By Richard Peck
As people age and become more frail, the issue of housing becomes more important.
A home that might have been safe when someone was younger might become too difficult to manage. A suburban neighborhood that was a wonderful place to raise children can become isolating and inconvenient if someone doesn’t drive any longer.
The nexus between housing and health is evident in assisted-living centers or nursing homes, which take care of people with minor or substantial physical limitations who require regular assistance.
But even when older people are independent, housing arrangements can affect health by influencing their access to medical care, engagement in activities, social connections and other components of well-being.
Senior housing options have proliferated over the past several decades and it’s important to understand what’s available or being planned in your community. What follows is a general description of the choices available. (A separate tip sheet will examine issues surrounding aging-in-place.)
♦ New Models for Senior Housing: Green House/Small House
♦ Continuing Care Retirement Communities (CCRCs)
Independent Living
Senior housing for independent living has many flavors. They include:
Active aging communities, such as Sun City, Ariz., accommodate younger seniors (in their 60s, primarily) who are physically independent and able to afford high entry fees and monthly rentals.
Active aging communities have been hit by the recession and the housing crisis limiting seniors’ ability to afford them.
Affordable senior apartments are largely government supported via Department of Housing and Urban Development (HUD) financing. Varieties include HUD Section 8 for low-income, HUD Section 202 for low-to-moderate income and HUD funding for on-property service coordinators.
Intergenerational housing ranges from accommodations added for seniors in private homes (including “granny flats”) to campuses designed to emulate traditional multi-generational neighborhoods.
HUD is financing some of these as a demonstration project called Elderly Housing for Intergenerational Families.
Senior cohousing communities are based on the condominium model but offer richer services and greater resident involvement. Projects have sprung up recently in states such as California, Colorado, New Mexico, Virginia and Oklahoma.
Story idea: A natural tension is developing between the needs-based development of senior housing in various communities and a “not in my back yard” backlash by community residents fearful of the impact of these projects on their neighborhood’s traffic patterns and overall character. Watch for these conflicts at local zoning and planning board meetings.
Information sources:
- International Council on Active Aging
- Intergenerational Housing Needs and HUD Program Options (report to Congress)
- National Association of Home Builders
- Department of Housing and Urban Development
- Senior Cohousing
- Cohousing
Assisted Living
Assisted living facilities provide (ALFs) provide personal assistance to people who need help with two or three “activities of daily living” (classically defined as feeding, dressing, bathing, toileting, ambulation and continence).
In recent years, assisted living has grown to encompass care of individuals with Alzheimer’s or other dementias at so-called “memory care” facilities.
ALFs have been under the microscope lately for poor quality care that involves egregious neglect and abuse of elderly residents, including fatalities. The Miami Herald’s series on deficiencies in assisted living is only one of similar reports from several other states over the years.
Key issue: ALFs are not as highly regulated as nursing facilities. Inspections and criteria are enforced by states with varying degrees of specificity and intensity. There is no federal oversight, as there is with nursing facilities (skilled and otherwise).
Assisted living is primarily financed privately, by families themselves. Costs run in the neighborhood of $40,000 a year. Medicaid in some states provides assisted-living support but this is not typical.
Story idea: Assisted living is growing faster than all other types of senior housing. But while the need is increasing, few people have set aside enough funds to pay for this type of care. This will provoke a financial crisis for many American families in the fairly near future.
Information sources:
- Assisted Living Federation of America
- National Center for Assisted Living
- Assisted Living Consumer Alliance
- CCAL – Advancing Person-Centered Living
- National Long-Term Care Ombudsman Resource Center
Memory Care
Specialized memory care facilities have been set up as a middle ground between assisted living and skilled nursing facilities for people with mild-to-moderate Alzheimer’s disease and other dementias. Like assisted living, they are mostly private pay.
(More severe dementia cases are best managed in skilled nursing facilities. In this setting, Medicaid is often the primary payer.)
Memory care units comprise the fastest-growing segment of long-term care. A survey of 80 top senior living providers disclosed that 17 percent of their residents live in special memory care units.
Story idea: People entering the early and middle stages of Alzheimer’s disease are burgeoning in numbers, accounting for the growing interest in specialized facilities and programs. Alzheimer’s medications are still limited in duration and effectiveness, so there is growing interest in behavioral management methods, including Montessori, computerized brain health exercises and the sensory stimulation of Snoezelen, a Scandinavian innovation.
