Supportive Services Programs in Naturally Occurring Retirement Communities. LITERATURE RELATED TO NATURALLY OCCURRING RETIREMENT COMMUNITIES (NORCs)

11/01/2004

Yalowitz, Nat. NORC Supportive Service Programs: The Need for Strong and Clear Governance. For presentation at the Joint Conference of The National Conference on the Aging and the American Society on Aging, Denver, CO. New York, NY: NORC Supportive Services Center, Inc., April 2002.

There are over 35 NORC supportive services programs (NSSPs) in five states, all of which are community based and on site at the housing units they serve. These housing units have close relationships with many existing social and health service agencies that served the communities before the coming of the NSSPs.

The author uses the experience in these NSSPs to examine governance issues for service programs in NORCs. The author emphasizes the importance of a clear, strong, workable governance structure that is committed to the principle of supporting the continued independence of the seniors the program serves. There should be an organized body of people who will take responsibility for setting the policies of the program, be accountable for finances, and will clearly set out the mission of the program. Governance objectives should be spelled out in contract language between the NSSP and the service agencies. Performance-based evaluation should be part of the program. Care should be taken that the program design and implementation cater to the seniors involved and not to the staff of the agencies. Seniors should feel empowered and should feel ownership of the program. Staff training in these principles is critical. NORC programs should be concerned with the "continued building of the community in which they are organized as well as the broader community." The article gives several examples of problems that have arisen when these principles are not followed. The author endorses the position taken by New York and Maryland legislators that there be a strong presence of housing leaders and consumer input in the governance structure of NORCs.

The Jewish Home & Hospital Lifecare System. What We Do: Retirement Community Services (NORCs). http://www.jewishhome.org/script.asp?SubCatIS=41.

This web site describes the Community Services Division of The Jewish Home and Hospital. According to the web site, this division provides nursing consultation, health education, care management and social services to hundreds of frail elderly residing in naturally occurring retirement communities (NORCs) in New York City. The authors state that "the NORC model of providing health and social services to elders has been very successful in assisting senior citizens who wish to remain in their homes and 'age in place'."

Chicago Mutual Housing Network. Overview of NORC Programming. http://www.chicagomutual.org/level4/norc/norcprogramming.htm.

Chicago Mutual Housing Network is using the Penn South model in a pilot NORC program at two sites funded by the Department of Housing and Urban Development and NORC Supportive Services, Inc., in New York. The web site lists services provided by month for three months.

Landsberg, Gerald, Catharine MacLaren, and Harry Schwartz. The Accomplishments, Issues and Prospects of Supportive Service Programs in Naturally Occurring Retirement Communities. Prepared for the Fan Fox and Leslie R. Samuels Foundation. New York, NY: Ehrenkranz School of Social Work, New York University, September 2002.

In the introduction to the report, the authors define a NORC as "an apartment building, a housing development or a neighborhood with a large concentration of older adults" (p. 1). They note that more than twice as many people live in NORCs as in housing planned specifically for the elderly. Since NORCs are not planned specifically for the elderly, they often lack supportive services. Organized programs of supportive services have been in place since the mid-1980s for NORC residents, 35 in the country of which 28 are in New York City and two in upstate New York. The authors attribute the large number of programs developed in New York City and upstate New York between 1986 and 2001 to the availability of support and funding from the state and the city. Table 1 of the report (p. 9) gives a list of the programs, the date each was established, and the number of housing units in the NORC. Table 2 (p. 13) gives for each program the number of housing units and the number of elderly (total, minority, and disabled). Table 3 (p. 14) provides selected demographics for supportive services clients, 1995 and 2000.

This report provides a summary of the programs in New York and a brief history of how they emerged, including the development of state and city funding streams. The report reviews key factors that shaped the programs and identifies lessons learned, considers programs in other states, and discusses the development of supportive services and the educational activities undertaken by the project at New York University (NYU). The report also includes extensive bibliographies on NORCs and related topics, as well as appendices with statistical materials on program performance, authorizing legislation, and other information.

The New York supportive services program has four objectives: (1) to provide a range of flexible and integrated community-based services (health, social, and allied services), (2) to stress preventive care and services that will enable people to remain at home and live independently, (3) to give consumers and their caregivers an active role in the major decisions affecting their care, and (4) to use the number and density of older people in the NORCs to facilitate care and the delivery of services. Factors shaping the supportive services program include:

  • Volunteer activities were the antecedents of the program; volunteer and intern activities remain important.
  • Program planning is based on resident surveys, NORC board and management, perceptions, and agency experience; outreach to residents is through flyers, work of mouth, etc.
  • Staffing issues (recruitment, retention, training, pay, case loads, shortage of geriatric social workers) affect the program.
  • Program governance through the board allows resident input.
  • The lead agency takes the major role in organizing and operating the program but partnerships with other agencies and linkages with other resources are important, and management of the NORC is important to keep the program running smoothly.
  • Financing is from city and state governments, the board, residents, grants, and users.

According to the authors, the key lessons learned have been:

  • The size and compactness of the NORC facilitates service delivery, enables outreach, and encourages social interaction and mutual support among residents.
  • Diversity, responsiveness, and flexibility are important characteristics of the service program. Each program is different. Resident input is important.
  • Staff relationships are important; changes to staff or services can be disruptive.
  • Group services, volunteer activities, and opportunities for informal help all foster the social contacts important for healthy aging.
  • Housing management can play a positive role in the program.
  • Collaboration with other community resources makes a wider range of services available to residents.

Programs outside New York include Services To Apartment house Residents (STAR) in Philadelphia which serves high-rise cooperatives, the Community Options program in suburban Cleveland which serves residents of four privately owned rental complexes, the Assistance-In-Living program in Greenbelt, Maryland, which serves a mixture of apartments and houses, and programs in two clusters of moderate income cooperative apartments in Chicago. A new program, the AdvantAge Initiative operated by the Visiting Nurse Service of New York, uses surveys as a tool to identify "elder friendly" housing options. This program is operating on a pilot basis in 10 communities nationwide.

