Summer 2008

Changing Choices — Aging in Place in the 21st Century
By Athan G. Bezaitis, MA
Aging Well
Vol. 1 No. 3 P. 30

Aging once offered few options to older adults choosing living arrangements. We’ve come a long way from the stark and difficult choice between home and impersonal institutional settings.

The expression aging in place has long been a rallying cry promoting independence among older adults. Studies show that 85% of elders aged 65 and older prefer to stay in their homes as they age. However, many people mistakenly believe institutional care to be their only residential alternative. Making a choice between toughing it out in their own homes or shuffling down a drab hallway to face fruit cups and mystery meat is an easy one.

Yet growing old in one’s home may not be the safest, most socially conducive, or cost-effective housing choice. An increasing number of developers and gerontologists recognize aging as part of a community as a compelling new way to help older adults remain independent and emotionally fulfilled.

 “After World War II, the idea of aging in place became everything that being put into a nursing home was not,” says William Thomas, MD, a professor at the University of Maryland Baltimore County Erickson School and the founder of The Eden Alternative, a nonprofit organization dedicated to deinstitutionalizing nursing homes. “We believed that it was the miracle solution to healthy aging, but living alone with no family nearby can be a really difficult thing to do even though conventional wisdom says it’s what’s best.”

Living at Home — No Panacea
Living independently is not for everyone. On top of the nearly 1 million homes that require modifications in order to make them more suitable for elders, many neighborhoods are not ideally situated for those with special needs. According to the 2001 American Housing Survey, of the 21.8 million older households, or those homes with someone aged 65 or older, only 11.4 million had access to public transportation. Even where public transportation was available, there was no guarantee of accessibility. Only 13 million older adults reported grocery and drug stores less than a mile away from their homes. It not surprising that the American Journal of Nursing estimates between 20% and 60% of elder home care patients are malnourished.

Nearly one half of those polled (46%) in the American Housing Survey lived alone. The feeling of isolation itself can be a killer. A 2007 study from the University of Chicago linked loneliness to high blood pressure and an increased risk of death from stroke or heart disease.

“Aging in place, in its current form, is outdated. Sort of like John Wayne, it represents individualism, saying, ‘I’m not going to depend on anybody and not going ask for help,’” Thomas says.

For those with special care needs who live alone, companionship carries a high price tag. According to the MetLife Mature Market Institute, the average cost for a home health aide is $19 per hour. Additionally, two hours a day of nonmedical care, such as housekeeping assistance, can cost close to $2,000 per month.

“Both models, traditional aging in place and institutional care, require a lot of money to run effectively,” Thomas says. “We need to consider two kinds of capital when devising optimal housing for elders. The first is monetary. The second is social capital, or people enriching each other’s lives through community. The problem that people have when they age in place all alone is they end up having no social capital and lack the relationships that are so important to quality of life.”

Welcome Alternatives
Communal housing combines the advantages of private homes with the benefits of connecting people to their neighborhoods. Experts recognize the developing trend as a new paradigm that is inclusive, sustainable, healthy, accessible, interdependent, and engaged. “Aging in community is a team approach, whereby a network of resources and services come to the older adult,” says Caroline Cicero, MSW, MPL, a researcher at the Archstone Foundation-funded Fall Prevention Center of Excellence at the University of Southern California’s Andrus Gerontology Center in Los Angeles.

In naturally occurring retirement communities (NORCs), housing based strictly on residential demographics utilizes the strength of numbers and geographic proximity to acquire health services and encourage social programs. The success of sharing resources in these naturally occurring living environments and other community housing developments has given rise to intentional cohousing communities built by and for older adults. The common thread is “a fostered sense of togetherness,” Cicero says. Even in low-income housing, experiments unofficially dubbed “housing with services,” experts have been successful in linking people to one another and providing services for autonomous, satisfied residents.

Ellen Miller, PhD, executive director of the University of Indianapolis Center for Aging and Community, sees elder housing as a continuum of services between independence and complete institutional care. “By being pro-aging in place, the notion gets out that you’re anti-institutional care,” she says. “The reality is that there needs to be greater awareness of the variety of housing options for all people with different needs.”

To support aging in place at locations with high concentrations of older adults, Miller has worked to develop networks of informal caregivers made up of neighbors, extended family members, churches, area agencies on aging, and local businesses. “The right neighborhood can help sustain the idea of aging in place,” she says.

In 2007, the Center for Aging and Community, along with the Indiana Division of Aging, implemented programs for five NORCs located throughout Indiana.

