Relevance to Centers for Independent Living (CILs)
CILs may assist older consumers with housing issues in several ways:
1. Assisting consumers to obtain personal care services,
2. Assistance in obtaining needed home modifications and identifying local contractors who provide quality services at a fair price
3. Identifying support groups and caregiver classes,
4. Providing other support that allows older consumers to remain in their homes.
This section discusses housing options and issues related to older adults, problems that may arise with different types of dwellings, options for personal assistance in their homes, and issues related to relocating.
Housing Options for the Older Adult | Housing Resources
Where we live affects our lives. It affects how likely we are to come into contact with other people. For example, a person in an apartment building could see people several times per day. An individual in a rural, single-family home may see people less frequently. The type of housing an individual resides in will determine the amount of effort needed to maintain the home. People residing in assisted living have different responsibilities than people in a single-family home or condominium. Some types of dwellings are easier to get around in than other types. A two-story home with an upstairs bathroom has mobility challenges that a ranch-style home or apartment building with an elevator does not have. There are many things for an older adult to consider when thinking about housing options. The purpose of this chapter is to introduce the reader to various environments where older adults live from an independent home to a nursing home and to discuss the challenges they may encounter in those environments.
What types of dwellings are older adults living in today? In a report by AARP, it was found that the majority of people over 45 live in single-family homes. Only 9% of people over 45 live in multi-unit buildings. This indicates that the majority of people as they age remain in their single-family homes. According to the U.S. Census on Housing, 89% of people over 55 reported they either strongly agree or somewhat agree they want to stay in their current residence as long as possible. This is an increase from 84% in 1992, a 5% increase in 8 years. As baby boomers age, this figure may continue to rise. Different age groups may have different expectations about aging, including where they will age. This is an important issue because of the increasing number of older adults and the rising costs of health care. Often, it is less expensive to offer an older adult services in the community to keep them independent and safe at home than it is to care for them in an institution. This is also important because centers for independent living (CIL) may be able to intervene and assist older adults in remaining independent in their homes either through direct services or referring seniors to appropriate agencies and businesses to get help.
An AARP survey reported people over 55 (86%) typically own their own homes and do not rent1. According to the U.S. Census on Housing, the number of elderly homeowners has risen over the last 20 years2. In 1970, 68 % of people 65 years and older in the United States owned the home they lived in as compared to 75% in 1990. These types of statistics may indicate that older adults have more buying power than they did previously. Home ownership is also an indicator of a long-term commitment to a community or residence.
What do people do if they find themselves needing assistance in caring for their home or themselves? There are a variety of options that someone who needs additional assistance may explore. The person may look at hiring help to come into the home. They may have modifications made to their existing home or purchase adaptive devices. They may look into other housing options that would provide more support and services. In the AARP housing survey, 82% of those surveyed responded that they would prefer to remain in their home if they needed assistance in caring for themselves1. Eight percent of those surveyed indicated that they or someone in their home had difficulty getting around the home. The most common mobility problem reported was climbing up and down stairs and the most common reason for mobility problems was arthritis. People who have difficulty going up and down stairs may benefit from having a bedroom and bathroom on the main floor. Sometimes when the main floor does not have a bathroom and remodeling is not an option, people with mobility difficulties utilize a bedside or portable commode. According to the AARP survey, of those respondents that lived in a dwelling other than a multi-unit building, 42% lived in a residence with 2 or more floors. However, 88% of respondents indicated that they have a bathroom on the main floor. A CIL could offer people information and referrals to help them adapt their environment to promote independence as they age.
Living with other people is also something older people may consider when dealing with housing issues. Living with others may offer benefits such as shared financial burden, shared household chores, and potential assistance with self-care. Older people who live with a spouse or family member are also less likely to have health problems and live in poverty2. The AARP housing survey found that 71% of people over 45 years old live with one or more other people1. Of the respondents that lived with another individual, 77% lived with their spouse. Some of these people may act as caregivers for their spouse or family member. They may benefit from support groups, caregiver classes, and peer counseling. CILs may offer some of these services or refer people to agencies that offer them.
Many older adults remain in their family home after retirement. The time they are most likely to sell their home and relocate is after their spouse dies or the individual moves to a nursing home . The pattern of older people remaining in their homes may increase with time and with the growing number of older adults. It may potentially become more difficult for the older adult to sell their home because the population of potential buyers will be smaller than the population of sellers.
Older adults who need assistance with some daily activities and still reside in a house may receive assistance from home care or an adult day program. Adult day programs can be very beneficial when an older adult requires assistance. Adult day services typically offer services such as supervision, meals, activities, and assistance with self-care like toileting and bathing. In addition, there are adult day centers that specialize in services for adults with dementia.