The report also includes case studies of seven open NORCs in New York that were done to assess the possibility of developing supportive services programs in such neighborhoods. The goal was to identify the problems of elderly residents of these communities and the services available to them and to identify the prerequisites for developing service programs for such communities. The authors identify eight general issues from these case studies:

  • Demographic and cultural changes shape the need for and use of community-based services.
  • Community institutions serve as conduits for information about programs and promote social cohesion as well as providing major services, such as hospital care.
  • Housing patterns and deficiencies matter, as do public services and infrastructure such as transportation and public safety.
  • Chronic illness and access issues are the major health problems identified.
  • Other services needed are home care, mental health care, nursing, social service coordination, transportation, and home repair and maintenance.
  • Problems within agencies and between agencies can interfere with service delivery.
  • Resource gaps exist including funding for local services, gaps in health insurance for home care, and reluctance of seniors to tap their own assets for personal care.

The size of the NORC shapes the scope of the program. The authors assert that the minimum number of older residents necessary to sustain a program in a service area is 1,000 over the age of 75 and a total of 3,500 over the age of 65. Based on the case studies of open NORCs and on the evaluation of the service programs for closed NORCs, the authors developed a list of prerequisites for programs in communities with large numbers of elderly residents:

  • A mix of housing densities and types.
  • A basic network of health and social agencies.
  • Inter-agency cooperation.
  • Community institutions such as churches, associations, etc.
  • A key agency to take the lead.
  • Resources to sustain the program.
  • A suitable space that is convenient, accessible, ample, reasonably priced, and comfortable.
  • Community support.

The report provides some details from various reports done on NORCs. An evaluation of four NORCs between 1994 and 1998 by Landsberg and Rock of New York University compared users and non-users of supportive services; users are more likely to be women, older than 85, and living alone. A survey of Penn South households (no date provided) described proportions of clients who used services: 8 percent used social services such as case management, 7 percent used information and referral, 4 percent used nursing services, 24 percent attended classes, 20 percent attended health screenings, and 12 percent attended lectures. Of those who did not use services, 18 percent did not like the program, 17 percent go elsewhere for services, 16 percent were not aware of the services, 9 percent did not yet need the services, and 8 percent did not need the services at all. Satisfaction was generally good for services but varied by type of service. A 1996 survey at Penn South and two other NORCs found cultural events to be the most popular service, followed by exercise and dance classes, and health events. The report notes that residents tend to be selective in their use of services and that group services seem to be more popular than individual services.

Lyons, Beverly P., and Carol Magai. "Reducing Health Risks and Psychological Distress among Older Black Residents of Naturally Occurring Retirement Communities." Journal of Gerontological Social Work 35, no. 1 (2001): 53-69.

Overview

The purpose of this study was to determine if certain health and social interventions could reduce health risks or improve psychological well-being among older NORC residents. The authors defined a NORC as a housing community where at least 65 percent of residents are aged 50 years or older. The first hypothesis tested was that the experimental group would show improvements in health behavior as a result of the health intervention. The second hypothesis was that the experimental group would experience improvement in psychological well-being as a result of the social intervention. The authors expected that these improvements would continue after the end of the experiment.

Methodology

The study participants were 45 older black residents at two NORC sites located three blocks apart. The authors did not specify the minimum age for participation in the study or the location of the NORCs. Participants were drawn from attendees at a health education seminar; 19 participants were in the control group (group 2, n = 19), and 26 were in the treatment group for the eight-week study. The authors say that treatment and control groups were randomly assigned to the two buildings to prevent cross-contamination between the groups through "diffusion effects." The treatment was a program that residents attended once a week, with 45 minutes devoted to health education and the other 45 minutes devoted to facilitating socialization.

Data collection occurred from August 1999 through December 1999 in three waves--a baseline survey, a post-intervention survey at the end of the treatment, and third survey two months after the treatment ended. The third survey determined whether the treatment's effects were sustained. The researchers collected data from 24 of 26, and 17 of 19 participants in the treatment and the control groups, respectively.

Findings

The average age of participants was 79 years old and 89 percent were female. The authors report that the "median income range" for all participants was "$4,000-$6,999; the authors do not specify whether this is an annual figure. The first hypothesis regarding health behaviors was not supported. The treatment group had higher scores on good health behaviors than the control group for all three surveys, so the results cannot be attributed to the treatment. The second hypothesis related to psychological well-being was supported because the treatment group experienced an improvement in psychological well-being, and this improvement was sustained after the treatment ended.

Recommendations

Short-term psychoeducational interventions could improve the quality of life for older minority residents of NORCs. The implications for social work practice include the need for social workers to increased sensitivity to cultural differences, broaden the focus of their assessments of older black clients, and introduce inexpensive, innovative, and interesting interventions. However, future studies need to determine if individual, environmental, and behavior practices may prevent the onset of diseases among the black populations.

Study Limitations

The authors point out several limitations. Diffusion effects could have occurred because of close proximity of the two NORCs. The sample was small. Although study participants were representative of older blacks in New York City, this minority population may differ in other regions in the country, which may affect the generalizability of the study findings. A long-term intervention may have produced different outcomes. Finally, the health behavior measures were not widely used instruments with good psychometric properties.

Another limitation of the study is that participants came from people attending a health forum. These people might be more social by nature and inclined to participate in community life. Thus, it is not clear how programs similar to the one used in the treatment group might affect people who are more socially isolated.

Hunt, Michael E. "Settings Conducive to the Provision of Long-Term Care." Journal of Architectural and Planning Research 18, no. 3 (2001): 223-33.

