other cases services and housing components will be delivered separately, by different sectors. Supportive housing can be rented, purchased as a condominium in fee simple, or obtained through a life lease." ²

Methodology

The study was conducted under the guidance of an advisory committee made up of representatives from the Public Health Agency of Canada (PHAC), Health Canada, and Canada Mortgage and Housing Corporation (CMHC). It began with a literature review to help identify issues related to supply and quality of supportive housing in Canada. The search for information focused on Canadian articles and research reports (published and unpublished) written since 1994.

Following the literature review, key informant interviews were conducted with experts in gerontology, provincial and territorial government representatives knowledgeable about housing policies and programs related to seniors, and practitioners and representatives of seniors organizations knowledgeable about seniors housing issues in their jurisdiction. These interviews were helpful in identifying innovative supportive housing projects across the country.

A survey of projects was designed to collect a wide range of information about each project including the type of project, sponsor, date of construction or adaptation, number and type of dwelling units, tenure type, support service arrangements, type of physical structure, location, profile of residents, and management and staffing. The survey was conducted by telephone, fax and online methods.

The unpublished test electronic database was developed using Microsoft Access. To be included in the database, projects had to have been:

built as, or adapted in the last 15 years to, supportive housing for seniors;
identified as innovative by key informants, reports, or publications;
funded in whole or in part by the non-profit or public sector; and
able to respond to the survey within the required timeframe.

Findings

The survey collected information from 244 supportive seniors housing projects across Canada, with most being in Quebec, Alberta, Ontario and British Columbia. About half the projects opened in the last ten years. About one-third of the operators defined their projects as assisted living. The survey identified projects from all sectors: public, private non-profit and private for-profit. They range in size from as small as a few residential units to as large as 400 units. One-bedroom suites appear to be the most prevalent although many projects offer more than one size of unit.

Almost all (99%) projects offer some services on site through their own organization. The majority of projects offer:

24-hour security;
unit repairs/maintenance;
meals served in a common dining room;
recreational activities;
hospitality services such as personal laundry and housekeeping;
help with medications; and
assistance with activities of daily living.

Some projects also offer:

transportation assistance (such as a facility-dedicated van);
escorts to appointments;
doctor visits;
social services (such as counseling and referrals);
mental health services;
meals on wheels or wheels to meals; and
palliative care.

The age of residents living in the projects ranges between as young as 63 and as old as 93. Most are women, and almost all are living alone. Residents of supportive housing come from many different cultural backgrounds, and some projects are sponsored by a particular ethnic or religious organization.

About 70% of the projects in the database report they have been designed to support "aging in place". As a result some residents are quite frail and need help with most activities of daily living. However, on average, about half the residents require little or no assistance and function quite independently. Many supportive housing projects have some residents with dementia; however, very few have been purposely designed to serve the needs of persons with dementia.

The majority of projects surveyed have an on-site service coordinator who helps residents access services. Most projects involve residents in management decisions that affect them. About half the projects have on-site staff. In some projects residents and front-line staff are asked to sit on advisory boards or are involved in some other capacity related to management.

Experts generally agree that supportive housing can improve the overall well-being and quality of life for seniors who need assistance with activities of daily living. Daily benefits such as the provision of nutritious meals, opportunities to socialize and participate in physical activities, and access to health services in the community when needed make it possible for seniors to maintain their independence and supports the aging process with dignity.

Issues

The report also discusses some issues debated among experts. One of the themes that arose from the interviews and in the literature centered on the issue of where supportive housing fits in the continuum of housing and care for seniors with greater health needs. For persons who do not require 24-hour nursing care, experts agree that most forms of supportive housing make it possible for residents to safely "age in place". However, for seniors with severe dementia or other chronic diseases that result in significant loss of abilities over time, supportive housing may not be able to sustain these individuals over the longer term. Although most projects reported that they have features that support aging in place, only 16% indicated that they have been designed to serve the needs of persons with dementia. As well, 54% restrict tenure for persons with mental health issues such as dementia.

Much discussion in the literature centers on standards of care (or lack of standards) and how this relates to the quality of life for residents in supportive housing. To help maintain a high level of quality of life in supportive housing, some key informants held the view that clear provincial policy guidelines related to standards and quality of services are needed. However, at the same time, concern was expressed about setting standards that are too restrictive.

At the time of the study, BC was the only province with any legislation in place related to supportive housing. Current legislation in BC restricts assisted living facilities to providing mainly hospitality type services and only one or two of the prescribed higher forms of more intensive services. ³ To be eligible for assisted living in BC, all persons must be assessed by the regional health authority as needing the level of care provided by assisted living facilities. The BC legislation specifically excludes people "who are unable to make decisions on their own behalf" from private and public assisted living unless they reside with a spouse who is able to make those decisions for them." ⁴

Key informants in the study cited the lack of national standards for supportive housing and differing access criteria for home support services across the country as barriers to the development of good quality supportive housing for seniors. CMHC's recently released report on a legal framework for supportive housing for seniors will help policy makers explore regulatory options. (See, A Legal Framework for Supportive Housing For Seniors: Options for Canadian Policy Makers, March 2005).

The study also found gaps in the supply and choice of supportive housing. There was consensus among key informants that demand for supportive housing may exceed supply in rural areas, and that there are insufficient affordable supportive housing options for low and modest income seniors, homeless seniors, seniors with dementia, and seniors from diverse sub-populations such as aboriginal elders, and gay, lesbian, bisexual and transgendered seniors.

Key informants in the Atlantic region stressed the need for more supportive housing in their provinces. A new study has begun to examine this issue. The study, Projecting the Housing Need of Atlantic Canadians, will bring together seniors, academics, service providers, housing developers and government departments from all four Atlantic provinces to help determine how to meet the housing needs of the area's rapidly aging population. ⁵

A review of provincial policies and guidelines found that most provinces and territories have an interest in supportive housing. For example, at the time of this study, BC had initiated many new housing developments under the federal-provincial cost-shared affordable housing program. As well, a number of jurisdictions including Nova Scotia, Newfoundland, and Alberta have strategic plans or proposed research or pilot projects in place to address issues related to supportive housing. The report provides a summary of these initiatives and the most current policies and guidelines related to supportive housing.

The test database

The unpublished test database includes projects' descriptions of innovative features in four areas: barrier-free design; management approach; partnerships; and support services (including the type of service package offered and the types of services offered through linkages with community agencies). It is fully searchable by key words (based on the variables included in the database) or location of project (province, municipality, postal code).

To date, the database includes 244 completed records. It also includes contact information for other projects that did not complete the survey within the time frame or were ineligible according to the screening criteria.

Uses for the database include (but are not limited to):

Searching for projects in a certain region
Examining the service offerings of a specific (or multiple) project(s)
Finding the contact information for projects

Conclusions

The survey of supportive housing projects for seniors represents the most current state of information on supportive housing in Canada. The report outlines a number of conclusions, including the following:

Supportive housing is defined quite broadly and encompasses many different models of housing and supports.
Supportive housing offers a wide range of potential benefits to seniors, particularly in the areas of health and overall quality of life. In its most supportive form, assisted living, it has the potential to be a viable alternative to traditional long-term care or nursing home care for many seniors.
A wide range of supportive housing options are available for seniors across Canada. However, options for modest and low-income seniors are fewer than for those with higher income levels. There are also gaps in the supply of supportive housing for seniors in rural and remote areas and some regions of Canada.
There appears to be almost a west (high) to east (low) ranking in terms of new development activity and range of supportive housing options being made available. This could be the result of demand, market conditions, or provincial government funding priorities.
There are some barriers in supportive housing options for certain special needs populations such as the hard-to-house and homeless, gay, lesbian, bisexual and transgendered seniors, and seniors with middle to later stages of dementia.
Supportive housing continues to show promise as a housing option for seniors who wish to remain independent but require some support, and there is some optimism that government policies that favour the renewed development of affordable housing in Canada will extend to supportive housing for seniors, if support services can be matched to new affordable housing units.
The unpublished test database of supportive housing for seniors in Canada gives promise of being a first stage toward the development of a valuable tool for those wishing to share, or obtain, information about housing projects, and the distribution of supportive housing across Canada. CMHC and Health Canada are considering further development and eventual publication of the database.

Part One: Background

1.1 Introduction

This report describes the results of a study undertaken as part of the development of a test, unpublished Searchable Database of Supportive Housing Options for Seniors (65+) in Canada. The study was conducted over a three-month period from January to April 2005 and represents the most current state of information on supportive housing in Canada. The purpose of the study was to:

Identify and survey supportive housing projects for seniors age 65+ across Canada;
Describe the projects that responded to the survey and identify selected examples of innovative projects;
Identify issues related to the supply and quality of supportive housing for seniors including benefits, limitations, barriers and gaps;
Describe the latest public policies and guidelines applicable to supportive housing; and
Develop a test searchable database that could serve as a future directory of supportive housing for seniors in Canada and also be used as a model for inventories of housing options for other special needs populations such as persons with disabilities.

1.2 Study Parameters

The starting point for the test database was Canada Mortgage and Housing Corporation's (CMHC) definition of supportive housing. CMHC describes supportive housing for seniors in the following way:

"Supportive housing is a term used to describe a range of housing options designed to accommodate the needs of seniors ⁶ through design features, housing management, and access to support services. At one end of the range, supportive housing refers to congregate housing with supportive features and services such as monitoring and emergency response, meals, housekeeping, laundry and recreational activities. At the other end of the range (referred to in most North American jurisdictions as "assisted living") personal care services are also provided for frailer senios with moe significant support needs. Professional services may be provided on a "home-care" basis in a supportive housing setting as they would be if the resident were living in a diferent kind of (non-supportive) residential setting. Supportive housing ⁷ may be provided by either the public or the private sector, for profit or not for profit. In some cases, one provider will be responsible for delivering the whole supportive housing package (services plus housing). In oher cases services and housing components will be delivered separately, by different sectors. Supportive housing can be rented, purchased as a condominium in fee simple, or obtained through a "life lease." ⁸

To be included in the database, projects had to have:

been built as, or updated in the last 15 years to, supportive housing for seniors;
been identified as innovative by key informants, reports or publications;
been funded in whole or in part by the non-profit or public sector; and
responded to the survey within the study timeframe.

1.3 Methodology

A number of concurrent activities were undertaken to complete the work in the study's time frame. These were:

a literature review;
key informant interviews;
an exploratory survey of potential projects across Canada; and
the development of a searchable database of projects.

Literature review

The literature review was prepared as a background paper (see Appendix A). The purpose was to help identify:

innovative examples of supportive housing projects for seniors in Canada;
the types of supportive housing options for seniors that are available in Canada; and
issues related to the supply and quality of supportive housing for seniors in Canada.

The search for information was focused on Canadian articles and research reports (published and unpublished) written since 1994. A standard literature search was performed using the Internet, various databases and academic abstracts. In addition to "supportive housing for seniors in Canada", key words such as those listed below were used:

Assisted living for seniors
Abbeyfield Homes
Life Lease housing for seniors
Congregate living for seniors
Seniors housing with support services
Seniors accommodation with support services
Purpose built housing for seniors with services
Evaluation of supportive housing for seniors
Quality of Life

In addition to searching in the above linear fashion, an advanced database was used to navigate between related and cited articles. In other words once a relevant article was found, other articles that cited the relevant article, or were cited in the article, were also identified.

Academic articles were sought in the following abstract databases:

AARP Ageline
Ovid Medline
PsycInfo
Social Sciences Index

In terms of unpublished literature, recent reports on supportive housing produced by Canada Mortgage and Housing Corporation, Health Canada (Atlantic Region) and Veteran Affairs Canada were reviewed. University Centres of Aging across Canada were also surveyed for recent reports and publications.

Key informant interviews

Key informant interviews were conducted to complement the literature review and to obtain the most recent information about supportive housing for seniors in Canada. The purpose was to:

Obtain sources including existing directories and lists of supportive housing projects.
Identify innovative projects.
Obtain information about current policies and guidelines related to supportive housing for seniors.
Obtain information related to the supply and quality of supportive housing including barriers and gaps.

Three types of key informants were interviewed: (a) provincial and territorial government representatives knowledgeable about policies and programs related to seniors and housing; (b) practitioners and representatives of seniors organizations knowledgeable about seniors' housing issues in their jurisdiction; and (c) academic researchers in the aging field with an interest in seniors housing issues.

The interviews with key informants were conducted by telephone. Respondents were sent the interview guide in advance. In many instances, the initial contacts led to other key informants in the same jurisdiction. A total of 48 key informants contributed to the research.

The list of contacts is attached in Appendix B.

Key informants were asked to identify innovative supportive housing projects in their jurisdiction, and to comment on issues related to the quality and supply of supportive housing for seniors. Provincial and territorial government representatives were asked to describe current public policies, programs and guidelines related to supportive housing for seniors in their province or territory.

Exploratory survey of projects

The exploratory survey of projects was designed to collect a wide range of information from as many identified supportive housing projects across the country as possible within the four-week field period. A structured questionnaire was used to collect the data. The design of the questionnaire was based on the same template that was used to design the content of the searchable database. The following question areas (or headings) were included in the template:

Background and history (type of project, sponsor, when built, partners).
Number and type of units.
Occupancy level and waiting list.
Tenure arrangements.
Support service arrangements.
Type of physical structure and amenity spaces.
Location (residential, rural/urban).
Profile of residents.
Management and staffing.
Contact information.

At the end of the survey, respondents were invited to list innovative features that their project offered that assist residents to age in place. They were also asked about their views on the issues related to the supply and quality of supportive housing for seniors. A copy of the questionnaire is attached in Appendix C.

Several approaches were used to identify potential projects for the survey, including the following:

Existing directories ⁹ at the provincial and municipal level. ¹⁰
Recommendations from key informants.
Reports and publications on supportive housing.

The search for potential projects was ongoing throughout the four-week field period. As projects and lists of projects were identified, they were entered into the survey sample list and distributed to the interviewers. Over 3000 potential projects were identified. A screening tool based on the survey's parameters was developed to help narrow the list to projects that fit CMHC's definition of supportive housing.

The survey was conducted by telephone, ¹¹ online and fax. Interviewers introduced the study using a script prepared by Health Canada. If requested, a letter from Health Canada describing the study was sent to potential respondents by fax or email. Most respondents chose to be interviewed by telephone.

