Broadband in Affordable Housing: A Guide for Providers

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1 Purpose of White Paper
1.1   Executive Summary
2 Three-legged Stool of Digital Inclusion
3 Benefits of Broadband Connectivity
3.1 Increased Access to Healthcare
3.2    Reduce Social Isolation/ Feelings of Loneliness
3.3    Increased Resident Engagement and Satisfaction
3.4    Increased Quality of Life
3.5   Increased Staff and Resident Efficiencies
3.6    Asset Management
4 Connectivity Models in Senior Housing
4.1   Individual ISP Subscriptions
4.2   Cellular Wireless Hotspots and Cellular Internet-Enabled Devices
4.3   Property-wide Internet Connections
5 Potential Affordable Housing Provider Business Models
5.1   Infrastructure Programs and Options
5.2   Options for Covering the Ongoing Service and Operations
6 Planning for and Selecting Appropriate Broadband Connectivity Approach
6.1 Vision and Strategic Planning
6.2    Building Considerations
6.3    Network Design Considerations
6.4 Software Considerations
6.5   Considerations for Resident/ Client and Family-Facing Solutions
6.6   Organizational Readiness
6.7    Operational Considerations
6.8    RFP Process
6.9   Project Implementation
7 Relevant LeadingAge Business Partners with CAST Focus
  7.1    Workgroup Members
7.2    Writing Workgroup
8 Contributors
9 References

1. Purpose of White Paper

The purpose of this paper is to help LeadingAge and other housing members, especially those in affordable housing, and leaders in other congregate housing organizations to understand the process for bringing broadband connectivity to their communities affordably. This understanding is especially important to affordable senior housing providers and their residents.

1.1 Executive Summary

In its goal to help organizations understand the process for bringing broadband connectivity to their communities affordably, “Broadband in Affordable Housing: A Guide for Providers” shares practical considerations to guide technology choices.

The white paper presents connectivity models in senior housing, as well as affordable housing provider business models. It also explains infrastructure programs and options for covering ongoing service and operations.

LeadingAge firmly believes that the recent Infrastructure Investment and Jobs Act with its significant broadband investments will create many unprecedented opportunities for affordable housing providers to get the funding and help they need to bring affordable and adequate broadband connectivity to their residents.

This guide gives affordable housing providers the knowledge they need to bridge the digital and equitable service gaps to the low-income populations they serve. Two key factors in implementing broadband are the building itself and network design.

The building itself may impact decisions around broadband connectivity strategy and options.

Building Considerations

The building itself may impact decisions around broadband connectivity strategy and options. The white paper outlines important considerations:

New Build vs. Existing Structure: Designing and implementing broadband connectivity networks and infrastructure is usually easier in new construction. When working with existing structures, the design team needs to consider existing restrictions that may block wireless signals.
Cottages vs. High-Rise: In a vertical community, like a high-rise, Wi-Fi coverage could be implemented more cost-effectively by floors. A horizontal community with individual cottages may be more expensive.
Construction and Stud Materials: Wireless signals suffer attenuation, shortening networks’ coverage distances, reducing reliability, and making networks unable to handle the speeds and bandwidth they would normally handle in free spaces. The white paper discusses how to plan for metal sheets, reinforcement grids, meshes, and studs that absorb electromagnetic energy and render wireless networks useless.

Network Design

Several important aspects that influence a network’s technical design and decisions on its individual components:

Building/ Campus-Wide vs. In-Building: Decide where the network should provide connectivity: throughout the campus, building-wide, or limited within buildings. These choices have significant implications on the infrastructure network design considerations, including placement of network components and the infrastructure’s cost.
Wired vs. Wireless: The network medium (fiber, copper, etc.) and choice between wired and wireless depends on many factors, including coverage distance; applications and use; needed speed and bandwidth; building materials, layout, and location; privacy and security requirements; and cost.
Public vs. Private: Network design includes segmenting the network appropriately, whether wired or wireless, physically or virtually, into a public or private network.
Spectrum and Interference Considerations: When wireless networks are a part of the solution, it is important to consider potential interference with other wireless signals that may affect the network’s performance.

The white paper also tells how to plan for and select the appropriate broadband connectivity approach, from visioning to operational considerations to evaluating solutions for patients, residents, clients, and families.

2. Three-legged Stool of Digital Inclusion

LeadingAge’s strategic plan emphasizes the importance of eradicating ageism and promoting equity and inclusion among the older adults that we serve, especially low-income populations, racial minorities, and other underserved populations. The digital divide is one of the most important inequity gaps to address, because our society is growing more reliant on digital technology and the internet for receiving everything from information to entertainment to health care, education, and essential supporting services.

Providers must consider addressing the Three-legged Stool of Digital Inclusion.

The recent COVID-19 pandemic starkly exposed the consequences of digital inequity of older adults, especially among underserved populations, and highlighted barriers to vaccine registration, digital social connectedness, and technology-enabled healthcare services. LeadingAge affordable housing providers witnessed firsthand the decline of health and well-being among the residents of our communities due to the lack of technology devices and broadband.

The National Digital Inclusion Alliance (NDIA) defines digital equity as “a condition in which all individuals and communities have the information technology capacity needed for full participation in our society, democracy, and economy.” ¹ To facilitate the successful adoption of internet and technology, providers must consider addressing the Three-legged Stool of Digital Inclusion:

Access to affordable, robust broadband internet service (broadband infrastructure and/or broadband subscriptions/service).
Affordability of internet-enabled devices (computers, tablets, smartphones, smart displays, and smart speakers) that meet the needs and preferences of culturally diverse older adult users, including non-English speaking users.
Adoption of technology though leveraging partnerships with staff, like activity and service coordinators, as well as content and programming partners, in addition to ongoing digital literacy training and technical support.

Residents of affordable housing face barriers at each leg of the digital inclusion stool that prevent them from equitable internet connectivity. Public-private partnerships and thoughtful program design is crucial to successfully engaging a community’s residents and staff.

Not only do most senior housing communities assisted by the U.S. Department of Housing and Urban (HUD) lack building-wide internet, but also research has shown that digital literacy training and education is important to increase older adults’ use of broadband services and technology.²

To help providers offer appropriate technology training and technical support, LeadingAge CAST has developed a Resident/Client Technology Guide exploring different models and options.³

3. Benefits of Broadband Connectivity

The COVID-19 pandemic accelerated the shift to online services, making digital access an essential lifeline to sustain health and economic well-being. For older adults who have low incomes, disproportionately people of color, little or no connectivity has deepened health and economic inequities: 22 million American seniors (42%) lack wireline broadband access at home. This situation includes many residents of affordable housing, who are nearly twice as likely to lack high-speed internet connections as the general population.

In fact, a recent national survey of service coordinators in federally assisted housing revealed that just over 20% of respondents said that few or no residents have reliable internet access, and only 8% said residents have reliable internet access.⁴

Older adults need affordable internet access to participate in the modern digital economy and education. Internet access also allows more low-income older adults to live independently longer by receiving health care and support services in their homes delaying the transition to costlier long-term care settings such as assisted living or nursing homes.

3.1 Increased Access to Healthcare

The rate at which the general public has adopted telemedicine has dramatically increased due to the COVID-19 pandemic, but many residents of affordable housing have been left out because of lack of access to broadband, devices, and education. This situation deepens health inequities for residents of affordable housing, who are disproportionately people of color who have higher prevalence of chronic conditions, and increases their healthcare costs in the long run.

Access to broadband and technology can enable telemedicine, telehealth, virtual visits, and remote patient monitoring for residents.

Barriers: An AARP survey during the spring of 2020 showed that lack of knowledge on how to use telehealth, and concerns about the possibility of medical errors or the confidentiality of health information, were barriers to use in approximately 50 percent of respondents.⁵ The population aged 65 and older reported the lack of access to computers and to high-speed internet, along with a lack of knowledge on use, as barriers to their use of telehealth services.

Solutions: Access to broadband and technology, along with appropriate education and support, can enable telemedicine, telehealth, virtual visits, and remote patient monitoring for residents. Studies have also shown that telehealth can save approximately $6,500 per person per year for some chronically ill and older adult populations.

3.2 Reduce Social Isolation/ Feelings of Loneliness

The pandemic has significantly increased feelings of isolation and loneliness among our older adult populations, especially those living in congregate living settings, such as senior housing, that have had to impose restrictions on visitations, communal dining, and group activities. Even prior to the pandemic, isolation and lack of socialization has had a devastating impact on this population.

