Supportive Services Programs in Naturally Occurring Retirement Communities. SUMMARY OF THE SITE VISIT TO THE NORC PROJECT

11/01/2004

The following information is based on discussions with the following 20 people on September 9, 2003: the NORC Coordinator, two advisory committee members, one staff person each from Jewish Family & Children's Service (JFCS), Jewish Community Center (JCC), and Covenant/CHAI Senior Housing, four NORC residents, and 10 research team members from the Washington University in St. Louis Center for Aging.

Description of the NORC and Its Residents

The Jewish Federation of St. Louis, which received the AoA grant, is taking a different approach than the other four AoA grantees in that St. Louis is studying the community and several types of programs in depth before designing its NORC service program. The Center for Aging at Washington University in St. Louis is partnering with the grantee to conduct the research.

Grantee staff define a NORC as an unplanned (naturally occurring) building, complex, neighborhood, or community housing in which there is a disproportionate number of individuals age 65 and older. These communities develop when residents age in place or people relocate to the community after age 50.

Using 2000 census data, research staff determined that "census tract 2150.02 and part of census tract 2153.01," which cover approximately one square mile in the western end of St. Louis, contained a large proportion of older people. Staff studied this area because it is adjacent to JCC, JFCS, and the publicly funded senior congregate housing site (Covenant House/CHAI), which has been in existence since the early 1970s for retirees and low-income older adults. The site has on-site services and programs for residents such as meals and activities.

The NORC community evolved, in part, through white and Jewish migration west to avoid integration in St. Louis City and the old neighborhoods of University City during the 1970s. Younger white families moved to Creve Coeur, which was a rapidly expanding area of new homes, schools, and small businesses. Jews migrated to the area to be closer to the JCC and a growing Jewish community. From 1961 to 1981, the number of Jewish households in the area increased by 25 percent. At present, the percentage of the population that is Jewish is declining (for unknown reasons).

The people who moved to Creve Coeur have aged in place. They have been joined by some older people who have moved to the neighborhood to be close to family, friends, or the JCC. Most Covenant/CHAI congregate housing applicants come from the community's condominiums and apartments and are people who report feeling isolated due to the "lack of community feeling" in the private residences.

The Creve Coeur neighborhood's private residences are not accessible to older adults who are frail or have mobility problems. The largely garden-style apartments have several stories and no elevators. These apartment complexes typically are 30 years old and were not built to be accessible in that they lack such things as walk-in showers, grab bars, or levers for faucets. The hilly neighborhood has few sidewalks, which makes walking to service providers and stores difficult, and limited public transportation. The neighborhood's ranch style houses have one step into the house, sometimes steep driveways, and laundry facilities typically located in basements that are difficult for older residents to access. The carpeting in homes may hinder residents' mobility, especially for those who use assistive devices.

Residents who can still drive have access to a broader range of services and activities. The neighborhood has the JCC, JFCS, two churches, a grocery store, a kosher restaurant, a gas station, a restaurant area with a movie theater, and a gym. Service providers and restaurants are at opposite ends of the neighborhood. However, signage in the area is poor and many residents are less comfortable driving at night, which can limit participation in certain activities.

NORC Residents

The Center for Aging used Census 2000 data to develop a profile of the NORC and its older residents. A total of 4,370 people live in the NORC community. Eighty-two percent of NORC residents are Caucasian, 7 percent African American, and 6 percent Asian. Grantee staff say that the neighborhood experienced an influx of Russian immigrants in the early 1970s and late 1980s. Comparable percentages for St. Louis County as a whole are 77 percent Caucasian, 19 percent African American, and 2 percent Asian. About 11 percent of the population has incomes at or below the federal poverty level, compared to 5.3 percent of St. Louis County.

Thirty-one percent (of the 1,337 NORC residents) are age 65 or older. Sixty-nine percent of this older population is age 75 or older, a large number of whom live in the congregate housing site, where the mean age is 79. The majority of older people are women living alone. Twenty percent of people age 65 or older report having a disability. Among this 20 percent, the most frequently reported disabilities are physical problems (44 percent), difficulty going outside alone (25 percent), sensory disabilities (17 percent), mental disabilities (8 percent), and self-care problems (7 percent) (individuals could report more than one disability).

NORC Building Management and Communication with Residents

The NORC has several privately owned apartment complexes and condominiums, as well as a publicly funded congregate senior housing complex. These complexes are receptive to programs for older people to varying degrees. Each private complex has a management company or a condominium association board. Most of these entities have been reluctant to assist their older residents, according to grantee staff. Apartment managers are reported to be uninterested in home modifications, likely because of the cost. Condominium boards have also resisted making modifications, perhaps because they would rather have older people move out than make a safe or comfortable environment for them. One exception is an apartment complex managed by an Ohio-based company that, until recently, sponsored programs for all residents, particularly those who are older. For example, the complex established an after-school program in which older residents tutor children. The complex has also sponsored bagel breakfasts. These programs are being cut back and it is not clear why. Covenant/CHAI has a number of programs for its residents and has a tenant council that meets every other month to advise on program planning and other issues of concern to residents.

