Conchy Bretos has created an affordable assisted living model that allows low-income and disabled senior citizens living in public housing facilities to remain in their own homes instead of being forced into nursing homes against their will. Over the last 15 years, she has helped public housing authorities in 23 states renovate public housing buildings to comply with assisted living facility regulations and finance start-up operations through state and federal funding. Along with her team at MIA Consulting, Conchy is now poised to change public policy on elderly care through a pending national demonstration project with the Department of Housing and Urban Development and the Department of Health and Human Services.
The New Idea
In response to the deplorable public housing conditions that she witnessed as Florida’s Secretary for Aging and Adult Services in the mid 1990s, Conchy created a new model for providing basic care services to the elderly while allowing them to stay in their own homes. Although private assisted living facilities (ALFs) have long existed for senior citizens who are able to pay hefty monthly fees, low-income and disabled senior citizens—many of whom live in public housing— are largely unattended by the market. Conchy’s model makes ALFs affordable for these seniors by retrofitting existing public housing buildings to comply with ALF regulations and by leveraging state Medicaid waiver funding to finance the ALFs’ start-up operations. Not only do these affordable ALFs allow the elderly to continue living with relative independence and dignity in their own homes, but they also generate employment for single minority mothers in the daily care of the residents and the maintenance of the facilities, often leading to a gradual revitalization of the frequently derelict or decaying urban neighborhoods where these ALFs are located.
Preliminary studies of the results of Conchy’s model have shown that residents’ physical and cognitive health actually improves significantly in these affordable ALFs as compared to traditional nursing homes. As hospitalizations, emergency calls, and dependence on medications drop, so does the financial burden on the Medicaid program, which often ends up covering the medical expenses of low-income and disabled seniors. Consequently, Conchy’s model not only helps the elderly stay in their own homes with basic services, but it also helps cut Medicaid costs at a time when both state and federal government budgets are becoming increasingly overwhelmed by public spending.
Conchy has already replicated her model in 40 ALF projects that serve approximately 5,000 seniors in 23 states through MIA Consulting, the for-profit group she founded in 1995 to help public housing authorities (PHAs) across the country adopt versions of her affordable ALF model. MIA Consulting works directly with interested PHAs to conduct feasibility studies, retrofit buildings to meet ALF standards, recruit residents and staff, manage day-to-day operations in the start-up phase, and conduct performance and impact evaluations. After an initial three- to five-year period of intensive involvement, MIA Consulting hands over the management of facilities to the local PHAs themselves. MIA Consulting is funded by contractor fees from PHAs and non-profit organizations that want to implement an affordable ALF model; all profits beyond the salaries of MIA Consulting’s two principals (the CEO and COO) are reinvested in the organization to help subsidize low-cost and pro bono consulting services.
The many impending consequences of an aging population on American society—particularly on the health care system—have yet to be seen, but what is certain is that institutions in both the public and private sectors will have to change dramatically to accommodate these demographic changes. According to the American Association of Homes and Services of the Aging, in the next 20 years both America’s elderly population and the country’s Medicare costs are expected to double, whereas GDP is projected to grow by only 75 percent in the same period. Senior citizens are in low-income brackets or who are disabled are especially at risk of failing to receive the medical attention they need. Many of these elderly either live in public housing or are poor enough to be eligible for public housing, and studies have suggested that they tend to suffer from higher rates of chronic illness than their wealthier counterparts.
Unlike senior citizens in higher income brackets, these seniors cannot afford expensive private ALFs that often cost thousands of dollars a month, nor are they willing to enter nursing homes where many feel a loss of identity and where the quality of care is sometimes questionable. However, since laws require that public housing residents be able to live independently, once these low-income or disabled senior citizens are deemed unfit to support themselves, they are often ejected from public housing and are either sent to nursing homes or become homeless. Coupled with the effects of a society that values the contributions of the young over those of the old, this phenomenon results in many senior citizens being effectively abandoned with little choice as to how to live out the remainder of their lives.
In financial terms, the forcing of low-income and disabled senior citizens into nursing homes or homeless shelters against their will places an enormous strain on the Medicaid budget. Without an emphasis on monitoring and preventive health, many of these senior citizens only receive medical treatment when their health is in significant danger, which leads to higher public health care costs. Not only is Medicaid already operating at a deficit now, but many states have also cut their Medicaid budgets as a result of the economic crisis of 2008 to 2009. Without systemic reform, the current model of public spending on elderly care and medical treatment is unsustainable, as evidenced by the current national debate on health care.