A growing body of research suggests that older adults who transition to senior housing are at considerable risk for isolation and loneliness. Older adults who live in senior housing communities frequently have lower incomes, less social support, and worse health compared to those who continue to live on their own in their community.⁶ A recent AARP Foundation survey found that two-thirds of U.S. adults are experiencing social isolation.⁷ The health risks of prolonged isolation are equivalent to smoking 15 cigarettes a day.⁸ Loneliness may be linked to a 64% greater risk for dementia.⁹

Technology offers endless possibilities for social connection, including staying in touch with friends and family, online communities and networks, virtual support groups, continued learning and education, virtual volunteering, virtual activities, and entertainment. The use of such technologies can help reduce isolation and depression. For example, a study in the Journals of Gerontology found that internet use among retired older adults reduces the probability of depression by 33%, with the largest reduction in people who live alone.¹⁰

Technology offers endless possibilities for social connection and can help reduce isolation and depression.

3.3 Increased Resident Engagement and Satisfaction

Accessible broadband and technology are attractive amenities for properties. Easy access can lower residents’ burden and enable them to engage and contribute within their communities. By layering on community engagement solutions or portals, residents can access on-demand community information, events and activities, community news, notifications, self-service capabilities, and give real-time feedback and input. Virtual platforms can also be a safe way to continue services even during weather-related emergencies, which enhances resident engagement and satisfaction.

This information flow not only means better engagement, but also translates into better resident satisfaction, especially when the management is responsive to residents’ feedback, requests, and preferences.

3.4 Increased Quality of Life

As older adults age in community, they may experience a number of factors that can contribute to decreased quality of life: reduced mobility, hearing or vision loss, lack of access to affordable transportation, ability to access resources and information, and more. Lack of accessible transportation can limit social interactions, as well as the ability to get to doctors’ appointments and the grocery store, all of which have a negative impact on health.

Broadband and technology access can give older adults safe access to online services and resources from their home, such as grocery delivery, online banking, health care, benefit enrollment, education, and employment that can increase their quality of life and ability to age in place.

3.5 Increased Staff and Resident Efficiencies

Technology-enabled solutions within communities can greatly improve the efficiencies of both staff and residents.

For Staff: Community-wide Wi-Fi can empower staff to be mobile and use technology such as computers and tablets throughout the property. It can allow staff to complete real-time documentation, work orders, assessments, coordination of services, and efficient repairs and/ or service delivery, including virtual activities and resident check-ins.

For Residents: Connectivity can also allow residents to perform self-service tasks, such as pay rent, complete forms, request maintenance, register for events, access community information, participate in virtual activities, and more— thus saving staff and resident time.

Moreover, in situations where physical interactions are halted (infection outbreak), etc., having a connected community builds a safety net to efficiently provide virtual programming and services to residents. Doing so proofs your community against potential future pandemics and other emergencies.

3.6 Asset Management

Critical building elements are also enabled through building-wide internet systems. Internet-enabled monitoring systems and sensors, such as water leak detection, flood detection, gas/air-quality monitoring, smoke/fire alarms, electrical use, monitored temperature sensors, and occupancy sensing can allow properties to detect issues early, respond quickly, and prevent more costly damage and repairs. Sensors may also lower energy consumption as well as insurance costs. Insurers are increasingly requiring sensors for coverage. Moreover, monitored environmental temperature sensors in residents’ units can help ensure a safe indoor room temperature, protecting the older adult and their heating/cooling system.

Further, installing wireless pendants instead of pull cords for emergency call systems makes emergency calls easier for residents to use and potentially available anywhere in the building. It may also allow shifting the responsibility from the housing property to a third-party responder, which in turn would significantly reduce insurance rates because of the lowered liability risks.

Deciding how to connect residents to an at-home service that meets your organizational goals is critical.

4. Connectivity Models in Senior Housing

As described in the ConnectHome Playbook developed and published by HUD, one of the most important decisions for your community is deciding how to connect residents to an at-home service that meets your organizational goals.¹¹ The models for connectivity fall into three main categories:

Individual Internet Service Provider (ISP) Subscriptions.
Wireless Hotspots/Internet-Enabled Devices (Cellular).
Property-wide Internet Connections.

These three models are not mutually exclusive. Most communities adopt a “menu approach” to address the connectivity needs of residents and staff. For example, a community may have a group of residents that cannot afford an individual ISP subscription. As a result, the community may provide loaner cellular-enabled tablets as a short-term strategy to connect the lowest-income residents, show them and potentially their families the value of paying for the service, and encourage higher-income residents to sign up for a discounted individual ISP subscription.

LeadingAge Recommendation: LeadingAge encourages housing providers to strive for property-wide internet connectivity to reduce the digital gap and provide more equitable access, services, and support to all their residents, regardless of income and ability to pay for broadband service.

The sub-sections below explain in more depth the different connectivity models.

4.1 Individual ISP Subscriptions

Most independent and affordable housing communities have one or more ISP providers available to residents. For example, Comcast and Verizon may be the two ISP providers in a particular area. An individual resident can contact either company to arrange for high-speed internet service to be provided along with other services, such as TV or phone service. A community may also choose to work with or partner with an ISP provider to offer bulk discounted pricing for residents. For example, Comcast may offer a discounted rate to residents living in a particular building.

A community may partner with an ISP provider to offer bulk discounted pricing for residents.

In some rural areas, where landline phone-based Digital Subscriber Line (DSL), cable, or optic fiber are not available, a resident may only have the option to sign up for satellite internet. Disadvantages of satellite service include the following:

Higher cost than other connectivity modalities.
Relatively slower internet speeds (usually up to 50 Mega bits per second (Mbps); StarLink offers connection speeds up to 200 Mbps per second but is much more expensive than others).
Interruption of service due to weather, in case of heavy rain and snowstorms.

Advantages: An individual ISP subscription model is found in many senior living communities, especially independent living, and in affordable housing communities. In many cases, an individual subscription gives the residents many options to consider when looking for the ISP provider that meets their needs. Furthermore, the ISP is more than willing to help promote the different options available to the residents.
In some situations where the building is already networked, such as with optic fiber, coaxial, and/ or ethernet cables to every unit, the price can be somewhat reasonable. Lastly, if there are broadband connectivity issues, the ISP provider will be the one responsible for fixing the connection or correcting the issue unless it is due to the end-user’s tablet, computer, TV, phone, or other device.

Disadvantages: Although this model is very common, it does have some significant drawbacks for the resident and senior living community.

The individual subscription model relies on the resident to take the initiative to contact the ISPs, navigate the different plans and options available, and enroll. Many times, the options, plans, and enrollment process are very complicated and require at least a one-year commitment.
The resident is the primary person responsible for paying for the installation and recurring monthly service fees.
At the organizational level, it is hard to track which residents are connected or not using this model. Organizations would not be able to equitably offer residents services that rely on internet connectivity.

While there are programs like the Lifeline Program from the Federal Communications Commission (FCC) and the Affordable Connectivity Program (ACP) (formerly Emergency Broadband Benefit (EBB)) that offer discounted internet connectivity to eligible low-income residents, their availability through ISPs is so far limited and not guaranteed. For example, people who live in rural areas may not be able to access them and enrollment has been a challenge. Please see Section 5.2.1, 5.2.2, and 5.2.3 for more information.

LeadingAge advocates for affordable housing providers to be able to secure internet connectivity service at a discounted rate for all eligible residents.

Awareness of such programs, their eligibility criteria, and their application processes is quite low among older adult residents who may qualify. In addition, the process of eligibility determination, application, and securing the service is quite complex, and each individual resident must follow the process.

LeadingAge Advocacy: LeadingAge continues to advocate for program changes that make it easier for affordable housing providers to secure internet connectivity service at the discounted rate for all their eligible residents. The option to do so is not available at the time of compiling this guide. However, the FCC in late January 2022 announced the possibility of establishing a dedicated outreach pilot program that would help HUD-assisted households, including those in project-based rental assistance housing such as Project-Based Section 8 and Section 202, gain access to the ACP.

4.2 Cellular Wireless Hotspots and Cellular Internet-Enabled Devices

A quick and somewhat easy approach to providing connectivity to residents is by giving them a broadband cellular wireless hotspot and/or an internet-enabled device, such as a cellular-enabled tablet. The hotspot will allow a resident to access a broadband connection by connecting laptops, tablets, and other devices to the hotspot device.

Moreover, smartphones, which are on the rise among older adults, including low-income ones, in many cases have a built-in-cellular network and the ability to work as a hotspot that allows other devices to connect to the internet, enabling “tethered internet connectivity.” The rules for tethering or using a hotspot for a smartphone, however, vary from provider to provider, may not be allowed for certain plans, and have limitations as noted below.

This option is normally used in situations where the building infrastructure does not have the wiring infrastructure to support the connectivity needed at the resident’s unit. For example, an older independent living community may not have the building properly wired for internet. Hotspots or internet-enabled devices are a good short-term solution.

Advantages: Residents who may be very reluctant to sign up for an ISP subscription may be willing to try the internet if available without having to commit or pay for the service long-term. Having a device that is already internet-enabled and does not require a connection to a hotspot is easier to use for a resident since a connection to the hotspot is not required. In most cases, hotspots are only used when a device does not have the built-in connectivity, such as most smart speakers.