Response rate

A multi-modal approach was used to develop lists of projects and to call for follow-up. Lists were developed through multiple phone calls to various municipal and provincial contacts. Where possible, names and numbers for potential projects were also harvested from websites. In Quebec the CLSCs were used as a key source of referral. A final list of potential projects was created and an official at each project was called and asked to participate in the survey. Exhibit 1 outlines the types and number of responses.

Exhibit 1 Response to Date

Total number of projects identified: 3151
Number eligible responded in time frame: 244 ¹²
Number eligible not able to respond: 70
Refused to participate: 89
Number not eligible: 989
Number not contacted (submitted too late, technical problems, busy, no answer, etc.): 1460
Duplicate contact name (i.e., responsible for multiple facilities 13): 299

Aggregate analysis

An SPSS (Statistical Package for the Social Sciences) file was created to assist in the aggregated analysis of the survey data. The aggregate analysis helped to identify overall trends in the responses to each area of the questionnaire.

Designing the database

The data collected was placed in ACCESS (a Microsoft Access database). ACCESS was chosen because it is a relational database that allows users to do searches using standard queries and in a "user friendly" manner. In order to add an additional element of "user friendliness" a home page and search function was constructed. The database allows users to update records, add new facilities, or perform inventory analysis. It can also be made available online.

Part Two: Findings of Phase One

2.1 Results of the Survey of Projects

This section describes the results of an aggregate analysis of the 244 projects included in the database. It provides an overall profile of the projects based on the responses to the question areas in the survey. Readers are cautioned not to draw conclusions about the distribution and characteristics of supportive housing in Canada from the results presented in this report . The projects that generated responses to the survey are not representative of the total number of supportive housing projects in the various jurisdictions and do not constitute statistically valid samples of supportive housing for seniors. The survey was exploratory and the projects contained in the database are those from which a response was received in the short time frame of the study. Nevertheless, the information provided gives some indication of the types of supportive housing projects that exist in the country. Follow-up work will be necessary to learn how well these projects represent the distribution and characteristics of all supportive housing for seniors in Canada

Regional distribution of projects in the database

The survey allowed the researchers to identify eligible projects and interview operators in each province across Canada. Only two potential projects were identified in the territories. However, neither one of these generated a response to the survey within the field period. The distribution of projects by province is shown in Exhibit 2.

Exhibit 2 Number of Projects by Region

Newfoundland: 2
Prince Edward Island: 2
New Brunswick: 2
Nova Scotia: 6
Quebec: 113
Ontario: 33
Manitoba: 7
Saskatchewan: 4
Alberta: 50
British Columbia: 25
Territories: 0
Total projects: 244

Most of the projects that were eligible and whose operator responded to the survey were located in four provinces: Quebec, Alberta, Ontario and British Columbia. It is interesting to note that more seniors live in these four provinces than elsewhere in Canada. ¹⁴

Alberta may appear to be relatively over-represented in the database. Although Alberta has a relatively small proportion of locally born seniors compared to other provinces, the recent net flow of seniors into Alberta from other provinces, the highest inter-provincial net flow in the country, is contributing to an increase in the overall numbers of seniors in that province. ¹⁵

Rural-urban distribution

The database contains projects from 172 different communities and municipalities in Canada. The survey asked respondents to self-identify whether they were located in an urban area, a small town or a rural area. ¹⁶ Exhibit 3 shows the rural-urban distribution of the projects in the database.

Exhibit 3 Rural-Urban Distribution

Percent of projects located in a:

Urban area: 55%
Small town: 42%
Rural area: 3%
Total: 100%
Number of projects reporting =: 244

As Exhibit 3 shows, 97% of the projects in the database are located in urban areas and small towns.

Description of projects in the database

Respondents were asked a number of questions at the outset of the interview to help describe the projects (i.e., how they identified their housing, their history, sponsor and partners). Here are the results:

Year first opened

The majority of the projects in the database opened their doors for the first time in the last fifteen years. Almost half (46%) of the projects were developed in the past ten years. The remaining projects have been adapted to supportive housing recently but were built more than ten years ago.

Classification and accreditation

Almost two thirds (63%) of the operators classified their projects as supportive housing. About one third classified their projects as assisted living facilities and a few labeled their projects in other terms (i.e., a seniors' lodge, housing with advanced care, supported apartments for independent seniors).

Operators who classified their housing as assisted living residences were asked if their projects were accredited. ¹⁷ About one third (N=27) of the operators responded affirmatively to this question. Accredited projects were located mainly in Quebec (70%); and Alberta (22%). The source of accreditation was not asked.

Funding sector

Exhibit 4 shows the percentage of projects by funding sector.

Exhibit 4 Percentage of projects by funding sector

Public: 34%
Private not-for-profit: 26%
Private for-profit: 36%
Other: 4%
Total: 100%
Number of projects reporting =: 244

Over half of the projects (N=146) in the survey were developed by the public or not-for-profit sector. Just over one third (N=98) have been developed by the private for-profit sector.

Partnerships

Just over forty percent of the projects in the database involved partnerships. The majority of these were located in Alberta, Ontario and Quebec. All of the projects in Saskatchewan (N=4) and a high proportion (85%, N=6) of the projects in Manitoba reported having partners.

In most cases (72%), the role of the partners was related to capital funding. A smaller proportion (17%) of the partnerships were related to the delivery of support services , and 10% of the partnerships involved other aspects such as conducting needs assessments or subsidizing rents.

Number and type of units

Projects ranged in size from as small as a few residential units to as large as 400 units. Exhibit 5 shows the range in sizes.

Exhibit 5 Size of projects
Number of units	Percent
9 or less	16%
10-19	15%
20-39	22%
40-59	18%
60-99	12%
100-199	13%
200-400	3%
Total	100%
Number of projects reporting =	242

Exhibit 5 indicates that the survey captured projects in all sizes. The average size is about 50 units.

Exhibit 6 lists the different types of dwelling units offered - studios/bachelors, one-bedroom suites, two-bedroom suites and larger units. About sixty percent of the projects in the database offer one type of residential unit, 29% offer two different types of units, and the rest (12%) offer a choice of three or more different sizes of units. Larger projects with more than 60 units in total were more likely to offer a full range of different types of suites.

Exhibit 6 Types of units offered most often

Percent* of projects that offer:

Studio/bachelor suites: 36%
One-bedroom suites: 85%
Two-bedroom suites: 39%
Three+ bedroom suites: 3%
Other types**: 3%
Number of projects reporting =: 244

* Percents will add to more than 100% because some projects offer more than one unit type.

** Other types of units reported included guest suites, rooms without kitchenettes, and connected rooms

As Exhibit 6 indicates, one-bedroom suites appear to be the most available.

Occupancy

Not all projects were fully occupied at the time of the survey. In fact, just fewer than sixty per cent were fully occupied. The average occupancy rate for all projects in the past 12 months of the study ranged from 30% to 100%. About half of the projects reported being 100% occupied over the entire past year.

Waiting lists

Most projects (62%) - regardless of occupancy rate - had a waiting list at the time of the survey. ¹⁸ Operators of almost all projects (92%) indicated that it was typical for them to have a waiting list.

Types of Tenure

The different types of tenure reported are presented in Exhibit 7.

Exhibit 7 Types of Tenure *

Rental: 94%
Life Lease: 8%
Co-op: 2%
Condo: <1%
Freehold: -
Number of projects reporting =: 244

* Percents will add to more than 100% because a small number of projects offer more than one type of tenure arrangement.

Exhibit 7 shows that the vast majority of the projects (94%) in the survey offer rental units. A small percentage of the projects offer more than one type of tenure arrangement. The combinations were mainly rental and life lease.

Support services

Respondents were asked a series of questions about support services - what was offered on-site, off-site and by whom (i.e., by their own organization or through linkages with other organizations). Almost all (99%) projects offered some services on-site through their own organization. The number of in-house services offered on-site ranged from 1 to 24 with the average number being 16.

The following is a list of the types of services offered on-site by the majority of projects through the project's own organization. The percentage of projects that offer these services is shown in brackets.

24-hour security (94%);
Unit repairs/maintenance (93%)
Meals served in a common dining room (90%)
Recreational activities (89%)
Hospitality services such as personal laundry and housekeeping (85%)
Help with medications (72%)
Assistance with activities of daily living (70%)

The following is a list of the type of on-site services offered by less than 50% of the projects through the project's own organization. The percentage of projects that offer these services is shown in brackets

Transportation assistance (such as a facility dedicated van) (48%)
Escorts to appointments (47%)
Doctor visits (41%)
Social services (such as counseling, referrals) (27%)
Palliative care (21%)
Mental health services (19%)
Meals on wheels/wheels to meals (18%).

Off-site services

About two thirds of the projects offered some support services through their own organization at another site. This could include services delivered to seniors living in their own homes in the surrounding area of the project. The number of services ranged from 1 to 22 with an average of 3 services offered off-site. The types of services included meals on wheels or wheels to meals, nursing services such as blood pressure checks, doctor visits, mental health services and palliative care.

Services provided through linkages with other organizations

About forty percent of projects used linkages with other organizations to provide some on-site and/or off-site services in addition to what they offered in-house. The provision of services such as mental health supports and palliative care were often arranged through these types of linkages.

Support service packages

Just over half (54%) of the projects in the survey offered a standard package of support services that all residents purchased. Twenty percent offered a flexible package with a menu of support services, and about the same percentage offered both a standard package and an additional flexible package.

A standard package of services included the following types of services. The percentage of projects that offered each service appears in brackets.

All meals (94%) or main meal only (8%)
Laundry (81%)
Housekeeping (88%)
24-hour security (98%)
Other services (i.e., recreation, two meals, cable, transportation) (18%)

Cost to residents for housing and services

Survey respondents were asked to provide information on the minimum and maximum monthly cost of housing and support services to their residents. Thirty percent did not provide information on the cost to residents of housing and services combined, 54% did not provide figures for housing only costs, and 72% did not provide information on the separate cost to residents of support services.

About 70% of respondents provided information on the minimum and maximum monthly cost to their residents for housing and services. The average minimum cost reported was $866, and the average maximum cost was $1,264.46. However, reported rates were as high as $4,200 per month and as low as $46.

Financial assistance

The majority (76%) of projects in the survey provide subsidies or make other forms of financial assistance available to residents who are in need. About half of the operators provide financial assistance for both housing and services. About one third provide financial assistance for housing only and 16% provide financial assistance for support services only.

Types of housing and amenity space available

Exhibit 8 shows the types of housing available in the participating projects.

Exhibit 8 Types of housing

Single family detached houses: 10%
Semi-detached, duplex, row houses or townhouses: 3%
Single story motel style apartment building: 14%
Apartments in multiple story building: 59%
Mobile homes: 0%
Other*: 14%
Total: 100%
Number of projects reporting =: 244

* Reported under "Other" were mainly smaller building types such as cluster bungalows, cluster group homes, mixed one story and two story, single lodge or group home, etc.

Close to one third of the projects that participated in the survey (29%) were part of a campus model where other types of accommodation and care were provided, such as long-term care residences.

Almost all projects (91%) were located in a residential neighbourhood. A small percentage (9%) was located in a downtown or commercial area.

Amenity spaces

Survey respondents were asked about the types of amenity space their project offers. Exhibit 9 shows the types of amenity space offered and the percentage of projects that offer such space.

Exhibit 9 Amenity spaces offered by projects

Common dining room: 96%
Outdoor common space: 96%
Indoor activity rooms: 94%
Lounges for socializing: 91%
Library/reading rooms: 73%
Private dining area for family occasions: 49%
Access to private yard or balcony: 38%
Overnight accommodation family visitors: 32%
Other amenity spaces*: 10%
Number of projects reporting =: 244

Over 90% of the projects offer a common dining room, outdoor common space, indoor activity rooms and lounges for socializing with friends and family.

* Other amenity spaces listed include a spa, exercise room, indoor or covered parking spaces, general store, movie theatre, and bowling alley.

Profile of residents

Survey respondents were asked to provide information about their residents, including the number occupying their projects; their age and gender; their living arrangements; their cultural background and language; their degree of independence; health status, and their level of dementia.

The total number of residents occupying a project ranged from 2 to 500. The average number was 55. Exhibit 10 shows the distribution.

Exhibit 10 Total number of residents

10 or less: 22%
11 - 20: 14%
21 - 30: 11%
31 - 40: 6%
41 - 50: 10%
51--60: 8%
61 - 99: 11%
101 - 500: 18%
Total: 100%
Number of projects reporting =: 243

Age and gender

Respondents were asked to give the approximate age range of the people living in their project - youngest and oldest. Based on their responses, the age of residents living in supportive housing ranges from 63 to 93. A number of projects, although purpose built for seniors, also served younger adults with disabilities. In fact, about 20% of the projects in the survey had some residents under the age of 55.

On average, 75% of the residents living in surveyed projects were women and 25% were men. However, in about 15% of projects almost all the residents were women.

Living arrangements

Almost all respondents provided information on the approximate percentage of persons living alone in their project. On average, 90% of residents were living alone. The survey did not ask how many couples were living in the project, but one could conclude that most of the 10% not living alone are living with their spouse.

Cultural and language groups

Respondents listed many cultural and language groups among their residents. In addition to Anglophone (Canadian, English) and Francophone (Quebecois), the following were reported:

Dutch
German
Italian
Ukrainian
Polish
Hungarian
Chinese
Japanese
Korean
Somali
Caribbean
Greek
Portuguese
Spanish
European in general
British

Degree of independence

Most respondents were able to provide an estimate of the percentage of residents in their project who required assistance with activities of daily living. According to these estimates, on average across all projects, just over half (54%) of residents were independent and required little or no assistance. About 40% on average required some assistance with activities of daily living, and 15% needed assistance with most activities.

Overall health of residents

Respondents were asked to estimate the percentage of residents in their projects who were in excellent health, good health, fair health, poor health, and very poor health.

Not all operators were able to give an estimate. For those who did (N=166), Exhibit 11 shows the results.

Exhibit 11 Estimate of residents' overall health

Average percent of residents who have:

Excellent health: 13%
Good health: 42%
Fair health: 42%
Poor health: 12%
Very poor health: 3%
Total: 100%
Number of projects reporting =: 166

Exhibit 11 reveals that about 15% of the residents living in the 166 projects that responded to this question had poor or very poor health. This percentage corresponds to the total percentage of persons who required assistance with most or all activities of daily living. The percentage of residents that had poor or very poor health in Alberta, British Columbia and Ontario projects had higher percentages, ranging from 15%-20%.