A NORC, a term coined in the 1980s by sociologist Michael Hunt and his colleagues at the University of Wisconsin-Madison, is a neighborhood or building in which a large proportion of the residents are older adults. Although AARP estimates that about 5,000 NORCs exist across the country, it has also reported them to be “the most dormant and overlooked form of senior housing.” NORCs are not senior apartment complexes or retirement communities, nor are they designed to meet elder health and social service needs. Rather, they are communities where a critical mass of older individuals has either aged in place over many years or moved to spend the rest of their lives.

At the five locations selected by the University of Indiana, in both urban and rural settings throughout the state, 40% of neighborhood residents were over the age of 60. The sponsoring agencies assisted, trained, and consulted with the communities to develop NORC programs that would provide food and social services to residents. The agencies also awarded $75,000 to each of the five locations for startup costs to give those neighborhoods a boost.

“One thing we learned is that whatever you think the residents need, you can’t create and impose it upon them,” Miller says. “The philosophy of ‘if you build it they will come’ doesn’t work because in all our wisdom we can’t develop a program unless the inhabitants want it.”

What distinguishes NORCs from other forms of intentionally developed communal housing is the absolutely critical initial step of conducting a needs analysis of the local community. Researchers distribute surveys, conduct interviews, and hold focus groups with local churches, businesses, residents, and informal caregivers to gather information about how to obtain the most basic needs of food, shelter, water, healthcare, transportation, and socialization.

“The success of the NORC depends on the collaboration of the community stakeholders we pull together,” she says. “Social services, healthcare providers, elders themselves, funding sources, and governmental agencies all need to unite to create synergy.”

Each NORC, Miller says, developed its own identity according to differences among individuals and communities. The same guidelines of implementation needed to be carried out in different ways. For example, in several locations, providing food to NORC residents proved to be a struggle. “When people weren’t getting what they needed, we brought the local grocer to the table, where we might discover the company did free deliveries three days a week. You find solutions by doing a little digging and talking to people.”

The local area agencies on aging, Miller says, along with the Jewish Federation of Greater Indianapolis, also proved to be valuable resources. The bottom line is that “it is a lot more cost efficient to help people than to pay for institutional care,” she says.

NORC resident James Golder, the longtime chaplain at the Newhope Baptist Church in Hillsdale, an inner city area on the northeast side of Indianapolis, agrees. “If we would love and care for one another, the world would be a better place,” Golder says. Part of the larger Martindale Brightwood neighborhood, Hillsdale received one of the Indiana NORC grants. Every day, Golder walks to his church to mow and keep up the grounds. He cuts the grass for other elders in the community who can no longer do the work themselves or cannot afford to pay for the service. He even grows a seasonal garden to provide fresh vegetables to neighbors.

Miller sees NORCs as a win for older adults, a win for the community, and a win for the state of Indiana. She also sees an economic advantage. “If we kept just two people out of nursing homes in each community, then it paid off,” she says. “And if there are more communities created throughout the state, we want to show that we can do this effectively and for not much money.”

Cohousing — Community Living
Cohousing, according to the Cohousing Association of the United States based in Boulder, CO, is a “type of collaborative housing in which residents actively participate in the design and operation of their own neighborhoods.” The physical layout of residences encourages both social contact and individual space, and occupants are consciously committed to living as a community. Private homes contain all the features of conventional homes, but residents also have access to extensive common facilities such as open areas, courtyards, a playground, and a common house.

While communal housing for older adults is relatively new, intergenerational communities have been around since 1991, with about 5,000 people living in close to 85 cohousing units across the country. These neighborhoods are generally made up of about 40 households per community with older cohousing neighborhoods running a bit smaller.

Janice Blanchard, former director of the Denver Office on Aging, believes that cohousing communities resonate for many baby boomers, given that many left their parental homes to live together, sometimes with a lover, often with friends, delaying marriage and childbearing for years.

“Living in community is not a radical idea. In fact, it is our natural state,” Blanchard says. “Homo sapiens, like our ancestors before us, are a tribal, communal animal; it is unnatural as a species for humans to live alone.”

Laura Beck lives in EcoVillage at Ithaca, a cohousing community located in the Finger Lakes region of upstate New York. As a program director for Eden at Home, part of William Thomas’ nonprofit, Beck delivers educational seminars to improve quality of life for care partner teams. She has also written extensively on cohousing and aging in community.

“Cohousing is a model where people come together intentionally and go through a shared-intention living process. It’s not a commune; people own their own homes,” Beck says. “There is shared infrastructure including a common house within each neighborhood. Everybody owns a piece of it; it is an extension of our homes.”

Beck describes a pedestrian environment in which cars are kept away from the center of the neighborhood that is “very intergenerational,” with ages ranging from newborns to people in their mid-80s. Decisions that involve the shared infrastructure are made by consensus. “This is a great opportunity to see how the intergenerational dynamic plays out, watching children create relationships with elders that are not their own grandparents,” she says. “They can learn from each other, and it happens organically every day.”

