Housing and Care Integration

Imagine living in a community where you have access to a wellness team that understands your health needs and can help you coordinate care with your primary care team, specialists, insurance providers, in-home caregivers, and more. A team that will help you address and overcome any barriers you may face to preventing illness and managing chronic conditions.

At Hebrew SeniorLife, we’ve made this vision for helping seniors live their best lives a reality through an approach that supports older adults right where they live, with services that connect the dots and provide the tools and education seniors need to get and stay healthy. 

We’ve integrated housing and care by taking the traditional model of senior housing and adding supportive services that focus on health, wellness, and prevention.

R3: Right Care, Right Place, Right Time

The Right Care, Right Place, Right Time Initiative - also known as R3 - is an innovative program that integrates wellness teams into senior housing communities. It was created by Hebrew SeniorLife to support residents in proactively managing their health by effectively linking housing and health care.

The goal of R3 is to improve lives, reduce costs, and help seniors stay independent and at home longer. 

The program won the Pioneer Institute 2017 Better Government Competition and The John A. Hartford Foundation 2021 Business Innovation Award.

Wellness Teams Help Residents Stay Healthy

The R3 model includes a wellness nurse and wellness coordinator working on-site with the existing housing team to provide supportive services to residents. Our focus is on improving health outcomes and quality of life.

Staff reach out regularly to individual residents to engage them around their health and wellness. Through these conversations they work to understand the barriers residents might face in remaining healthy, then follow up to address needs and connect them to resources. The wellness team also provides individualized case management and support, all centered around the resident’s choice and preferences.

In addition to the work of the wellness teams, all staff in the community - including maintenance, dining, administrators, and social work - are trained to contribute to care coordination efforts.

I feel like it’s a second family. I can go down and talk to them when I’m feeling blue and they really help me. 

The type of support the wellness team can provide includes:

  • Connecting residents to services to address key needs such as mental health, brain health, nutrition, and chronic disease management. 
  • Coordinating care after a hospital or rehab stay to ensure smooth transitions back home.
  • Serving as a link between primary care and other providers.
  • Leading on-site health education and wellness programming around topics of interest to residents.

Our purpose is to empower residents in managing their health so they can stay active and engaged in their community - living their best life.

I have the sense that for almost any physical or medical problem, I’ve got somebody to talk to….being checked in with regularly does feel good. 

Impact of Housing and Care Integration

The R3 program has been proven to support the health of residents who participate. An evaluation of the demonstration project provided by the LeadingAge LTSS Center at UMass Boston determine that the initiative resulted in:

  • A 16% decline in inpatient hospitalization rate and 22% decline in 30-day hospital readmission rates
  • A 19% decrease in trips to the emergency room
  • A 25% decline in total days admitted to a hospital per resident
  • 90% of identified service needs being met

Resident satisfaction with the program is high: 87% of participants would recommend it to a friend.

The wellness nurse helped me organize my medication. She made a chart for me and I’ve got it hanging on my wall so I make sure I know what I’m taking. 

Research published in the journal Health Services Research showed that the partnerships between health care systems and affordable housing sites developed in R3 improve health care outcomes while reducing unnecessary spending and/or use. 

Read More About the Research

Where to Find R3

R3 is part of life at Hebrew SeniorLife’s three supportive living communities: Center Communities of Brookline, Jack Satter House in Revere, and Simon C. Fireman Community in Randolph.

It is also being implemented at a growing list of senior housing communities outside of Hebrew SeniorLife in Greater Boston and across the country.

You must live in an R3 community to use the services of the wellness team.

Woman wellness coach sitting with woman resident

See R3 in action

The best way to learn how integrated care and housing works is by hearing directly from the residents and staff who participate.

Woman wellness coach with man senior

Bring R3 to Your Community

If you work in senior housing and would like to bring R3 to your community, Hebrew SeniorLife can help. We can consult on planning and implementation, or provide full service staffing and rollout of the model.

See How We Can Help