Hunt notes the importance of a supportive social network to the well-being of older people and so asserts that environmental design should have as a goal the design of communities that are conducive to, or foster, such support networks so that people can age in place. He identifies three types of NORCs: (1) aged-left-behind localities, (2) aging-in-place localities, and (3) retirement destination localities. This article briefly describes the first two types but focuses on retirement destination localities.

Older people are attracted to retirement destination localities by a more convenient lifestyle or an amenity-oriented lifestyle. Those seeking convenience are usually the older elderly, often widowed women, looking for proximity to shopping, services, or companionship. Those seeking amenities are often the younger elderly, independent, married, and more affluent, looking for vacation or resort-type localities, or older migrants on a seasonal basis. Convenience-based NORCs are of particular interest to providers of long-term care. They show the importance of considering environmental design and social support together.

The author cites previous literature that identifies the characteristics of NORC residents, their reasons for moving to a NORC, both why they left their previous residence and what attracted them to the NORC, and their satisfaction with the NORC. He cites differences other studies found between younger and older NORC residents. He summarizes the factors that explain the attraction of apartment complexes that have become retirement destination NORCs: location, management, and design.

The NORC dilemma is how to meet the service needs of older residents without making the apartment complex less attractive to younger residents, in order to maintain the age-integration that is attractive to older NORC residents. Hunt cites three approaches identified in earlier literature. First, in the static approach, residents remain in the complex as long as their service needs do not exceed what the complex offers; when they do, they move to a more supportive environment. Second, the complex can expand services to meet the needs of residents as they age. The third approach, the balanced model, allows residents to add services for themselves but the complex expands the services it provides only to a limited degree or responds by linking residents in need with community-based services. Where the complex expands services to meet resident needs, it is likely to become known as retirement housing.

The author identifies two major lessons learned from retirement destination NORCs. First, a sense of community and the proximity of shopping combined with the availability of health care are key features of a retirement destination NORC. Second, an environment that is attractive to older people is also attractive to younger people; that is, a NORC is simply a good place to live. The possibility of social connections is a key attribute of retirement destination NORCs. Hunt links concepts from the New Urbanism, with its emphasis on fostering a sense of community, to NORCs.

Marshall, Linda J., and Michael E. Hunt. "Rural Naturally Occurring Retirement Communities: A Community Assessment Procedure." Journal of Housing for the Elderly 13, no. 1-2 (1999): 19-34.

Overview

The goals of the study were to develop a diagnostic tool that communities could use to determine what type of rural NORC exists in their localities and to determine which variables are associated with the various types of NORCs. In the introduction, the authors provide an overview of the benefits of NORCs to rural areas, with a particular focus on economic benefits.

Methodology

Based on previous research, the authors identified 62 villages or townships in 16 zip codes in rural Wisconsin with a "high percentage" of older residents (the authors did not specify the percentage). The authors then obtained Census data for these 62 communities. The authors classified these areas into three types of rural NORCs: amenity (17), bi-focal (36), or convenience (9). According to the authors, this classification was based, in part, on the characteristics of certain demographic groups likely to be attracted to specific areas. For example, the authors found that young, active retirees from urban environments were attracted to amenity NORCs. The bi-focal NORCs attracted retirees wanting both the natural amenities and the ability to live in close proximity to friends and family. In addition, local residents who were relocating from a rural area to a neighboring community were often more attracted to convenience NORCs. Using the variable, NORC type, a stepwise discriminate analysis was conducted on the variables available in the Census database.

Findings

Twelve out of a set of 27 Census variables showed significant results and were subsequently used in the authors' analyses. These variables included income variables (household income, retirement income, social security income), resident characteristics (percent over 50 years of age, percent with less than a ninth grade education, percent born in Wisconsin), housing characteristics (percent of housing units vacant), and resident employment characteristics (percent employed in forestry/agriculture, construction, transportation, retail sales, or entertainment).

Relative to the other two types of NORCs, amenity NORCs had higher vacancy rates and a smaller proportion of Wisconsin-born residents. Employment patterns also differed significantly with both convenience and bi-focal NORCs showing a higher percentage of forestry and agricultural workers than did amenity NORCs, amenity NORCs showing a higher percentage of construction workers compared to bi-focal NORCs, and bi-focal NORCs showing a higher percentage of transportation workers compared to amenity NORCs.

The authors identified four variables that distinguished among the three types of NORCs: percentage Wisconsin-born residents; percentage of transportation workers; percentage of retail or sales workers; and the percentage of residents age 21 and older with less than a ninth grade education. Using these four variables, the authors accurately classified 59.68 percent of the NORCs in their sample--100 percent of amenity NORCs, 36.1 percent of bi-focal NORCs, and 77.8 percent of convenience NORCs. Because the results for the bi-focal NORCs were poor, the authors eliminated the bi-focal NORCs from the analysis and repeated it. In this last analysis, the percentage of vacant housing, per capita retirement income, and the percentage of workers employed in the entertainment industry, were significant in discriminating between the amenity and the convenience NORCs.

Recommendations

The authors assert that they can accurately identify amenity and convenience NORCs using a small group of Census variables. However, they cannot identify bi-focal NORCs because people who seek out these NORCs likely differ from other retirees on the basis of "psychographic" rather than demographic variables such as those found in Census data.

Bassuk, Karen. "NORC Supportive Service Programs: Effective and Innovative Programs That Support Seniors Living in the Community." Care Management Journals 1, no. 2 (1999): 132-37.

Mutual Redevelopments Houses (more commonly known as Penn South Cooperative) was built in 1962 with union funds and tax breaks from New York City. Initially, Penn South was designed to be affordable housing for a working population in the Chelsea area of Manhattan. This complex of 10 buildings has over 6,200 residents living in more than 2,820 apartments. Seventy-five percent of current residents are age 60 or older. Most of these residents have aged in place; however, older people also have migrated into the community as supportive services became available.

The NORC has had supportive services since 1987, through the Penn South Program for Seniors (PSPS).1 The Board of Directors of the Penn South Cooperative forged a relationship with the United Jewish Appeal - Federation (UJA-F), which became the oversight agency for PSPS, and a source of funding for it.

