Home: Honoring elders means allowing them to age in place, in the communities
they helped build.
By Lise Funderburg
Metropolis
November 1996
Every morning, Victor Rohde descends five flights of stairs to the vestibule
of his Greenwich Village apartment house to retrieve the New York Times. He takes
the paper back upstairs, reads through it, and, weather permitting, heads out
to Abingdon Square Park for the rest of the morning.
For 103-year-old Rohde, these modest treks represent his sole contact with
the outside world. They serve as a walking diary of his life in the community
where he's always lived. He remembers the corner saloon, now a hair salon,
where beers cost a nickel and lunch was free. He remembers where the horse-drawn
trolleys stopped and when they were first replaced by electric cars and later
by buses. He was married a few blocks away at St. John's Lutheran Church;
he and his wife, who passed away last winter, lived in this one-bedroom apartment
for 70 years. They raised their daughter in this apartment, on this street,
in this neighborhood. Even the simple furniture in Rohde's narrow, tidy flat
holds decades of memories, evidence of a life fully lived, sharply contrasted
by the circumscribed world he now inhabits. But as isolated as this life
might seem, Rohde doesn't want to trade it for anything else -- not to move
in with his daughter in Staten Island (though they talk three times a day),
and certainly not for a nursing home.
The desire to stay independent, at home, and in a familiar neighborhood
is one that Rohde shares with 84 percent of U.S. residents over 55, according
to the American Association of Retired Persons (AARP). This is no small number;
the percentage of citizens older than 65 has tripled since the turn of the
century to nearly 13 percent today, and that group -- now some 33 million
-- will double by 2030. Social service providers, government officials, and
developers are scrambling to respond to the housing needs of America's elderly.
And the 1990 Americans with Disabilities Act (ADA) has helped, too, by raising
awareness about accessibility issues, which are central to the frail elderly
as well as the disabled.
But the unaccommodating nature of the young-and-abled world leads many older
people to self-segregate for safety and comfort. Marriott International has
built or purchased more than 80 assisted-living complexes, which are typically
atrium apartment buildings with gathering spaces inside and a semblance of
hotel hospitality at the door. Housekeeping and assistance with bathing are
available in the package, starting around $30,000 per year. Other elder-care
companies offer several options -- from basic apartments to round-the-clock
nursing -- on one site. A tenant might start with her own apartment, then
move two or more times as her frailty increases.
The Del Webb Corporation has built Sun City developments, for the "active
adult community... aged 55 and better," since 1960. There are now 10
Sun Cities, with golf courses, shopping centers, churches, and recreation
complexes, near resort-climate hubs such as Phoenix, Las Vegas, and Hilton
Head, South Carolina. Sun City homes run from $100,000 to $300,000. The average
age of residents is 65, and only one of these 10 developments offers assisted
care; in the others, the residents typically move out when they lose their
ability to live independently.
But a "retirement community," be it a suburban development or
a nursing home, doesn't appeal to everyone. The concept of "aging in
place," a term coined by social service providers, refers to older people
of varying abilities living independently, with convenient medical care,
in safe environments that adapt to their changing needs.
As the baby boom generation gets older and life spans increase (79 years
is now the average), it's harder to view aging Americans as a monolithic
group, says David C. Schiess, executive director of the American Seniors
Housing Association, a Washington, D.C.-based trade group for developers.
For example, Sunbelt retirement communities tend to serve a segment that
is younger, healthier, and wealthier than those who are living in the urban
centers of the Northeast, Schiess notes. He describes the trend defined by
the financially solid "young old": A couple moves to Florida after
retirement. They stay about 10 years, until one person dies (usually the
man). Then, Schiess says, "the widows move back to their home states,
where they have a support network of friends and family, or to where their
adult children live."
Housing developers have started to respond to this reverse migration, according
to AARP senior housing specialist Leon Harper. One approach is to select
sites that encourage family and community ties, he says. For instance, along
Route 95, a major artery in the Northeast, senior housing is springing up
all over. "Within 25 miles or so of cities such as New York and Philadelphia,
housing is being built so residents will still have access to their children,
their institutions, and their old communities," Harper points out.
Maintaining these ties has fiscal advantages for care providers, because
families step in where the staff would need to otherwise. When older tenants
are close to their families, friends, or helpful neighbors, Harper explains,
these caregivers provide as much as 80 percent of needed resources and services.
Another benefit, something that is well known in multigenerational communities
everywhere, is that in these strategically placed developments the elderly
have a sense of belonging, not a feeling of isolation often associated with
so-called "adult communities."
As we age we require specific services in order to thrive in any community.
Elders need food and drug stores nearby, good transportation, and access
to medical care. And while many older people seek the stimulation of the
younger generation, such interactions require free-flowing access to the
community.
Two decades ago, one New York doctor recognized these needs, and crafted
a multidisciplinary approach to serve the needs of a lower Manhattan neighborhood.
Since then, Philip Brickner has been piecing together Medicaid and Medicare
funds, hospital and private contributions, and volunteer time to coordinate
three overlapping programs from St. Vincent's Hospital. Nursing Home Without
Walls, Chelsea Village, and Living at Home work with the frail elderly in
their homes. Some 340 limited-income patients are enrolled in Dr. Brickner's
programs at any given time, usually for about two years. All the patients
are housebound, with the exception of Victor Rohde.
A team -- doctor, nurse, and social worker -- makes quarterly visits to
patients who live in Chelsea, Greenwich Village, Little Italy, and Chinatown.