Despite clear indications that low-income and disabled seniors are falling through holes in the social safety net and that public health care costs for the elderly are excessively high, changing public policy in this area is very difficult. As with any public policy problem, there is a great deal of inertia in the existing system, and a large number of stakeholders in the public, private, and social sectors must all be engaged in the debate. Nevertheless, given the heavy influence of the Federal Department of Housing and Urban Development (HUD) and Department of Health and Human Services (HHS) in elderly housing and care in America, working with government authorities is critical to reach national scale in this field.
Conchy’s mission is to make assisted living accessible to low-income and disabled seniors who either live or are eligible to live in public housing facilities. Interested PHAs contact MIA Consulting directly to initiate an inexpensive feasibility study where Conchy and her team determine local demand for assisted living services and explain the process of financing and operating an ALF to the PHA’s staff and board of directors. If the PHA ultimately decides to move ahead with the project, then MIA Consulting guides the PHA through all the necessary steps to set up an effective and financially sound ALF, including retrofitting existing public housing buildings to meet government licensing standards for ALFs; hiring and training staff, many of whom are minority single mothers who also live in public housing; recruiting residents; buying supplies; monitoring regulatory compliance; and managing initial ALF operations. For the first two to three years, MIA Consulting staff are actively involved in the daily management of the ALF as well as data collection and impact assessment at 6- and 12-month intervals. Throughout this period of intensive accompaniment, Conchy draws upon more than 15 years of experience and contacts in the aging sector plus the political savvy gained from her public service as Florida’s Secretary for Aging and Adult Services to assemble an affordable public-sector ALF in a highly expeditious manner.
In recruiting residents, MIA Consulting looks first and foremost for vulnerable seniors, such as those who suffer from medical problems like blindness, diabetes, or heart problems or those who have no family. Residents can count on basic home care, round-the-clock monitoring, and transportation to medical appointments, but unlike many nursing homes, there are no doctors or full-time nurses on duty, thus dramatically reducing costs. Staff supervision gives both residents and their relatives the peace of mind that usually comes with a nursing home, but the fact that residents live in a home-like environment rather than an institutional one has been shown to boost both their mental and physical health. Conchy recalls that upon opening Helen Sawyer Plaza, her first pilot facility in downtown Miami, she explicitly decided not to lock up Alzheimer’s patients in separate wards, as is common practice, because she believed that such a policy was inhumane. To the staff’s surprise, under MIA Consulting’s management not a single Alzheimer’s patient got lost in the complex; the patient’s sense of orientation was actually bolstered by all the support that they received from staff and fellow residents. The model also improves neighborhood security by providing a source of formal employment in urban areas that are often in need of regeneration, thus enabling many minority single mothers the opportunity to support their families through stable jobs.
Not only does Conchy’s model improve low-income and disabled senior’s quality of life, but it also creates enormous cost savings in the housing and care of some of the country’s most disadvantaged seniors. Conchy finances the start-up costs of these assisted living facilities using federal housing and utilities subsidies from HUD and state Medicaid waivers that allocate money for seniors who do not enter nursing homes. On average, supporting these seniors in a public housing facility with assisted living services costs Medicaid $30 to $50 a day; putting them in nursing homes costs Medicaid $150 to $200 per day. Over the course of a year, this represents an average savings of $30,000 per resident in Florida alone. Moreover, Conchy is so effective at streamlining ALF operations that the facilities are often profitable by the time that MIA Consulting transfers management responsibilities to the local PHA. Helen Sawyer Plaza went from losing money when Conchy originally acquired the facility in 1995 to making a $1M profit in the year that MIA Consulting handed the facility back over to Miami-Dade County.
Although MIA Consulting has not been able to dedicate many resources to extensive documentation of its work, Conchy is conscious of the importance of independent impact evaluations and has collaborated with third-party evaluators. These evaluations are often prohibitively expensive, but Conchy’s work has generated enough interest to attract Florida International University, which did an impact study of Helen Sawyer Plaza in the 1990s, and the news channel CBS, which researched and ran a report on one of MIA Consulting’s projects and its associated cost savings for Medicare. Stephen Golant, an investigator from the University of Florida at Gainesville who specializes in gerontology, has been identified by HUD to rigorously evaluate the model’s impact if a pending agreement between HUD and HHS to create a national pilot program based on Conchy’s model is approved by both agencies.