Level of dementia

Respondents were asked what percentage of their residents had dementia. Averaging the responses across all projects in the survey indicated that about one third of the residents have some dementia. Exhibit 12 shows that on average a small percentage (3%) of residents have severe dementia and 11% have medium dementia. The survey did not ask how many of these residents might also be living alone. However, since 90% of residents live alone, it can be concluded that most of the residents with dementia are living alone.

Exhibit 12 Average estimate of resident's level of dementia

Percent of residents with:

No dementia: 64%
Mild dementia: 22%
Medium dementia: 11%
Severe dementia: 3%
Total: 100%
Number of projects reporting =: 172

Respondents from Quebec reported that an average of 17% of the residents in their projects have medium or severe dementia. This is higher than the percentage for all projects as a whole.

Are projects designed to serve the needs of residents with dementia?

Given the results in Exhibit 12 it is interesting to note that only 16% of all the projects in the survey (N=244) reported that their residence was designed to serve the needs of persons with dementia.

Are projects designed to support "aging in place"

Respondents were asked if their project supported "aging in place" - in other words can people live in their project as long as they wished. According to respondents, the majority of all projects (70%) are designed to support "aging in place".

Restriction on tenure

In spite of reporting that residents can "age in place", some projects restrict or limit tenure for certain reasons. For example, 54% of projects restrict tenure for people with mental health issues that could include dementia. This would partly explain why on average, 64% of residents in surveyed supportive housing had no dementia. (see Exhibit 12). Other reasons for tenure limitations or restrictions include physical health (45%) and disability (54%). About one quarter of all surveyed projects placed no limitations or restrictions on tenure.

Most (83%) respondents reported that their project required that residents' health status be assessed as part of their initial residency eligibility.

Management

Respondents were asked a number of questions related to the management of their projects (i.e., the availability of an on-site service coordinator, and the level of participation of residents and staff in management decisions).

On-site service coordination

The majority (72%) of respondents indicated that their project had an on-site service coordinator. When asked to describe the main role of this co-coordinator, about half (47%) of the respondents reported that their on-site service coordinator was directly involved in the provision of services as well as making referrals. About one third (35%) of respondents reported that their service coordinator was mainly involved in the provision of actual services and about one tenth (9%) indicated that their service coordinator's role is mainly to make referrals and/or assist residents with acquiring appropriate services from community support agencies.

How residents are involved in management

Most (70%) of the 244 projects reported that residents are involved in management decisions that affect them. In one third (33%) of all projects, residents are invited to sit on advisory committees. In just over twenty percent (21%) of all projects, residents are invited to sit on the management board, and in 11% of all projects, residents were involved in some other capacity such as residence councils. The analysis suggested that there might be some provincial differences in these results, however, there were too few respondents in some of the provinces for the results to be definitive.

Staff involvement in management

About half (49%) of the 244 projects in the survey had front line staff such as nurses, nursing assistants and social workers. For those operators that employed front-line staff, just over one quarter (27%) reported that staff were invited to sit on management advisory committees. Just over twenty percent indicated they had staff representation on their management board. Most (52%), however, reported that staff was involved in management in other ways.

Innovative features

Respondents were asked to describe features of their project that they felt were innovative in four areas: barrier-free design; support services; management approach; and partnerships. A list representing the types of responses given is shown below¹⁹.

Examples of innovative barrier-free design features (79 operators gave examples)

Projects that are designed to be wheel chair accessible throughout without losing their residential and family ambience
Outside spaces that are completely barrier free
Elevator doors that open automatically upon approach
Garage doors that open automatically
Front doors that open automatically
Family-style kitchens that are completely barrier free
Wheel chair accessible showers
Barrier-free bathtubs
Stacking washers and dryers
Open plan design

Examples of innovative support services (155 operators gave examples)

24-hr support, 7 days a week
Support packages that are tailored to individual needs
Support services that are designed with input from seniors in the community
Excellent linkages with community support services to provide a range of services
Continuous improvement of services through monitoring and evaluation
Comprehensive support packages that includes access to mental health services, physiotherapy services etc.

Examples of innovative managemens approaches (76 operators gave examples)

Working as a team with residents and staff
Satisfaction surveys with residents and staff to continually improve services
Regular monthly meetings of all parties to address issues when they occur
Residents are encouraged to participate in management decisions
Flexible, open door policy
Use a customer focus
Encourage family involvement in management
Resident committees meet monthly with management board
Solicit opinions from all stakeholders before making major changes
Encourage volunteer involvement in management

Examples o innovative partnerships (55 opeators gave examples)

Share activities and programs with long-term care home
Encourage partnerships between all three levels of government
Maintain a close linkage with other organizations in community serving seniors such as hospitals, health authorities, long-term care etc.
Take a multi-disciplinary approach to working together with health, housing, social services

Which features make projects supportive?

Respondents were asked to describe the features of their project that made it supportive. Almost all projects (N=234) gave a response. Many respondents spoke of the 24-hour support they provided. Others mentioned the family, homelike ambience with services nearby. Still others talked about their accessible design and affordability. The types of responses given can be summarized as follows²⁰:

Provision of 24-hour support gives residents comfort, safety, and security knowing help is readily available when needed
Easy access to a full range of amenities and services
Housing and services that are affordable
Provision of good meals
Available support services within a family setting
Beautiful setting, close to all amenities
Designed to be accessible throughout
Excellent staff
Feels like home but with staff nearby if needed
Right combination of services - housekeeping and meals

2.2 Innovative Examples of Supporting Housing

One of the objectives of the study was to identify examples of innovative supportive housing projects across the country. The survey was designed to collect information related to innovation based on CMHC's definition of supportive housing and its five key components: residential character, supportive physical environment, access to necessary supportive services, progressive management philosophy, and affordability and choice. ²¹

What makes a supportive housing project innovative?

The ideal supportive housing project should be located in a safe, attractive, residential, neighbourhood. Regardless of its size and type, the project should appear homelike and have a design that "blends" into the surrounding architecture. Residents should have control over their own private space and be allowed to personalize their space with their own furniture and possessions. Access to private outdoor space such as a patio or balcony is also important.

Projects that are innovative should support aging in place as much as possible by including features that make the physical environment accessible, flexible and safe. Building layouts should encourage socialization and mutual support through the provision of attractive common areas where residents can work on hobbies, carry on conversations, eat meals, exercise or entertain visitors in groups. Common areas and private spaces should be flexible enough to meet the changing needs of seniors without major renovations. Design features that help to prevent accidents, such as bathroom grab bars, non-slip flooring, wider doors, easily reached electrical outlets and handrails in hallways, should be provided.

Innovative projects provide easy access to necessary support services through an on-site service coordinator and/or on-site staff. There should be a "menu" of services that can be flexible as residents' needs change over time. Typical support services include meals, housekeeping, personal laundry, transportation, assistance with medication, help with dressing and bathing, wellness clinics, information and referral, and social and recreational activities. Innovative projects would also offer access to services such as palliative care and mental health services.

Innovative projects have a progressive management philosophy that would include strategies such as involving residents in decisions that affect them, communicating regularly with residents through meetings or newsletters, establishing realistic expectations about what can be provided, having guidelines for resident selection, supporting front-line staff in their work, and establishing policies on residents' rights. Progressive managers are older people friendly, good listeners, and make a point of getting to know and work with residents' family members and friends.

Innovative projects look for ways to offer affordable options and choice in housing and support services. This may come about through partnerships or other avenues. Seniors come from all walks of life and have different needs and preferences. Projects that incorporate a mix of tenure options, residential unit sizes, and choices to access needed support services are most likely to succeed in meeting the differing and changing needs and preferences of their residents.

Examples of supportive housing projects with innovative features

The following projects are examples of supportive housing in the database that incorporate the types of innovative features described in the section above. Key informants for this study or in past research have identified these projects as good models of supportive housing.

W. J. Phillips Residence
Alberton, Prince Edward Island
The W.J. Phillips Residence opened in 1998. It is located in a small community on a site that offers a range of housing choices (including studio suites and one-bedroom units) and a full menu of on-site support services to its residents. The multiple story residence is operated on a private not-for-profit basis and has 28 rental units - half are studio suites and half are one-bedroom apartments. The project offers supportive housing to both seniors and younger persons with disabilities.

Parkland Estates
Halifax, Nova Scotia
Parkland Estates offers many supportive features and amenities on-site, including a fitness studio and spa as well as a movie theatre and underground parking. This multiple-story apartment building, opened in 1998, has 230 units including studios, one-bedroom, and two-bedroom units. It is a rental building, operated on a for-profit basis and offers subsidies for housing and services to residents who cannot afford to pay the full price. The building is part of a continuum of care campus with three buildings in total - one of the other buildings is more specialized and serves persons with greater health needs.

Place Legault
Beaconsfield, PQ
Place Legault is a small project, typical of the many small projects in Quebec. It is not-for-profit and offers five units - two one-bedroom and three two-bedroom - in a motel style building. Some of the nine single residents share apartments. The project has many amenities including access to a private yard or balcony and overnight accommodation for visiting family or friends.

160 Charlotte
Ottawa, Ontario
160 Charlotte is a rent-geared-to-income public sector funded multiple-story apartment building that has evolved over the last ten years into a full-service supportive housing project for seniors and younger persons with special needs. It was assessed as a high needs building in the early nineties, and has provided on-site support services since 1995 through partnerships and linkages with community agencies and government support. Residents are offered a flexible service package that provides access to a full range of on-site and off-site services.

Greenwood Court
Stratford, Ontario
Greenwood Court opened in 1994. It is sponsored by the tri-county Mennonite Home and partnered with the Mennonite Church and Spruce Lodge. It offers life lease as well as rental units - 103 in total, a mixture of studios, one-bedroom and two-bedroom units. It is fully occupied with a waiting list. It has no on-site staff but does have an on-site coordinator and offers a service package that includes meals, housekeeping and laundry and the option to add assistance with activities of daily living if needed. According to the survey, the property also offers banking services, a general store, and a bowling alley.

Sokol Manor Supportive Housing
Brandon, Manitoba
Sokol Manor opened in 1999 and is sponsored by the Polish Gymnastic Association. It is operated on a private-for-profit basis and was made affordable through funding partnerships with both the federal and provincial governments. Sokol Manor is a single story motel style building, with a total of 10 studio units, and offers a full range of support services, including palliative care. The residents' ages range from 80 to 98, with the average age being 88.

Wedman Village
Edmonton, Alberta
Wedman Village is a public sector rental development sponsored by the Good Samaritan Society, an organization with a recognized proven track record in supportive housing. It opened in 1994 and has 30 units, all studios. The project offers a full range of services, including mental health services and palliative care, on-site and through linkages with other agencies. Wedman Village was not purposely designed for residents with dementia, however 15% of the current residents have medium or severe dementia. The residents are quite frail - with most needing some or a lot of assistance with activities of daily living. Their ages range from 72 to 99.

Logan Manor
Agassiz, British Columbia
Logan Manor opened in 2003. It is a private for-profit project located in a rural area and it defines itself as an assisted living project. Logan Manor was sponsored by BC Housing and the Fraser Valley Health Authority and offers 32 residential units - 30 one-bedroom and 2 two-bedroom units. It is 100% occupied, has a waiting list, and offers the full range of services, including mental health services and palliative care. The residents are mainly of Dutch and German background and quite frail. They range in age from 75 to 95, and are mostly women living alone. Eighty percent need some assistance with activities of daily living.

Abbeyfield Port Alberni
Port Alberni, Vancouver Island, BC
This is an Abbeyfield house developed in 2002 by the local Abbeyfield Society. The Society renovated a one-story former nursing home and converted it into the current house. Abbeyfield Port Alberni is a bustling place with lots of activities and social interaction with the surrounding community (as evidenced by the newsletter posted on their web page). There are 19 bed-sitting rooms, a standard service package that includes all meals, housekeeping and laundry and a flexible package that includes other services such as help with activities of daily living. Abbeyfield Port Alberni offers a full range of amenities including overnight accommodation for family members who live out of town. The average age of residents is 86, most are women and all live alone.

2.3 Issues Related to Supportive Housing for Seniors

The discussion in this section reflects findings from the literature review (see Appendix A) and key informant interviews with experts in gerontology and seniors housing issues (see Appendix B).

Benefits and limitations

The literature review conducted in connection with this study supports the results of previous work (such as the background review conducted for the 2000 CMHC Supportive Housing for Seniors publication) in terms of the potential benefits of supportive housing for seniors, particularly those related to health and overall quality of life. Recent evidence suggests that supportive housing in its most supportive form (such as assisted living) has the potential to be a viable alternative to traditional long-term care or nursing home care. ²²

There is general agreement that supportive housing can improve the overall well-being and quality of life for persons who need assistance with activities of daily living. Daily benefits such as the provision of nutritious meals, opportunities to socialize and to participate in physical activities, and access to health services in the community when needed make it possible for seniors to maintain their independence and supports their aging process with dignity.

With respect to possible limitations of supportive housing, the main theme that arose from the interviews and in the literature centered on the issue of where supportive housing fits in the continuum of housing and care for seniors with greater health needs. For persons who do not require 24-hour nursing care, experts agree that most forms of supportive housing make it possible for residents to "age in place". However, for seniors with severe dementia or other chronic diseases that result in significant loss of abilities over time, not all forms of supportive housing may be able to sustain these individuals over the longer term. ²³

In BC, where the development of assisted living projects have been on the rise, there is some debate among experts about the government's recent changes in residential care and home health services for seniors and the implications of this direction. There is a concern that the government's promotion of assisted living projects will result in a reduction of residential beds and services available to seniors and persons with disabilities. There is also a concern that the increase in assisted living developments, many of which tend to target higher income seniors, will come at the expense of more affordable options for low-income. As well, the issue of less government involvement in the supply of seniors' housing as a result of more private sector developments has been raised as a red flag by some. ²⁴

A 2001 paper by Stephen Golant examined assisted living as a potential alternative to traditional forms of long-term care. ²⁵ Golant, who is familiar with the American model of assisted living, discusses the issue in the Canadian context ands provides much food for thought. He recommends that governments at all levels in Canada recognize the assisted living option as a legitimate, non-institutional long-term care approach that can fill a big gap in the currently available elder housing and care continuum. Further, the author suggests that the "traditional" forms of long-term care are increasingly unable to satisfy the new realities of senior consumer demand.

