Barbara A. Ormond, Kirsten J. Black, Jane Tilly and Seema Thomas
This report was prepared under contract #HHS-100-97-0010 between the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, Office of Disability, Aging and Long-Term Care Policy and the Urban Institute. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the ASPE Project Officer, Gavin Kennedy, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. His e-mail address is: Gavin.Kennedy@hhs.gov.
Policymakers are interested in learning how best to encourage successful aging in place by supporting people at home and in the community. Data from surveys have consistently shown that older people want to remain in their own homes as long as possible. Providing health and social services to assist the elderly not only offers individuals the support they might need to maintain their independence in their own homes but may also forestall early or unnecessary institutionalization in an acute or long-term care facility. With the population of elderly (age 65 and older) projected to double over the next 30 years, policymakers are looking at models for the delivery of supportive services that take into account the likely increased demand for such services, seniors' preference for services at home, and the possible need for public funding to help pay for services for those most in need.
One proposed delivery model would establish an integrated set of supportive services for residents of naturally occurring retirement communities (NORCs). An NORC is a community with a large proportion of older people residing within a defined geographic area. It is distinguished from other areas that also have high concentrations of older residents, such as assisted living communities or continuing care retirement communities, in that it is "naturally occurring," that is, it was not designed specifically as a community for older people but rather evolved in such a way that a large proportion of its residents are older. In this paper, we look at service delivery models that target residents of NORCs.
Findings presented in this report are based on information derived from three sources--a review of the literature, discussions with national experts on NORCs, and case studies of NORCs and their associated services programs in five Administration gency on Aging (AoA) demonstration sites. In each of the five demonstration sites (Baltimore, Cleveland, Philadelphia, Pittsburgh, and St. Louis), Jewish social services agencies provide supportive services for the elderly.1 Based on the literature and expert opinions, we develop a conceptual model of NORCs and NORC supportive services programs, which we use to structure a discussion of the five demonstration projects. We then highlight policy issues related to NORC supportive services programs for consideration by stakeholders and policymakers at the federal, state, and local levels. An annotated bibliography is provided as an appendix.
The literature we reviewed was mostly descriptive rather than analytic and lacked the consistency necessary for cross-site analysis. However, it did provide a rich set of observations on which to base an analytical framework. Our conceptual model of NORCs and their associated supportive services programs has four components: the NORC and associated community resources; the organizational structure on which its services program depends; the services provided and outcomes potentially associated with these services; and funding. Various forces, either internal or external to the NORC, influence each component. The purpose of the conceptual model is to clearly distinguish between NORCs and the programs that serve them while emphasizing the dynamic nature of both the communities and the programs. Although we found great variety in the characteristics of the communities and their services programs, certain issues and challenges are common to all sites. We focus on those commonalities in our discussion, using the conceptual model as a framework for comparison across the sites.
NORCs and community resources--Grantees view the NORC as encompassing the housing complexes and independent housing units where older residents reside, as well as the various resources available in the community, such as community centers, houses of worship, health care providers, shopping centers, and public transportation. While the resources in the community are an attraction for residents, respondents in all sites identified physical layouts that present problems for older residents either within a resident's home (e.g., bathroom facilities that can only be accessed by stairs) or within the community (e.g., neighborhoods without sidewalks). Grantee staff at all sites noted that most older residents have lived in the community for decades, staying largely because of personal ties as well as connections with community institutions. Migration was an important factor in some communities, either in-migration, such as the influx of older Russian immigrants to Baltimore and Pittsburgh in the late 1980s that contributed to a change in the culture of the community, or out-migration from these same communities that has led to a growing though not dominant aged-left-behind population.
Services programs and community organization--Each grantee site is connected in some way to the local Jewish Federation, but services are not limited by religious affiliation. In all of the sites except Philadelphia, the impetus for the NORC supportive services program came from an agency serving the NORC rather than from the NORC residents themselves. Because the service agencies have taken the initiative in organizing the program for NORC residents, they faced challenges that might not have arisen if the programs had been internally driven such as securing the cooperation of building managers in program development and service delivery, gaining resident participation and support, and communicating with residents and getting to know their needs. Establishing a communication channel between the program and the residents is an important task for NORC services programs. At most sites, program staff have either developed an internal entity that represents residents, as in Baltimore's Senior Friendly Neighborhoods (SFN) Advisory Council, or used an existing internal structure, such as Philadelphia's co-op boards. Suburban areas present particular challenges to agencies trying to start services programs since existing neighborhood organizations rarely represent the views of older residents and usually lack information about elderly households.
Program services and outcomes--In the four grantee sites that have implemented programs, social workers or activity coordinators are a main point of contact with residents. Common services include transportation, reduction of physical barriers, and provision of opportunities to socialize or to learn. The grantees provide some services directly, but several categories such as home health care or mental health services are more often addressed through referrals. Grantees noted that resident preferences change over time, reinforcing the finding that ongoing communication between residents and program staff is crucial. All grantees reported difficulty addressing the problem of resident mobility both within residences and in the larger community.