The doctor and nurse administer medications, monitor chronic health problems,
and arrange for specialists to come by as needed. The social worker helps
sort out paperwork, from medical entitlements to eviction notices, and is
available for counsel throughout the year. During visits, the team identifies
hazards that can quickly end independence: a loose electrical wire or rug
that can be tripped over; a stair or bathtub that needs railings or handles.
In this way, they are designers, too, checking for potential threats but
also thinking in terms of ergonomics to make the environments comfortable
for their frail occupants.
Laura Sheppard, 94, who lives in an apartment complex in Chelsea, stays
at home thanks to the care of her 76-year-old only child, Viola, and the
Chelsea Village program. Laura Sheppard's longest walk each day is to the
kitchen, for breakfast. The Sheppards have occupied their apartment for the
last 45 years. Today, with her social worker's assistance, Viola Sheppard
is trying to arrange for a health- care attendant to come in two days a week,
so she can have a break.
Family members visit, but most of the women's time is spent on their own.
Even Viola Sheppard doesn't go out much, except to shop for food and to attend
church on Sundays. As with Rohde, most of the Sheppards' closest acquaintances
and friends have died or moved on. But this is their home and both would
rather live -- and die -- here than anywhere else. As long as they're able
enough to get out of bed (the fragile boundary line, Brickner says, between
part-time and round-the-clock care) and as long as the Chelsea Village team
comes by, that's what they'll do.
While Brickner's program isn't new, society's growing response to this group
is, and it's due in large part to the expanding political power of older
Americans. For example, 70 percent of registered voters over 50 voted in
the 1992 presidential election, whereas only 43 percent of those aged 18
to 24 did. And there's economic clout as well; some communities offer tax
breaks to developers of senior housing, encouraging the arrival of active
retirees with savings and pensions to spend locally.
But for the frail elderly, especially those with limited incomes, the Sun
City solution is out of the question. These people are not planning what
to wear on the golf course; they're wondering if they can get out of bed
and if the Social Security check will arrive in time to pay the rent. They
often have to negotiate within the limits of what Medicare and Medicaid will
provide. Medicaid now takes the full brunt of the $30,000 average annual
cost of a nursing home; such expenses have prompted federal and state governments
to recognize that people who may need assistance don't have to be institutionalized.
Just because a man can't cook doesn't mean he's ready for a nursing home.
If he lives in Oregon, Texas, California, or Maryland, states that have taken
the lead on this issue, he can choose from several exemplary programs that
provide home-based care.
Until recently, assisted living was a luxury restricted to those who could
afford it. "We're struggling to expand the concept into the general
population," Harper says, "so that no matter what your level of
income or what community you're in, that assistance is available to you." The
Philadelphia Corporation for Aging (PCA) is an example. Funded largely by
federal monies apportioned by the Older Americans Act of 1973 and by the
state lottery, PCA provides free home repair to low-income seniors. Such
programs benefit the neighborhood as well: consistent upkeep protects everybody's
property values.
On a broader scale, naturally occurring retirement communities (known as
NaRCs) are a new target for aging-in-place support. James Callahan, professor
of social policy at Brandeis University, has identified 22,000 such communities
across the country, where at least 45 percent of the heads of households
are 65 or older. The communities may evolve in a Manhattan high rise or in
a suburban enclave. Callahan is researching the feasibility of making age-related
adaptations, such as building ramps and lengthier walk signals, on a community-wide
basis. In the six years since the ADA was passed, some attention has been
paid to universal design and accessibility, but many places remain hostile
to those with impaired movement, sight, and hearing.
More than goodwill, economics are bound to be the primary motivation for
such modifications as well as for programs like Dr. Brickner's: typically,
caring for people in their own homes costs some 40 percent less than nursing
facilities.
That Dr. Brickner's typical patient runs up smaller bills than a local nursing
home would raises a morbid question: Year for year, his program might be
less expensive, but doesn't its success mean that people will live longer,
and thus cost society more? "If the intention is strictly to save money," Brickner
says sarcastically, "you might just as well take people out and shoot
them, and at a much earlier age. I mean, why wait until they're 80? Take
them out at age 50."
Of course, this is absurd. But Brickner believes our national obsession
with productivity prematurely discards older people. Some ethicists, he notes,
argue that money going into elder care would be better spent on curing childhood
diseases and birth defects. As America ages, the question of what sort of
life is worth living will be increasingly debated.
For Victor Rohde, a life worth living is one lived at home. Although he
walks to the square every day he can, gone are the warm nights when he would
get a beer from the corner and sit on the stoop with his neighbors. Now,
the other tenants are nice enough, he says, "but they go about their
business. It's a younger crowd." And though they helped him sort out
furniture after his wife died and invite him to brunches and parties, Rohde
would rather read mystery novels or the paper. "He's very private," says
nurse Theresa Maja, who heads the Chelsea Village program. But he is neither
isolated nor depressed; he's friendly, funny, quick, and seems quite happy
in his busy neighborhood. He wishes he could walk faster -- his pace is a
slow, short shuffle -- but he gets where he wants to go.
Leon Harper suggests that many of the younger and able-bodied have difficulty grasping the profound significance staying at home has for the elderly. Brickner, however, sees up close how much it matters: "People are desperate to avoid going into an institution. I've had patients say they'd rather die at home than live in a nursing home." Aging in place allows them some control over their lives, Harper says, "Even if it's just 'when I want to eat' or 'when I go to the bathroom' as opposed to highly scheduled institutional living. That takes away their whole sense of dignity." At home they can keep their sanity just by looking around them, remembering who they are and what they have accomplished.