Supportive Services Programs in Naturally Occurring Retirement Communities. LITERATURE RELATED TO GENERAL HOUSING AND POLICY

11/01/2004

Robert, Stephanie A. "Community Context and Aging, Future Research Issues." Research on Aging 24, no. 6, (2002): 579-99.

This article was written as the introduction to a special volume of Research on Aging addressing "Community Context in Aging Research." It provides an overview of the issue of community context and a brief summary of the four articles on the topic in the volume. It begins with a review of definitions of community. Community can be defined by the physical space in which people live, by political boundaries, or other physically delineated spaces; or it can be defined by social rather than physical boundaries such as shared interests, identity, or interactions. The community context is crucial in life-course and aging research because of the need to consider the spatial distribution of the aging population and the implications that this distribution has for meeting the needs of the aging population. In addition, community can be the repository for social capital and social inequalities that may require response through services.

Different communities may attract different types of older adults with different needs and different capacities for contribution to the community. Some communities made up predominately of older adults were formed primarily through the in-migration of older adults and others primarily by the out-migration of younger adults, which may have implications for the characteristics of the older adult population. Furthermore, although racial and ethnic diversity of communities is increasing, segregation is still the norm, which may affect individual well-being.

The problems that communities face may depend on the community context. Specifically, some areas may be looking at the best way to attract healthy and wealthy older adults while others may be struggling to determine how to best meet the needs of the population they already have. The rate of growth of the community may determine the rate of growth in the need for services. The devolution of responsibility from the Federal Government to the states and from the states to local communities means that communities must balance services across age groups and service groups. There is a great diversity in the ability of communities, both within states and across states, to accept publicly funded services at home rather than in nursing homes.

There is growing popular and scientific interest in the role of community in individual well-being. For example, there is interest in how income inequality within the community affects individuals in the community even when they are not poor, or in whether older individuals are seen as resources for the community or drains on community resources.

The availability of survey data has had the effect of focusing attention on the individual outside of the community context. The four articles summarized in this article all extend research to the effects of the community on the individual. Cotter, Hermser, and Vanneman discuss the contribution of the structure of the labor market on employment patterns. Specifically, they consider whether metropolitan areas with higher demand for female labor lead to narrower gender variation in employment rates, if the shifts made to accommodate female labor market participation makes workplaces more amenable to older female workers and differences in individual and community expectations of women's roles. Extensions to this research might include looking at whether "gendered labor markets" are associated with quality of life in retirement, particularly for women.

Kim and Lauderdale look at the determinants of living arrangements of older adults with a particular focus on the Korean-American immigrant community. They find that differences in living arrangements in metropolitan areas are partly explained by co-location of Korean ethnic businesses and subsidized housing. They conclude that government-subsidized housing provides Korean-American older adults, who on average have lower incomes, the opportunity for independent living. They suggest that the acceptability of services may vary by cultural preferences.

Lee and Robert look at the role of race differences in the community context in explaining health disparities at older ages. They show that older black adults tend to live in socially and economically disadvantaged communities compared with non-black older adults of similar income and education and that the observed health differences are only partly explained by individual socioeconomic status.

Lawrence and Schigelone look at community coping responses to the stressors of aging in a continuing care retirement community. They describe communal responses to problems such as the institution of a buddy system to check up on community members and provide social support.

Finally, this introductory article proposes the research approach of trying to look at old problems in new ways and also to look at new problems in new ways. The author asserts that the four articles in this volume show that community characteristics provide additional information useful for explaining individual level outcomes.

Lawler, Kathryn. Aging in Place, Coordinating Housing and Health Care Provision for America's Growing Elderly Population. Joint Center for Housing Studies of Harvard University and Neighborhood Reinvestment Corporation, 2001.

In this paper, Lawler discusses the relationship between health and housing and their roles in addressing the needs of a growing elderly population. The author argues that the bureaucratic separation of services and the lack of coordination between health and housing combine to deter seniors from successfully aging in place. She advocates a customized care model of service delivery, that is, one that can be tailored to the needs of the individual, rather than the current production model of service delivery that can lead to either "overcare" or "undercare." The author asserts that aging in place allows individuals to maintain their social support network, can limit the negative effects of relocation and transitions, and may lead to cost savings by minimizing the provision of inappropriate care. She cites results from a survey conducted in 2000 by AARP suggesting that the majority of seniors wish to remain in their current residence for as long as possible. However, the current system of public subsidy for housing and health care services presents structural barriers that prevent the coordination of these services for those in need. These barriers include separate federal funding sources, separate administrative jurisdictions (state vs. locality), and separate regulatory standards (medical vs. construction and development). Additionally, the eligibility criteria for health care and housing services differ and often conflict with each other.

