Living Arrangements of the Older Population

Living Arrangements of the Older Population

The vast majority of older Americans live independently in the communitythey are not institutionalized in facilities such as nursing homes or retirement homes. According to data from the 2005 Current Population Survey (http://www.bls.gov/cps/) and the 2005 American Community Survey (http://www.census.gov/acs/www/), the U.S. Census Bureau estimates that less than 5% of the population aged sixty-five and over live in nursing homes. An additional 5% live in some type of senior housing, which frequently offers supportive services for residents. The U.S. Administration on Aging (AoA), in A Profile of Older Americans: 2006 (March 2007, http://www.aoa.gov/PROF/Statistics/profile/2006/2006profile.pdf), notes that even though the overall numbers of older Americans living in nursing homes is smallnearly 1.6 million people, or 4.5%, who were sixty-five and older in 2000the percentage of older adults in nursing homes increases dramatically with advancing age, from 1.1% of sixty-five- to seventy-four-year-olds, to 4.7% of people aged seventy-five to eighty-four, to 18.2% of those aged eighty-five and older.

The living arrangements of older adults are important because they are closely associated with their health, well-being, and economic status. For example, older adults who live alone are more likely to live in poverty than those who live with their spouse or other family members. Older adults living alone may also be socially isolated, and their health may suffer because there are no family members or others nearby to serve as caregivers.

LIVING WITH A SPOUSE, OTHER RELATIVES, OR ALONE

Table 3.1 shows that 23.1 million out of 113.1 million householdsor one in fivewere headed by a person aged sixty-five or older in 2005. It also shows a consistent increase in the number of households headed by people aged seventy-five and older, from 8.4 million in 1990 to 11.6 million in 2005.

According to the AoA, in A Profile of Older Americans: 2006, more than half (54.8%) of community-dwelling, civilian (noninstitutionalized) older adults lived with their spouse in 2005. Significantly more older men than women10.9 million (71.7%) of older men, compared to 8.4 million (42%) of older womenlived with their spouse. (See Figure 3.1.) This disparity occurs because women live longer than men, are generally younger than the men they marry, and are far less likely to remarry after the death of a spouse, largely because there are relatively few available older men. Among adults aged seventy-five and older, less than one-third (30.2%) of women were living with their spouse in 2005.

In addition, the proportion of older adults living with their spouse decreased with age. Census Bureau data reveal that in 2005, 11.7 million (63%) of adults aged sixty-five to seventy-four lived with their spouses, compared to 7.5 million (45%) of adults aged seventy-five and older. (See Table 3.2.)

In A Profile of Older Americans: 2006, the AoA reports that in 2005, 10.6 million (30.1%) of community-dwelling older adults lived alone, including 7.7 million women and 2.9 million men. They represented 38.4% of older women and 19.2% of older men. Not surprisingly, the percentage of older adults who live alone rises with age. Nearly half of women aged seventy-five and over (47.7%) lived alone in 2005. Figure 3.2 shows that the percentage of women aged seventy-five and over living alone rose from 37% in 1970 to 54% in 1990 but decreased slightly by 2004, when the figure stood at just under 50%. During the same period the percentage of older men aged seventy-five and over living alone remained relatively stable until 2000, when it increased somewhat from 21% to 23% in 2004.

Race and ethnicity play a role in the living arrangements of older adults. In 2005 older African-American and non-Hispanic white adults were more likely to live