Moreover, hotspots allow the residents to connect more than one device, such as a laptop, a Wi-Fi tablet, and/or a smart speaker. If the resident already has a smartphone and is paying for a cellular plan, their plan allows tethering, and its data limits and speed are satisfactory for the resident’s needs, having separate Wi-Fi services adds an unnecessary expense.

This model of connectivity allows you to easily transfer and reissue a hotspot connection and/or internet-enabled device to residents. By paying for the service, the community or other entity can free the residents from having to enroll and pay for the service themselves.

Disadvantages: In some buildings that have poor cellular service, this solution may not be a viable option. Most hotspots and internet-enabled devices have monthly data thresholds with high penalties for overages, or “unlimited” plans that restrict heavy data usage and throttle the connection, significantly lowering the internet speed once the data threshold is reached.

Other disadvantages for this approach include the following:

The monthly subscription cost is higher than cable or fiber and wired or Wi-Fi distribution.
The connection bandwidth/ speed is lower than cable or fiber and wired or Wi-Fi distribution.
Limited data is allotted per device/ hotspot per month. Exceeding those limits may result in throttling down the speed of the connection further, as mentioned above, or significantly higher overage fees.
Cellular signal strength may vary from unit to unit within the building depending on location, construction materials, etc., which affects internet connection, reliability, and speed. Cellular signal boosters may be used to mitigate those situations.

As a result, this model is usually recommended as a short-term solution. It can also be a first step to pilot test the viability of a broadband connectivity strategy in the community.

A property-wide internet connection can connect residents while eliminating barriers, such as confusing enrollment processes, installation, and monthly service fees.

4.3 Property-wide Internet Connections

A property-wide connection by design provides every unit in the property with a broadband internet connection, as well as connectivity in common areas. There are several ways to provide a campus-wide connection, such as Fix-Point, Point-To-Point, Wired, Wireless, and potentially emerging 5G. Section 6 will review the different considerations for each network design and component.
Advantages: A property-wide internet connection has advantages. You can connect large numbers of residents while eliminating barriers, such as confusing enrollment processes, installation, and monthly service fees. You can track who is using the service and by how much through the appropriate network management tools.

Disadvantages: A property-wide internet connection usually requires a large initial investment for the infrastructure, unless the ISP invests in preparing, and later owns, that infrastructure (please see Section 5.1.2), as well as operational costs such as ongoing funding for the monthly fees. This model also takes a significant amount of upfront planning and coordination. Other important considerations include network management, including handling network traffic, providing technical support, and managing network security.

Typically, the earlier the planning process starts for a new building, or building upgrades or renovation or retrofitting, the better. This process is time consuming, and it takes time to see results initially. The recommended approach, it is worth the effort for the residents and the organization, as well as the staff.
Be sure to check the ConnectHomeUSA Playbook from HUD for more how-to information on addressing the three-legged stool of digital inclusion: connectivity, devices, and digital literacy.¹²

5. Potential Affordable Housing Provider Business Model

5.1 Infrastructure Programs and Options

5.1.1 HUD New Construction and Substantial Rehab: Broadband Requirement

In December of 2016, HUD published a final rule requiring installation of broadband infrastructure at the time of new construction or substantial rehabilitation of multifamily housing that has more than four rental units funded or supported by the U.S. Department of Housing and Urban Development (HUD).¹³

The rule applies to most HUD construction-related programs:

Public Housing Capital Fund.
Project-based Vouchers.
Section 8 Project-based Housing Assistance Payments (including Section 8 New Construction, Section 8 New Construction Set-aside for Section 515 Rural Rental Housing, Section 8 Substantial Rehabilitation, Loan Management Set-aside, and Property Disposition).
Section 202 Supportive Housing for the Elderly.
Section 811 Supportive Housing for Persons with Disabilities.
HOME Investment Partnerships.
National Housing Fund.
Continuum of Care.
Housing Opportunities for Persons with AIDS.
Choice Neighborhoods Initiative.
Community Development Block Grant.

Although not stated in the final rule or in the preamble to it, HUD confirms that this new rule also applies to the Rental Assistance Demonstration (RAD), which converts public housing capital dollars to project-based vouchers or Section 8 project-based housing assistance payments. The rule does not apply to multifamily rental housing that only has a HUD-insured mortgage or that has a loan guaranteed under a HUD loan program.

Substantial rehabilitation is defined as the following:

Significant work on the electrical system of the multifamily rental housing: Complete replacement of the electrical system or other work for which the pre-construction cost estimate is equal to or greater than 75% of the cost of replacing the entire electrical system. In the case of multiple buildings with more than four units, “entire system” refers to the electrical system of the building undergoing rehabilitation; or
Rehab costs that near replacement costs: Rehabilitation of multifamily rental housing in which the pre-construction estimated cost of rehabilitation is equal to or greater than 75% of the total estimated cost of replacing the multifamily rental housing after rehabilitation. In the case of multiple buildings with more than four units, the replacement cost must be the replacement cost of the building undergoing rehabilitation.

Broadband infrastructure is not required in the following cases:

The location makes installation infeasible, such as a rural area with no close broadband internet connectivity.
The cost of installation would result in an undue financial burden.
The structure of the housing makes installation infeasible (for substantial rehabilitation only). ¹⁴

Please note: HUD requires broadband but does not directly provide the funding for it. HUD subsidies do not directly cover the cost of initial broadband infrastructure, and they do not cover the ongoing costs of internet service. Some internet installation costs for new and rehabbed properties may be built into reserve accounts through Project Capital Needs Assessments (PCNAs) or through underwriting of tax credit-financed properties. LeadingAge is recommending that HUD expand the uses of existing reserve accounts for internet infrastructure, but the agency has not yet issued this guidance.

In the meantime, low-income housing tax credit properties have seen more success building it into underwriting costs and development plans, as highlighted in some case studies.
It is also worth mentioning that this program leaves out a huge part of the affordable housing portfolio that is not at a refi/rehab/new construction cycle, and that much of senior housing throughout the Section 202 program cannot take on debt to recapitalize or reposition.

Please note that there are many HUD programs serving older adults, such as the following:

Section 202 Project Rental Assistance Contracts
Housing Trust Fund
Capital Magnet Fund
Low Income Housing Tax Credits
Multifamily housing bonds
USDA Section 515 / 521

Please check the specific program and funding to see what aspects of your broadband project (infrastructure, ongoing service cost) could be financed, and/or rolled into expenses, and/or rent.

LeadingAge strongly recommends that housing providers invest in bringing broadband to their residents.

Importance of Resident Internet Access: Again, while government regulations do not require broadband infrastructure in the cases mentioned above, LeadingAge strongly recommends that housing providers invest in bringing broadband to their residents. Internet access is highly beneficial for residents’ physical and mental health, as this guide discusses. The following section explains several ways and opportunities that providers can leverage to comply with this rule.
To learn more about solving barriers to access, see Bridging the Digital Divide in Affordable Housing Communities: A Practitioner’s Resource for Multifamily Operators.

5.1.2 Partnership with ISPs

Housing providers, especially ones serving large communities, or communities with a large enough number of residents (30 units or more, but it may vary depending on the location of the building, availability of ISPs, competition among them, and size of ISP) can often leverage the size of the population to partner with ISPs.

Partnering may significantly reduce the housing community’s share of the upfront broadband infrastructure cost.

Local ISPs may consider expanding their network and reach into the community. The ISP may be willing to invest in preparing the infrastructure within the provider community, including bringing fiber optic to the buildings and even units, as well as internal network wiring, switching and distribution, and modems and access points. In return, they would execute an exclusive contract to provide internet, phone, and/or television services either in bulk, or to individual residents, at a pre-set rate for enough years to recoup their upfront cost, typically about five years.

This approach reduces upfront investment and significantly reduces the planning, implementation, ongoing management, maintenance, and support effort needed to bring broadband into your community. However, the ISP owns the infrastructure, which limits what you can do with it, at least in the near- to mid-term future, and locks you and potentially your residents in terms of service and monthly fees. In addition, many ISP-installed systems have come with exclusive marketing and exclusive wiring contracts, which can conflict with HUD rules around preserving resident choice. Make sure your arrangements with ISPs offer choice in compliance with these rules.

5.1.3 Partnership with Local Government, Authorities, and Utilities

In some communities, especially rural or quasi-rural communities where ISPs do not have reach, and/or where the senior housing community is not large enough, the cost of expanding broadband might be prohibitive both for the provider organization and the ISPs to undertake.

In those cases, we have seen some successful examples where housing communities collaborate with local government, authorities, and utility companies to leverage different funding streams, such as economic development grants. Housing communities may benefit from funding to build roadways, water, sewer, electricity, and/or other utilities projects that dig, lay conduits, and pull fiber. In some cases, communities may tap into these efforts to create a broadband cooperative to bring broadband services to schools, local government offices, libraries, and housing communities.