PSPS programs included:

  • Group activities, case management, home care coordination, and nonacute nursing.
  • Organized volunteer activities and support groups.
  • Adult day care.
  • Social model day program for seniors with dementia.
  • Case management.
  • Program to help residents gain financial assistance.
  • Legal guidance related to routine matters.
  • Psychiatric care.
  • Nursing and home care
  • On-site location of a geriatric medical practice.

When PSPS was five years old, Penn South's Cooperative Board felt that, due to their financial commitment to the program, they should have more of a management role in PSPS. In reaction, the UJA-F helped transition with fiscal oversight and responsibility to Penn South Social Services, Inc., which the Board established for that purpose. The new nonprofit corporation continues to contract with outside agencies to provide services.

The author asserts that the NORC services program saved approximately $11 million in one year by preventing 460 hospital stays and 317 nursing home placements. It is not clear which program(s) saved money, nor is it clear how the number of prevented institutionalizations was calculated.

In 1997 through 1998, the case management team worked with 644 clients and families.2 Over 50 percent of these clients were age 85 years or older and almost 25 percent were over the age of 90. Furthermore, nearly 30 percent were never married; 79 percent live alone; 33 percent had no family or friends to provide assistance. In 1999, PSPS provided services for over 1,200 seniors and their families. The volunteer program had 149 senior citizen volunteers that donated over 8,000 hours of services, who saved $80,000. The total program budget was not provided.

Hunt, Michael. "Naturally Occurring Retirement Communities." In Encyclopedia of American Cities and Suburbs (517-18). New York: Garland Publishing, Inc, 1998.

Approximately 27 percent of Americans 55 years and older lived in NORCs (no date given). Only 5-7 percent lived in planned retirement communities. NORC design features, such as lack of elevators in multistory buildings, can prevent some residents from aging in place. The authors did not present information about their methods and analyses, which are largely described in other articles.

NORCs evolve in three ways--"aged-left-behind", "aging-in-place", and "in-migration." Residential managers find apartment NORCs ideal because older people tend to pay their rent consistently and there tends to be minimal damage to their apartments. Rural NORCs are appealing to their host communities because of the economic benefits they provide.

An aged-left-behind NORC develops when an area with an unpleasant environment experiences a significant economic decline. As a result, younger residents leave, while many older residents are unable to do so because of emotional or economic ties to the area, lack of financial resources, or the inability to move. Typically, older residents of these NORCs need medical, social, and personal services.

An aging-in-place NORC has residents who remain in their homes for many years and have a strong desire to remain in their communities. These communities can have residents with varying levels of income.

In-migration NORCs develop when older people move to an area for the convenience of its lifestyle. For example, residents may be seeking the companionship of others, proximity to shopping and services, a hospitable climate, availability of a range of activities, and a more leisurely life. Residents of some of these NORCs may live there on a seasonal basis.

Apartments and condominium complexes were consistently places of in-migration. Location, management, and design were the major factors that cause in-migration to certain housing complexes. Location mitigated the social isolation by improving proximity to friends and family. Management played a key role because referrals were important in older populations seeking hospitable environments.

Yalowitz, Nat, and Karen Bassuk. An Intergenerational Community with Supportive Services, The NORC Model at Penn South Program for Seniors. Presented at the American Society on Aging, San Francisco, March 1998.

In this article, the authors look at the definition of NORCs and their supportive services programs, the structure of the models developed, their financing, the clients served, and the need to see these programs as evolving entities with intergenerational issues. They emphasize the need for the models to remain flexible and to reflect the needs of the community they serve as well as the need for the community served to take major responsibility for the development of the program.

Penn South (officially the Mutual Redevelopment Houses, Inc.) is a 36-year-old, moderate/middle-income co-op in Manhattan. New York state legislation passed in 1994 established 10 NORC supportive services programs. Penn South developed into a NORC primarily through "aging-in" although there has also been some recomposition, immigration, and congregation as described in the literature. It is an example of a closed NORC.

The New York state legislation used as its criteria for a NORC that at least 50 percent of households have one member over 60 years of age or that the complex contain over 2,500 residents that are elderly. All of the New York state programs are constructed as private/public partnerships; each housing entity must match funds provided by the state. Financial participation gives the residents a feeling of having a stake in the program, which breaks down some of the barriers to accepting social services.

The Penn South Program for Seniors (PSPS) was started with funding and oversight through UJA-F and was the model for the legislation that was later passed. The Penn South model starts with the assumption of client participation. The program offers group activities, volunteer program, case management, home care coordination, and nonacute nursing care. Social activities include classes, holiday parties, and trips. Under the case management program, social workers work with the client and, where possible, the family to facilitate acquisition and management of services. Seventy-nine percent of clients live alone; 33 percent have no family or friends to help them. The nursing services program provides Medicare and non-Medicare reimbursable care that helps prevent hospitalization or nursing home placement.

Despite the success of the program, the authors assert that there is a need to evolve in order to meet any gaps in services, to strengthen the NORC multigenerational community, and to redefine NORCs in order to remain politically viable. Examples are given in each of these areas from programs and activities at Penn South. Many of the examples on meeting service gaps focus on how to get as many services as possible for as little money as possible. Strengthening the multigenerational aspect of the program is presented as a way to promote intergenerational activities, break down ageism, and help with the long-term survival of the program. Redefining NORCs from the original definition set out in the New York state legislation is also seen as a way to assure the long-term viability of the program by promoting its spread outside of urban areas.

The authors conclude with the observation by Bruce Vladeck, Health Care Financing Administration (HCFA), that NORCs are the future of long-term care. As cost effective and efficient ways to strengthen communities while delivering services, the authors assert that the NORC model deserves broader support in order to be replicated throughout the country.

