|
2005 White House Conference on Aging Solutions Forum
Long Beach, California
Center Director Jon Pynoos presented testimony at the May 13 Solutions Forum that was hosted by the American Occupational Therapy Association. In his prepared remarks, Dr. Pynoos enumerated three main barriers to aging in place. These obstacles were related to limitations in current legislation, organizational barriers in subsidized housing, and funding barriers.
Aging in Place
May 13, 2005
Jon Pynoos, Ph.D.,
Director, National Resource Center on Supportive Housing and Home Modification and Co-Director, Fall Prevention Center of Excellence, Andrus Gerontology Center, University Of Southern California
The dominant preference of older adults is to age in place, or to remain in one’s current home and community as long as possible. Such a strong attachment to place is understandable when length of tenure is taken into account; in 1996, 65% of elderly homeowners had lived in the same home for more than 30 years (AARP, 1996). For many such residents, their current housing represents a sense of security, neighborhood connections, and memories of a place where they raised a family.
Unfortunately, however, the housing stock is woefully inadequate to accommodate the needs of our rapidly growing aging population. For too long, we have been building housing that is inaccessible, unsafe, and unsupportive. I refer to this as “Peter Pan Housing”, designed for persons who will never grow old.
Components Needed to Facilitate Aging in Place
Enabling older adults to remain in their home and community is a complex task because it requires policy efforts on multiple fronts:
1. Need for a Supportive Environment
Approximately 1.14 million older persons with health and mobility problems have unmet needs for additional supportive features in their dwelling units (HUD, 1999). A large number of these older adults may find it impossible to safely age in place because of physically deficient housing conditions even though they value continuity in their living arrangements.
2. Need for Supportive Services
In addition to physically supportive environments, older persons may require personal assistance with tasks such as preparing meals, ambulating, bathing, and shopping. Many community-dwelling older adults are disconnected from needed services largely because l ong-term care policy in the U.S. lacks an emphasis on home and community-based services.
3. Need for a Range Of Housing Options in the Community
Aging in place requires a range of community-based housing alternatives such as affordable housing connected with services and assisted living. Maintaining older adults in the community is well-aligned with the Olmstead Decision issued by the Supreme Court in 1999 that requires states to provide services in the “most integrated setting appropriate” to the needs of persons with disabilities.
Barriers to Aging In Place
1. Limitations of Current Legislation
Government response to improving the suitability of conventional housing has been slow to evolve, limiting the ability of older adults to age in place. The Fair Housing Amendments Act of 1988 requires accessibility features in housing settings over four units and enables persons with disabilities to make “reasonable accommodations” in the retrofitting of existing multiunit dwellings. However, the law is vague on the definition of “reasonable”. In addition, it leaves out entirely single-family houses and smaller housing complexes in which a majority of older persons live.
2. Organizational Barriers in Subsidized Housing
Organizational barriers lead to difficulties in linking housing and services to help older adults age in place. A large number of agencies and entities such as HUD, various state-level departments (e.g., housing finance, community development, aging/human or social services), public housing authorities, AAAs, and community organizations have some level of involvement in financing and delivering housing and services. However, none is formally charged with coordinating or integrating a complex pool of limited resources and multiple providers. Furthermore, HUD has taken a “bricks and mortar” approach to housing and is reluctant to provide funding for services. This problem is underscored by the reality that savings that might result in health or service expenditures do not accrue to agencies that fund the development and operation of the housing.
3. Funding Barriers Need To Be Addressed
The ability to facilitate aging in place is difficult because Medicaid, the primary government program that pays for long-term care services, overwhelmingly funds nursing home care. In 2000, Medicaid spent $67 billion on long-term care, 75 % of which paid for nursing home and institutional care (Wiener, Tilly, And Alecxih, 2002). While nursing home care has become a form of entitlement, community-based care services are still optional. Moreover, Medicaid pays for only limited home modifications that can help prevent accidents such as falls, help caregivers, and promote independence.
Aging in place: strategies to support independence
Policy makers should support a range of strategies that target the home as well as the broader community.
1. Utilize Home Modifications
Increasing evidence suggests that home modifications can have an important impact on the ability of chronically ill or disabled persons to live independently. They can enhance independence, help prevent accidents such as falls, and facilitate caregiving. Home modifications are adaptations to the physical environment that improve accessibility and supportiveness. They include features that are supportive (e.g., grab bars and handrails). forgiving (e.g., carpeted floors), controllable by residents (individual thermostats at appropriate heights); and easy to use (e.g., places to sit while cooking).
2. Expand Service Coordination
Service coordination links residents of housing complexes and services. Services coordinated for residents include home-delivered meals, in-home supportive services, transportation services, and assistance with locating other living arrangements. Service coordinators successfully marshal a number of new services for residents. Policy makers should continue to support this strategy.
3. Develop Affordable Assisted Living
To address the needs of older adults for housing that provides on-site personal care services and 24 hour supervision as an alternative to nursing homes, we need to develop more affordable assisted living. Programs should be developed that both allow conversion of existing Section 202 projects into assisted living and develop new facilities that are able to use housing vouchers, Medicaid Waivers, and SSI payments to make them affordable.
4. Promote Visitability and Universal Designed Housing
Aging in place would be more feasible if supportive and adaptable settings were built in the first place. Unfortunately, we continue to develop single family housing and small town house complexes (four or fewer units), that are inaccessible and lack supportive features. This is penny wise and pound foolish. It is a deterrent to aging in place. For the future generations of the elderly and persons who experience disabilities, we need to build more appropriate housing in the first place. Such housing should follow the principles of Visitability by providing at a minimum an accessible first floor (e.g., zero step entrance, wide doors and corridors, accessible bathroom). It would be even better to embrace the principles of Universal Design by building in such features as non-skid tiles, walk in showers and multi-level counters. Enhanced efforts are necessary to encourage consumers that are building or remodeling houses to ask for these features. Although somewhat more costly initially, universal design, as applied to housing, will ultimately reduce later expenditures necessary for remodeling or retrofitting.
5. Create Elder-Friendly Communities
Understanding the needs of an older person requires the examination of more than just the individual, but the wider environmental settings in which the person lives. A considerable number of older people live in buildings or communities populated by large concentrations of the elderly. Most of these naturally-occurring retirement communities (NORCs) offer the opportunity to rebuild communities so that they are “elder-friendly” in terms of the presence of senior centers, available services, appropriate transportation, and convenient stores, churches, and parks. Equally important are the maintenance of sidewalks, the legibility of signage, and appropriate lighting. Future planning and policy initiatives must recognize the environmental context as key to healthy aging communities.
Summary
The dominant preference of older adults to “age in place” is largely absent as an explicit goal of U.S. long-term care policy. Systemic legislative, organizational, and funding issues hamper the development of a coherent policy on aging in place. However, there is increasing recognition that policy must de-emphasize institutional care and focus on supporting home and community-based care. The U.S. must move toward adopting comprehensive, national policies to support independent living on three fronts: 1) accessible and supportive home environments, 2) supportive services, and 3) a range of residential options in the community.
Home
|