It is difficult to gauge the contribution of program activities to successful aging in place. The programs at the study sites were in different stages of development when they received the AoA grant funding, so comparisons across sites are inappropriate. Evaluation and outcomes measurement were not program components at most of the sites, although two sites are conducting studies in conjunction with outside researchers that may provide useful information on program outcomes in the future.
NORC services program funding--Most of the programs have some external funding beyond the AoA grant; sources include the Department of Housing and Urban Development (HUD), private foundations, and the service organizations themselves. Sustaining funding for their services programs is a challenge all sites will face when their AoA grant runs out. Currently, external fundraising is in a very early stage in most grantee sites although several sites have made contacts with local and state governments and local organizations. Developing an internal funding stream from such sources as resident activity fees or contributions from building management may be important for the long-term viability of programs as well as an indicator of the value residents attach to the program.
The NORC supportive services concept is an intuitively appealing model to help more seniors age in place. However, the execution can be challenging, as the case studies discussed in this report show. Our research both highlights ways that supportive services programs can contribute to the goal of assisting elderly community residents age in place and also suggests some limitations for policymakers considering the NORC supportive services program model.
Short-term versus long-term program outcomes--Many sites were successful in designing programs to address short-term goals such as providing assistance with immediate health and social needs or a specific health condition. However, a good supportive services program must also work toward the long-term outcomes of successful aging in place. Goals that might contribute to this outcome would include developing trust between the residents and the program so that the program becomes a source to which residents can turn to when their needs change and improving community awareness by educating residents and their families about available services.
Communication and program evolution--Because the needs of community residents are constantly changing, a supportive services program must be dynamic if it is to continue to meet these needs. Establishing two-way communication between residents and program staff allows the staff members to learn about the residents' needs and preferences, and helps residents learn what the program has to offer. Such communication is critical if the program is to remain responsive to community needs as the community evolves through internal (aging in place) and external (in-migration) forces.
Outcomes measurement--Outcomes measurement is an area greatly in need of further research. Few programs have set explicit outcome goals. Most programs have only limited data on outcomes, and most of this data is in the form of program participation. Ideally, the development of outcome measures would be part of program planning, as it is in St. Louis, and would be in place from the beginning of the program. As with any type of program, outcomes data could provide information needed to support funding decisions and could be used as a tool in program management to improve operations and effectiveness. In addition, strong outcomes data on successful models could be used in the consideration of program replicability.
Limitations of supportive services program in supporting aging in place--A supportive services program cannot be expected to take on the full burden of meeting the changing needs of aging community residents. Public institutions within the larger community might better address problems such as better street signage to aid older drivers or paved sidewalks to facilitate pedestrian access. However, services programs can contribute to resolving such issues by educating the community about areas of particular concern to older residents, participating in coalitions of community stakeholders, and advocating on behalf of older residents.
Program funding--The benefits of supportive services programs accrue first to individual recipients by helping them maintain their independence in their own homes; next, to the larger community in their contribution to sustaining the diversity and stability of neighborhoods; and, finally, to society if public costs associated with aging and declining health are lessened through the potential lower use of acute or institutional health care services. The challenge, as with many supportive services programs, is finding the right private-public-philanthropic resource mix, and the right balance among individual, community, and societal obligations. Where possible, program costs should be borne by the individuals to whom the benefits accrue, but it may be appropriate for communities and society, who reap some of the benefits, to bear somepart of the costs, particularly . For example, government might shoulder most of the financial cost in the case of services provided to low-income residents who might not be able to meet these costs on their own.
Expanding supportive services programs to less densely settled communities--Some communities may be better able to support NORC supportive services programs than others. In the sites we visited, programs that had attempted to serve residents of single-family houses encountered greater difficulties. Further research is needed to adapt the supportive services program model to less densely settled communities, possibly in the form of pilot projects with associated research and evaluation components.
Our findings illustrate the diverse approaches taken by the five sites in forming and operating NORC supportive services programs and show the ways such programs might adapt to meet the various and changing needs and preferences of their residents. This diversity highlights the fact that there is no one-size-fits-all NORC program model. Stakeholders face the challenge of balancing the need for a flexible program structure with the establishment of clear program outcome guidelines, all while keeping in mind the overall goal of successful aging in place. Research on both frail and active elderly will provide a broad picture of the various contributions seniors make in their communities. Understanding the evolution of NORCs and their supportive services programs can assist public and private community planning policymakers in their efforts to help seniors remain a part of the community.
Baltimore, Cleveland, Philadelphia, and Pittsburgh have active NORC supportive services programs; in St. Louis, the program was under development at the time of our site visit.