New York City Dept. for the Aging, and United States Administration on Aging. Support Services for the Frail Elderly Residents of Federally Assisted Housing: Final Report Findings and Recommendations. New York, NY: New York City Department for the Aging, 1997.

Program Description

The demonstration project--Vladeck Cares Program for Seniors--was designed to (1) provide coordinated services to older people, with one or more limitations in activities of daily living (ADLs), who lived in Vladeck Houses, a large public housing complex and (2) to identify minority populations who needed but were not accessing services and recommend methods of outreach to these communities. Vladeck Cares was designed to meet the first goal by linking frail older people to needed services and entitlements through provision of case management and assistance, information and referral, transportation assistance, mental health counseling, arrangement of home care, and volunteer-provided support services. The project's second goal arose from the concern that attendees at the complex's Good Companions Senior Center were generally white and Jewish and did not live in the complex; this group did not reflect the demographic profile of the complex.

The New York City Department for the Aging, the New York City Housing Authority (which owns Vladeck Houses), and Henry Street Settlement house collaborated in funding and managing Vladeck Cares. Vladeck Houses is a public housing complex of 54, six-story buildings located on 14 acres in lower Manhattan. About half of the complex's 1,700 households were led by someone age 60 or older, totaling 1,008 people age 60 and older lived in the complex. About two-thirds of these older heads of household were female, 70 percent lived alone, and 63 percent had incomes below poverty. Only 20 percent of older residents are white, 53 percent are Latino, 17 percent Asian, and 11 percent black. Henry Street Settlement House, which is a long-standing social services provider, operated Vladeck Cares.

Start-up Issues

The project advisory committee, composed of a diverse group of religious and service organizations, helped modify the project as needed, referred clients to the project, and helped recruit volunteers. The project developed Vladeck Cares: Policy and Program Guidelines at the beginning of the project and revised it after two years to accommodate what staff learned during the project implementation. The demonstration project found that the service coordinator and her staff did not have sufficient time to provide needed outreach and volunteer coordination or mental health services. Client intake screenings had revealed an unmet need for mental health services due to older residents' social isolation and signs of depression. Thus, the project hired two more staff; one was an outreach/volunteer coordinator and the other a bereavement/mental health counselor, both of whom reported to the service coordinator. The project also found less need for emergency home care and home delivered meals than originally thought so the project shifted emphasis to service coordination and non-Medicaid covered services. The program originally arranged for two vans to be available weekday afternoons for shopping and medical appointments, but found it more practical to arrange and provide carfare and escort services on demand.

Communication

Outreach methods to residents included print materials in English, Spanish, and Chinese, information fairs in building lobbies, articles in the housing site newsletter, and a survey distributed to all elderly Vladeck House residents. The survey appeared to be the most effective outreach method but ethnic groups varied in their responses to the other methods.

Participation

Each person contacting Vladeck Cares or the Good Companions Senior Center was offered information and referral about the project's potential benefits and entitlements. Clients potentially eligible for the program were interviewed using a client intake form and then assessed using a standard form if they appeared to be eligible for services. A professional assessment committee reviewed the project's screening and client assessment forms and made final determinations when eligibility was questionable.

Vladeck Cares projected it would have case management responsibility for up to 60 clients a year, but, by the end of the second year, project staff were serving 145 active cases. Staff conducted 1,100 office visits during the two-year demonstration project. The project recruited 14 volunteers and students to help with administrative tasks, telephone reassurance and friendly visiting for clients, assistance with instrumental activities of daily living (IADLs), and running small errands. Licensed nurses working toward their bachelor degrees did vital sign and medication monitoring, blood pressure screening, medication education, and nutrition counseling. Social work students did case management and counseling under the supervision of the service coordinator.

The program served a total of 145 clients with an average age of 75. Seventy-one percent of clients were Hispanic compared with 50 percent in the complex; Asian, white, and black populations were underrepresented in the program compared with their proportion of the elderly population in the complex. About 73 percent of clients lived alone. More than 8 in 10 self-referred to the Vladeck Cares after hearing about the program from the senior center, flyers, friends, or the survey, and 17 percent of clients heard about the program from agencies, including Good Companions Senior Center.

Evaluation/Data

The project set up a computerized client database for every client who entered the program. The first year's data indicated high penetration among the Latino senior population. Program staff felt at this point that a large number of older people were still underserved so they increased outreach to the underserved population. At the end of the grant period, 20 percent of Latino, 12 percent of African American, 11 percent of Asian, and 6 percent of white older people were enrolled in Vladeck Cares.

A survey of residents, conducted 18 months into the project, found that 71 percent of residents had not been aware of Vladeck Cares before it began outreach. Most who entered the program during the two-year grant period heard about it through the senior center or from a program flyer. Seventeen percent of clients were referred by an agency, primarily the senior center. The survey response rate was less than 20 percent. Analysis of client data showed that participation rates declined as residents lived further away from the program and as the age of residents increased.

Recommendations

The demonstration project had several recommendations for other NORC sites. Regarding cultural issues, the program must recruit advisory committee and staff members from varied backgrounds would facilitate reaching out to and working with the minority populations in a NORC. Outreach efforts should be varied and multilingual, as well as tailored to the cultural preferences of residents. The program must be flexible enough to evolve to meet the changing needs of residents and the changing environment within which the program works. The emphasis of a service program should be on coordinating and linking residents with existing community programs and services. The program offices should be as centrally located as possible when the older population lives in a geographically dispersed NORC and outreach should occur in the more remote locations. A computerized database is essential for reporting and analysis that promotes understanding of the NORC residents and their needs and for communication with funders. A resident survey should be conducted about six months after a project starts to give the program time to begin operations and work out implementation issues.

Nadeau, E.G., and David J. Thompson. "Senior Co-Op Housing: Focusing on Community, Health Care and Services." In Cooperation Works! How People Are Using Cooperative Action to Rebuild Communities and Revitalize the Economy, edited by Cooperative Development Services (77-94). Rochester, MN: Lone Oak Press, 1996.