NORC Service Organization Structure

The two partner agencies--JCC and JFCS--offer mental health, limited transportation, recreation, socialization, nutrition, adult day services, and homemaker assistance. JCC administers the adult day care and cafeteria-style nutrition programs, which are open to the community and located in the Covenant/CHAI house. The nutrition program is the most successful program in terms of use; it provides a congregate meal five days a week to approximately 200 residents.

The Covenant/CHAI house offers limited programming, which includes one social worker for each of the three buildings. These staff used to limit their activities to such things as helping residents fill out food stamp applications, but now staff refer residents to service providers, such as housekeeping services. The staff also make arrangements for services such as podiatric care, nutrition, employment counseling, home health services, and blood pressure checks. Although these services are open to the community, those taking advantage of them are generally building residents.

Evolution of the NORC Service Program

Grantee staff believe that doing primary research on the service needs of the NORC community is the best way to determine which types of NORC service programs would be most responsive to community need. The goals of the new programs will be to stabilize the neighborhood, improve property values, contribute to the economic vitality of the business community, and offer cost efficiencies in service delivery. Staff contacted the Center for Aging and asked them to conduct the research because the Center offered a multidisciplinary approach to studying older adults.

NORC Service Program's Communication Methods

An external advisory committee was developed with representatives from service providers, churches and temples, resident complexes, state representatives, and lay leaders to provide input into the development of the service program. The committee had met once as of September 2003. The goal is to have the advisory committee be the vehicle of communication with NORC residents. In addition, the advisory committee has plans to publish a quarterly newsletter about the NORC service program as it develops.

Studies Related to Services Program Development for the NORC

The Center for Aging screened 494 NORC residents out of a total population of 1,337 people age 65 and over to determine their suitability for participation in one or more of seven studies. People were eligible to participate in the studies if they were age 65 or older, lived in the NORC, and did not have dementia.

Researchers said they did not have sufficient time because of grant funding deadlines to select a random sample of NORC residents, so they recruited volunteers from the community. Participants were recruited using a variety of methods, including visiting people in their homes, direct mail, and word of mouth; staff considered this last method to be the most effective way to recruit participants. Staff held a "kickoff breakfast" in September 2002, which approximately 200 NORC residents attended. Then staff made presentations at places older people in the community were likely to frequent, such as churches and shopping centers. Research staff did some limited mail recruiting from Covenant House, and also included Covenant House residents if they volunteered.

Recruiting took longer than researchers had anticipated because multiple contacts were necessary to assure older adults that no one was going to invade their privacy. Many potential participants were reluctant to join the study or too busy. Others did not understand why staff were talking about offering programs when no program yet existed.

The volunteers completed an initial telephone screening interview, which lasted 10 to 15 minutes. The researchers could not say how many of the people screened had dementia. People that completed the interview were demographically similar to NORC residents.

Of the 494 study participants,

  • 72 percent lived in privately owned or rented condominiums, apartments, or houses;
  • 69 percent were female and 59 percent of all participants lived alone;
  • 33 percent did not drive;
  • 14 percent still worked;
  • 36 percent volunteered; and
  • 17 percent were family caregivers.

On average, they had 13.5 years of education and were 79.3 years old.

Analysis of the data has not yet been completed, but early results indicate that older residents need transportation, knowledge of available community resources, home delivered meals/meal preparation, in-home care, and access to health care. Next steps for the researchers are to complete the data analysis and finish the seven studies that are in various stages of development.

The seven studies include the following:

  1. Needs assessment. Of the 494 participants, 320 will participate in a one-to-two hour interview to gain information on residents' personal characteristics, social support networks, self-rated health, well-being and life satisfaction, social and religious activities, current service use and unmet needs, and perceptions of the neighborhood. The interview relies largely on standardized measures, such as a depression scale and an activity checklist. Trained graduate student interviewers conduct the interviews.

  2. Community Connections. Eleven participants were recruited for an eight-week wellness program. Researchers first conducted focus groups with 48 participants who expressed interest in this type of program during the telephone screening. The focus groups were designed to elicit information on the residents' sense of health and wellness, concerns, enablers, barriers to engaging in everyday activities, and level of interest in a new wellness program. Focus group participants expressed the desire to feel more connected with the community and to be more aware of available supports and resources. Their concerns about the future focused on finances, driving, where to get support, and feeling alone, and they expressed interest in a course to address these needs. Transportation was also an area of expressed concern.

    The course that evolved from these focus groups is called "Community Connections for Successful Aging." The 11 participants were recruited from the focus groups. Researchers had to call far more than 11 people during recruitment because many focus group participants were too busy for the class. Three of the 11 original program participants withdrew for health reasons.

    Based on results from questionnaires that program participants filled out before and after the class, participants achieved their personal goals for the class and increased perceived knowledge, self-confidence, and the frequency of healthy behaviors. A few of the participants agreed to be peer leaders for future courses.