Given the influence of HUD’s policies in PHA operations around the country, Conchy believes that the most effective approach to expanding her model nationally is via a shift in public policy. She has been heavily involved in drafting a memorandum of understanding (MOU) between HUD and HHS that would establish a pilot program for the public-sector assisted living facility model in eight different cities, funded by HUD and jointly overseen by both departments. The MOU has been endorsed by senior HHS officials, and Conchy expects that the agreement will be officially signed at the beginning of 2010. Under the terms of the MOU, MIA Consulting would retain its independence but would play a critical advisory role to the eight pilot projects. To achieve this, Conchy plans to expand MIA Consulting beyond its current capacity by hiring a chief financial officer, a program director, legal staff, and operations staff experienced in government reporting and compliance.
In the meantime, Conchy and her team are continuing to build relationships with individual PHAs in various locations around the U.S., which is how her model has spread to 23 states over the past 15 years. During this period Conchy has experimented with 11 different affordable ALF models, each with varying types and levels of services depending on local needs. This flexibility has allowed her to adapt to differing state and local regulations and preferences that greatly influence the design of each affordable ALF. Conchy believes that working with governments on a state-by-state basis will continue to be fundamental to her expansion strategy, given that housing policy and funding sources vary significantly by state. Securing the official support of HUD and HHS will facilitate and expedite her collaborations with individual PHAs as well as initiate a process of standardization across the country. Conchy has also received requests to export her affordable ALF model internationally to countries like Chile and Costa Rica, where she would be able to leverage both personal contacts and the Spanish language to lay the necessary groundwork for model facilities. She sees international expansion as the logical next step after consolidating the spread of her model throughout the U.S.
Conchy was born and raised in Cuba by her grandmother, who she says greatly shaped her personality and character. The Cuban values with which Conchy grew up emphasized respect for elders and their critical role in society. When Conchy was 14-years-old, she joined 14,000 other unaccompanied minors who were flown to the U.S. under Operation Pedro Pan, a collaborative effort between the U.S. government and the Catholic church in Miami to shelter the children of Cubans who opposed Fidel Castro’s new regime in the early 1960s. Conchy and her brother were sent to live in an orphanage in Lincoln, Nebraska, where she recalls feeling the first stirrings of a lifelong resistance to perceived injustice. Living in the orphanage also taught her resourcefulness and instilled in her the belief that individuals can take action to change their own reality.
At age 30 Conchy enrolled in Oberlin College for her undergraduate degree while working full-time and raising three children. Her time at Oberlin, a liberal institution with a deep-seated social conscience, represented a turning point in her life in terms of cementing her commitment to improving the lives of some of America’s most vulnerable populations. After finishing her degree, she became very active in public sector agencies and citizen organizations like the World Health Organization, the United Negro College Fund, the Florida Commission on Hispanics, and the Miami-Dade Women’s Fund, which she founded in 1991.
In the early 1990s Conchy made an unsuccessful but highly visible bid for public office in Miami, which prompted the governor to ask her to serve as Florida’s Secretary for Aging and Adult Services in Tallahassee. It was during her time as Secretary that Conchy witnessed the squalid living conditions of many of Florida’s low-income and disabled senior citizens. Upon leaving office in 1994, Conchy founded MIA Consulting with the dream of equipping public housing facilities with assisted living services for disadvantaged seniors. By leveraging her political connections and skills, she persuaded Miami-Dade County to allow her to use Helen Sawyer Plaza in Miami as a test case. She converted the failing public housing operation into a nationally acclaimed affordable assisted living facility using $1.27M in Medicaid waivers for residents who were able to stay in their homes rather than being moved to nursing homes. Conchy’s early success led to similar contracts in states like Ohio, Tennessee, West Virginia, and Pennsylvania in ensuing years. In 2006 she was named one of the inaugural winners of the Purpose Prize, which recognizes leading social innovators in their encore careers, for her contributions to the fields of public housing and aging. The Purpose Prize brought increased visibility and funding to MIA Consulting, thus enabling Conchy and her team to expand their marketing and pro bono consulting efforts and to finance a new ALF in Tampa, Florida.