Home care may allow the individual who wishes to remain in their home a safe solution when they need extra support and services. There are many home care agencies across the country that provide skilled care and home support services. Skilled care is care that is directed by a doctor and provided by health care professionals. For example, a person receiving skilled care in their home may have home therapy from an occupational or physical therapist or they may have home nursing services. An individual receiving support services may have someone come to their home for housecleaning, meal preparation, or other tasks that need to be done for the resident to remain safe in their home. An individual receiving home care services may also obtain a combination of skilled and supportive services. They do not have to receive one or the other.
There are many advantages that apartment and town home type dwellings have for older adults. Apartments, condos, and town homes eliminate the need for the older adult to care for the home exterior. Most often, the home is on one floor, which is beneficial for the group of individuals that find climbing stairs a challenge. These dwellings often have fewer square feet than single-family homes, so there is less space to clean. There may be more opportunity for socializing with peers when living in an apartment or town home due to the close proximity of neighbors. Home health is also an available service for individuals who live in apartments, condominiums, and town homes.
There are a few disadvantages to weigh as well. Town homes may also have stairs to climb to get to second story bedrooms and bathrooms. Moving to an apartment or town home from a single-family home means leaving neighbors behind that may have become friends, leaving a house with many memories and familiarities, and downsizing of mementos accumulated over the years. Town homes and apartments may offer fewer options for home modifications.
Senior apartments are much like regular apartments except they may have a minimum age requirement for residency. They may also have features like a walk-in shower with a bath bench and hand held shower, lever door handles, call buttons or cords in the bathroom and bedroom, night lights, grab bars in the bathroom, and other features to help the older adult function independently and safely in their apartment. Some senior apartment complexes may have a floor of assisted living apartments and congregate meals. They may also offer more socialization opportunities. Home health services may be available to people in senior apartments.
Continuing care communities have a variety of dwellings and services that they offer. They usually guarantee the individual a lifelong residence. In a continuing care community, an individual can move from an independent living home to an assisted living residence to a skilled nursing facility. The person does not have to move in this specific order. For example, say an older woman is in her independent living apartment and falls. She is admitted to the hospital where they find she has a broken hip. The surgeons fix her hip and she remains in the hospital for a short time for therapy. She then moves to the skilled nursing facility to heal and for additional therapy to regain strength and function. When she has healed well and is functioning independently, she moves back into her independent living apartment. Sometimes individuals in this type of a situation may continue therapy as an outpatient at the rehabilitation department in the skilled nursing facility. They may actually be discharged home a little earlier than someone who resided in an independent living apartment who did not have a rehabilitation department so readily available.
The costs of a continuing care community can be expensive. Continuing care communities usually have an entrance fee and a monthly fee . The entrance fee is usually between $20,000 and $400,000. Monthly payments usually range from $200 to $2500 per month. Contracts vary from facility to facility.
The Assisted Living Quality Coalition defines an assisted living facility as:
A congregate residential setting that provides or coordinates personal services, 24 hour supervision and assistance (scheduled and unscheduled), activities, and health related services; designed to minimize the need to move; designed to accommodate individuals residents' changing needs and preferences; designed to maximize residents' dignity, autonomy, privacy, independence, and safety; and designed to encourage family and community involvement.
By this definition, there were 11,459 assisted living facilities in the United States in 1998 housing 521,500 residents6. The most common monthly rent was $1,582, which is about $19,000 per year. In 1997, 84% of people 75 and older had incomes of less than $25,000 per year. This obviously is not an affordable option for the majority of people over 74 years old. There are some assisted living facilities that cost less, but often those provide fewer services and offer less privacy.
The most common type of living quarters in an assisted living facility was a room, and the most common type of room was a private room with a full bath.6 The second most common type of living quarter was an apartment, and the most common type of apartment was a one-bedroom with single occupancy. In the survey, 73% of all the rooms and apartments were private and 62% had their own bathroom. Some people in assisted living share living quarters and bathrooms with other people. This is important to be aware of when thinking about older people with disabilities. There are older adults who have equipment that may need to be rearranged or removed to allow others to use the facilities. People who are blind may have difficulty locating items and navigating in the room if they live with others who rearrange the environment. These are potential problems because 25% of assisted living units are shared by 2 unrelated people and 38% of assisted living residents have to share a bathroom.
Less than half of assisted living facilities will take someone who needs help with transfers.6 Most will admit someone who uses a wheelchair or walker. In the majority of assisted living facilities, a person could move from fairly independent to needing help with bathing, dressing, and medications, as well as to using a wheelchair for locomotion. However, most assisted living facilities discharge a resident when they need help with transfers, demonstrate moderate to severe cognitive impairment, or display behaviors like wandering or resisting help with self-care.
The most common types of services assisted living facilities provide include: housekeeping, 2-3 meals per day, 24 hour staff, medication reminders, medication storage, assistance with medications, assistance with bathing, assistance with dressing, nurse on staff, and therapy services.6 These services may be provided by the facility itself.