  3. Home modification. Researchers selected a convenience sample of 80 residents who received an assessment of their homes to determine the modifications necessary to improve safety and/or mobility. Then, residents received any recommended home modifications that they agreed to have free of charge. Residents were chosen based on their responses during the needs assessment. For example, if respondents expressed a fear of falling, they were considered for inclusion in the study. The project was designed to determine the outcomes of the home modifications with respect to residents' quality of life. A follow-up visit will be conducted with all 80 recipients three months after the modifications and the associated training are completed. Researchers will be assessing residents' satisfaction with and confidence in navigating their home environments. The barriers that assessors most frequently encountered included unsafe showers or bathtubs, dim lighting, low or soft chairs, items out of reach, steps at home or entry way, long distances to carry items, and opening jars (jar design). The most frequently employed solutions were grab bars in showers, recessed lighting and lamps, hydraulic seat boosters, reachers for high and low items, ramps, rolling carts for carrying items, and jar openers requiring minimal hand strength or grip.

  4. Cognitive mapping. This study had 26 participants who left their home at least three times a week to participate. Participants gave demographic and other information to researchers who conducted "cognitive mapping interviews" in which participants drew diagrams of places they visited during a three-day period. The study found that older people

    • tend to use the facilities and resources within the community and "stay within their zip code,"
    • try to avoid night activities,
    • find construction zones confusing,
    • find some street signs difficult to read,
    • change doctors and other service providers so routes are accessible,
    • use landmarks to guide them in their travels, and
    • are frustrated with current transportation options or do not want to rely on family and friends for transportation.

    The researchers have concluded that features of the environment that influence the choices older adults make about where they go include lighting, signage, store size, staff friendliness, accessibility, financial incentives, and proximity of services. In addition, NORC residents need transportation options for evening events and cultural and social activities that are both flexible and inexpensive. Municipalities need to be aware of the importance of signage, construction zone planning, and landmarks.

  5. Service provider survey. Ninety-nine service providers, including local Area Agencies on Aging (AAAs) , health care agencies, transportation providers, and counseling providers, received mail surveys to determine their perceptions of gaps in services and the needs of the NORC's older population. Twenty-seven percent of the surveys were completed; these were used as the basis for the data analysis.

  6. Family Education/Communication. This project is designed to help NORC residents and their adult children make decisions about service needs and preferences before a crisis occurs. The sample consists of 30 older residents who are single and have at least two of their adult children living in the St. Louis area. Methods included a mail survey and an interview with residents to gather information that was not captured in the needs assessment. Participating families received an in-home educational session with parents and their children that utilized an individualized workbook consisting of responses from each family member's surveys. The session also focused on the families' communication skills and decision making processes. Researchers follow up with assessments one month after the educational sessions to see how family relationships changed. This study is not yet complete.

  7. Informal Support Systems. The purpose of this project is to identify and describe the types of informal and formal support networks that exist among NORC residents. The researchers conducted field observations, informal interviews with 35 key informants, and five focus groups. The interviewees were those who answered, "Yes" to the question "Do you help your neighbor or friends?" on the needs assessment.

Preliminary findings are that residents moved to the NORC to be close to services, close to family and friends, to find security, and to find housing adapted for older adults (e.g., buildings with elevators, ranch-style houses). Characteristics of people who provide informal support include "do gooders," people with special talents, immediate neighbors, and kinship groups. The types of support these people provide include transportation, picking up groceries, carrying heavy loads, picking up newspapers or mail, sharing information, helping in emergencies, and watching out for very frail people. There are limits to how much help people will provide with transportation because some feel overwhelmed by the volume of requests they receive. Some people expressed reluctance to give help in emergencies because of fear of liability in the case of accidents. People watch out for their frail neighbors but expressed the thought that those who are frail should move to another environment because they might harm themselves or others. The kinds of help that people will not provide include transportation for frail people and help with personal care needs. Finally, people are reluctant to help those who are not congenial.

NORC Service Program's Communication Methods

An external advisory committee was developed with representatives from service providers, churches and temples, resident complexes, state representatives, and lay leaders to advise on the development of the service program. The committee had met once as of September 2003. The goal is to have the advisory committee be the vehicle of communication with NORC residents. In addition, the advisory committee plans to publish a quarterly newsletter for NORC residents about the NORC service program.

NORC Service Program Challenges

Although staff have not yet developed the service program for the NORC, they anticipate some challenges. One is NORC residents' lack of awareness that JCC and JFCS serve people who are not Jewish. In addition, it will be challenging to serve people in single-family homes because of the difficulties in finding an activities center in such neighborhoods. Another issue is that staff believe that residents do not want to hear about services until they need them, nor do they want to live in an area where residents are perceived as needy. Finally, it is hard to recruit Asian NORC residents because of language barriers and the fact that Asian elders often take care of their grandchildren and stay within their own communities.

NORC Service Program's Funding Sources

The AoA grant amounted to $1.26 million. Approximately $500,000 is being used to fund the research that the Center for Aging is conducting. In the future, The Jewish Federation hopes to provide administrative funding for the project sufficient to cover one staff person and mailing and printing costs. The original 17-month grant award has been approved for a 12-month, no-cost extension. The conclusion of the grant is now December 31, 2004. Future funding sources will be determined as the service program develops.

Recommendations

No recommendations were provided at the time of the site visit.


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