Using information from a series of 60 interviews the author conducted with senior service providers across the nation between June and August of 2001, the author identifies four key elements consistently present in most successful aging-in-place programs: a choice of health care and housing options; flexibility in the range of services offered; the ability to maintain mixed generation communities; the ability to provide ongoing assessments of health-service needs in order to identify the appropriate level of services and make any adjustments. She also identifies challenges to developing and maintaining an aging-in-place program, which include: differences between rural and urban settings; lack of understanding of the elderly community's perceptions of alternative residential care settings; the physical deterioration of housing stock; and different skill sets of housing and service providers. She notes that the different skill sets may also create opportunities for partnership.

Several opportunities exist for the coordination of health and housing services at the federal, state, and local levels, in particular, aligning HHS and HUD programs and funding streams toward one another. Programs that HHS and HUD have initiated in the last few years that the author feels should be continued and expanded include the HUD Service Coordinator Grant, the HUD Assisted Living Conversion Program, and the HHS-sponsored PACE Program. Alternatively, a program that pulls funding from both federal health and housing streams could be developed in one agency. The 1999 Supreme Court-issued Olmstead v L.C. ruling, which requires states to develop an Olmstead Plan that redirects services from institutional settings to community-based alternatives, presents states with an opportunity to address housing and health-service needs within the long-term care delivery system.

Numerous opportunities already exist for better coordinating the health and housing needs of seniors. Community development corporations and community-based nonprofits can play a large role in identifying housing and health service needs of elderly residents in the community. Naturally Occurring Retirement Communities (NORCs) offer models for service delivery based on the concept that a neighborhood or apartment building with a high density of seniors aging-in-place affords the opportunity to bring services to seniors instead of transporting or relocating seniors to the services or to alternative residential settings. Community-based organizations can serve elderly residents aging-in-place by offering paraprofessional support services that are often less costly than the services of licensed medical or housing professionals. These organizations are also helpful in facilitating the organization of long-range community planning efforts and development issues that address the needs of elderly residents aging-in-place. Furthermore, community efforts to encourage and support aging-in-place can be linked with goals to build community stability or revitalize neighborhoods by focusing on rehabilitating the housing stock, encouraging diverse resident demographics, and promoting home ownership since most seniors own the homes they live in.

The author summarizes findings from case studies of three different projects that offer ways state and local governments can combine health and housing services for seniors. The first case study focused on Atlanta, Georgia, and used GIS technology to locate communities with a high density of seniors, communities with seniors at risk, and communities with diverse age structures. The location of health services and housing services were also mapped. This information was designed to assist government officials in planning services to meet the needs of a growing elderly population.

The second case study focused on the Penn South NORC, a cooperative housing arrangement of 2,820 units and 6,200 residents. In 1985, more than 75 percent of Penn South's resident population was 60 years old or older. At that time, Penn South's board organized to develop services programs to forestall nursing home placement and encourage the elderly to remain in their own homes. The cooperative organized various social and health-related community organizations to provide care coordination, group recreation, cultural and artistic programs, home-care coordination and non-acute nursing care, volunteer opportunities, and preventive health and education services among other programs.

The third case study focused on Florida's Elder Community Program, which offers communities within the state of Florida the opportunity to assess their own facilities, services, housing stock and recreational activities. The program was a grassroots effort with the state providing the framework and assessment tools and residents doing the work, thereby affording residents the opportunity to design their own programs and plan changes to create more Elder Friendly Communities. This program offered communities the flexibility to decide how much or how little to spend to improve transportation, recreation, and housing. Currently 23 communities are participating in the program, and one grocery chain has become an elder friendly business.

National Investment Center for the Seniors Housing and Care Industries. NIC National Survey of Adult Children: How They Influence Their Parents' Housing and Care Decisions. Annapolis, MD: National Investment Center for the Seniors Housing and Care Industries, 2000.

Overview

The goal of this study was to ascertain the roles, knowledge, and decisions that influence adult children who may have responsibility for their parents' housing and care.

Methodology

The study employed a telephone survey of approximately 1,500 adult children between the ages of 45 to 64. Two-thirds of this population had a parent who did not currently need supportive care. However, 14 percent were responsible for a parent who had received professional care services within the past two years at home. About 7 percent had a relative residing in an "assisted living" community. Finally, 3.5 percent had a relative residing in an "independent living" community.

Findings

Many adult children were uninformed about independent living and assisted living options. Only 40 percent were familiar with independent living and 27 percent with respite care services. Many adult children found the terminology about senior housing and care to be confusing and irregular. Despite the fact that 73 percent of the respondents stated that their older relative has less than $25,000 annual household income, 77 percent of adult children had not discussed the costs of seniors housing with that relative. Physicians' recommendations were most often used for decisions about home health care services. Furthermore, the authors believed that seniors housing and care providers needed to educate other professionals about the benefits they offer. Finally, adult children provided financial support for senior housing and care services.