This approach may significantly reduce the housing community’s share of the upfront cost needed to bring broadband services to their communities.

5.1.4 Grants and Government Funding

Many large technology companies, especially ones in the ISP space, have foundations with grant opportunities to help economically uplift, improve equity, and reduce the digital inequities in the communities they serve.

Providers should explore and consider pursuing grant opportunities from private donors and foundations, especially ISP foundations, as well as government funding. Federal Communications Commission (FCC), U.S. Department of Agriculture (USDA), and the National Telecommunications and Information Administration (NTIA) grants are a few examples.

LeadingAge advocated for recent infrastructure funding, which creates unprecedented opportunities for connectivity in affordable housing.

Most recently, the final infrastructure bill signed into law on Nov. 15, 2021, includes billions of dollars for affordable connectivity. It also includes over $65 billion for broadband-for-all programs¹⁵ that will, among other things, do the following:

Expand broadband availability, especially in rural communities.
Ensure ISPs offer affordable options accessible to low-income Americans.
Make permanent the Emergency Broadband Benefit , which provides subsidies towards household service and device costs.
Allocate over $42 billion in grants to states to improve middle- and last-mile internet infrastructure, including the infrastructure for multifamily residential housing and housing for older adults.
Allocate over $2.75 billion to implement programs to enhance digital equity, including digital literacy.

The bill also specifically calls out elderly, low-income, and multifamily residential housing as beneficiaries of the new broadband investment dollars through the Broadband Equity, Access, & Development (BEAD) Program. Moreover, the bill specifically directs NTIA to consult with HUD on distributing the funds.

LeadingAge believes that these historic investments will create many unprecedented opportunities for affordable housing providers.

LeadingAge Recommendation: LeadingAge firmly believes that these historic investments, for which it advocated¹⁶ and continues to advocate¹⁷ along with our state partners, will create many unprecedented opportunities for affordable housing providers to get the funding and help they need to bring affordable and adequate broadband connectivity to their residents. LeadingAge hopes this guide gives affordable housing providers the knowledge they need to bridge the digital and equitable service gaps to the low-income populations they serve.

5.1.5 Organizational Commitment and Strategic Investment

The final option is for housing provider organizations to realize the value that adequate broadband connectivity could bring to their organizations, residents, staff, and families—and to decide to strategically invest in their buildings’ connectivity infrastructure.

5.2 Options for Covering the Ongoing Service and Operations

5.2.1 Resident Subscription with ISPs (Lifeline) and Limitations

As mentioned in Section 4.1, residents can make their own arrangements through an ISP to connect to broadband internet. Programs like the Lifeline Program from the FCC, which provides up to a $9.25 monthly discount on service for eligible low-income subscribers and up to $34.25 per month for those on Tribal lands, can help offset the cost of broadband.
Subscribers may receive a Lifeline discount on either a landline phone or a cellular wireless service, but they may not receive a discount on both services at the same time. Lifeline also supports broadband internet service and broadband-voice bundles. FCC rules prohibit more than one Lifeline service per household.

Lifeline is available to eligible low-income consumers in every state, commonwealth, territory, and on Tribal lands. The Lifeline program is administered by the Universal Service Administrative Company (USAC). USAC is responsible for helping consumers apply for the program, understand eligibility requirements, and keep their benefit current through an annual recertification process. USAC’s website provides additional information on the program, including program requirements.

To participate in the Lifeline program, consumers must either have an income that is at or below 135% of the Federal Poverty Guidelines or participate in certain federal assistance programs, such as the Supplemental Nutrition Assistance Program (SNAP), Medicaid, Federal Public Housing Assistance, Supplemental Security Income, the Veterans and Survivors Pension Benefit, or certain Tribal programs. You can see if you are eligible by reviewing “Do I Qualify?” at LifelineSupport.org. To apply for Lifeline, a consumer must generally use the National Verifier application system.

Individual ISPs may also have their own discounted broadband plan for residents, which is typically called “Internet Essentials.” However, these types of programs have income restrictions, and the bandwidth speeds may not meet residents’ needs. The process for enrollment may also be very complicated. For example, some programs only allow you to apply online and may require documentation sent via email or fax. Even with the discounted rate, the financial cost may be too high for a resident.

As mentioned earlier, the availability of Lifeline broadband service through ISPs is limited and not guaranteed, such as in a rural area. Awareness of such programs, their eligibility criteria, and their application processes are quite low among older adult residents who may qualify. In addition, each resident must go through the complex process of determining eligibility determination, applying, and securing the service.

LeadingAge Advocacy: LeadingAge continues to advocate for program adjustments that make it easier for affordable housing providers to secure internet connectivity at the discounted rate for all of their eligible residents. At the time of compiling this guide, that option is not available.

The EBB pays $50-$75 per month for internet connectivity and up to $100 to help households buy a device.

5.2.2 EBB’s Permanent Successor: The Affordable Connectivity Program (ACP)

The Affordable Connectivity Program (ACP) is a new, long-term $14 billion program that will replace the Emergency Broadband Benefit (EBB). It was authorized by Congress as part of infrastructure legislation in the fall of 2021.

Unlike the EBB, which provided an internet service discount of up to $50 per month for qualifying households, the updated internet discount program provides a lower monthly internet discount of up to $30 per month but removes pandemic restrictions that would have caused the discount to end when the public health emergency is no longer extended. This change turns the short-term, emergency-targeted benefit into an established, long-term program to increase digital access.

The discount amount of up to $75 for qualifying tribal households is retained in the ACP; in addition, the new internet program adds a “high-cost area” option for higher discount amounts.

The EBB also included the option for households to receive a discounted connected device. Few participating ISPs provided this option to households, but LeadingAge considers device access a critical component of digital inclusion. The ACP retains both the monthly services discount (at the lower rate) and the one-time device discount.

Households enrolled in the EBB Program as of Dec. 31, 2021, will continue to receive their current monthly benefit during a 60-day transition period. During the transition, most previous enrollees in the EBB will not have to re-enroll or re-verify their eligibility, and their previous benefit amount will be maintained before being reduced. New enrollees can continue to apply for the EBB before that date and will be carried over to the new program.

LeadingAge considers device access a critical component of digital inclusion.

An FCC order dated Dec. 8, 2021, provided additional guidance on the transition period for legacy enrollees. EBB participants will need to re-verify their income eligibility to continue receiving the discount after the 60-day transition period if the following applies:

They previously enrolled under a provision that allowed households with substantial income loss due to COVID-19 or
They previously enrolled through an ISP’s existing COVID-19 discount program.

The FCC has also directed ISPs participating in this program to notify all households and participants enrolled in the EBB about the upcoming program changes and to update relevant websites. ISPs are also expected to communicate the changes to enrollees.¹⁸

Enrollment in the ACP is open for households with at least one member qualifying under any of the following criteria:

Has an income that is at or below 200% of the federal poverty guidelines.
Participates in certain assistance programs, such as Supplemental Nutrition Assistance Program (SNAP); Medicaid; Federal Public Housing Assistance; Supplemental Security Income (SSI); Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); or Lifeline.
Participates in Tribal-specific programs, such as Bureau of Indian Affairs General Assistance, Tribal Temporary Assistance for Needy Families (Tribal TANF), or Food Distribution Program on Indian Reservations.
Is approved to receive benefits under the free and reduced-price school lunch program or the school breakfast program, including through the USDA Community Eligibility Provision.
Received a Federal Pell Grant during the current award year.
Meets the eligibility criteria for a participating provider’s existing low-income program.

5.2.3 Offered as Option by Housing Provider Blended with Rent, but Not in Lease

Some communities make the decision to provide a broadband internet connection as an optional additional service for the residents that is not included in the lease. In many cases, the housing provider already has the broadband infrastructure in the building and the unit is already set up to either have a hard-wired connection and/ or access to in-unit Wi-Fi, or both. The community does still have the monthly broadband fee for the building service; however, the community can try to recoup the monthly expense by charging residents a minimal monthly fee for the service.

If the community is using its own infrastructure and a resident has a technical issue with the broadband service, the community will be responsible for addressing the issue, either in-house or by contracting with an outside party. In some cases, a community may work with an ISP to provide access to broadband service and to manage the network and technical issues. This type of service is called Managed Internet Service Provider (MISP). An MISP model is typically used in situations where the residents can afford to pay a bit more for internet service to offset the cost of the MISP fees for the community.

Senior living communities also can partner with local stakeholders to partially cover the cost of a broadband connection.