Issues related to quality

Much discussion in the literature centers on standards (or lack of standards) of care and how this relates to the quality of life for residents in supportive housing. To help maintain a high level of quality of life in supportive housing, some key informants held the view that clear provincial policy guidelines related to standards and quality of services are needed. However, they also expressed concerns about setting standards that are too restrictive.

At the time of the study, BC was the only province with any legislation in place related to supportive housing. Current legislation in BC restricts assisted living facilities to providing mainly hospitality type services and only one or two of the prescribed higher forms of more intensive care. ²⁶ To be eligible for assisted living in BC, all persons must be assessed by the regional health authority as needing the level of care provided by assisted living facilities. The new BC model specifically excludes people "who are unable to make decisions on their own behalf from private and public assisted living unless they will reside with a spouse who is able to make those decisions for them". ²⁷

Key informants in the study cited the lack of national standards for supportive housing, and differing access criteria for home support services across the country as barriers to the development of good quality supportive housing for seniors. CMHC's recently released report on a legal framework for supportive housing for seniors will help policy makers explore regulatory options. (See, A Legal Framework for Supportive Housing ForSeniors: Options for Canadian Policy Makers, Canadian Centre for Elder Law Studies, March 2005.)

Gaps in the supply of supportive housing

The literature review suggests differences in the supply and choice of supportive housing across the country. British Columbia, Alberta, Quebec and Ontario appear to be well served, particularly by the private sector. There was little disagreement among the key informants that the private sector has stepped up to try and fill the gaps in supportive housing across the country. Several key informants held the view that the most innovative forms of supportive housing in Canada were in fact being developed by the private sector. ²⁸ Most of the private sector developments, however, are being targeted to the high end of the market in terms of income.

The literature review identified gaps in supportive housing in rural areas. This trend was consistent across the country and was also confirmed by our key informant interviews. Provinces such as Newfoundland and Saskatchewan as well as the Territories have many small rural communities. These jurisdictions are particularly challenged to meet the need for affordable supportive housing for seniors, according to key informants from these areas of the country. Seniors and native elders living in remote or isolated communities with few formal services and virtually no purpose-built seniors housing are nevertheless reluctant to leave these communities and move to better served places far away from family and friends.

The lack of affordable supportive housing options is a cause of concern for key informants from organizations representing seniors interviewed for this study. There is complete agreement that seniors with low and modest incomes have the least choice. According to some experts, middle-income seniors in wealthier provinces such as Ontario and Alberta also have less choice.

The interviews with seniors advocacy agencies in the Atlantic Provinces indicated that many modest and low-income seniors with little or no support are living in older housing stock in need of repair - including subsidized housing. In Newfoundland, where out-migration is highest in the country, younger family members are often not available to provide the necessary support.

According to one seniors advocacy agency in New Brunswick, 70% of seniors living in nursing homes have no assets and little income. Seniors on low income with some health related needs but not requiring the level of care offered in a nursing home have no supportive housing options, according to this same key informant. "There is virtually no affordable supportive housing out here" is a viewpoint that was expressed more than once by key informants from the Atlantic region.

There may be another gap in supply of supportive housing for seniors from the growing multicultural communities in Canada. According to one expert, it is a "myth" that all cultural groups look after their own seniors. Residences that appeal to the general public are often not sensitive to the needs of residents from minority cultural groups, particularly those from visible minority groups and the Aboriginal community. Some cultural groups have responded by developing their own supportive housing projects. However, an ever-increasing foreign-born population in Canada that may not be served by current supply might drive the demand for culturally sensitive supportive housing options in the future.

The literature review also revealed barriers in supportive housing options for other special needs populations such as the hard-to-house and homeless, gay, lesbian, bisexual and transgendered seniors, and seniors with middle to later stages of dementia.

Supportive housing continues to show promise, however, as a housing option for seniors who wish to remain independent but require some support. There is some optimism that recent changes in government policies that favour the renewed development of affordable housing in Canada will extend to supportive housing for seniors, if support services can be matched to new affordable housing units.

2.4 Current Provincial and Territorial Public Policies and Guidelines for Supportive Housing for Seniors

Interviews were conducted with policy makers across the country to obtain the most recent information about provincial and territorial government policies, guidelines and programs related to supportive housing. The information obtained through the interviews was combined with a review of government websites.

It is challenging to digest and compare the different types of policies related to supportive housing for seniors across Canada. There is no uniform approach. The literature review identified that there is no standard definition of supportive housing across the country. Although all provinces and territories have some initiatives that are aimed at assisting seniors in later life with their housing and health care, each takes a different approach. British Columbia's policies and programs appear to be the most integrated. There is a "one stop" access point in BC for comprehensive information about seniors housing and related community resources including a directory of housing projects in the province.

At the other end of the country, a new inter-provincial and multidisciplinary study on seniors housing has begun. On February 4, 2005 a new $1.2 million five year research project was announced at Mount Saint Vincent University. The study, Projecting the Housing Needs of Atlantic Canadians, brings together seniors, academics, service providers, housing developers and government departments from all four Atlantic provinces to help determine how to meet the housing needs of the area's rapidly aging population. ²⁹ This study is the first of its kind in Canada and will help substantiate supply and demand issues for supportive housing and other forms of housing for seniors in the Atlantic region.

The Nova Scotia government was one of the first provincial governments to introduce supportive features and strategies for "aging in place" for senior tenants living in non-profit housing managed by the province. These strategies are described in a 1996 CMHC research report ³⁰ and were introduced after an earlier study ³¹ found that between one third and one half of senior tenants living in non-profit housing in Nova Scotia required more support to maintain their independence than they had been receiving at the time.

BC is still the only province with regulations to guide the quality of assisted living residences. Alberta plans to follow suit. According to key informants, Alberta's approach to assisted living (AL) will not be as restrictive as BC's and will follow the American model of AL that supports "aging in place". In the U.S. model, assisted facilities are typically free standing (as opposed to physically linked to a nursing home in Canada) and are more likely to employ dedicated on-site staff to assist residents with their personal care and nursing needs. ³² Most key informants in this study raised the issue of the lack of consistent standards and monitoring for all kinds of supportive housing in Canada, including assisted living.

Provincial key informants participating in the interviews agreed that they would like their governments to do more in the area of supportive housing. The gap most often mentioned was providing more options for modest and low-income seniors and seniors living in rural or isolated areas. As well, some key informants identified gaps in supportive housing for special needs groups such as seniors with dementia.

Most key informants talked about a current renewed interest in supportive housing. Some provinces have recently initiated many new housing projects under the federal-provincial cost-shared program. Other provinces have strategic plans or proposed research or pilot projects in place to address issues related to supportive housing.

Summary of existing programs, policies and guidelines for supportive housing for seniors

The following are examples of some of the more recent supportive housing policies and programs in place across the country.

British Columbia has several policies and programs in place to promote and assist the development of supportive housing for seniors. In 2002, it instituted Bill 73, The Community Care and Assisted Living Act, which encouraged an expansion of the assisted model of housing. Both the public and private sectors embraced this direction and assisted living projects have become a growth industry in the private and not-for-profit sector. In BC, assisted living is seen as part of a housing continuum that ranges from independent living to long-term facility based care. It is not seen as an alternative to long-term facility based care.

Another recent initiative in BC is the Independent Living Program. ILBC provides funding for supportive housing and assisted living projects. The program's goal is to create 3,500 affordable independent living units with support services across the province by 2006. At the time of this study, more than 15 new developments had been announced across the province, including some in northern and remote areas.

In BC, the Seniors Housing Information Program (SHIP) ³³ provides one stop access for information related to seniors housing. In addition to operating an online seniors housing directory, SHIP has a database of resources and services for seniors as well as a resource library. SHIP also provides other client services, including housing counselling to assist seniors in their decisions about accommodation options. SHIP is a good example for others wishing to create a one-point access of integrated housing information for seniors.

In October of 2004, Alberta introduced a program to address the gaps in affordable supportive housing in rural areas. The Rural Affordable Supportive Living Program partners the provincial government with regional health authorities and the private and/or voluntary sectors to address the housing and health care needs of seniors outside the boundaries of Edmonton and Calgary.

In a number of provinces, supportive housing is provided through partnerships between affordable housing programs and community service delivery agents. For example, in Saskatchewan, the Saskatchewan Housing Corporation administers the Saskatchewan Assisted Living Services (SALS) Program and the Social Housing for Seniors program. This is an integrated approach by the housing and health systems in Saskatchewan to address the needs of seniors on low incomes who need assistance with daily living. Saskatchewan believes in an "aging in place" philosophy and is planning to address gaps in rural areas by expanding their program to small communities.

Manitoba, Ontario and Quebec take similar approaches to the provision of supportive housing.

In Manitoba, local housing authorities as well as private for profit and private not-for-profit housing sponsors partner with regional health authorities to provide supportive housing for seniors. The housing sponsors provide the rent/service package and the health authorities provide the care component including assistance with activities of daily living delivered through the home care program. This approach enables many frail seniors to remain independently in the community. However, key informants reported that some seniors who require 24-hour supervision may still need to move to a long-term care facility.

Ontario's initial supportive housing program was born out of research conducted during the eighties that showed a need for support services for low-income seniors and families living in social housing. A provincial supportive housing program was introduced that provided additional funding for support programs in communities across the province that were considered "under-serviced" in this area. Today, supportive housing buildings are owned and operated by municipal governments or not-for-profit groups. Accommodations, on-site services, costs and the availability of subsidies vary with each building. The housing portion of supportive housing is rental accommodation covered by the Tenant Protection Act, 1997. The Ministry of Health and Long-term Care funds personal care and support services costs. Critics have long pointed to a lack of clear direction from the Ontario government for supportive housing for frail seniors and other special needs populations. At the time of this study, the Government of Canada and Ontario had just signed an Affordable Housing Agreement to jointly commit $602 million dollars over the next four years to increase the supply of affordable housing in the province. It is not yet known how much of this money will go towards increasing supportive housing for low and modest income seniors in the province.

In Quebec, supportive housing programs are offered through the Société d'habitation du Québec. They are aimed at providing affordable decent housing for low to moderate income households through a low income rental housing program and a housing allowance program. There are currently no subsidies for on-site services. The Ministère de la Santé et des Services sociaux (MSSS) operates a registry of supportive housing projects. The registry shows that approximately 20% of these projects are small - containing nine dwelling units or less.

The MSSS offers a program to reduce the cost of construction of supportive housing. Under this program, developers can apply for an amount of up to $1000 per dwelling unit. As a result of this program, both private for profit and private not-for-profit housing providers were spurred to develop supportive housing projects for seniors, although usually geared to high incomes. A lot of these projects are small, owner-operated residences that also offer support services. Unlike some other provinces, and according to the key informant representative interviewed, rural areas in Quebec are well serviced.

Of the remaining provinces and territories, only Nova Scotia and Nunavut have integrated approaches to housing and support services for seniors.

Nova Scotia responded to the need for supportive housing ³⁴ by retrofitting non-profit housing to be wheelchair accessible and providing housing managers with educational tools and resources related to "aging in place" for seniors.

In Nunavut, the Nunavut Housing Corporation partners with Home and Community Care Services to provide supportive housing for elders in the community. There are currently four Elder Centres that offer a continuum of care from independent living units to 24-hr supervised care.

The remaining Atlantic provinces and the Territories do not have integrated supportive housing programs or coordinated approaches to housing and health service delivery, although Newfoundland has developed a draft provincial strategy for supportive housing.

Part Three: Test Electronic Database of Supportive Housing for Seniors in Canada

An unpublished test electronic database was developed using Microsoft Access.

3.1 Description and Function

The objective of the database is to serve as a repository of electronic information for the projects identified in this study. ³⁵

The database lists projects that self identified as either supportive housing or assisted living according to the criteria presented. The database includes information gathered through the survey and is fully searchable by key words (based on the variables included in the database) or location of project (province, municipality, postal code).

The database includes 244 completed records of supportive housing for seniors projects form across Canada. It also includes contact information for the projects that did not complete the survey within the time frame or were ineligible according to the screening criteria (Exhibit 1 provides the types and number of responses obtained in the survey).

3.2 The Database

The test database starts with a "home" page that provides options about where to go, or what to view, next. Clicking on the buttons allows records in the database to be viewed in various formats. As a fully functional MS Access database, it provides possibilities for additional options and further expansion and development.

The test database can be used to conduct a variety of tasks, including the following.

Searching for projects in provinces and territories.
Finding information on the types of services that are offered specific projects or multiple projects.
Finding contact information for projects in the database.

3.3 Conclusion

The survey of supportive housing projects for seniors represents the most current state of information on supportive housing in Canada. The test, unpublished database gives promise of being a first stage toward the development of a valuable tool for those wishing to share, or obtain, information about housing projects, and the distribution of supportive housing across Canada.

CMHC and Health Canada are considering further development and eventual publication of the database.

Appendix A: Literature Review

Introduction

The main purpose of the literature review was to identify:

Innovative examples of purpose-built supportive housing projects for seniors aged 65+ in Canada;
The range of supportive housing options in Canada; and
Issues related to supply and quality of supportive housing in Canada.

Method

The search for information was focused on Canadian articles and research reports (published and unpublished) written in the last ten years (since 1994). A standard literature search was performed using the Internet, various databases and academic abstracts. It is interesting to note that searching for "supportive housing in Canada" using Google produced 466,000 hits. To narrow the search further, additional key words such as those listed below were used:

Supportive housing for seniors
Assisted living for seniors
Abbeyfield Homes
Life Lease housing for seniors
Congregate living for seniors
Seniors housing with support services
Seniors accommodation with support services
Purpose built housing for seniors with services
Evaluation of supportive housing for seniors
Quality of life

Academic articles were sought in the following abstract databases:

American Association of Retirement Persons Ageline
Ovid Medline
PsycInfo
Social Sciences Index

In addition, the review included recent reports on supportive housing produced by Canada Mortgage and Housing Corporation, Health Canada (Atlantic Region) and Veteran Affairs Canada. As well, interviews were conducted with leading experts in gerontology and with government policy.