Recommendations

The authors suggested a massive campaign to educate consumers about their options, as well as changing the perception of financial affordability.

Pynoos, Jon, and Phoebe S. Liebeg. Housing Frail Elders: International Policies, Perspectives, and Prospects. Baltimore, MD: Johns Hopkins University Press, 1995.

Overview

The authors of this study analyzed past and current housing program policies for frail elders in industrialized societies, and compare them to the United States.

Several efforts over the past two decades have tried to improve integration of services into government-assisted housing for the elderly. For example, Congress in 1978 created the Congregate Housing Services Program (CHSP) to provide service coordinators and a variety of services to older tenants in public and Section 202 housing. While the program began in 63 sites, controversy existed over whether HUD's should be responsible for payment of services. Additionally, an evaluation of the CHSP created further disagreement; OMB argued that CHSP did not save money, and the money would have been better spent on nursing-home care. However, Congress insisted the CHSP program continue, but because of budget constraints and lack of enthusiasm for support among the Reagan and Bush administrators, it was limited to the same number of participants at the same sites. The second phase of the CHPS involved more restrictive targeting.

Findings

The experience of the CHSP demonstrates how political and bureaucratic influences can make it difficult to create a strong housing and services relationship. The authors cite three major structural changes that prompted the transition of the United States toward a system of residentially based long-term care. First, private markets and consumer preferences favored residential care. Second, state governments had limited resources, yet growing demands for services as a result of federal mandates. Finally, budget implications had a major impact on current efforts to reform federal housing and long-term care policy.

AARP. "Understanding Senior Housing for the 1990s, An American Association of Retired Persons Survey of Consumer Preferences, Concerns, and Needs." Washington, DC: AARP, 1990.

Overview

This study reports results of an AARP housing study on emerging housing trends for older adults. Notable findings include the preference for aging in place is more prevalent in the current survey (1989) than in 1986 (86 versus 78 percent), there is more receptivity to age-segregated housing (40 versus 32 percent), more awareness among older people of the need for help around the house (65 versus 40 percent), and more anticipation of the need for help in the future (55 versus 33 percent). Over half of respondents reported that they have done little or no planning for their future housing needs, especially among those over 75 years of age, with lower incomes, and those not currently married. As a result, the most vulnerable older people are those who have done the least planning for the future and are most susceptible to being forced out of their homes because of a crisis.

Methodology

The survey updates a 1986 AARP national survey. The sample included 1,500 adults age 55 and older interviewed by telephone in 1989 about (1) current housing arrangements, (2) community preferences, (3) preferences for housing options and related services, (4) household activities, (5) housing costs, (6) safety and security concerns, and (7) planning for future housing needs. Results were analyzed by gender, age (55-64, 65-75, and 75 and over), income, marital status, race, home ownership, health limitations (no limitations, some limitations, or a great deal of limitations), mobility (moved within the past five years or not), planning (planned a lot or a moderate amount for future housing needs, or planned a little or none) and community type. Community type consisted of the following categories: retirement housing or buildings planned for older adults, communities or buildings where the majority of residents are 60 and older (NORC), and communities in which the majority are under 60 (non-NORC). The questionnaire is provided as an appendix to the report.

Findings

With respect to community type, 5 percent lived in a retirement community or building and 27 percent live in a NORC. Of those in a NORC, 80 percent said the older people had lived there a long time rather than having moved in recently. Most residents of NORCs or retirement communities like living in communities with a majority of older residents; only 11 and 7 percent of residents of retirement communities and NORCs, respectively, would prefer a better mix of ages. Social activities were mentioned by 10 percent of those living in communities composed predominately of older people as a positive attribute of their living situation; those in retirement buildings or communities were twice as likely as those in NORCs to mention this (20 versus 9 percent).

With respect to housing option preferences, 32 percent of older Americans are considering moving to an apartment that provides meals, housekeeping, transportation, and social activities, and 17 percent are considering moving in with a family member. Those limited by health were the most likely to be interested in board and care homes and were more likely to be interested in age-segregated housing.

With respect to help with household activities, both heavy and light household chore help was the most frequent help used (23 to 30 percent, depending on the chore), followed by light housekeeping (9 percent) and grocery shopping (9 percent). These percentages more than double when older adults talk about expected future assistance needed. In addition, 14 and 11 percent expect to need help with cooking and personal grooming, respectively, in the future.

More than 8 in 10 older people do not want to leave their current home. Those living in NORCs are more likely to want to stay. Over one-fifth expect to move but only 13 percent say they want to move. Most would like to live in a neighborhood with people of all ages but in a household of people of the same age. Residents of NORCs were less likely than residents in retirement communities or buildings to have moved in the past five years (23 versus 53 percent).