5.2.4 Partnerships – Managed Care Plans, ISP, Cell Towers, Splash Page

Senior living communities also have an opportunity to partner with local stakeholders to partially cover the cost of a broadband connection. For example, some senior living providers will partner with an ISP to arrange a bulk discounted rate (or account credit) by allowing the ISP to install cell towers on the building roof. A provider may be able to offer broadband internet connectivity at a lower rate if it connects residents, staff, and visitors to the internet service through a branded splash page with marketing information from an ISP or another third-party sponsor such as a health care system, physician group, or managed care plan.

Other interested parties may be willing to partially cover the cost of the internet connection. For example, a managed care plan may be interested in a digital health education strategy that would reduce the cost of health care for its enrollees in your community, especially if the health education strategy requires a broadband internet connection to engage residents. If most of your residents have the same Medicaid managed care plan, then the plan may be willing to cover a portion of the monthly internet connection cost. The partnership opportunities are typically more difficult to negotiate and secure ahead of your project start.

5.2.5 Standard of Service – Broadband as a Utility, included with Rent to ALL Residents

Some senior living communities provide a campus-wide broadband connection to individual units as a standard of service utility. These connections may be hard-wired and/or Wi-Fi. While HUD does not currently view internet as a utility to be included with standard utility allowances, in some cases, this service is included in the building’s operating costs through initial financing without passing the costs onto residents, as is illustrated in one of the case studies that used Low-Income Housing Tax Credits (LIHTC). Some communities bill for the low cost of the internet connection separately to residents not eligible for subsidy, in case of blended occupancy; however, in other cases the community may choose to absorb the connectivity cost. Please make sure to check HUD housing program and/or any other rules applicable to your project on what you can and cannot do related to charging residents for internet.

6 Planning for and Selecting Appropriate Broadband Connectivity Approach

6.1 Vision and Strategic Planning

Visioning and strategic planning are key foundational steps to the success of a broadband connectivity approach. The connectivity should be viewed as a tool to achieve specific resident and organizational goals and be part of a well-founded overall organizational strategy.

Consider the following areas as part of an organization’s initial vision for broadband connectivity within your senior housing line of business.

6.1.1 Strategic Goals, Desired Outcomes, then Business Goals

Instead of reviewing business/strategic goals first, start with the potential outcomes of a successful broadband connectivity program in your housing community. Digitally connecting more residents to broadband leads to increased social connectedness and engagement and access to health care, which can all improve mental, spiritual, emotional, and physical well-being.

How can you build a business case for residents and family members to see the added value of a new broadband service?

Knowing these outcomes, how could you build a business case for the stakeholders, including family members, to see the added value in your new service? A myriad of family caregiver products and services on the market today are doing this.

Consider broadband connectivity as a way to offer and deliver home and community-based supportive services that other business units within your organization may have, which you would not normally offer in housing or affordable housing. Some of these services could bring additional revenue to your organization from third-party sources, such as health plans like Medicaid managed care or Medicaid Waiver programs in your state. These services may also be of interest to families if you show them the value of connectivity, possibly through a short-term cellular-connected tablet loaner program.

Finally, the broadband connectivity, as mentioned above, may be a conduit for other potential third-party strategic partners who may share your goals of improving the health and wellbeing for your residents. These partners— local hospitals, physician groups, grocery chains, and transportation companies—may have your residents as loyal clients and want to reach them digitally.

6.1.2 Community Setting and Availability of Broadband Service

The type of connectivity, the strategy, and approach you can realistically pursue is going to vary, potentially significantly, based on the community setting, as well as circumstances and opportunities for partnerships with ISPs, local authorities, or others. For example, if you live in a remote area, you may only have limited options for selecting an ISP. However, you still need to think outside the box and decide which strategy and connectivity approach you will adopt.

For example, you might go with the de facto ISP provider. Or you could partner with utility companies and leverage local infrastructure projects to connect to another provider a few miles away. You could raise money and invest in that infrastructure. Or let others who are willing to invest contract with you for the service for at a set rate for a certain period of time.

Once you have the connectivity to the campus/ building, decide if you should have a building-wide connectivity approach or individual ISP subscriptions. If you bring connectivity building-wide, decide if you should bundle it with rent and offer it to all residents, find ways to absorb/ subsidize that cost, or offer connectivity as an add-on at a discounted rate, depending on what is allowed under the specific affordable housing program and the financing you have at your building.

6.1.3 Resident Population and Options for Sustainable Business Models

As discussed earlier, the business model to support your broadband program will vary depending on the resident population on your campus, in addition to the location of the community and availability of broadband. For example, in a market rate community, the residents may be more willing to adopt a model where the resident pays the full or partial cost of connectivity.

In an affordable housing community, however, you will likely need to adopt a program that allows you to offset the cost not only of providing connectivity, but also of providing viable device options such as smart speakers, tablets, and portals; programming; and training and technical support for the residents.¹⁹ As mentioned earlier, examples may include partnership with managed care, delivering technology-enabled services covered under Medicaid Waiver Programs, etc.

Section 5 provided viable business model options for one-time investments in the broadband infrastructure and for ongoing operational sustainability.

Plan for the exponential increase in users’ bandwidth demand—currently estimated at 50% year over year.

6.1.4 Desired Applications, Speed & Bandwidth Needs, and Future Demands

Each application will have its own speed and bandwidth requirements. For example, a video chat-based application, HD TV service, or video streaming application will require more bandwidth, and hence a higher speed connection, than using a simple web browser, email, or a community portal application.

Having multiple applications running at the same time will increase the speed and bandwidth needs. If your organization has specific resident-facing social connectedness and/or telehealth applications, these applications will also have minimum speed and bandwidth requirements to operate. Make sure you also understand the speed and bandwidth needs of applications that your staff and or service partners use.

Another important factor in the speed, and ultimately bandwidth, calculations is the number of devices in each unit, the kind of devices, and how often they will be used. Providers can use this online calculator to roughly estimate the required speed based on the number of residents (e.g., one or two persons) and the number of applications they may be running. Today, a one-person apartment may need at least a 15 Mega bits per second (Mbps) connection speed if they use video conferencing and video streaming applications, which are very common nowadays. The minimum desired speed becomes 30 Mbps if the apartment has two people.

The total connection speed, and again in turn bandwidth, your community needs will also depend on the size of the community, including the number of apartments/ units, and their size or number of bedrooms. If your building has 20 one-bedroom apartments each with a single resident and 10 two-bedroom apartments for couples, your network may have to handle speeds of 20 X 15 + 10 X 30 = 600 Mbps in the worst-case scenario. This happens only if all the residents are using all their devices, including their video conferencing and streaming services, simultaneously, which almost never happens in practice.

However, network engineers use contention ratio, which refers to the ratio of the users that are likely to be using the network simultaneously at maximum demand on speed. The ratios commonly used range from 1:6 for relatively small buildings with up to 100 users, to 1:8 for medium-sized buildings with 100-500 users, and up to 1:10 for larger campuses/ buildings with upwards of 500 users.

In the example above, building your main connection speed would be 600/6 = 100 Mbps, using the conservative small building contention ratio of 1:6. That scenario would make your internet provisioning cost much less than the worst-case scenario contention ratio of 1:1, which requires a 600 Mbps connection that is much more expensive connection than a 100 Mbps connection.

Plan for Speed and Bandwidth Increases: One thing that is certain about the internet is the exponential increase in speed and bandwidth demand by users year over year—currently estimated at 50% year over year.²⁰ It is prudent to future-proof the investment in your connectivity infrastructure by doing the following:

Understanding and estimating your demand on bandwidth today (B_t).
Estimating the anticipated annual increase in demand on bandwidth year over year (I_a).
Determining the anticipated shelf-life of your infrastructure before you may need to upgrade it (Y).

Then you can calculate the minimum future speed and bandwidth (Bf) capacity you need to build your network to handle from the get-go, using this equation: B_f=(B_t+ I_a )^Y_.

As an example, if a building needs a 1 Giga bits per second (Gbps) speed today, experiencing 60% increase in demand year over year, and you expect the network to serve your purposes for the next five years, then you need to build your network to handle (1 + 0.6)⁵ = 10.49 Gbps.

Be sure to consider the building structure when you want community-wide Wi-Fi indoors and outdoors.

6.2 Building Considerations

In addition to the location of the community, and the population served, the building itself may impact your choices when it comes to your broadband connectivity strategy and options. Below are a few considerations to keep in mind.

6.2.1 New Build vs. Existing Structure

Generally speaking, it is easier to design and implement broadband connectivity networks and infrastructure when you have a new construction project. Then you are starting from a blank page, and your architects and network engineers have the freedom to design the network, dig for fiber backbone, place conduits, select and position switching cabinets, place access points, etc. in optimal ways. They can even select building materials suited for wireless signals, etc.

However, when you are working with existing structures, your design team needs to take into consideration many existing restrictions that may impede the propagation of wireless signals. These restrictions may range from available wiring to free conduits to building materials such as metal structures, steel reinforced concrete, etc. This planning may also have significant implications on the scope of the renovation/ upgrade project, its timeline, and its budget.