Board and care homes are similar to assisted living facilities, but on a smaller more intimate scale. They are private homes that provide a room, meals, and assistance with daily activities and care. They may or may not be licensed. Some states allow board and care homes to offer some type of medical care, but they are not considered medical facilities.
About 30% of assisted living facilities in the United States are specialized in dementia care or have some sort of a dementia care unit. Certain things are available in dementia care assisted living facilities that may not exist in traditional assisted living facilities such as space for wandering, staff trained in dementia and dementia related issues, activities that are appropriate for people with dementia, and support for the families of the individual with dementia.
The majority of people entering a dementia care assisted living facility come from home or an independent-living retirement community.8 Most often when people are discharged from this type of a facility, they enter a skilled nursing facility. The primary reasons that people are discharged to a skilled nursing facility from a dementia care assisted living facility is that the person is needing a higher level of care than the facility is able to provide. Behaviors are a major factor in a resident being discharged to a skilled nursing facility, even when dementia care assisted living facilities are designed to handle problem behaviors.
Residents in dementia care assisted living facilities differ from people with dementia that are living in their homes in that they are older, more cognitively impaired, and more likely to need physical assistance or reorientation.8 They differ from people with dementia who are in skilled nursing facilities in that they are less cognitively impaired, are less dependent on caregivers, and have fewer additional diagnoses.
Skilled nursing facilities provide the highest level of care for residents. These facilities are regulated and licensed by the State Department of Public Health. They take a variety of payer sources from Medicare, Medicaid, private insurance, and out of pocket funds. They provide personal care, supervision, safety, and ambulation. They also have nursing services, therapy services, social workers, dieticians, doctors, activities personnel, and pastoral care. Some people enter a skilled nursing facility for a short time while they recover from an illness or injury or they enter as a long-term resident.
The National Nursing Home Survey of 1999 found that there were 18,000 nursing homes in the United States. On average, nursing homes in the U.S. have 105 beds and run at 87% occupancy. At the time of the survey, there were 1.6 million nursing home residents with 90% of them being over 65 years of age. The average daily charge to residents in nursing homes is $116 per day. Medicaid covers payment for the majority of nursing home residents. However, of people who are discharged from a nursing home, Medicare is the primary source of payment. These people are generally in the nursing home for short-term care while they recover from an illness or injury. They may be receiving therapy services while they recover.
Between 3-5 % of people over 65 years of age are admitted to a nursing home each year. Forty-five percent of women and 28% of men over 65 years of age will be admitted to a nursing home at some point in their life. Some factors that have been identified as predictors of nursing home admission include increased age, being female, living alone, being white, poor social support network, physical and mental impairment, functional impairment, and having certain medical conditions. CILs may be able to intervene to reduce some of these risk factors prior to the individual entering a nursing home. They may be able to connect seniors with other seniors and expand their social network. They may also be able to help people obtain assistive devices and offer training in their use to decrease an individual's level of functional impairment.
Dementia is a leading cause of nursing home admissions.8 There are other diagnoses as well that have been associated with entering a nursing home. They include bowel and bladder incontinence, rigidity, bradykinesia, behavioral disturbances, and dementia with depression. Falls have been associated with premature nursing home admission. CILs may be able to help older adults in decreasing their risk for falls in the home and out in the community. They may be able to offer training, education, or home modifications to reduce the risk of falling. CILs may also be able to refer seniors to agencies and organizations that would be able to offer similar services.
The majority of people admitted to a nursing home come from the hospital; the second place most people come from is a private or semi-private residence. If CILs are able to work with other agencies and use their expertise in promoting independence and safety, perhaps more older adults could remain in their homes or avoid hospitalization that would lead to a nursing home placement.
Thirty-three percent of people discharged from a nursing home in 1999 recovered and 24% were deceased9. The average length of stay in the nursing home for those who recovered was 62 days and the average length of stay for those who died was 568 days (just over a year and a half). Just prior to discharge, 80% of those discharged needed assistance with dressing and bathing, and 37% needed assistance with walking. This is important for CILs to know if they are involved in helping an individual transition from the nursing home to a community-based residence. These may be areas that need to be addressed.
In an article by Chapin & Dobbbs-Kepper (2001), the authors state that relocating especially to a nursing home, creates risk of depression and suicidal ideation in the older adult . Relocation has also been associated with weight loss, stress, isolation, grieving, and general decline. Relocation is expensive and people have to get rid of possessions due to limited space in their living quarters. These are all serious outcomes of relocating that must be weighed against the foreseen benefits of the older adult changing residences.