2005
Age of householder and size of household 1990 1995 2000 Totala Whiteb Blackb Asianb Hispanicc Non-Hispanic Whitec
aIncludes other races, not shown separately.
bBeginning with the 2003 Current Population Survey (CPS), respondents could choose more than one race. 2005 data represent persons who selected this race group only and exclude persons reporting more than one race. The CPS in prior years only allowed respondents to report one race group. See also comments on race in the text for this section.
cHispanic persons may be of any race.
       Total 93.3 99.0 104.7 113.1 92.7 13.8 4.1 12.2 81.4
Age of householder:
       15 to 24 years old 5.1 5.4 5.9 6.7 5.1 1.1 0.2 1.2 4.0
       25 to 29 years old 9.4 8.4 8.5 9.1 7.2 1.3 0.4 1.6 5.7
       30 to 34 years old 11.0 11.1 10.1 10.1 7.8 1.4 0.5 1.7 6.2
       35 to 44 years old 20.6 22.9 24.0 23.2 18.6 3.0 1.1 3.1 15.7
       45 to 54 years old 14.5 17.6 20.9 23.4 19.1 3.0 0.8 2.1 17.1
       55 to 64 years old 12.5 12.2 13.6 17.5 14.7 1.9 0.6 1.3 13.5
       65 to 74 years old 11.7 11.8 11.3 11.5 9.8 1.2 0.3 0.7 9.1
       75 years old and over 8.4 9.6 10.4 11.6 10.4 0.9 0.2 0.5 9.9
One person 23.0 24.7 26.7 29.9 24.1 4.3 0.7 1.9 22.4
       Male 9.0 10.1 11.2 12.7 10.2 1.8 0.3 0.9 9.3
       Female 14.0 14.6 15.5 17.2 13.9 2.5 0.4 1.0 13.0
Two persons 30.1 31.8 34.7 37.2 31.7 3.7 1.1 2.7 29.3
Three persons 16.1 16.8 17.2 18.3 14.6 2.4 0.9 2.4 12.4
Four persons 14.5 15.3 15.3 16.5 13.4 1.9 0.8 2.5 11.1
Five persons 6.2 6.6 7.0 7.2 5.8 0.9 0.3 1.6 4.4
Six persons 2.1 2.3 2.4 2.5 1.9 0.4 0.1 0.7 1.2
Seven persons or more 1.3 1.4 1.4 1.4 1.0 0.2 0.1 0.4 0.6

alone than older Hispanic and Asian adults1.1 million (36%) older African-American and 8.7 million (31%) older non-Hispanic white adults, compared to 492,000 (22%) older Hispanic and 170,000 (16%) older Asian-American adults. (See Table 3.2.)

Among the racial and ethnic groups, in 2004 older Hispanic and African-American women were the most likely to live with relatives other than a spouse (36% and 33%, respectively). (See Figure 3.3.) The living arrangements of older men broke down somewhat differently along racial and ethnic lines than did those of older women. Older African-American men were two and a half times more likely to live alone than were older Asian men (27% versus 10%). Like older Hispanic women, however, older Hispanic men were the most likely of any group of older men to live with relatives other than a spouse (16%).

Multigenerational Households

In the press release "Grandparents Day 2003: Sept. 7" (August 25, 2003, http://www.census.gov/Press-Release/www/releases/archives/facts_for_features_special_editions/001330.html), the Census Bureau states that in 2003 there were 3.9 million multigenerational households (4% of all households), such as grandparents living with children and grandchildren, in the United States. Many of these households included older relatives such as great-grandparents, uncles, and aunts. The Census Bureau finds that such multigenerational households are frequently located in areas where new immigrants live with relatives or where housing shortages or high costs force families to double up their living arrangements, or in areas with high rates of out-of-wedlock children and the unwed mothers live with their parents.

Mireya Navarro, in "Many Families Are Adding a Third Generation to Their Households" (New York Times, May 25, 2006), asserts that even though multi-generational households remain uncommon, they are growing in popularity in some parts of the United States, especially in areas with substantial immigrant populations and in states with higher than average costs of living such as California. Navarro observes that homebuilders are not only designing houses to accommodate low-income multigenerational families but also multimillion-dollar homes for wealthier families wishing to accommodate relatives. Still, many such living situations are driven by financial need and the multigenerational housing trend has likely increased in response to increased housing prices.