Penn South is a co-operative with 2,820 units that provides a range of services. Penn South was built in the early 1960s by the International Ladies Garment Workers Union (ILGWU). The demographics changed significantly in the 1980s because many families left and the remaining residents aged in place. As they did, problems began occurring. For example, some residents needed help with financial management and others wandered without supervision.

In 1986, David Smith, board president of the Penn South co-op at the time, met with social service experts from the United Jewish Appeal - Federation (UJA-F) to discuss how to meet the needs of the aging population. Together they created the Penn South Program for Seniors (PSPS), which was a partnership between Self-help Community Services and the Jewish Home and Hospital for the Aged. Residents could access services by paying a $15 annual fee; fees were waived for those who could not afford it. PSPS now has over 700 members. There were approximately 12 paid staff and over 100 volunteers. The PSPS program had an annual budget of approximately $400,000 and received about $120,000 from UJA-F, and $100,000 from Penn South's board in 1996. The State Office of Aging, the City's Department of Aging, and foundations contributed the remaining amount.

The PSPS program has spurred the development of other programs in Coney Island, New York (Warbasse House), and the Lower East Side, New York (Co-op Village). The UJA-F created a consortium of agencies that provides a variety of services necessary for independent living. UJA-F and other co-op board organizations lobbied for the state legislation that appropriated $1 million in 1994 to assist 10 NORCs in New York. According to the authors, this was the first state funding made available to NORCs in the United States.

Hunt, Michael, John Merrill, and Carolyn Gilker. "Naturally Occurring Retirement Communities in Urban and Rural Settings." In Housing and the Aging Population: Options for the New Century, edited by W. Edward Folts (107-120). New York, NY: Garland, 1994.

The authors describe findings from their previous work on NORCs, most of which are described elsewhere in this annotated review. According to the authors, rural NORCs have a major, largely positive impact on the economy of local communities. In many rural areas, the older population's transfer payments, dividends, interest, and rent income are major contributions to the municipality's economic base.

According to the authors, the three main factors that affect the evolution of NORCs are location, management, and design, in order of importance. Location is the chief initial attraction of a NORC because residents are close to family or friends, shopping, and services. Management played a crucial role as well because the management's role in maintenance can spur word-of-mouth referrals. Finally, the design of a NORC was not necessarily an attraction, but could potentially be an impediment to independent living.

Lanspery, Susan C., and James J. Callahan. Naturally Occurring Retirement Communities: A report prepared for The Pew Charitable Trusts. Waltham, MA: Brandeis University, Heller School, Policy Center on Aging, October 3, 1994.

This article provides a summary of the literature on NORCs, discusses the NORCs program model, presents findings from analysis of 1990 Census data, and discusses and reframes recommendations.

The U.S. population is aging, with the share of the population over 65 expected to increase to 20 percent by 2025 from the current 12.5 percent. An AARP survey in 1992 showed that 86 percent of older Americans want to age in place, compared with 78 percent in 1986. NORCs are one of the major consequences of this trend. NORCs are defined in this report as housing developments or neighborhoods where at least half of the residents or heads of households are 60 years of age or older or where a large concentration of older people live.

Factors that have led to interest in programs focused on NORCs to facilitate the delivery of health and supportive services include (1) the potential for economies of scale, (2) the successes of similar programs linking senior housing and services, (3) the extensive number of NORCs nationwide, (4) the potential to help preserve communities, (5) the strong desire of older adults to age in place, and (6) the increasing support for helping people with disabilities to remain in the community rather than moving to institutions.

The definition of NORC has changed over time. Community informants report that the impact of an aging local population begins to be felt when their share of the population exceeds about 26 percent, although density and geographic spread make a difference. The authors conclude that it is preferable to specify a range of population and density when defining a NORC. They note that NORCs are "probably more varied than alike," varying by physical size, population size, population characteristics, and reason for existence among other things. They may come into existence by accumulation (older people left behind as more mobile segments of the population leave), recomposition (in which older people replace other residents who are leaving) and congregation (where population inflows are of all ages, but with greater numbers of older people). Recomposition and congregation NORCs in rural areas can be further characterized as amenity NORCs (which attract older people who are generally better off in most ways and are looking for the amenities of rural life), convenience NORCs (which attract local people generally moving from a rural area to a nearby rural community for the convenience it offers), and bi-focal NORCs with characteristics of both. NORCs can also be classified by management or ownership with a closed NORC having one management entity (e.g., an apartment complex or mobile home park) as compared with an open NORC that has multiple owners or management entities. Open NORCs may also consist of one or more closed NORCs.

The number of NORCs appears to be on the rise. The only data available are the 1990 Census data and the 1993 AARP survey. Demographically, NORC residents more closely resemble non-NORC members than people in retirement housing. The latter are more likely to be widowed and to have lived less long in their current residence or area. As compared with non-NORC residents, NORC residents are likely to be older, less likely to be employed, have slightly lower incomes, more likely to own their own homes outright, and have a slightly lower level of education.

Eighty-one percent of NORC residents say their neighborhood or building is a NORC because people have lived there a long time rather than because older people have moved in. They like living in the NORC because of common interests with their neighbors and the quiet atmosphere. Table 1 of the article gives comparative demographic information on NORC and non-NORC residents. NORC residents are more likely to rate highly the usefulness of current and proposed NORC services and these ratings are consistent across a range of services. (The study does not indicate whether the differences between the groups are statistically significant.)

The article discusses various types of NORCs and NORC-centered service programs. Minnesota has developed a block nurse program. UJA-Federation in New York has sponsored a comprehensive program of social, health, and individual services at the Penn South and other moderate-income cooperative housing units. In this program, resident needs are gauged through contact with residents in various ways, and the services are financed in part by the cooperative corporations themselves. Consumer-driven residence service programs (RSPs) have been started in New Jersey and Massachusetts with the goal of providing a single point of access to services. Other efforts have begun or are being considered in Boston, Philadelphia, Connecticut, and Washington, D.C., in NORC or NORC-like areas.