Results of the Search

The search for articles and reports produced over 100 references including a number of provincial and municipal directories of housing for seniors. Of the numerous articles and reports, about 25 non-academic reports and 10 academic publications contained material relevant to the research questions about supply and quality, benefits and barriers of supportive housing. The following provincial housing directories were used to identify projects:

Seniors Housing Information Program (SHIP), British Columbia - SHIP has been in existence since 1985 and is well established as a credible source of information on seniors housing in BC. The directory includes all types of purpose built seniors housing and has a separate section on supportive housing and ³⁶ assisted living projects. SHIP estimates that the directory, available as a searchable database online at www.seniorshousing.bc.ca or in hard copy, includes 95% of all projects developed in the lower mainland and at least 70% in the rest of the province. ³⁷ About 20 projects were identified through SHIPS as good examples of supportive housing in BC.
The Care Guide is the Canadian affiliate of an American publication on seniors housing and services. The Canadian directory covers Ontario and BC and is endorsed by the Ontario Residential Care Association (ORCA) and the British Columbia Residential Care Association (BCRCA). This directory represents mainly for-profit, privately funded projects but also includes some publicly funded supportive housing projects and home support services. The directory is partially funded through advertisements as well as member fees. The directory is published by region in Ontario and is divided into sections by provider type. It includes: independent supportive living, assisted living residences, long-term care residences, Alzheimer care, home care services, home support services and hospice care. About 35 potential projects were identified through this resource.
Alberta Senior Citizens' Housing Association (ASCHA) is a voluntary, non-profit association that represents and provides services to all types of congregate seniors housing operators in Alberta. On their website they offer searchable information on over 600 seniors housing residences. It is possible to search by region and by type of housing. There are plans to develop a rating system for housing providers to advise users which residences offer high operating standards. A number of projects were identified through this site.
Ontario Association of Non-Profit Homes and Services for Seniors (OANHSS) is a provincial membership-based organization that has represented not-for-profit providers of services, care and housing for seniors for over 80 years. The association's website provides a list of not-for-profit facilities, housing and services in Ontario and is searchable by type of housing and region. As well, the site has links to government departments and other helpful resources for seniors and families looking for housing and services. The database includes supportive housing, life lease housing, retirement homes, social housing and adult lifestyle housing. The site was helpful in located some recently developed projects.

In addition to the provincial directories, numerous municipal lists were used to identify projects during the fieldwork phase of this study. Interviewers screened projects obtained through these lists for eligibility. The following CMHC publications collectively described about 50 potentially innovative supportive housing projects. These projects were included in the database and contacted during the field work phase for inclusion in the inventory:

Neighbourhood Group Homes for the Elderly: The Planning, Design and Development Process, 1997
Housing Options for Persons with Dementia, 1999
Housing Options for Older Canadians: User Satisfaction Study, 1999
Supportive Housing for Seniors, 2000
Alternative Tenure Arrangements, 2000
Life Lease Housing in Canada: A Preliminary Exploration of Some Consumer Protection Issues, 2003
Partnership Courier Newsletter (1995 to 2004)

Definition of Supportive Housing

Supportive housing is a broad term and has variations in its definition across the country. CMHC ³⁸ first defined supportive housing as the form of housing that helps seniors in their daily living by combining a physical environment that is specifically designed to be safe, secure, enabling and homelike with support services such as meals, housekeeping and social and recreational activities. Supportive housing allows residents to maximize their independence, privacy, dignity and decision-making abilities. According to CMHC, for housing to be supportive it must have the following five key components: ³⁹

Residential character
Supportive physical environment
Access to necessary supportive services
Progressive management philosophy
Affordability and choice

Keeping these key components in mind, supportive housing can be developed in many forms depending on the types and level of services to be provided, the project size desired, the types of accommodation preferred, the type of tenure wanted, and the types of sponsorships available. Services can be provided through a combination of on-site and off-site arrangements and be made available to both residents and older people living in the surrounding neighbourhood. Highly service-enriched supportive housing, such as assisted living, can be an alternative to unnecessarily moving seniors into nursing homes.

Supportive housing can be developed by the for-profit, the not-for-profit, or the public sector - or be partnerships between these sectors. It can be made available in a range of tenure types such as rental, leasehold, condominium, and life lease. ⁴⁰ It is also possible to combine different tenure types in individual projects.

The CMHC definition of supportive housing appears to be gaining acceptance and has been endorsed or adopted by organizations concerned about seniors including the National Advisory Council on Aging, the Seniors Health Promotion Network in Atlantic Canada, and Veteran's Affairs Canada. ⁴¹

Several provinces have developed their own definition of supportive housing that is eligible for public funding. For example, in British Columbia, supportive housing is defined as housing with a combination of on-site support services including at a minimum: a private living space with a lockable door; monitoring and emergency response; at least one meal a day; housekeeping; laundry, and recreational opportunities. ⁴² Nursing and other health services are delivered by the local health authority or privately as they would be to other individuals living independently in the community.

In BC, supportive housing may be privately or publicly delivered. Publicly funded supported housing may fall under the Independent Living BC Program. Potential tenants are assessed by the local health unit to access this housing. Other forms of supportive housing in BC include Abbeyfield housing (small scale group living) and congregate care (larger scale projects that are typically not subsidized and offer studios, one bedroom and two bedroom suites usually with a kitchenette, and meals provided in a main dining room).

In BC, Assisted Living (AL) falls under a separate category of housing from Supportive Housing but can still fit under CMHC's definition of supportive housing. Assisted Living in BC is described as housing and a range of support services including assistance with personal activities such as grooming, bathing or taking medications. It can be privately or publicly delivered. The cost to residents in privately delivered AL projects can range from $1400 to $6000 per month. Publicly funded projects may fall under the Independent Living BC Program. All assisted living buildings in BC are required to register with the Assisted Living Registrar.

Other provinces that offer public funding for some form of supportive housing include Alberta, Saskatchewan, Manitoba, Ontario and Quebec. In Ontario, publicly funded supportive housing is designed for people who need minimal to moderate care - such as homemaking or personal care and support - to live independently. Accommodation usually consists of bachelor, one bedroom or two bedroom rental units within an apartment building. ⁴³ Most supportive housing offers amenities such as meeting rooms, lounges and tuck shops. This housing is sometimes located on the grounds of a long-term care home, allowing tenants to take advantage of some of the programs offered by that home. Supportive housing buildings are owned and operated by municipal governments or non-profit groups including faith groups, seniors' organizations, service clubs and cultural groups.

Ontario also includes life lease housing under their supportive housing definition. In Ontario life lease projects are developed by not-for-profit or charitable organizations. Many life lease projects in Ontario offer residents on-site support services for a fee. Assisted living, however, is listed under retirement homes on the government website. Retirement homes in Ontario are largely offered by the private sector and are unregulated.

In September 2000, Alberta approved the Seniors Supportive Housing Incentive Program. ⁴⁴ Designed to increase the supply of supportive housing in Alberta, the program provided a total one-time capital funding of $10 million dollars to eligible housing providers. The funding assisted existing housing providers to upgrade or renovate their projects to support "aging in place". Projects funded under this program were contacted as part of this study.

In Saskatchewan, publicly funded supportive housing falls under a program called Saskatchewan Assisted Living Services (SALS). ⁴⁵ Similar to Ontario's program, is designed for tenants living in senior rental units managed through the Social Housing Rental Program. The services include one meal per day served in a common area, laundry, housekeeping, personal response service for unscheduled needs, and the co-ordination of services and activities. Co-ordination is provided at no charge to tenants, but tenants pay for the activities and services they use.

A recent report on supportive housing in Atlantic Canada ⁴⁶ concluded that each province in that region had their own definition of supportive housing which made the introduction of clear policies and programs more challenging. The report indicates that, although some provinces are looking at developing supportive housing strategies or policies, none have done so to date.

The Need for Supportive Housing

The need for supportive housing for seniors in Canada has been widely discussed. In addition to the CMHC publications referred to above, the National Advisory Council on Aging (NACA) has endorsed this form of housing as a potentially viable alternative to more expensive nursing home care for seniors. ⁴⁷ In an earlier publication, NACA made the case for more affordable supportive housing and challenged all levels of government and the private and public sectors to respond. ⁴⁸

Some advocacy groups try to make the case for supportive housing by linking housing to health. A recent report by the Seniors Health Promotion Network in Atlantic Canada, states, "housing is the major variable in an older person's life, physically, socially, financially, and psychologically." ⁴⁹ The report goes on to discuss the importance of a supportive environment for "aging in place" and promotes more government involvement in stimulating affordable housing options for seniors. This theme is echoed by a recent Ontario report on supportive housing by the Toronto District Health Council. ⁵⁰

Although there may be reasons to believe that housing conditions are linked to physical and mental health and that good housing will have a positive impact on health status, there are few documented linkages that substantiate housing as a determinant of health. A qualitative study completed a decade ago reported that supportive housing may have a positive impact and improve the social functioning of residents but concluded that further research was needed. ⁵¹ Recently, Canada Mortgage and Housing Corporation's National Housing Research Committee (NHRC) announced the establishment of a working group, Population Health and Housing, that will promote, suggest, advise and inform research into housing and health status at the population level. The working group will also promote the application of existing knowledge about the health-housing link. ⁵²

Another debate evident in the literature is whether supportive housing or other forms of community-based care are a more cost effective way to support the frail or chronically ill elderly than institutional or nursing home care. ⁵³ One study in Quebec compared the cost and resources associated with disabilities of elderly people living at home, in intermediate care (which could include forms of supportive housing) and in nursing homes . ⁵⁴ The study found that the cost of care was least at home and most in the nursing home setting, with intermediate care in between. While this suggests that it may be more cost effective to care for the elderly with disabilities at home or in intermediate settings such as supportive housing, the authors caution that the care was provided by less skilled people in the two less costly settings and thus the quality of care must also be taken into account. The study also does not address the issue of quality of care.

A study recently completed by Social Data Research Ltd. on supportive housing for older homeless women ⁵⁵ also addressed the question of cost-effectiveness. The literature review for this research identified a recent US study on the impact of supportive housing for homeless people with severe mental illness. Although addressing a unique target population, the study provided some evidence that supportive housing may be cost beneficial. Using an experimental case-control study design and adjusting for demographic and other pre-intervention differences between cases and controls, the analysis revealed that homeless people placed in supportive housing experienced marked reductions in repeat shelter use, hospitalizations, length of stay per hospitalization, and time incarcerated. ⁵⁶ The researchers conclude that the availability of supportive housing reduces homelessness and the use of institutions. Because emergency shelters and institutional living are typically more expensive than supportive housing, it may well be a sound investment of public dollars to provide the operational funds needed to create supportive housing. The results of this study, however, cannot be generalized to other special populations such as frail seniors.

Issues Related to Quality and Supply

The study team for this literature review identified over 1500 potential supportive housing projects developed across Canada in the last 15 years. There appears - at least in some parts of the country - to be a growth spurt of seniors housing, particularly in the private sector. The inventory screened these potential providers to determine how many fit CMHC's criteria of supportive housing.

Scanning the various directories and lists of more recently developed supportive housing projects across the country leads one to conclude that seniors living in BC may have the most array of choices and those living in the Atlantic provinces, the least. Quebec also appears to offer a good range of affordable choices including many smaller projects. Ontario and Alberta are well served by the private sector but seniors with modest or low incomes in these provinces may have difficulties finding good quality supportive housing. The authors of the Atlantic Canada report referred to earlier found in their research that in their region, Nova Scotia offered the most choice in affordable supportive housing and Newfoundland/Labrador provided the fewest options.

According to recent research and interviews with key informants, rural areas and smaller communities are less well served. ⁵⁷ Rural-urban discrepancies in services were addressed in a recent paper focusing on the needs of older adults in rural Saskatchewan.⁵⁸ Based on the research conducted, the article identifies the challenges of growing older in an aging, rural community and makes specific recommendations for improving services to rural elders. The author concludes that services that specifically address the needs of older rural residents have been neglected in many parts of the country. As a consequence, seniors who have special health needs (and may require supportive housing) often have to travel far away from their community and family and friends.

A recent report by the Royal Canadian Legion also concludes that rural-urban location is an issue in terms of supply of supportive housing in Canada. Medium to larger communities where there is a critical mass of private/public money, more vocal and visible demand by older seniors, community support, and often more government attention have a higher concentration of new developments. ⁵⁹

Regulating the Quality of Supportive Housing

There are a few studies that address the issue of regulating the quality of supportive housing. Few provinces have regulations in place that guide the quality of supportive housing being offered to seniors. A current research project being funded by CMHC under its external research program addresses the need for regulation to deal with the many issues arising from supportive housing. ⁶⁰ The study involved extensive consultation with both seniors and professionals familiar with the issues involved. Key findings from the research can be summarized as follows:

Seniors indicated a high level of interest in, and desire for, supportive housing. Physical security was an issue for those who considered themselves to be independent and not frail, but who would appreciate the peace of mind such housing could provide.
Many participants in both groups expressed concerns about confusing regulations and terminologies.
Seniors generally did not know how to access information about supportive housing in their area. Consequently, there was strong support for a seniors "hotline" or centralized source of information.
Cost and affordability was a concern for both the seniors and professionals who were interviewed. It was clear that seniors must understand the cost implications before they move to supportive housing.
Participants in the study voiced considerable support for the establishment of a provincial "ombudsman" whose office could field complaints and resolve disputes.

BC is the first province to regulate assisted living. For an operation to be listed as an assisted living project in BC, the sponsor must register with the provincial Office of the Assisted Living Registrar. In BC, assisted living refers to residences that offer housing designed to meet the needs of seniors, hospitality services, and personal assistance to adults who can live independently but require regular help with daily activities. ⁶¹ Assisted living is similar to supportive housing in BC in that both offer housing and services to meet the needs of their resident population. They differ in that supportive housing operators may not provide the full range of services available to residents in assisted living.

In an information package available online to potential registrants in BC, guidelines are provided to assist operators decide if they meet the definition of assisted living. In order to qualify as an assisted living provider, projects must provide five hospitality services: meals, housekeeping, laundry, social and recreational opportunities and a 24-hr emergency response system. Each service is described in detail in terms of the Act's requirements.

In addition, six personal assistance service areas are identified in BC's assisted living applicant's guide: activities of daily living; storage, distribution, administration and monitoring of medications; maintenance or management of resident cash resources or property; monitoring of food intake or therapeutic diets; structured behaviourial program; and psychosocial rehabilitation or intensive physical rehabilitation. Assisted living residences may provide any number of these personal assistance services at a less intensive "support" level. However, the Act limits assisted living residences to providing only one or two personal assistance services at the more intensive prescribed level. Facilities that wish to provide more intensive services must upgrade their residence to the residential care level.

BC's assisted living applicant's information booklet also provides guidance on health and safety standards, staffing requirements, role of health professionals, and entry and exit requirements.