These range from a few hundred homes with a clubhouse to large, self-contained towns. The larger communities usually offer a variety of housing types, from free standing single-family homes to condominiums. In some communities, the homes offer features that are specifically designed with the older adult in mind, such as lever faucets and doorknobs, brighter lighting, ramps, and handrails. As these communities age with residents reaching their 80's and 90's, often home adaptations need to be made to accommodate the residents, like installing grab bars and ramps.
Retirement communities typically have an age restriction. The age restriction terms vary from community to community . Retirement communities also have community associations that take care of things like lawn and gardening, home maintenance, club memberships and maintenance, trash service, snow plowing, and some home utilities. There are association fees for retirement communities and the amount varies with the community.
Retirement communities often have a wide variety of activities offered. They offer activities such as golf, tennis, swimming, dancing, theater, ceramics, woodworking, biking, exercise rooms, and more. In addition, there are many opportunities to interact with peers.
People may relocate because of a life-changing event like becoming a widow or retiring and having a change in health status. There are three types of relocation that older adults usually make. The first move occurs after a couple has retired. At this time, they may move to a warmer climate and a community that caters to the older, active adult. The second move occurs when the older adult develops a chronic disability that limits their functional ability. At this point, the older adult typically moves closer to family for support. The third move occurs when the older adult has a severe disability or illness that can no longer be handled by the family or home care services. The older adult may move to an assisted living or nursing facility. Not all older adults make all of these moves in residence. However, these are some types of typical moves that an older adult may make.
Some of the negative reactions that the older adult may experience when moving include disorientation, anger, depression, confusion, illness, grief, and idealization of the old or new residence.15 Some of the factors that may influence the older adult's reaction to the move include his/her experience in planning for the move, what he/she thinks of the new residence, and how comfortable he/she is in their new home.
1AARP (2000, May). Fixing to Stay: A National Survey on Housing and Home Modification Issues. Retrieved June 29, 2004, from http://research.aarp.org/il/home_mod_1.html.
2Federal Interagency Forum on Aging-Related Statistics. Older Americans 2000: Key Indicators of well-Being. Federal Interagency Forum on Aging Related Statistics, Washington, DC: U.S. Government Printing Office. August 2000.
3Golant, S. (2002, Summer). Deciding where to live: the emerging residential settlement patterns of retired Americans. Generations, 66-73.
4Mayo Clinic (2003, July 1). Home care service: What is it and how do you find the right provider? Retrieved June 30, 2004 from http://www.mayoclinic.com/invoke.cfm?id=HO00084.
5AARP (n.d).. Housing choices: continuing care retirement communities. Retrieved July 7, 2004 from http://www.aarp.org/life/housingchoices/Articles/a2004-02-26-retirementcommunity.html.
6Hawes, C., Phillips, C., Rose, M., Holan, S., & Sherman, M. (2003). A national survey of assisted living facilities. The Gerontologist, 43 (6): 875-882.
7Department of Health and Human Services: Administration on Aging. (2004, March 9). Housing with services: board and care. Retrieved July 7, 2004 from http://www.aoa.gov/eldfam/Housing/Housing_Services/Board_Care.asp.
8Kopetz, S., Steele, C., Brandt, J., Baker, A., Kronberg, M., Galik, E., Steinberg, M., Warren, A., & Lyketsos (2000). Charcteristics and outcomes of dementia residents in an assisted living facility. International Journal of Geriatric Psychiatry, 15: 586-593.
9Jones, A. The National Nursing Home Survey: 1999 summary. National Center for Health Statistics. Vital Health Stat 13 (152). 2002.
10Tinetti, M & Williams, C. (1997). Falls, injuries due to falls, and the risk of admission to a nursing home. New England Journal of Medicine, 337 (18): 1279- 1284.
11Rubenstein, L.Z., & Josephson, K.R. (2002). Epidemiology of falls and syncope. Clinics in Geriatrics Medicine, 18: 141-58.
12Jones, A. The National Nursing Home Survey: 1999 summary. National Center for Health Statistics. Vital Health Stat 13 (152). 2002.
13Chapin, R. & Dobbs-Kepper, D. (2001). Aging in place in assisted living: philosophy versus policy. The Gerontologist, 41 (1): 43-50.
14Seniorresource.com (1996-2004). Adult retirement communities. Retrieved July 7, 2004 from http://www.seniorresource.com/hasc.htm.
15Ohio State University Extension. (n.d). When seniors relocate. Retrieved July 7, 2004 from http://ohioline.osu.edu/ss-fact/0143.html.
An agency in the U.S. Department of Health and Human Services. The AoA is part of a federal, state, tribal and local partnership called the National Network on Aging. The AoA is one of the nation's largest providers of home- and community-based care for older persons and their caregivers. On their website, the AoA offers descriptions of various types of housing options. They also provide links to additional resources. This information is available at www.aoa.gov. Click on the subheading "Elders and Families" and then click on the heading "housing."