Conclusions

In conclusion, the report states that those who least want to leave their homes are those who are most vulnerable and who may lack a support system, presenting a challenge to policy makers that want to help these individuals remain at home and to providers of services for such people.

Newman, Sandra, and Raymond J. Struyk. "Housing and Supportive Services: Federal Policy for the Frail Elderly and Chronically Mentally Ill." In Building Foundations: Housing and Federal Policy, edited by Denise DuPasquale (435-64). Philadelphia, PA: University of Pennsylvania Press, 1990.

Overview

There was not a strong market response to the dearth of housing for the frail elderly and chronically mentally ill because typically these households have lower incomes, and developers lack the experience needed to meet the needs of these groups. These populations have a high demand for supportive services and could require environmental features to enable independent living. The largest disparity between the two groups was that characteristics of care varied and the median age drastically differed.3 Coupled with differences in informal support, this fostered different living environments to sustain independent living.

Approximately, 9 percent of the elderly needed assistance in physical activities due to the chronic health problems. Most of this requires help with toileting and getting in and out of bed or a chair. In 1985, about 400,000 people in elderly headed households were at risk of being institutionalized. The author anticipated that the number of households headed by an elderly person would remain stable until the baby boom generation reaches retirement in the early part of the 21st century, where it would then increase drastically. Institutionalization could be averted if people received varying levels and types of nonmedical supportive services where they lived. However, obtaining this help was difficult and expensive. The primary challenge was to create a cost-effective program that still provided valuable services. The author reviewed various housing programs created by the government.

Housing with Support Services

There were three types of housing with support services. The first type consisted of projects designed for use by physically impaired people. The second type provided support services to people living in government-subsidized housing. The third type was the small Congregate Housing Services Program, which is used to delay the need for institutional placement of its residents. Several states have launched congregate housing programs, which were "mixed income" and primarily financed by state housing bonds and insured under the FHA 221 (d)(4) program. Since 1980, the number of additional households assisted each year had dropped notably, and the composition of the funded units has been shifted from constructing homes to rent supplements or housing vouchers. Moreover, funds were being appropriated only for the elderly and handicapped by the Section 202 program.

Housing in Relation to Long-Term Care Policy

Housing and long-term care policies were technically not linked because the United States had no articulated long-term care policy. The current legislation through two clauses enabled the expansion of community-based services. First, it could occur through the "creative use of coverage options in the state Medicaid plans." Second, another possibility was through the Section 2176 "waiver program."4 Furthermore according to the authors, community-based programs have not been able to effectively prove that they minimize costs because many experimental programs have not been able to define the appropriate target population. The targeting issue would need to be a grave concern in designing new housing initiatives.

Future Policies

Housing-based options were packages of assistance that combine supportive services with a housing-based solution, such as the CHSP. A long-term care based option was where housing assistance was added as necessary to community-based long-term care assistance.

Housing-Based Options

CHSP. In 1985, the monthly cost of supportive services received by CHSP participants was about $340.5 The authors then derived the approximate cost of the housing services and housing subsidies and concluded that total rent was $430 per month and federal outlays were $274 per month. Therefore, the full cost of services was $770 and the subsidy component was $614 per month.6

Intermediate Care Facilities. The authors claimed this costs approximately $45 per day, or $1,350 per month, where residents received assistance through Medicaid and paid all their income except $35 per month for this care. The authors then estimated the monthly cost of Medicaid to the government to be $890.

Targeting and State Interest in Congregate Housing

Two major considerations arose about congregate housing as a substitute for nursing homes care. The first concern was how to determine the appropriate margin of error in selecting low-income tenants for congregate facilities, such that congregate care would not cost more for each person who has not entered the nursing home. Secondly, the interest of the states in congregate housing programs was crucial because the cost sharing varied and could foster a strong interest on the part of the states to forestall or delay institutionalization. According to the authors, if congregate housing services could demonstrate effectiveness in reducing institutionalization, then states should be more willing to share in the cost of a federal congregate housing program.

LTC-Based Options

Life Care at Home (LCAH) and Social/Health Maintenance Organizations (S/HMO) were new long-term care insurance and service delivery models primarily for middle-income households. LCAH combined financial and health security of a CCRC with the freedom and independence of living at home. LCAH pooled the risk of its enrollees and enabled more individuals to participate it. This was currently done in Philadelphia. The S/HMO relied heavily on HMOs as the service provider, where the provider assumed responsibility for a full range of services

Conclusions

Congregate housing according to the authors was considered to be the most promising housing-based approach. However, the complexity and types of support services offered must be studied and altered continuously to continue program effectiveness. States should have a genuine interest in creating a joint federal-state congregate housing program, since congregate programs could possibly reduce overall long-term care costs by minimizing entry into nursing homes and reliance on Medicaid. In addition, the authors suggested that a stronger working relationship was needed to evolve between HUD and HHS to improve cost savings and services.


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