Life lease housing is another form of supportive housing where regulation has been an issue from a consumer protection standpoint. Developed mainly by not-for-profit sponsors and partnerships, there has been steady growth in this type of housing over the past twenty years. The latest estimate is that there are as many as 200 projects in Canada, two thirds located in Ontario and Manitoba. A recent CMHC study examined life lease housing in Canada from the perspective of consumer protection. ⁶² The study found that the province of Manitoba was the only province to have enacted legislation specific to life lease housing. The Life Leases Act, which is administered by the Residential Tenancies Branch, became law in Manitoba on December 1, 1999. The CMHC study concluded by identifying a number of consumer protection issues that may be of interest to governments considering legislation on life-lease housing, including: disclosure; safety of deposits prior to occupancy; security of occupancy; refunding of entrance fees; replacement reserves; warranty protection; provision of services; governance; and dispute resolution.

Residents' Perspective on the Quality of Supportive Housing

Another way to address quality in supportive housing is to examine programs and services from the perspective of their benefits to residents. The literature search uncovered a few studies that independently evaluated different forms of housing for seniors as well as studies that measured resident satisfaction with different aspects of their housing. Some of these findings had relevance for supportive housing.

As part of the 2000 CMHC study on supportive housing, a small number of residents living in different housing options were interviewed. This small qualitative component of the study provided some rich descriptions about the benefits of supportive housing from the perspective of residents. It was clear from these interviews that residents who were fortunate enough to live in one of the more innovative examples of housing uncovered by the study were very happy with the quality of their lives.

CMHC subsequently conducted a wider, more systematic study of resident satisfaction that supported the findings of the smaller more qualitative research. ⁶³ The researchers conducted 24 case studies of housing options (including supportive housing projects) for Canadians across the country and interviewed over 500 residents. They examined resident satisfaction in detail across several major areas: housing features (private and common spaces), tenure arrangements, social involvement and interaction, management and operational approaches, support services, amenities and overall satisfaction.

Overall, the User Satisfaction study found a high level of resident satisfaction with most aspects of supportive housing; however, some projects were rated more highly than others. It was difficult to discern which factors distinguished those providers who received a high rating and those who did not because the study was presented in a descriptive manner and did not draw any conclusions. The research did seem to show that the provision of responsive support services was important to residents and that most supportive housing providers in the study were successful in this regard.

Moving to congregate forms of housing can be a difficult adjustment to make after living in one's own home. In a recent study that looked at factors related to seniors' adjustment to assisted living in Alberta ⁶⁴ the authors presented data on the experience of client-centred care from the perspective of seniors living in residential care settings. What prompted the study was a perceived shift in focus of residential care facilities in the province from the traditional staff-centred medical model to one that emphasizes client-centred principles such as independence, dignity, fairness, participation and security.

Three main themes emerged from the data analysis in the Alberta paper that have broader implications for residents living in supportive housing and quality of life. First, seniors had important values and preferences about physical setting, the people within the setting, and the community where the housing was situated. Second, the ability to choose a residential care environment that was congruent with their values and preferences was important for residents' adjustment and satisfaction. Third, contentment resulted when there was a good fit between preferences and experiences. This match between preferences and experience is the essence of client-centred care from the residents' perspective. The study concluded by stating that choices among models of care, appropriate staffing levels and training, and recognition of family contributions may improve the practice of client-centred care.

Another study supports the premise of the Alberta paper in understanding the factors that facilitate adjustment and ultimate quality of life for residents moving into supportive housing. ⁶⁵ The study, based in BC, found that personal, social, building, and a combination of these factors are related to adjustment to congregate care. In particular, adjustment is better among younger residents, those in better health, those who have stronger support from their families, and for those with an end unit and with a view of nature. The authors found that adjustment was worse when the housing did not offer activities that are important to residents.

Supportive housing in its more intensive form of assisted living has been put forth as an alternative to more traditional institutional care for seniors with dementia. The literature search uncovered one academic paper that addressed this issue in relation to quality of life. The study, based in Alberta, compared the effect of specialized services on the quality of life of residents with middle to late-stage dementia living in assisted living facilities to those living in traditional institutional facilities. ⁶⁶ The study used a prospective matched group design that involved 24 long-term care centers and four assisted living residences and 185 residents. The researchers found that the assisted living group of residents demonstrated less decline in activities of daily living, more sustained interest in the environment, and less negative affect than residents in the traditional institutional institutions. There were no differences between groups of residents in the two settings in concentration, memory, orientation, depression, or social withdrawal. The authors conclude that the quality of life for adults with middle to late-stage dementia is the same or better in a purpose built assisted living residence than in traditional settings.

Staffing and family support is another issue related to the quality of supportive housing and ultimately the quality of life of residents. A recent study compared three different types of settings in Alberta - adult family living, assisted living, and dementia care residential settings. ⁶⁷ Recall and stylized time-use methods were used to assess the types of tasks and amounts of service provided by family and staff caregivers in the three settings. The study found that family members provide about 30% of on-site services to residents. Family members spend most time in enhancing well-being, while staff spend most time in housework. Patterns of care differ across the three settings. Family members of residents in assisted living residences tended to spend more time providing care than those in the other two settings. Given the major involvement of family members in service provision, the researchers recommend that future program policies and practices recognize this involvement and its impact on family caregivers.

Barriers and Gaps in Supportive Housing

The background research completed by Social Data Research Ltd. for the 2000 CMHC report on supportive housing identified some barriers to access and development of supportive housing. It would appear that most of these are still an issue today. The barriers included:

Zoning restrictions;
The NIMBY factor;
Lack of government leadership (some strides have been made here with the introduction of recent federal/provincial affordable housing agreements);
Lack of knowledge about aging;
Lack of guidelines and information about seniors' housing needs;
Lack of awareness about aging in place; (this theme was also raised in the Atlantic Canada report - the authors concluded that for aging in place to be a desired outcome policies and programs are needed to support this concept ⁶⁸); and
High cost of land

The National Advisory Council on Aging (NACA) identified three major barriers to supportive housingaffordability, cost of development, and availability. ⁶⁹ These themes were further supported in the report completed by The Royal Canadian Legion ⁷⁰.

Affordability

Affordability is still a major issue for many seniors. The private sector response to the need for supportive housing is targeted mainly at those with a higher income. Seniors "of fixed middle and low incomes are challenged to find more affordable options when they are faced with the hard choice of moving to a more supportive environment". ⁷¹

Cost of Development

Governments at different levels are beginning to respond to a call for more publicly-funded affordable housing although seniors may not always be the priority group. Nevertheless, in the search for recent developments, a number of new supportive housing projects for seniors funded through federal-provincial-municipal agreements were uncovered, mainly in BC. There may still be barriers related to the cost of development in other parts of the country. ⁷²

Availability

Making supportive housing more widely available is still an issue. The lack of options in rural areas and smaller communities has been noted. There are still not enough affordable options. There is also a lack of options for some special target populations including seniors with dementia, the homeless or hard to house, and gay, lesbian, bisexual and transgendered seniors.

From a different perspective, a recent paper makes the point that society's negative attitude towards persons with disabilities and older persons may be an underlying "unspoken" barrier to the development of policies and programs that benefit seniors.

The author concludes that "we are not likely to see old people being treated as important members of society until we see a change in attitudes towards disability." ⁷³

Gaps in supportive housing for special populations

The literature identifies at least three special needs populations that may have fewer options when it comes to supportive housing: hard to house older persons or those who were formerly homeless; gay, lesbian, bisexual and transgendered (GLBT) persons; and persons with dementia.

Two years ago, Social Data Research Ltd. surveyed housing providers across Canada in an attempt to identify supportive housing projects designed for hard to house or formerly homeless older persons (for this target population age 45 or older is defined as "senior"). Only a handful of projects were uncovered and most served a mixed age population. The researchers also surveyed mainstream retirement homes and supportive housing projects and found that they were not designed to meet the needs of this population. This led the researchers to conclude that there was a large gap in housing options for older persons who are hard to house or formerly homeless. ⁷⁴

CMHC recently completed a national study that examined housing options for elderly or chronically ill shelter users. ⁷⁵ The study confirms what the Ottawa researchers concluded - that the housing needs of elderly homeless persons in Canada are largely unmet. Further, not enough is known about how to serve this more difficult-to-house population. The Ottawa study found that supportive housing, if designed with the special needs of this population in mind, holds much promise. The challenge is finding a way to fund the development of such a project. In Ottawa this is ongoing; however, some strides have been made through local partnerships.

Another special needs population with few supportive housing options are GLBT seniors. In a population-based study completed by Social Data Research Ltd. on the health and wellness needs of gay, lesbian, bisexual and transgendered persons, one of the themes that emerged was the lack of supportive housing for older GLBT persons. ⁷⁶ In addition to the survey, focus groups were held with older persons in this target population. Participants spoke of the difficulty of integrating into "main stream" retirement communities where other older residents are often less tolerant. The desire to have a "GLBT" retirement residence was often expressed.

The Ottawa study is not the only study that identified a gap in services for GLBT seniors. A recent study also acknowledges gaps in health and long-term care for the GLBT population in Canada. ⁷⁷ The researchers used a qualitative exploratory design that included focus groups with elders and family members. The authors made specific reference to the impact of discrimination on the health and access to health services of this population. The article makes specific reference to long-term care services and identifies barriers to care including homophobia (fear or hatred) and heterosexism (assumptions that all forms of sexuality other than heterosexuality are deviant) by staff and other residents.

Although some strides have been made in the development of supportive housing options for persons with dementia ⁷⁸ those at the front line still have some concerns that existing facilities can meet the needs of persons in later stages of dementia. ⁷⁹ A recent demonstration project in western Canada evaluated the implementation of client-centred community-based residential care for individuals requiring nursing home care. ⁸⁰ The researchers examined three residential settings: assisted living, dementia care, and adult family living. The study of these settings was part of a larger initiative that was meant to increase the scope of community-based care for frail seniors needing nursing-home level support. The results of the study showed that although staff and family members endorsed a client-centred approach, they found its implementation very challenging both in terms of caregiver stress and available resources. The researchers concluded that in order for the client-centred approach to be effective for persons requiring nursing-home level care, funding and resources would likely have to be increased.

Another study with implications for supportive housing examined the extent to which municipal housing providers are aware of and concerned about tenants with dementia, what their expectations were for the future and how they saw themselves responding, including the barriers they would face to making necessary changes. ⁸¹ This study had a number of interesting findings. It found that housing providers who were aware of and concerned about older tenants with dementia in their building were making an effort to support these tenants as well as other frail tenants. Strategies used by these housing providers included working with health and social service agencies and with families, providing education on dementia to staff and other tenants, increasing the monitoring of special tenants by their own housing staff, and making minor physical modifications to buildings. Barriers to making changes that would accommodate the needs of older tenants included cost (identified much more frequently than any other barrier), lack of staff in housing agencies, lack of skill in managing persons with dementia, and concerns about turning their seniors housing into long-term care facilities.

Future Demand for Supportive Housing

At the "big picture" level, most experts agree that the demand for supportive housing in Canada will be driven by a number of health, social, and economic trends. ⁸² Realities like the aging of the Canadian population, predicted increases in life expectancy, potential increases in the numbers of older people with chronic diseases who may need support, and increases in the number of older people living alone may all play a role. These phenomena will challenge both the formal and informal system of support for older people and dictate the development of viable alternatives. Although each cohort of seniors is wealthier and healthier than the last, there is debate in the literature as to whether this will translate into a better quality of life if the appropriate services are not available. ⁸³ Supportive housing in its many forms shows much promise in providing alternative forms of housing for older persons who need some care. These alternatives can benefit both individuals and society.

Summary

Scanning the literature indicates that there is a wide range of supportive housing options available for seniors in Canada. One of the reasons for this is that supportive housing is defined quite broadly and encompasses many different models of housing and supports.

The current literature review supports the results of previous work in terms of the potential benefits of supportive housing for seniors, particularly those related to health and overall quality of life. Recent research also shows that supportive housing in its most supportive form has the potential to be a viable alternative to traditional long-term care or nursing home care.

At the same time, the review reveals continued gaps in the supply of supportive housing, particularly in rural and remote areas and some regions of Canada. There appears to be almost a west (high) to east (low) ranking in terms of new development activity and range of supportive housing options. This could be the result of demand, market conditions, or provincial government funding priorities.

The literature review also reveals barriers in supportive housing options for certain special needs populations such as the hard-to-house and homeless, gay, lesbian, bisexual and transgendered seniors, and seniors with middle to later stages of dementia. As well, options for modest and low-income seniors are fewer than for those with higher income levels.

Supportive housing continues to show promise as a housing option for seniors who wish to remain independent but require some support. There is some optimism that recent changes in government policies that favour the renewed development of affordable housing in Canada will extend to supportive housing for seniors, if support services can be matched to new affordable housing units.