Information source:
- Alzheimer’s Association
- Assisted Living Source (directory of memory care units)
New Models for Senior Housing: Green House/Small House
Green House and Small House are more “homelike” alternatives to nursing homes or large, multi-unit assisted-living facilities. Green Houses, which have been around since the mid-1990s and have spread to at least two dozen sites nationwide, are laid out with a central living/dining/activities area surrounded by 10 or 12 private bedrooms.
Dedicated staff serve residents in need of chronic care at the assisted living/nursing home level 24/7.
The Small House is a more flexible version of the Green House model: It can be somewhat larger and tied more directly to a nursing home’s staff and operations.
The National Alliance of Small Houses (NASH) is opening a training center for would-be administrators and staff in Northampton, Mass., this year.
Story idea: The stereotypical gloomy, hospital-like nursing home is giving way (slowly) to a household-like setting for long-term care. With this has evolved new thinking about appropriate management of these round-the-clock facilities, including more personal involvement with residents and more independent decision making by staff.
Information sources:
Continuing Care Retirement Communities (CCRCs)
CCRCs are campuses that provide various levels of senior housing and care, including independent living apartments, assisted living and full-scale skilled nursing homes.
CCRCs typically provide services such as dining, laundry, exercise facilities, libraries and activities centers with their extent and variety varying from one campus to the next.
CCRCs are financed primarily by entrance fees totaling hundreds of thousands of dollars and monthly rentals of several thousand a month. They’re an option, obviously, for relatively well-off retirees.
Regulation of CCRCs varies and typically involves state agencies responsible for overseeing assisted living facilities and nursing homes.
Story idea: CCRCs have encountered financial difficulties because of the housing crisis and the recession. They are also challenged by growing competition from independent living arrangements that offer an increasingly robust array of home-based healthcare services.
Story idea: The New York Times recently called attention to segregation that can occur in CCRCs. Residents of independent living may not want to dine or share activities with assisted living or nursing home residents with obvious disabilities. Or, management may institute policies that restrict the rights of residents to dine where they like or engage in joint activities.
Information sources:
- Directory of Continuing Care Retirement Communities
- Continuing Care Retirement Communities: What they are and How they Work (AARP)
- Continuing Care Retirement Communities: Risks to Seniors (U.S. Senate, Special Committee on Aging)
- LeadingAge
- National Long-Term Care Ombudsman Resource Center
Skilled Nursing Facilities
Nursing homes are financed primarily by Medicare (for short-term post-acute services) and Medicaid (for chronic care), with a modicum of private pay and private insurance. The cost can run up to $100,000 a year.
The quality of nursing home care is an ongoing concern, with for-profit facilities of late coming under a harsh spotlight. Nursing homes are governed by tough federal regulations under a survey system administered by the states, but enforcement state-to-state varies.
Skilled nursing facilities provide “post-acute” services, such as rehabilitation (physical, occupational and speech therapy) and cardiac monitoring, for up to 100 days. Some SNFs provide renal dialysis under Medicare’s End-Stage Renal Disease program.
SNFs’ post-acute services have become financially challenged, with recent Medicare payment reductions of 11.1 percent and regulatory pressure to economize on rehabilitation service delivery. SNFs are also under pressure to assist hospitals in reducing hospital readmission rates, producing Medicare savings envisioned under the Accountable Care Act.
SNFs are also grappling with proposed cuts in Medicaid, their principal payment source, by economically-challenged states. Combined Medicare/Medicaid cuts are forcing facilities to trim staff and operations, possibly threatening quality of care or continuing availability of that care.
Story tip: Watch for SNFs either establishing close partnerships with hospitals or developing additional clinical expertise to secure Medicare referrals and buttress their financial survival. By the same token, watch for SNFs reducing staff and encountering regulatory pushback or going out of business altogether.
Story tip: The number of nursing homes has been declining in recent years, and some experts now predict a shortage of nursing home beds for aging baby boomers down the road. Accompanying this trend is an expansion of home and community based services that offer increasingly complex medical services and long-term care supports in people’s homes.
Information sources:
- American Health Care Association
- LeadingAge
- Alliance for Quality Nursing Home Care
- Consumer Reports Nursing Home Guide
- The National Consumer Voice for Quality Long-Term Care
- Advancing Excellence in America’s Nursing Homes: Consumer Action Plan
- Nursing Home Compare (from Medicare)
- National Long-Term Care Ombudsman Resource Center
Richard L. Peck has covered aging-related topics for 30 years as editor of Geriatrics and editor-in-chief/contributing editor of Long-Term Living (formerly Nursing Homes/Long Term Care Management).