6.2.2 Cottages vs. High-Rise

Another consideration is whether the community is a vertical one, like a high-rise where Wi-Fi coverage could be implemented more cost-effectively by floors, compared to a horizontal community with individual cottages. Considering the building structure is especially important when you desire to have community-wide Wi-Fi connectivity indoors and outdoors, as opposed to connectivity just inside the cottages themselves.

6.2.3 Construction and Stud Materials

Wireless signals suffer attenuation, shortening networks’ coverage distances, reducing reliability, and making networks unable to handle the speeds and bandwidth they would normally handle in free spaces. Metal sheets, reinforcement grids, meshes, and studs form what is known as a Faraday cage that absorbs electromagnetic energy, rendering wireless networks useless.²¹ Elevators in high-rise buildings are one example of such mostly metal Faraday cages and are known to be blind spots for both cellular as well as Wi-Fi signals. If you want Wi-Fi coverage inside the elevator, make sure you identify elevator shafts so that engineers can provide appropriate solutions and design options.²²

Similarly, other building materials, like thick concrete, brick, cinderblock, and even timber walls, may also contribute to the attenuation of wireless signals. “Which Buildings Can Block Wi-Fi Signals” may help you select building materials, anticipate attenuation of Wi-Fi signals, and design your network.²³ For example, the building materials used in an existing building may force you to rely more on wired networks, at least to run signals into pre-existing Faraday cages imposed by the building structure.

6.3 Network Design Considerations

Network design considerations include deciding the network topology, medium, architecture, and components.²⁴ Network components include conduits, wiring, network cabinets, switches, and hubs; individual residents’ modems; and, for wireless networks, routers, wireless access points, and repeaters.

However, those technical aspects of the network design require higher-level input and decisions from housing providers. What follows highlights the most important aspects that will influence the technical design and decisions on the individual components of your network.

6.3.1 Building/ Campus-Wide vs. In-Building

When designing your network, you need to decide where your network should provide connectivity. Below are some options:

Throughout the campus, including outdoors areas in the case of a multi-building or cottages campus.
Building-wide, including in residents’ individual private units, as well as in common areas like activity rooms, common dining areas, hallways, etc.
Limited in buildings, either just in the residents’ individual private units, or just in common areas.

These choices have significant implications on the infrastructure network design considerations, including fiber loop(s) conduits placement, switching cabinets, density, and placement of Wi-Fi access points (for example, in case of building or campus-wide wireless coverage). Ultimately, these factors affect the cost of your infrastructure.

The location of Wi-Fi connectivity has significant implications on the infrastructure network design considerations and cost.

6.3.2 Wired vs. Wireless

The network medium (fiber, copper, etc.) and choice between wired and wireless depends on many factors, including the following:

Coverage distance.
Applications/ use.
Needed speed/ bandwidth.
Building materials, layout, and location.
Privacy and security requirements.
Cost.

When it comes to network medium, fiber carries network signals the farthest, supports the fastest speeds, and has the highest bandwidth capacity, followed by copper.²⁵

However, wireless networks are increasingly gaining in popularity. Section 6.2.3 of the Strategic IT Planning Workbook can help you decide what to do, including ways to overcome some of the shortcomings of wireless networks.²⁶

6.3.3 Public vs. Private

Another aspect of the network design is segmenting your network appropriately, whether wired or wireless, physically or virtually, into a public or private network.
Private networks are dedicated to individual residents, staff, and business partners and related applications. Public networks are usually meant for visitors and guests. Each has its own restrictions and network management measures, including security, access, and bandwidth management. Bandwidth management includes throttling based on user class (guest, resident, staff, or partner), certain applications, business needs, and package allocations and limits.

6.3.4 Spectrum & Interference Considerations

When choosing to have wireless networks as a part of your solution, you also need to consider potential interference with other wireless signals that may affect the performance of your wireless network.

Wi-Fi networks typically operate in 2.4, 3.6, and 5 GHz bands. Devices that generate and/or operate on or near these frequencies can interfere with the Wi-Fi network signals, significantly reducing their speed, range, and reliability.

Planning to operate devices in certain spectrums will impact the design configuration of the network’s wireless parts.

Interference sources in the 2.4 GHz band include nearby 802.11, 802.11b or 802.11g Wi-Fi networks, cordless phones, microwave ovens, elevator motors, cellular/ wireless ISPs, and Bluetooth devices. Similarly, 5 GHz Wi-Fi networks can interfere with nearby 802.11a or 802.11n WLANs, 5 GHz cordless phones, and outdoor wireless 5GHz bridges.
Planning to operate devices in these spectrums will consequently impact the design configuration of the wireless parts of your network.

6.4 Software Considerations

6.4.1 Staff Applications

IT leaders should meet with each operational area of the business to inventory the software applications that staff use. It may be feasible to meet with each user in the department. However, it may make more sense to identify department managers or super-users from larger departments.

Be sure to meet with each department so that you understand the department’s future technology needs. Include departments and business units that are in the formation stage, as well as departments that may not use technology today. These departments may benefit from using a technology application in the future.

Plan on asking questions related to broadband connectivity needs, including these topics:

Anticipated bandwidth needs and potential growth in demand on bandwidth over the years.
Information/data needs.
Existing workflows and how they would change with the appropriate connectivity in place.
Operational policies and procedures.
Cross-departmental information/data needs and processes and use of technology.

If you are partnering with local home and community-based providers outside your own organization, you would need to do the same. You may need to understand other pieces of software they need or use, plus their needs for interoperability, integration, and data/ information exchange.

It is important to inventory the software applications the residents use.

6.4.2 Resident Applications

As more and more residents are adopting technology or moving into communities with more technology, it is important to inventory the software applications the residents use. The inventory should include not only desktops or mobile devices, but also digital displays or Smart TVs that may be running video streaming services or video chat applications that consume large amounts of bandwidth.

Similarly, residents may need to run specific secure audio-video conferencing telehealth applications required by clinicians. You would need to factor the requirements of such applications, from at least the bandwidth need, end-user device, and network security standpoints.

Please also be mindful of the diversity of the users/ residents and language/ cultural aspects. For example, residents may have special applications that are culturally specific to their needs, such as Russian speaking television programing, applications that have multilingual menus and user interfaces, and apps that allow them to communicate internationally.

6.4.3 Visitor Applications

It is also important to understand what other applications visitors are using. For example, a family member may visit and use FaceTime group video chat to connect the resident with family members from afar. A home health nurse may need to use real-time video conferencing to initiate a telehealth visit with a remote physician. Or the nurse may need to connect a tablet/ smartphone to access the resident’s chart and document and verify the visit, or to deploy a hub for a biometric RPM telehealth system.

6.5 Considerations for Resident/ Client and Family-Facing Solutions

6.5.1 Social Connectedness and Engagement Technologies

Social connectedness and engagement technologies help maintain and enhance an older adult’s relationships with peers, family, friends, and caregivers. These technologies include social networks, video chats, audio chats, photo sharing, activity/event sharing, email, text chat, and picture chats.

Types of social engagement technologies include the following:

Life stories.
Community activity and event management (community apps, community blogs, activity calendars, digital signage, in-house TVs, smart speakers, etc.).
Exercises, mental exercises, and games, including arts and gamified rehabilitation.
Music.
Facilitated communication and conversations.
Companion apps or robots.
Virtual reality (VR).

Consider these needs together with your potential engagement partners and the solution’s implications on the existing or planned IT infrastructure. Consider the impacts on the network, internet access, speed, and potential growth in demand on bandwidth.

Consider the telehealth needs from clinical partners and how those needs will affect the solutions you are evaluating.

Please refer to the LeadingAge CAST Social Connectedness and Engagement Technology Selection Tool for additional information.

6.5.2 Telehealth and RPM Technology

Telehealth can be defined broadly as the use of electronic information and telecommunications technologies to provide access to health assessment, diagnosis, intervention, consultation, supervision information, and education across a distance. Telehealth technologies include telephones, facsimile machines, electronic mail systems, videoconferencing, and Remote Patient Monitoring (RPM) devices, which are used to collect and transmit data for monitoring and interpretation.
There are two primary modes of delivering telehealth:

Store-and-Forward (Asynchronous): In store-and-forward telehealth, clinical information such as data, images, sound, and video is captured locally. Then it is temporarily stored for transfer at a later time as encrypted email or messages using specially designed store-and-forward communications modems and software. The information goes to a secure web server or electronic health record via phone lines or a high-speed internet connection (including DSL, ADSL, cable, fiber-optic, or cellular modems). The consulting provider then reviews the stored data and makes diagnosis, treatment, and planning recommendations.²⁷
Real-Time Interactive Systems (Synchronous): Real-time telehealth sessions are live and interactive, and they frequently use videoconferencing technologies. Often, a nurse or technician uses special instruments such as a video otoscope to examine the ear or an electronic stethoscope at the consulting provider’s direction to perform a physical examination remotely. Or real-time communication may be a patient and a nurse practitioner consulting with a specialist via a live audio/video link, or a physician and a patient in an exam room communicating through an interpreter who is connected by phone or webcam.

