Supportive Services Programs in Naturally Occurring Retirement Communities. BACKGROUND

11/01/2004

While many older people remain active throughout their lives, some may have deteriorating health that makes them unable to carry out daily activities.4 With increased impairment, older people may experience functional limitations that can manifest in increased difficulty performing instrumental activities of daily living (IADLs), including shopping, preparing meals, and managing medications.5 More serious limitations in activities of daily living (ADLs), such as eating, bathing, or dressing, can make independent living even more challenging without assistance.6 Cognitive impairment can affect a person's ability to carry out both IADLs and ADLs.7 Certain psychosocial factors, such as the death of a spouse, financial problems later in life, a decline in health or activity, and loneliness, may lead to social isolation and depression.8

As impairments and social isolation increase, so does an older person's need for assistance. A common course of action for people needing services has been to relocate, sometimes closer to family or friends, more often to residential facilities (such as continuing care retirement communities, nursing homes, assisted living facilities, and board and care homes) that are structured to provide assistance with numerous activities. Many people continue to live at home and receive help from family, friends, or neighbors. Others may attend adult day care or hire agency or individual workers to deliver the home health, personal care, and homemaker services they need. These options require individuals or their families to find, coordinate, manage, supply, or finance these services, sometimes with governmental assistance from Medicaid, the AoA, or state-sponsored programs. The assistance may be advisory, such as suggesting where to find needed services, or it may be financial, or both. These approaches are not necessarily mutually exclusive; people may use several as their circumstances change.

The NORC supportive services program concept embodies another approach that may successfully support older people and their families in the community. One articulation of the goal of NORC services programs is to provide services that are "flexible, responsive to needs and interests identified by the individual and, to a considerable extent, client-directed."9 NORC services programs help identify needed services and service providers, and coordinate service delivery. Some services may be publicly financed; others may be financed through philanthropic contributions and payments made by the individuals receiving the services.

One of the earliest models of a supportive services program was developed in 1986 in the Penn South Houses, a ten-building complex of cooperative apartments housing more than 6,000 residents in New York City. Based on resident input gathered through a survey, the Penn South Program for Seniors was created to provide both the well and frail elderly with opportunities to remain active and involved in the community, as well as to provide on-site health and social services to assist residents aging in place. The Penn South program served as a model for other programs in the city sponsored by the United Jewish Appeal-Federation of New York. Currently, 28 supportive services programs operate in NORCs in New York.

Supportive services programs for residents of NORCs can be similar to those offered in "purpose-built" communities for seniors. Accommodations made for seniors vary widely across different purpose-built housing, from accessibility considerations in the federal Department of Housing and Urban Development (HUD) Section 202 supportive housing for the elderly program,10 to a specified set of services available in a given assisted living facility,11 to the levels of assistance in continuing care retirement communities.12 These options do not have a standard program but vary by facility; residents may choose the level of service they want by the type of facility they choose and, often, by the level of services at an individual facility.

An important distinction between NORCs and purpose-built communities is how they were formed. NORCs are "naturally occurring," that is, they were not designed to serve as senior housing but developed over time as the community aged and changed. Many NORC residents chose to live in these communities before reaching age 65 and may not have considered the services available for seniors when they made that choice. In contrast, residents of purpose-built senior communities chose both the community and the level of available services when they chose the community. In purpose-built senior housing, both management and residents expect that some level of services or accommodation to the needs of seniors, if only in the physical layout of the structure, will be an integral part of the community. Often the level of available services is part of the contract governing the residences. In contrast, the need for services or improved accessibility in NORCs postdates the establishment of the community, so services must be integrated into the existing community structures. Further, because the residents of an NORC did not choose the community based on the level of available services, resident needs for services and preferences for service delivery are likely more heterogeneous. This heterogeneity presents a challenge for designing and implementing supportive services programs in NORCs.


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