The growth of NORCs is not universally applauded. For example, housing policy in Minneapolis and Rochester appears to be designed to discourage the development of NORC-like situations. Planners fear that a predominance of older residents will result in negative votes on school funding issues, will require more expensive public services, and cause zoning problems.

After presenting this background on NORCs, the authors propose a model linking NORCs and services. The key elements of the proposed model are consumer participation, a focus on resource development and service coordination rather than case management, broad involvement of stakeholders from the beginning, and cost sharing. The model is derived from a model that has worked well in senior housing based on the assumption that density will allow economies of scale, collective activities, cooperation with local businesses, geographic-specific legislation, financing through membership fees, and development of a sense of community. The differences between this model and other models of senior services are presented in a chart (pp. 22-23). In particular, the NORC population is distinguished by being all of the elder population in a targeted geographic area rather than those eligible for specific programs such as private insurance or Medicare, and financing is drawn from numerous sources including insurance, government payments, block grants, and out-of-pocket payments.

The author then delineates important factors for developing and implementing NORC programs. Specifically, there should be a clearly identified lead entity. Other factors are listed that will facilitate development and implementation including a closed NORC, a homogeneous population, a service-rich area, consumer-oriented agencies, identifiable stakeholders with an interest in cooperation, urban-like concentration, strong neighborhood or consumer groups, higher consumer income, and a relatively autonomous lead entity.

The author uses 1990 Census data to identify NORCs using a definition of at least 40 percent of householders of age 65 or more in Census block groups or those with at least 200 householders over age 65. The age 65 is used as a cutoff rather than younger ages seen in some studies for three reasons: (1) age 65 is more conservative, (2) age 65 is more convenient statistically, and (3) age 65 is the age for Medicare eligibility. The choice of a minimum of 200 householders was made because it suggests some economies of scale; it is in the mid-range of what is generally considered large enough to support a full time services coordinator in senior housing. Using these definitions, the authors found that about 10 percent of all 1990 Census block groups qualify as NORCs, representing about 3.5 million households. These NORCs show great diversity in housing age, income, and functional limitations, but single elder residents predominate over married elder residents in all but one of the identified NORCs.

The authors point out a critical difference between NORCs and integrated service networks. In the latter, a set range of services is marketed to a membership group, while in the former, the emphasis is on giving discretion and control over the types of services included to the members of the group. Services are typically of a social services nature rather than traditional health services. The authors conclude that establishing a formal linkage between NORCs and health and supportive services will have considerable benefits. In appendices the authors provide a summary of their findings and highlights from their case study.

Hunt, Michael E., D. Arch, and Leonard Ross. "Naturally Occurring Retirement Communities: A Multiattribute Examination of Desirability Factors." The Gerontologist 30, no. 5 (1990): 667-74.

Overview

This study analyzed the factors critical to attracting older people to NORC apartment complexes. Apartment NORCs are unique because they have become the most widespread form of alternative housing for the elderly in the U.S, according to the authors. Previous research shows that the availability of desirable supportive neighborhood services are a major attraction for older people. Furthermore, safety and proximity to services and peers also attracts this population.

Methodology

The purpose of this study is to provide quantitative measures that describe the relative importance of certain apartment complex characteristics, as identified in a previous study, in attracting older residents to non-NORC apartments. Results from a preliminary survey of NORC residents identified three critical factors that explain the desirability of NORCs: location, management, and design. The current study looked at three NORC and two non-NORC apartment complex sites located in Madison, Wisconsin. The housing was intentionally selected to vary according to location, building type, age of the housing, and management company.

A subject sample from each apartment complex was drawn from either the apartment or city directory. Of those contacted, 64.7 percent agreed to a telephone interview, and 143 people were interviewed. In order to measure the relative importance of the three NORC attributes identified in the preliminary survey, a multi-attribute scaling procedure assigned weights to various apartment complex attributes that could affect decisions to move into the setting. These attributes were organized into a "tree" structure to compare the relative importance.

Findings

Location was the most important factor in attracting older residents to the apartment complex for both NORC and non-NORC elderly, with management and design relatively equal but less important. Location specifically included the distance to shopping/service facilities and proximity to friends, age peers, and family as well as neighborhood safety. Older NORC resident's valued social factors while older non-NORC residents placed more importance on distance factors. In terms of management, which includes factors such as upkeep and resident manager, both NORC and non-NORC residents valued upkeep more than the presence of a resident manager, and both found the design of the individual unit to be more important than the complex's design. Finally, the housing features that attracted older people were attractive to younger people as well.

Study Limitations

Some of the participants in the preliminary survey were in the final study as well. The authors did not think this posed a significant problem because the surveys occurred one year apart and used differing methodologies. It is not clear whether the authors randomly selected their pool of potential interviewees. Thus, the generalizability of these results is unclear.

Hunt, Michael E. "The Naturally Occurring Retirement Community." In Housing the Very Old, edited by Gloria M. Gutman and Norman K. Blackie (161-72). Burnaby, British Columbia, Canada: The Gerontology Research Center, Simon Fraser University, 1988.

Overview

This study focuses on how apartment complex-type NORCs evolve. According to the author, NORCs in apartment buildings are probably the most common form of alternative housing in North America and house more of the older population than do planned retirement communities. In Madison, Wisconsin, there are about three times as many NORCs as planned retirement communities.

Methodology

To learn more about how these communities evolve, three NORCs in Madison, Wisconsin, were studied. Interviews were conducted with a total of 72 residents, or approximately 25 percent of residents age 60 years and older. Interviews were also conducted with a representative from the management for each apartment complex. The four major categories of questions were designed to ascertain the demographic characteristics of the older population living in the NORC, reasons for attraction to the NORC, the quality of life in the NORC, and reasons for moving away from the NORC.