Consider the telehealth needs from your clinical partners, such as health systems, physician groups, home health agencies, etc. Consider how those needs will affect the solutions you are evaluating. Ask how telehealth needs will work with the existing or planned IT infrastructure, including network, internet access, speed, and potential growth in demand on bandwidth.

Please refer to the LeadingAge CAST Telehealth/RPM Selection Tool for additional information.

Older adults and people with disabilities who live in the community, and in service-enriched congregate settings, often use medication reminders and dispensers.

6.5.3 Medication Management Technology

Medication reminders, medication dispensers, and devices that combine informing, reminding, and dispensing functions are patient-focused technologies that aim to improve medication adherence. Most often, older adults and people with disabilities who live in the community, as well as people in service-enriched congregate settings such as assisted living facilities and housing with services, use these devices.

The devices can be stand-alone or integrated into larger systems. Stand-alone technologies can provide single or multiple functions, and they may have advanced functions, including monitoring and data transmission.

Medication Dispensing: Personal devices help patients take their medications properly and can improve adherence. A single function medication dispensing system is easiest to use and least expensive, but it has limited functionality by design. Multi-function systems seek to enhance medication adherence by using two or more functions. Advanced technologies address one or more medication adherence elements, such as medication ingestion, metabolism, and adjustment, but they are more complicated to use.

Medication dispensers often lack portability and require a standard electric outlet for reliable functioning. Nonetheless, they are appealing to both older adults and people with disabilities because these groups frequently have difficulty opening medication bottles and handling and sorting small pills. These dispensers mean patients need to handle medication containers less often, ultimately making the medication easier to take.

Medication Reminders: Medication reminders are devices that prompt patients to take their medications, using audible or visual cues or both. The complexity of these devices ranges from wrist-watch alarms that generate alerts at various times to programmable computer software that informs users when it is time to take their medications. Because they are portable, some medication reminder devices can be incorporated into a person’s daily routine with relative ease.

Some devices combine a reminder technology with an automated dispenser that releases medication at specific times or intervals the user specifies.²⁸ While some of these devices dispense only one medication, others can dispense multiple medications and/or handle varying schedules.

Combination Devices: Recently, medication dispensers and reminders have been integrated with health-management capabilities, such as monitoring of overall health and storage of health information. These devices may offer broader self-management opportunities for older adults and people with disabilities.

The most advanced consumer-targeted technologies are devices that combine medication reminding, dispensing, and monitoring. These systems remind the user to take the medication, dispense the medication, and facilitate monitoring of when and in what quantities the medication was taken.

For example, some devices ask the user to log the date and time when the medication was taken, while others collect and store this information automatically. Some of these devices can also report this information to the clinician and/or caregivers using internet, telephone, or text messaging.

This information allows caregivers to monitor how well patients are adhering to their medication regimens and to take action when problems occur. Medication reminder and dispenser systems can cost up to $1,000, and the caregiver notification function can cost an additional $10 to $50 per month.

For these devices, think about the impact on IT infrastructure, including network, internet access, speed, and potential growth in demand on bandwidth.

Consider these needs from your clinical partners, such as health systems, physician groups, home health agencies, pharmacists, etc. Then ask how these needs will affect the solution you are considering. Think about the impact on the existing or planned IT infrastructure, including network, internet access, speed, and potential growth in demand on bandwidth.

Please refer to the LeadingAge CAST Medication Management Technology Selection Tool for additional information.

6.5.4 Functional Assessment and Activity Monitoring Technologies

Functional assessments for an older adult encompass many aspects of daily living and can be grouped into two general areas: physical (activities of daily living, gait, hearing, etc.) and cognitive (memory, behavior, cognition, etc.). Activity Monitoring Systems may be classified as:

Passive: Requires no intentional interactions from the assessed older adult or
Interactive: Requires intentional interaction from the assessed older adult.
Sensors can be Fixed/Embedded in the environment and/or
Integrated in Wearable/Carried by the assessed older adult.

Consider these needs from your clinical partners, such as health systems, physician groups, home health/ home care agencies, therapists, etc. Consider the impact their needs will have on the type of solution and on the existing or planned IT infrastructure, including network, internet access, speed, and potential growth in demand on bandwidth.

Please refer to the LeadingAge CAST Functional Assessment and Activity Monitoring Tool for additional information.

6.5.5 Safety Technology

Safety Technology is a broad category of technology that may be either resident facing and/or staff facing. The different types of safety technology include the following:
Emergency Notification Systems/Communication/Response Systems.

Fall Detection and Prevention Technologies.
Location Tracking Systems.
Access Control Technology.
Elopement Prevention Technology.
Surveillance and Monitoring (Security and Environmental) Systems.

Consider these needs along with your potential outside safety partners, such as emergency medical services, fire department, etc. Think about how the needs will affect the type of solution you choose, as well as the existing or planned IT infrastructure, including network, internet access, speed, and potential growth in demand on bandwidth.

Work with outside safety partners, such as emergency medical services and fire departments, when considering safety technology solutions.

Please refer to the LeadingAge CAST Safety Technology Selection Tool for additional information.

6.5.6 Case/Care Management and Coordination Technologies

The ability to communicate with, and educate, residents is an important feature for care management. Technology that accomplishes these goals can provide substantial benefits. Care planning and coordination technologies can educate patients and help them manage chronic conditions, support and stabilize post-acute patients, ease shared care and care transitions, and coordinate support services for older adults.

Consider these needs from your service coordinator, if you have one, and/ or your clinical partners, such as health systems, physician groups, home health agencies, other home and community-based service providers, etc. Consider how the needs affect the type of solution you choose, as well as the existing or planned IT infrastructure, including network, internet access, speed, and potential growth in demand on bandwidth.

Please refer to the LeadingAge CAST Shared Care Planning and Coordination Selection Tool for additional information.

6.5.7 Entertainment and Leisure Technology

Entertainment and Leisure Technology includes technologies that help residents with technology leisure activities, such as watching movies, listening to music, and playing games. Technology has enhanced the quality of leisure, making it possible for people to communicate faster and to connect to remote areas more easily. It brings along all kinds of new equipment that people use for fun activities, like gaming consoles, exercising machines, virtual reality headsets, and so on.

Consider how the solution you choose will affect the existing or planned IT infrastructure, including network, internet access, speed, and potential growth in bandwidth demand. Many of the online streaming services, which are growing in popularity among Americans of all ages and income levels as a substitute or supplement to traditional television service, require a fast, consistent broadband connection.²⁹

6.6 Organizational Readiness

6.6.1 Who Are Your Stakeholders?

Have you identified all key stakeholders? Doing so is crucial to building out the best possible strategy. Generally, one of the first stakeholders is the person with a customer engagement or communications role within the organization. This type of talent will focus first on the connections among people in different social or non-social settings, rather than the technology.
An IT professional should also be involved in the group. Additional stakeholders that may be beneficial are executive leadership, activity directors (especially for engagement technologies), operations management, and business development.

If you have service partners, you need to engage them and seek their input. Finally, you certainly need to engage representation from residents and family to better understand their needs, wants, and ability/ willingness to pay for the service. It is good to keep your initial strategy group small. Interact with a broader group of stakeholders for input when appropriate and request resources when needed, especially when implementation begins.

6.7 Operational Considerations

6.7.1 Managing Network/Infrastructure

Network management itself is the entire process of monitoring and maintaining everything in your network(s). It includes all of your connections, hardware, and software. Your network administrator/ administration team is tasked with making sure that the network is functioning optimally and that all the endpoints are maintained.

The administrator needs to keep an up-to-date record of all the devices on your network and permissions on different networks.

Your network manager or network administrator uses set processes that allow them to oversee the network(s) in your community, including the ones dedicated for business (staff and partners), residents, and/ or visitors, whether these are physically separate, or virtual, networks. The workflows of network management are evolving because so many new technologies and connections are being introduced.

The administrator needs to keep an up-to-date record of all the devices on your network and permissions on different networks. The administrator should develop a protocol to assess how well the devices work and manage the lifecycle of all the devices. Outdated devices whose operating systems and applications have not been updated, patched, or maintained properly can pose a security risk.³⁰

There are five areas of function in network management. The International Organization for Standardization (ISO) defined these five areas:

Fault Management. Fault management is the process to identify and fix any errors in the system. The problem is identified, the source of the problem is identified, the problem is fixed, and the process is documented.
Configuration Management. This is the process to monitor and maintain devices and network configurations. Because configurations can change with new programs and updates, they need to be monitored at all times.
Performance Management. Performance management keeps track of the devices and network and how the network is performing. When devices run too slowly, it can indicate that they need to be updated or that there is a possible issue, including possibly a virus, malware, or an attack on the network.
Security Management. Security management encompasses a great deal and is ever-growing. There are many tools to help your network management verify allowed devices, then monitor the network to maintain cybersecurity standards. Please see LeadingAge CAST’s Cybersecurity Resources for more information.³¹
Accounting Management. Accounting is also called administration. This process includes granting access or authority to users.