Beck writes about the strong sense of ownership that residents develop through community building. Unlike developer-driven projects or NORCs, cohousing residents design a locality that reflects their needs. The process takes about two and a half to three years to complete and involves building relationships with neighbors long before the physical land exists. Developers may guide the planning process but the community’s mission and character, according to Beck, are in the hands of the residents.

Elder Cohousing — A Holistic Venture
Cohousing developments built exclusively for older adult residents, known as elderhoods, are the newest cohousing trend, although fewer than 20 exist throughout the country. These arrangements incorporate aspects of community service, social activism, and spirituality into their collective ethos. For example, ElderSpirit in Abingdon, VA, a development founded by a former nun now in her 70s, includes a spirit house for prayer and meditation. According to Beck, elder cohousing residents “are committed to a holistic view of aging.”

Group activities deal with illness and dying, allowing residents to collectively discuss how they will provide for one another over time. In an article titled “Elder Co-Housing: Building a Collaborative Elderhood,” Beck writes that unlike the more prescriptive models of continuing care retirement communities, elder cohousing offers a “grassroots approach that offers flexibility should residents need to respond quickly to changes in the community.”

The ideal way to handle the need to provide services for groups of frail elders at once, Beck suggests, would be to combine the support systems of cohousing with home healthcare services. “Borrowing from the best of both worlds, the result would be an integrated approach to providing care that is both efficient and comprehensive,” she writes.

An example of Beck’s ideal model exists at Glacier Circle in Davis, CA, the country’s first self-planned elder housing development. Its 12 residents plan to rent one of their units at below market value to a skilled nurse who will provide care.

Cultivating Relationships for Positive Aging
Dedicated to helping seniors age in place through the American Association of Homes and Services for the Aging’s (AAHSA) nonprofit, mission-driven members, Alisha Sanders recently conducted a study of three senior housing communities in the Denver area. Sanders serves as a policy and research analyst at AAHSA’s Institute for the Future of Aging Services, the applied research arm of the organization.

 At the selected locations, residents, most of whom are in their 80s, live on Social Security or small fixed incomes. Between 120 and 250 people inhabit each building in the apartment-style homes subsidized by the U.S. Department of Housing and Urban Development.

 Sanders unofficially terms these living arrangements “housing with services” and finds the congregate settings bringing people together in close proximity creates an additional advantage. In the Denver study, a variety of methods was used to link the residents to health and supportive services and to arrange social activities. “These housing arrangements are different than [sic] many other apartment complexes because there is so much going on that brings the people together,” she says.

Within each building, common areas shared by all residents are always bustling, Sanders says. According to a comprehensive report from the Denver study posted on the AAHSA Web site, a resident in a focus group following the study reported, “It’s like a big happy family here. We call it the Hover family.” A family member of another resident said, “My dad would say the camaraderie is the best part of this place.”

 Sanders recalls a service provider who usually observes a great deal of isolation and depression among older adults but discovered greatly reduced levels of loneliness at the Denver property where she worked. “From the residents’ point of view, the No. 1 thing they said was so important to them was the sense of community they had there,” Sanders says. “The neighborliness and the social activities are what many said kept them independent because they weren’t isolated and had so many opportunities for action.”

Investment in Social Capital
Housing with services, along with NORCs and elder cohousing, link affordable elder housing to health and supportive services and, most importantly, weave older adults into the fabric of the community.

Thomas calls communal living the next right answer for America for the reason that communities are sustained and supported by the people who live in them. Human relationships, he says, “go from being important to vital,” infusing mutual interdependence. “This is practical stuff,” he says. “The tool people use to create social capital is community. It’s true in tribes in South America and in midtown Manhattan. It’s about creating a new approach to aging in America that is not going to bankrupt the country.”

— Athan G. Bezaitis, MA, is a freelance writer based in southern California.

Aging and Community:  A Boomer-Friendly Trend
As baby boomers enter their 60s, many are becoming empty nesters, widowed, divorced, or yearning for something more than rambling around a house by themselves for the next 20 or 30 years. At family reunions and intimate gatherings of old friends, there is the familiar buzz—”What are you going to do? Where are you going to go? What’s next?”

Boomers on the cutting edge are (once again) buying property together, creating a variety of places that blend the best of privacy and communal sharing. From co-housing communities to golden girl homes to high-rise artist co-ops, boomers are redefining where and how they will live—breaking down the old stereotypes and rules, and building new visions of great places to grow old.

— Janice Blanchard, former director of the Denver Office of Aging, works full time on aging in the community and anticipates the release of her first book on the topic.