Findings

The following summarizes findings from interviews conducted with residents. The majority of residents interviewed for the study were widowed women living alone (80 percent). Approximately two-thirds were age 65 to 75 at the time of the interview. About a third said they moved to the NORC when they were under 60 years of age, while half moved to the apartment community between ages 60 and 75. About a third said they had lived in the NORC between 11 and 20 years, another 23 percent said they had lived in the NORC more than 21 years. Over three-quarters had moved to the NORC from the same part of town, with about half moving after selling homes they had lived in for a long period of time.

The most frequently cited reason for moving to a NORC was that the size and maintenance requirements of their former residence were becoming problematic. According to respondents, these problems were most frequently associated with death of a spouse or cohabitant and failing health. Respondents reported that they least liked the upkeep and isolation of their former residence, but most liked the privacy and location of their home near close friends and neighbors.

Consistent with their reasons for moving away from their former residence, respondents indicated they were attracted to the NORC mainly for two reasons, its location and that friends or relatives lived there. Older residents had heard of the NORC by word of mouth and personal referrals seemed to be the predominant form of advertising.

About half of respondents said they liked life in the NORC better than where they had lived before, with more than a third rating it about the same. The most common reasons for liking the NORC better were fewer stairs, less space, and management's ability to maintain the NORC. Almost half reported socializing with neighbors more often since moving to the NORC. Although some respondents mentioned that moving to a smaller apartment was difficult, most were willing to trade-off the disliked qualities of the apartment lifestyle for its location and freedom from maintenance responsibilities.

When asked if they planned to move away from the NORC about 30 percent of respondents said "maybe" and another 10 percent said "yes." Respondents said they would move either because of a need for more health care or to lower their rental costs. Respondents also said these reasons were the primary reasons most residents moved away from the NORC. However, those who moved away reported they had left because of barriers in the design of the NORC such as stairs in the living unit and laundry room. Nonetheless, most respondents felt that nothing should be done to provide assistance to help residents live independently in the NORC, and, if residents needed more health care then they should go somewhere else where care could be provided.

Conclusions

The author finds location, management, and design to be main factors in the initial attraction to a NORC. In terms of location, a NORC's proximity to shopping and service facilities as well as family and friends are key. Residents expect that NORC will be well maintained, thus building maintenance is important. The design of a NORC can also help eliminate potential barriers to independent living.

NORCs were also found to be desirable to housing managers. Resident managers reported that older residents were desirable tenants because of their stability, which is often cost-effective, dependability with rent payments, and lack of wear and tear on the apartment itself.

Study Limitations

It is not clear whether the survey sample was randomly selected, so the generalizability of findings is in doubt.

Hunt, Michael E., and Gail Gunter-Hunt. "Naturally Occurring Retirement Communities." Journal of Housing for the Elderly 3, no. 3/4 (1985): 3-21.

In this study, the authors examine the evolution of NORCs and compare them to a typology of planned retirement communities (RCs) and community-based housing. According to the authors, the supportive services available in neighborhoods are the main attraction for each living arrangement.

The authors define a NORC as "a housing development that is not planned or designed for older people, but which over time comes to house largely older people" and can range from an entire neighborhood to a single apartment building. NORCs differ from planned communities in several ways: (1) they are not specifically designed for older people, (2) they are age-integrated, (3) they are often single buildings or a small complex of buildings that house fewer than 500 people, (4) they are most often not marketed as retirement communities nor are they generally considered retirement communities by their residents, (5) they may provide few, if any, services to their residents, and (6) the residents are generally younger than residents of planned retirement communities. Given these differences, the authors propose that NORCs be added to the typology of retirement communities developed by University of Michigan researchers (M.E. Hunt et al., Retirement Communities: An American Original. New York: The Haworth Press, 1984).

Communities evolve into NORCs (that is, they become communities with at least 50 percent of their residents being 50 years old or older) either by aging in place (residents move in before they reach age 50 and stay until they are past that age) or by relocation (people older than 50 move into the community), or a combination of both. The authors use a case study of a NORC in Madison, WI, to demonstrate the process of becoming a NORC. The area has an array of readily accessible services (post office, medical care, banks, shops, restaurants, grocery store, and the like) and public transportation, as well as a range of housing options by type and cost. The services were present in the community before the older people settled there and may have contributed to the area's attractiveness. The apartments are well maintained and of adequate quality, and the physical environment is accessible. The large number of older people provides opportunities for companionship. Crime is low. The authors assert, "The evolutionary pattern of NORCs suggests that neighborhood and services are even more important than the housing unit itself". They note that planned retirement communities and NORCs have in common their proximity to neighborhood facilities and services.

Age heterogeneity is a major factor distinguishing planned retirement communities from NORCs. The authors state that, since people have different preferences regarding the age structure of their communities, NORCs provide an alternative to planned retirement communities. They stress the desirability of decentralizing services and planning multifamily housing around service centers; public transportation between decentralized service centers would increase access to services. Residents living in supportive neighborhoods may require fewer external services to remain independent.

Hunt, Michael, and Leonard Ross. Naturally Occurring Retirement Communities, The Invisible Housing Alternative. A brochure funded by the AARP Andrus Foundation, n.d.

In this brochure, a NORC is defined as a community that is not designed or planned for older people, but over time had attracted "a preponderance of residents 60 years of age." Three main factors are cited as determining the attractiveness of a NORC: location, management, and design. Location near a grocery store is particularly important. Good management, usually in the form of a resident manager, is important, as are well-maintained grounds and buildings. The design of the building, particularly the level of barriers to independence, is more often a reason that people move away rather than one that attracts them to the building. Many of the features that make a good NORC are also those that make housing desirable for all people. At the back of the brochure is a checklist of features to look for in "A NORC That's Right for You."


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