In some cases, an ISP provider may indicate it offers “managed network” services; however, that may not be the case. Be sure to ask questions about the specific managed service the ISP provides and compare that service to the five key areas above.

6.7.2 Alternative Options/Upgrades

Your organization may offer a standard broadband service at low cost or no cost to residents. However, there may be residents who are able and willing to pay more for speed upgrades or would like to work with another ISP provider. In most independent living communities, the resident will have several options or alternatives to what the housing provider offers, and the provider should allow them to exercise choice. Your network design, configuration, and management tools should easily allow accommodating such options.

6.7.3 Education on Appropriate Options

It is important to educate the residents, and potentially their family members, on the available broadband options. Be sure to highlight the key differences between the service packages or options they have. For example, inform the residents what services and speeds each option will or will not support, such as multiple devices, streaming HD content, etc. Furthermore, let the residents know what their expectations should be in terms of technical support for each option, including alternative ISP provider, when applicable.

In many cases you may need to increase staff capacity as an organization to help support connectivity, the connected technology, residents, and possibly staff. If only limited staff capacity is available, it can be difficult to educate and provide adequate training and support to residents on the technology. For example, a social worker may now spend a significant amount of time helping residents get on Zoom or use a smartphone. You may want to consider outsourcing this function. Please see CAST’s Resident/Client Technology Guide for more information.

6.8 RFP Process

6.8.1 Preparation

Preparing a request for proposal (RFP) can be the start of the final selection process and an opportunity to share information about your organization with the vendor. This information will help the vendor gain an understanding of your organization’s characteristics, including the number of sites and residents, levels of care, staff, and unique services. The vendor will need this information to ensure that its service supports the organization’s work, mission, vision, values, and goals.

Make sure the vendor has information about the organization’s current IT infrastructure and its state. In addition, the vendor would need to know the desired state that your planning team has put together. Include potential expansion goals in terms of resident units, services, applications, functionalities, speeds, expected growth in demand on bandwidth, and/or preferred infrastructure and life expectancy. This resource provides you with a few templates of RFPs for different types of broadband projects that many providers would find useful.

Create an objective method of scoring specific items on the RFP that are important to your organization. Consider including the list of “must-have” functionalities, features, and evaluation criteria in the RFP to help you choose vendor finalists. Organize a team of readers from the various stakeholders to evaluate and score each vendor’s proposal. Ask the vendors to supply the appropriate number of copies for the readers.

Vendors that are unable to meet your organization’s needs may be eliminated during the process of evaluating proposals.

By prioritizing and listing, your purchasing-decision process and vendor evaluation will be more focused and efficient.

6.8.2 Evaluation

Next, it is time for the team to develop a set of criteria that it will use to review and select an appropriate broadband approach that can help the project achieve its desired goals and meet the organization’s needs.

It is important to identify desired services, functionality, and features. Then categorize those desires as either something you need (must have) or something you want (nice-to-have). This exercise will help you clarify what features, services, and functionality are most important. You will also identify which functionality and features may need to be eliminated due to budget constraints. By prioritizing and listing, your purchasing-decision process and vendor evaluation will be more focused and efficient.

6.8.3 Selection

Using the prioritized list of needs and requirements, review and compare multiple service offerings, in terms of the following:

Both up-front cost/ investment and ongoing operations costs.
Length of contractual commitment (if the ISP is investing in your infrastructure).
Speeds and bandwidth supported today and when it may need to be updated to keep up with growing demand on bandwidth.
Services included (e.g., network management, technical support, billing, etc.).
What you may need to provide/ support as an organization, whether in terms of one-time equipment/ infrastructure, or ongoing support (like support staff). Please note that you would need to factor in these costs when comparing RFPs.

These factors will help you identify service providers that best meet your needs, as well as the best value for money option, given your budget and the funds/ investments you already secured, or you know that you can secure.

6.9 Project Implementation

6.9.1 Program Implementation & Support

Objective: Create a cross-functional project team and execute the project.
Key Deliverables: Established project implementation team, project implementation plan, project kickoff, detailed design, pilot testing/ evaluation, live tech solution. Once the broadband approach(s) has been identified and approved and the project has been funded, the implementation phase begins. The project team will create a detailed project plan, and the project will kick off.
Agree upon Project Scope and Goals: The project implementation team should be a resident-centered interdisciplinary team consisting of the following, at a minimum: community management, engagement/ activity director, service coordinator, IT, and, if appropriate, residents and families. Develop a project plan identifying milestones, resources, tasks, and timeline.

The resident’s ability and willingness to pay for broadband and services options needs to be part of the mapping.

Outline Project Tasks. Project tasks include mapping business processes and developing new processes and procedures. The implementation team should be resident-centered so the focus should also be on their needs, preferences, and wants. The resident’s ability and willingness to pay for broadband and services options needs to be part of the mapping. Otherwise, we create a one-size solution that would not fit all.
Set Leadership: The project manager will have overall responsibility for the project and will manage scope, costs, timelines, resources, communications, arising issues, and risks. Implementation projects contain a number of interrelated and parallel activities that can be represented by individual team leads. A central planning and reporting tool or dashboard can be used to keep the project team, stakeholders, and staff informed and coordinated.
Create a Detailed Design: The project team’s first step will be to create a detailed design of the approach using the vendor’s solutions. Document any new processes, metrics, protocols, and procedures. Capture any issues, gaps, or risks. During this part of the project, the team will develop high-level approaches for change management, reporting, security, and meeting regulatory requirements.
Develop and Configure: Detailed schedules and plans will be created for change management, security setup, report design and access, and regulatory compliance.
Test and Pilot: This activity will include detailed testing of the functionality, training, security rollout, and report validation. The organization may choose to evaluate the approach at an initial pilot site to validate the design and ensure the requirements for achieving the stated goals are met. The pilot activity can be the final user acceptance test, or a separate user acceptance test can be conducted prior to going live. Once testing, training, and validation are complete, the team can prepare for going to live production.
Go Live: During the go live phase, the solution is turned on and broadband access provided to the residents. The project team should be prepared for initial support requests, clarifications, and issues capture and resolution.

6.9.2 Evaluation of Outcome and Goal

Once the project is complete, monitoring and evaluation are important functions to see if the project goals, identified in the goal setting phase, were achieved. The transfer of knowledge from the implementation team to those who will be using the system is critical for the system’s sustainability.

The transfer of knowledge from the implementation team to those who will be using the system is critical for the system’s sustainability.

Refresher training and an internal user group ensure that users are aware of the system’s new features and functionality as they are developed. A financial analysis should be done post-implementation to see if the project’s goals were attained.

Resident champions are key to the ongoing success of the approach. Identifying best practices and reporting enhancements and success stories also help to maintain momentum during the initial rollout and beyond.

A project review should be conducted to capture lessons learned, open issues, and identify next steps.

7. Relevant LeadingAge Business Partners with CAST Focus

Below are a few LeadingAge CAST Business Partners that may be able to help with technical aspects of planning for bringing broadband connectivity in senior living:

Provinet: https://www.provinet.com
Thrivewell Tech: https://www.thrivewelltech.com
Health Signals: http://www.healthsignals.net
SeniorTV (now Sentrics): https://sentrics.net
Corning Optical Communications: https://www.corning.com/optical-communications/worldwide/en/home.html
VCPI: https://www.vcpi.com
Pinnacle Communications: https://pinnaclecommunications.com
Prelude Services: https://www.preludeservices.com

8. Contributors

7.1 Workgroup Members

Davis Park, Front Porch Center for Innovation and Wellbeing
Donnald J. Heckelmoser Jr, LSC Service Corporation
Jeff Curran, National Church Residences
Juliana Bilowich, LeadingAge
Gunnar Tande, Jonathan Rose
Linda Couch, LeadingAge
Majd Alwan, LeadingAge CAST
Mohini Mishra, Selfhelp
Ricky Foor, Givens Communities
Russell Lusak, Selfhelp
Ryan Elza, Volunteers of America National Services
Scott Code, LeadingAge CAST
Tim Bete, St. Mary Development Corporation
Todd Stuller, Mercy Housing

7.2 Writing Workgroup

Majd Alwan, LeadingAge CAST
Mohini Mishra, Selfhelp
Ricky Foor, Givens Communities
Ryan Elza, Volunteers of America National Services
Scott Code, LeadingAge CAST

9. References