References

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Canada Mortgage and Housing Corporation, Housing Options for Persons with Dementia. 1999
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Eales, Jacquie, Norah Keating and Annita Damsma, "Seniors' experiences of client centred residential care", Aging and Society , 21, 279-296, 2001.
Gnaedinger, Nancy, Supportive Housing: An International Literature Review. Submitted to: The Steering Committee on Supportive Housing, British Columbia Ministry of Municipal Affairs, July 27, 1998.
Hawes, C. "A key piece of the integration puzzle: managing the chronic care needs of the frail elderly in residential care settings". Generations , 23, 51-55, 1999.
Hébert, Réjean, Dubuc, Nicole, Buteau, Martin, Desrosiers, Johanne, Bravo, Gina, Trottier, Lisa, St-Hilaire, Carole, and Chantale Roy, "Resources and costs associated with disabilities of elderly people living at home and in institutions". Canadian Journal on Aging , Vol. 20 no. 1, 1-21, 2001.
Hébert, Réjean and Anne-Cécile Desfaits, "CIHR's Institute of Aging: Improving the Health and Quality of Life of Older Canadians", CJNR , Vol.35 Number 4, 181-186, 2003.
Keating, N.C., Fast, J. E., Connidis, I. A., Penning, M. & J. Keefe, "Bridging policy and research in eldercare". Canadian Journal on Aging , 16, 22-41, 1997.
Keating, Norah, Fast, Janet, Dosman, Donna, and Jacquie Eales, "Services Provided by Informal and Formal Caregivers to Seniors in Residential Continuing Care". Canadian Journal on Aging , Vol. 20 No. 1, 23-45, 2001.
MacKenzie, Patricia, "Aging people in aging places: addressing the needs of older adults in rural Saskatchewan". Rural Social Work, Special Australian/Canadian Issue , December 2001.
Moran, Lori, White, Elizabeth, Eales, Jacquie, Fast, Janet and Norah Keating, "Evaluating consumer satisfaction in residential continuing care settings". Journal of Aging and Social Policy , Vol. 14(2), 2002.
National Advisory Council on Aging, 1999 and Beyond: Challenges of an Aging Canadian Society, 1999.
National Advisory Council on Aging, The NACA Position on Supportive Housing for Seniors. No. 22, 2002.
National Housing Research Committee, Research Focuses on Regulations for Supportive Housing for Seniors. Spring Newsletter, 2004.
Reimer, Marlene A., Slaughter, Susan, Donaldson, Cam, Currie, Gilllian, and Michael Eliasziw, "Special care facility compared with traditional environments for dementia care: A longitudinal study on the quality of life". Journal of the American Geriatrics Society , Vol. 52, NO. 7, July 2004.
Seniors Health Promotion Network, More Than Shelter: Housing Policy Kit for Seniors in Atlantic Canada. Health Canada Atlantic Region, 2004. www.msvu.ca/nsca/projectreports.asp
Social Data Research Ltd. and Anne Wright Associates, How Well are We Doing?: A Survey of the GLBT Population in Ottawa. Sponsored by Pink Triangle Services, www.pinktriangle.org/wellness, 2001.
Social Data Research Ltd., Supportive Housing Model for Older Homeless Women, Final Report. Prepared for Cornerstone/LePilier, Ottawa, 2003.
Stone, Sharon Dale, "Disability, dependence, and old age: problematic constructions". Canadian Journal on Aging , 22 (1), 59-67, 2001.
Toronto District Health Council, Building on a Framework of Support and Supportive Housing in Toronto: Supportive Housing for Seniors. September, 2002. www.tdhc.org
Veteran's Affairs Canada, Review and Determination of Housing Issues for Veterans and Seniors, The Royal Canadian Legion, 2004. www.legion.ca/asp/docs/serv_bur/housing_e.asp

Appendix B: Key Informants

British Columbia

Greg Steves, Manager, Housing Policy Branch, British Columbia (B. C.) - Community, Aboriginal & Women's Services
Jennifer Love, Assisted Living Coordinator, for Susan Adams, Registrar, Office of the Assisted Living Registrar
Bob Crane, Policy Analyst, Housing Policy Branch
Veronica Doyle, Regional Director, Housing and Community Resource Development, Vancouver Island Health Authority
Monica Jako, Manager of Corporate Affairs, B. C. Housing
Craig Crawford, Seniors Housing Information Program
Gloria Gutman, Gerontology Research Centre, Simon Fraser University
Andrew Wister, Gerontology Research Centre, Simon Fraser University
Neena Chappell, University of Victoria Centre on Aging
Anne Martin Matthews, University of British Columbia, Family Studies
Sarah Jarvinen, Community Education Manager, Seniors Housing Information Program

Alberta

Kildy Yuen, Associate Director, Housing Innovation & Policy, Housing Innovation & Policy, Alberta Seniors
Bruce West, Director, Supportive Living and Long-term Care Development, Alberta Seniors and Community Supports
Laurel Stain, Director, Alberta Centre on Aging (former Director, Manitoba Centre on Aging)
Norah Keating, University of Alberta

Saskatchewan

Rupen Pandya, Manager, Saskatchewan Housing Corporation
Larry Chaykowski, Executive Director, Saskatchewan Housing Corporation
Kevin McArthur, Policy Analyst, Saskatchewan Housing

Manitoba

Joan Miller, Director, Manitoba Family Services & Housing
Joy Gertson, Coordinator of Research, Manitoba Housing and Renewal Corporation
Laurel Strain, Former Director, Manitoba Centre on Aging
Linda Dando, Director, Long-term Access Centre/Home Care, Winnipeg Regional Health Authority
Kathy Taylor, Housing Manager, Winnipeg Regional Housing Authority

Ontario

Kevin Sullivan, Team Leader, Research, Ontario Ministry of Municipal Affairs/Public Infrastructure and Renewal
Brian Davidson, Manager, Supportive Housing, Ministry of Health and Long-Term Care (MOHLTC)
Ivy France, Manager, Housing Policy, Region of Peel Housing & Property Development
Kate Murray, Program Consultant, CCAC Branch, MOHLTC
Karen Singh, CCAC Branch
Ray Applebaum, Peel Senior Links
Margaret Denton, Director, McMaster Centre for Gerontological Studies
Ann Dobson, Executive Director, Seniors Association for Residential Housing, Ottawa
Kathy Wright, Executive Director, Alzheimer Association, Ottawa

Quebec

Francois Renaud, Agent de recherché, Société d'habitation du Quebec (SHQ)

New Brunswick

Tom Henderson, Senior Research Analyst, Planning, Research & Evaluation, New Brunswick Housing Corporation
Bruce Oliver and David Dell,Policy Analysts, New Brunswick Housing Corporation
Joanne Fellows, Board member, Third Age Centre, Fredericton
Alex Arsenault, President, New Brunswick Non-Profit Housing Association

Nova Scotia

Valerie White/Stephen Coyle, Senior Citizens' Secretariat, Nova Scotia Department of Health
Cathy Crouse, Executive Director, Nova Scotia Centre on Aging

Newfoundland

Rosemary Lester, Executive Director, Seniors Resource Centre Association of Newfoundland and Labrador Inc.

Prince Edward Island

Janet Wood, Planning Officer, Social Ppolicy Development, P.E.I. Health and Social Services
Lorrie Weeks, Department of Family & Nutritional Sciences, University of Prince Edward Island

Yukon

Cathleen Lewis, Policy Analyst, Yukon Housing Corporation

North West Territories

Gary R. McLellan, Director, Policy and Programs, NWT Housing Corporation

Nunavut

Amy White, Senior Policy Analyst, Nunavut Housing Corporation

Appendix C: Survey Questionnaire

Supportive Housing Directory Survey 1.0

Name of Project
Full Address Street; City; Province; Postal Code
Name of contact person
Title of contact person
Telephone number for contact person
Email address for contact person
Web site for project (if applicable)

A. Background

A1. In what year did this project open?

A2. Is this project.

Public non-profit?
Private non-profit?
Private for profit?
Other?

A3. What is the name of the sponsor?

A4. Was there a partnership involved in the development of this project?

a) Yes b) No

(If Yes) Who was involved?
(If Yes) What was their role?
Funding/financial related
Delivery of support services
Other (Please describe)

B. Number and type of units

B1. How many residential units does the project have in total ?

Total?

B2. How many are:

a) Studio/bachelor suites
b) One-bedroom units
c) Two-bedroom units
d) Three-bedroom units
e) Other types (Please describe)

C. Occupancy

C1. What was the average occupancy rate in the past 12 months? %

C2. Is the project fully occupied now?

a) Yes b) No

C3. Do you have a waiting list now?

a) Yes b) No

(If yes) Is this unusual or do you typically have a waiting list?

Unusual to have a waiting list
Typically have a waiting list

D. Tenure arrangements

D1. What are the tenure arrangements? (Check all that apply)

Rental
Life lease
Co-op
Condo
Free hold
If yes to freehold

D1a. Do freehold residents own.:

property and dwelling
dwelling only and lease property
other (Please describe)

E. Support services

E1. Which of the following services do you offer to residents either through your own organization or through linkages and/or partnerships with community agencies or both?

E2. How flexible is your resident support service package?

Do you have.

A standard package of support services that all residents purchase

(If Yes) What is included in the package?

All meals
Main meal only
Laundry
Housekeeping
24-hour security
Other (Please list)
A flexible package with a menu of support services
Both
Other (Please describe)

E3. Can you provide a monthly range ( minimum to maximum ) breakdown of costs to residents for services and/or housing?

Minimum in $ Maximum in $
Housing and services
Housing only
Support services only
Other (Please describe)

E4. Are there subsidies or other forms of financial assistance available to residents?

a) Yes b) No

(If Yes) Is the financial assistance related to housing, support services or both?

Housing
Support services
Both
Other (Please describe)

F. Type of structure and amenity spaces

F1. What type of housing is this project? (select all that apply)

Single family detached houses
Semi-detached, duplex, row houses or townhouses
Single story motel style apartment building(s)
Apartments in multiple story building(s)
Mobile homes
Other (Please describe)

F2. Is the project on a campus or site with a range of housing types and support services for seniors? a)Yes b) No

F3. What type of amenities does the project offer? [multiple mention]

Common dining room(s)
Indoor activity room(s)
Library/reading room(s)
Lounges for socializing
Private dining area for family special occasions
Overnight accommodation for visiting family members
Outdoor common space or garden
Access to private yard or balcony for each unit
Other amenities (Please describe)

G. Location

G1. Is the project located in a residential area?

a) Yes b) No

G2. Is the project located in a city, small town or village, or rural area?

City
Small town or village
Rural area

H. Residents

H1. What is the total number of residents?

H1a. What is their approximate age range?

a) Youngest
b) Oldest

H2. What is their average age?

H3. What percentage are women?% men?% Don't Know

H4. Approximately what percentage are living alone?%

H5. What are the main cultural or language groups? (Please list)

a)
b)
c)

H6. In terms of level of independence, how would you describe the residents living in this project? Would you say most are

Independent - need little or no assistance
Semi-dependent - need some assistance with daily activities
Dependent - need assistance with most activities of daily living
Other (Please describe)

H7. In terms of health, what proportion would you say have.

a) Excellent health%
b) Good health%
c) Fair health%
d) Poor health%
e) Very poor health%

H8. What percentage of residents would you say have.

a) No dementia %
b) Mild dementia?%
c) Medium dementia?%
d) Severe dementia?%

H9. Is this project purposely designed to serve the needs of seniors with dementia?

a) Yes b) No

H10. Does the project restrict or limit tenure for reasons such as.

Mental health
Physical health
Disability
Other reasons (Please describe)

H11. Is clients' health status assessed as part of residency requirement?

a) Yes b) No

I. Management

I1. Does the project have an on-site support service coordinator?

a) Yes b) No

(If Yes) What is their main role?

Provision of services
Making referrals
Other (Please describe)

I2. Are residents participating in management decisions that affect them?

a) Yes b) No

I3. Are residents invited to sit on advisory committees and/or the management board?

Advisory committees
Management board
Other (Please describe)

I4. Does the project have any front-line staff such as nurses, nursing assistants, social workers?

a)Yes b) No

( If Yes ) Are front-line staff invited to sit on your management committees or management board?

Advisory committees
Management board
Other (Please describe)

J. Closing

J1. In each of the following areas, what are the features of this project that you would consider most innovative?

Barrier free design?
Support services?
Management approach?
Partnerships?
Other?

J2. What features make this project supportive?

J3. Does this project support "Aging in Place"? In other words can people live here as long as they wish?

a) Yes b) No

J4. Based on your experience in this field, what are the key issues related to the supply and quality of supportive housing for seniors in Canada?

J5. Are you familiar with any other supportive housing projects built for seniors that you would recommend we contact?

a) Yes b) No

Contact 1 info
Contact 2
Contact 3
Contact 4

Thank you very much

¹ Terminology varies significantly from province to province, and internationally; for simplicity and to facilitate comparison, the term "supportive housing" is used here to refer to housing with services for seniors regardless of government involvement and independent of any specific government program referring to 'supportive housing' in its title or description.

² CMHC research report 'A Legal Framework for Supportive Housing for Seniors: Options for Canadian Policy Makers' prepared by Margaret Isabel Hall, Canadian Centre for Elder Law Studies, Vancouver, British Columbia, March 2005

³ Spencer, Charmaine, Assisted Living in British Columbia's 'New Era'. Seniors Housing Update, Vol. 13, No. 1, 2004.

⁴ Ibid.

⁵ For more information about this study, contact Don Shiner, Ph.D., Principal Investigator, Nova Scotia Centre on Aging, Mount Saint Vincent University, Ph: (902) 457-6398; Email: donald.shiner@msvu.ca

⁶ In this report "seniors" are defined as people 65 years of age or older.

⁷ Terminology varies significantly from province to province, and internationally; for simplicity and to facilitate comparison, the term "supportive housing" is used here to refer to housing with services for seniors regardless of government involvement and independent of any specific government program referring to "supportive housing" in its title or description.

⁸ Extracted from CMHC's research report "A Legal Framework for Supportive Housing for Seniors: Options for Canadian Policy Makers" prepared by Margaret Isabel Hall, LLB,LLM, Canadian Centre for Elder Law Studies, Vancouver, British Columbia. March, 2005.

⁹ An online search uncovered a number of provincial directories of seniors housing. The study team examined the content of these directories and selected projects that had the potential to meet CMHC's definition of supportive housing.

¹⁰ Interviewers at the frontline were given the task of contacting municipal offices across the country to locate local listings.

¹¹ Interviewers from POLLARA conducted the survey using a Computer Assisted Technology (CATI) system. The results are automatically processed into a format compatible with SPSS and ACCESS.

¹² These are the projects that were included in the database

¹³ Respondents responsible for more than one eligible project were asked to select their most recent/innovative project

¹⁴ Statistics Canada, Population by sex and age group, by provinces and territories, CANSIM, 2004.

¹⁵ A Portrait of Seniors in Canada: Third Edition, 1999.

¹⁶ Note the question did not provide any guidelines in terms of population size.

¹⁷ Accreditation can come from different organizations, such as the Canadian Council on Health Services Accreditation www.cchsa.ca. CCHSA is a voluntary accreditation body for Canadian organizations providing health care services. British Columbia is the only province to date that legislates assisted living and has an assisted living registrar. www.healthservices.gov.bc.ca/assisted/index.html.

¹⁸ There may be two reasons why some projects indicate that they have a waiting list even through they may not be fully occupied. One is that the question to do with occupancy rates asked respondents to give their "average" occupancy rate over the last year. Two, some seniors may ask to be placed on a waiting list for a particular residence and may not be ready to move when a vacancy becomes available. Waiting lists are often not updated on a regular basis.

¹⁹ Because the question was open-ended in nature as opposed to asking respondents to check-off a list of possible features using close-ended categories, it would be misleading to report frequencies or percentages.

²⁰ It is not possible to give percentages for each type of response as the question was open-ended and qualitative in nature.

²¹ Canada Mortgage and Housing Corporation Research Report, Supportive Housing for Seniors, prepared by Social Data Research Ltd. 2000.

²² Please refer to two recent CMHC research reports prepared under the External Research Program - Life Lease Supportive Housing: Combining the Best Aspects of Housing and Complex Care, by The Capital Care Group, February, 2005; and, A Legal Framework for Supportive Housing For Seniors: Options for Canadian Policy Makers. By the Canadian Centre for Elder Law Studies, March 2005.

²³ Some recent forms of supportive housing are designed to offer a continuum of care. See for example, The Laurier House Model of Care, developed by The Capital Care Group in Edmonton, Alberta. The model is described in the CMHC research report, Life Lease Supportive Housing: Combining the Best Aspects of Housing and Complex Care: Volume 1, by The Capital Care Group February, 2005.

²⁴ Cohen, Marcy, Murphy, Janice, Nutland, Kelsey, and Aleck Ostry, Continuing Care: Renewal or Retreat? BC Residential and Home Care Restructuring 2001-2004, Canadian Centre for Policy Alternatives, April, 2005.

²⁵ Golant, Stephen, M. "Assisted Living: A Potential Solution to Canada's Long-term-Care Crisis". Unpublished paper prepared by Dr. Golant, a US-Canada Senior Fulbright Scholar while in residence at Simon Fraser University. January, 2001.

²⁶ Spencer, Charmaine, Assisted Living in British Columbia's 'New Era'. Seniors Housing Update, Vol. 13, No. 1, 2004.

²⁷ Ibid.

²⁸ The Laurier House model developed by the Capital Care Group in Alberta is an example of an innovative project completed by the private sector without any government funding.

²⁹ For more information about this study, contact Don Shiner, Ph.D., Principal Investigator, Nova Scotia Centre on Aging, Mount Saint Vincent University, Ph: (902) 457-6398; Email: donald.shiner@msvu.ca

³⁰ Canada Mortgage and Housing Corporation, Aging in Place: Strategies to Meet the Needs of Senior Tenants in Non-Profit Housing, 1996

³¹ Nova Scotia Housing and Consumer Affairs, Aging in Place Study, 1993.

³² Golant, Stephen, M. "Assisted Living: A Potential Solution to Canada's Long-term-Care Crisis". Unpublished paper prepared by Dr. Golant, a US-Canada Senior Fulbright Scholar while in residence at Simon Fraser University. January, 2001.

³³ Additional information can be found at www.seniorshousing.bc.ca.

³⁴ These initiatives arose out of earlier research conducted by the province of Nova Scotia in cooperation with CMHC that showed a need for supportive housing in seniors non-profit housing.

³⁵ The database is preliminary. Much of the information must be verified before publication.

³⁶ Recent legislation in BC has mandated the registration of assisted living projects - projects that choose not to be registered cannot call themselves "assisted living" and must either down grade their service level to less support or increase their level of support to the residential care level (long-term facility based care).

³⁷ Interview with Sarah Jarvinen, Community Education Manager for SHIP - Sarah was provided with the selection criteria for supportive housing being used for the inventory and identified twenty projects that she felt were particularly interesting.

³⁸ CMHC Research Report, Supportive Housing for Seniors, Prepared by Social Data Research Ltd. 2000.

³⁹ For a description of each of these components, please refer to "Supportive Housing for Seniors".

⁴⁰ For a description of this form of supportive housing please refer to CMHC Research Report, Life Lease Housing Canada: A preliminary exploration of some consumer protection issues. Prepared by Lumina Services Inc. 2003.

⁴¹ National Advisory Council on Aging, "The NACA Position on Supportive Housing for Seniors, No. 22, 2002; Seniors Health Promotion Network, "More Than Shelter: Housing Policy Kit for Seniors in Atlantic Canada", Funded by Health Canada Atlantic Region, 2004; Veteran's Affairs, "Review and Determination of Housing Issues for Veterans and Seniors", The Royal Canadian Legion, 2004.

⁴² As defined by the Seniors Housing Information Program (SHIP).

⁴³ Ontario Government Website - Ministry of Health and Long-term care, www.health.gov.on.ca

⁴⁴ For more information see Alberta government website, www.seniors.gov.ab.ca.

⁴⁵ For more detail on this program refer to www.dcre.gov.sk.ca/housing/programs/p-SALS.html

⁴⁶ Seniors Health Promotion Network, "More Than Shelter: Housing Policy Kit for Seniors in Atlantic Canada", Funded by Health Canada Atlantic Region, 2004.

⁴⁷ National Advisory Council on Aging, The NACA Position on Supportive Housing for Seniors. No. 22, 2002.

⁴⁸ National Advisory Council on Aging, 1999 and Beyond: Challenges of an Aging Canadian Society, 1999.

⁴⁹ Seniors Health Promotion Network, More Than Shelter: Housing Policy Kit for Seniors in Atlantic Canada, 2004.

⁵⁰ Toronto District Health Council, Building on a Framework of Support and Supportive Housing in Toronto: Supportive Housing for Seniors. September, 2002.

⁵¹ CMHC, The Impact of Supportive Housing on a Downtown Homeless Population. Research Report, March 1993.

⁵² CMHC, National Housing Research Committee Newsletter, Spring 2003.

⁵³ Keating, N.C., Fast, J. E., Connidis, I. A., Penning, M. & J. Keefe, "Bridging policy and research in eldercare". Canadian Journal on Aging, 16, 22-41, 1997; Hawes, C. "A key piece of the integration puzzle: managing the chronic care needs of the frail elderly in residential care settings". Generations, 23, 51-55, 1999; Gnaedinger, Nancy, Supportive Housing: An International Literature Review. Submitted to: The Steering Committee on Supportive Housing, British Columbia Ministry of Municipal Affairs, July 27, 1998.

⁵⁴ Hébert, Réjean, Dubuc, Nicole, Buteau, Martin, Desrosiers, Johanne, Bravo, Gina, Trottier, Lisa, St-Hilaire, Carole, and Chantale Roy, "Resources and costs associated with disabilities of elderly people living at home and in institutions". Canadian Journal on Aging, Vol. 20 no. 1 2001, 1-21.

⁵⁵ Social Data Research Ltd., Supportive Housing Model for Older Homeless Women, Final Report prepared for Cornerstone/LePilier, Ottawa, 2003.

⁵⁶ Culhane, Dennis, P. Metraux, Stephen & Trevor Hadley. The Impact of Supportive Housing for Homeless People with Severe Mental Illness on the Utilization of the Public Health, Corrections and Emergency Shelter Systems. Fannie Mae Foundation, 2001.

⁵⁷ Interview with Sarah Jarvinen, Community Education Manager for SHIPS.

⁵⁸ MacKenzie, Patricia, "Aging people in aging places: addressing the needs of older adults in rural Saskatchewan". Rural Social Work, Special Australian/Canadian Issue, December 2001.

⁵⁹ Veteran's Affairs Canada, "Review and Determination of Housing Issues for Veterans and Seniors", The Royal Canadian Legion, 2004.

⁶⁰ National Housing Research Committee, "Research Focuses on Regulations for Supportive Housing for Seniors", Spring Newsletter, 2004, p16.

⁶¹ BC Office of the Assisted Living Registrar, Assisted Living Information for Applicants. (available online www.healthservices.gov.bc.ca/assisted/index.html

⁶² CMHC, Life Lease Housing in Canada: A Preliminary Exploration of Some Consumer Protection Issues, Prepared by Lumina Services Inc., 2003.

⁶³ CMHC, Housing Options for Older Canadians: User Satisfaction Study, Part 2: Resident Satisfaction Survey Results, prepared by The Gerontology Research Centre, Dr. Gloria Gutman and Mary Ann Clarke Scott, Simon Fraser University, Vancouver, BC, in collaboration with Nancy Gnaedinger, Danielle Maltais, Luba Serge and David Bruce, 1999.

⁶⁴ Eales, Jacquie, Norah Keating and Annita Damsma, "Seniors' experiences of client centred residential care", Aging and Society, 21, 2001, 279-296; Moran, Lori, White, Elizabeth, Eales, Jacquie, Fast, Janet and Norah Keating, "Evaluating consumer satisfaction in residential continuing care settings". Journal of Aging and Social Policy, Vol. 14(2), 2002.

⁶⁵ CMHC, Research Report, The Adjustment of the Elderly to Congregate Care in Housing. Prepared by Robert Gifford for Optimal Environments, Inc., 1999.

⁶⁶ Reimer, Marlene, A. Slaughter, Susan, Donaldson, Cam, Currie, Gillian, and Michael Eliasziw, "Special care facility compared with traditional environments for dementia care: A longitudinal study on the quality of life". Journal of the American Geriatrics Society, July 2004, Vol. 52, NO. 7.

⁶⁷ Keating, Norah, Fast, Janet, Dosman, Donna, and Jacquie Eales, "Services Provided by Informal and Formal Caregivers to Seniors in Residential Continuing Care". Canadian Journal on Aging, Vol. 20 No. 1, 2001, 23-45.

⁶⁸ Seniors Health Promotion Network, "More Than Shelter: Housing Policy Kit for Seniors in Atlantic Canada", Funded by Health Canada Atlantic Region, 2004.

⁶⁹ National Advisory Council on Aging, The NACA Position on Supportive Housing. No. 22, 2002.

⁷⁰ Veteran's Affairs Canada, "Review and Determination of Housing Issues for Veterans and Seniors", The Royal Canadian Legion, 2004.

⁷¹ ibid..

⁷² Seniors Health Promotion Network, More Than Shelter: Housing Policy Kit for Seniors in Atlantic Canada. 2004.

⁷³ Stone, Sharon, Dale, "Disability, dependence, and old age: problematic constructions". Canadian Journal on Aging, 22 (1), 59-67, 2001.

⁷⁴ Social Data Research Ltd., "Supportive Housing Model for Older Homeless Women", Final Report prepared for Cornerstone/LePilier, Ottawa, 2003.

⁷⁵ CMHC, Housing Options for Elderly or Chronically Ill Shelter Users. Prepared by Nancy Gnaedinger and Luba Serge, 2003.

⁷⁶ Social Data Research Ltd. and Anne Wright Associates, How Well are We Doing?: A Survey of the GLBT Population in Ottawa. Sponsored by Pink Triangle Services, 2001. www.pinktriangle.org/wellness

⁷⁷ Brotman, Shari, Ryan, Bill, and Robert Cormier, "The health and social service needs of gay and lesbian elders and their families in Canada". The Gerontologist, April 2003, Vol. 43, Issue 2, pg 192.

⁷⁸ CMHC, Housing Options for Persons with Dementia. 1999

⁷⁹ Interview with Ann Dobson, Executive Director, Seniors Association for Residential Accommodation and Health (SARAH), Ottawa.

⁸⁰ Chapman, Sherry Anne, Keating, Norah, and Jacquie Eales, "Client centred, community-based care for frail seniors". Health and Social Care in the Community, 11(3), 253-261, 2003.

⁸¹ CMHC, Research Report: Adapting Municipal Housing to Meet the Needs of Older Tenants with Dementia. Prepared by Myra Schiff and Nancy Gnaedinger, 1997.

⁸² CMHC, Supportive Housing for Seniors, Prepared by Social Data Research Ltd. 2000; National Advisory Council on Aging, The NACA Position on Supportive Housing for Seniors, October 2002; Seniors Health Promotion Network, "More Than Shelter: Housing Policy Kit for Seniors in Atlantic Canada", Funded by Health Canada Atlantic Region, 2004.

⁸³ Hébert, Réjean and Anne-Cécile Desfaits, "CIHR's Institute of Aging: Improving the Health and Quality of Life of Older Canadians", CJNR 2003, Vol.35 Number 4, 181-186.

	Our organization offers		Provides thru linkages
	On site	Off site	On site	Off site
Breakfast
Lunch
Dinner
Snacks
Meals on wheels
Wheels to meals
Personal housekeeping
Personal laundry
Assisting residents with:
Preparing meals
Bathing
Grooming
Dressing
Toileting
Medications
Other home nursing services
A doctor available to residents
Mental health services
Social services
Palliative care
Transportation assistance
Escorts to appointments
Recreational activities
24 hour security
Yardwork/outside maintenance
Unit maintenance/minor repairs
Other (Please describe)

ARCHIVED - Searchable Database of Supportive Housing for Seniors in Canada: Final Report

We have archived this page and will not be updating it.

We have archived this page and will not be updating it.

Table of Contents

Abstract

Executive Summary

Introduction

Terminology

Methodology

Findings

Issues

The test database

Conclusions

Part One: Background

1.1 Introduction

1.2 Study Parameters

1.3 Methodology

Aggregate analysis

Designing the database

Part Two: Findings of Phase One

2.1 Results of the Survey of Projects

Year first opened

Classification and accreditation

Funding sector

Partnerships

Number and type of units

Occupancy

Waiting lists

Types of Tenure

Support services

Off-site services

Services provided through linkages with other organizations

Support service packages

Cost to residents for housing and services

Financial assistance

Amenity spaces

Age and gender

Living arrangements

Cultural and language groups

Degree of independence

Overall health of residents

Level of dementia

Are projects designed to serve the needs of residents with dementia?

Are projects designed to support "aging in place"

Restriction on tenure

On-site service coordination

How residents are involved in management

Staff involvement in management

Examples of innovative barrier-free design features (79 operators gave examples)

Examples of innovative support services (155 operators gave examples)

Examples of innovative managemens approaches (76 operators gave examples)

Examples o innovative partnerships (55 opeators gave examples)

Which features make projects supportive?

2.2 Innovative Examples of Supporting Housing

2.3 Issues Related to Supportive Housing for Seniors

2.4 Current Provincial and Territorial Public Policies and Guidelines for Supportive Housing for Seniors

Part Three: Test Electronic Database of Supportive Housing for Seniors in Canada

3.1 Description and Function

3.2 The Database

3.3 Conclusion

Appendix A: Literature Review

Introduction

Method

Results of the Search

Definition of Supportive Housing

The Need for Supportive Housing

Issues Related to Quality and Supply

Regulating the Quality of Supportive Housing

Residents' Perspective on the Quality of Supportive Housing

Barriers and Gaps in Supportive Housing

Affordability

Cost of Development

Availability

Gaps in supportive housing for special populations

Future Demand for Supportive Housing

Summary

References

Appendix B: Key Informants

British Columbia

Alberta