Grandparents Raising Grandchildren

InGrandparents Living with Grandchildren: 2000 (October 2003, http://www.census.gov/prod/2003pubs/c2kbr-31.pdf), Tavia Simmons and Jane Lawler Dye of the Census Bureau report that in 2000, 5.8 million grandparents lived with grandchildren under eighteen years of age. Forty-two percent of them (2.4 million) were responsible for their grandchildrenthey had assumed the role of primary parents in their grandchildren's lives.

The AARP conducts research about grandparenting through its Grandparent Information Center. In State Fact Sheets for Grandparents and Other Relatives Raising Children (October 2006, http://www.giclocalsupport.org/pages/state_fact_sheets.cfm), the AARP indicates that 4.5 million children live in households headed by grandparents and another 1.5 million children live with other relatives.

GRANDPARENTS' RIGHTS.

The high rate of divorce in the United States has caused many grandparents to become separated from their grandchildren. As a result, some grandparents have sought visitation rights to their grandchildren. Since the 1980s a growing number of cases have been heard in the courts, prompting most states to enact legislation governing how and when grandparents may see their grandchildren. At issue is whether fit parents can be legally forced to allow grandparents to visit grandchildren. In most states grandparents must show that visitation is in the best interest of the child. In Georgia grandparents must show that the children would suffer harm if they were denied visits.

In Troxel v. Granville (530 U.S. 57 [2000]), the U.S. Supreme Court heard arguments to decide whether non-parents, including grandparents, could legally sue for child visitation rights. Under a state of Washington statute that allows anyone to petition for the right to visit a child at any time, Jennifer and Gary Troxel petitioned for the right to visit their two granddaughters more often than Tommie Granville, the girls' mother, desired. A Washington superior court, which was authorized under the statute to grant visitation rights when a child's best interest might be served, granted the Troxels additional visitation. Granville appealed the ruling, which was overturned based on the court's decision that nonparents could not sue under the statute. The Washington Supreme Court agreed with the ruling and declared the statute unconstitutional because it interfered with parents' right to rear their children. The question of the statute's constitutionality was brought before the U.S. Supreme Court, which concluded in a 6 to 3 decision that it violated the due process clause of the Fourteenth Amendment, under which parents would have the right to make decisions about the care, custody, and control of their children. In her opinion, Justice Sandra Day O'Connor (1930) wrote that "the liberty interest at issue in this casethe interest of parents in the care, custody, and control of their childrenis perhaps the oldest of the fundamental liberty interests recognized by this Court." Essentially, the Court left grandparents with little or no recourse in trying to win visitation rights.

HOMELESSNESS

According to the U.S. Department of Housing and Urban Development's Office of Community Planning and Development, in The Annual Homeless Assessment Report to Congress (February 2007, http://www.huduser.org/Publications/pdf/ahar.pdf), less than 2% of people age sixty-two and older were homeless during a three-month study periodFebruary to April 2005compared to 15% of the total population of homeless Americans. Older Americans may be less likely than younger ones to be homeless because social programs such as Social

Living arrangement Total 15 to 19 years old 20 to 24 years old 25 to 34 years old 35 to 44 years old 45 to 54 years old 55 to 64 years old 65 to 74 years old 75 years old and over
aIncludes other races and persons not of Hispanic origin, not shown separately.
b2005 data represent persons who selected this race group only and excludes persons reporting more than one race.
cPersons of Hispanic origin may be of any race.
       Totala 230,261 20,652 20,392 39,283 43,313 41,924 29,513 18,375 16,808
Alone 29,859 135 1,367 3,772 3,912 5,162 4,922 4,212 6,378
With spouse 19,026 201 3,248 20,268 28,084 27,752 20,194 11,752 7,526
With other persons 81,376 20,316 15,777 15,243 11,317 9,010 4,397 2,411 2,904
Whiteb 187,550 15,949 15,959 30,764 34,727 34,496 24,975 15,741 14,940
Alone 24,148 90 1,008 2,779 3,004 4,004 4,045 3,525 5,693
With spouse 102,435 173 2,843 16,988 23,569 23,753 17,702 10,467 6,941
With other persons 60,967 15,686 12,108 10,997 8,154 6,739 3,228 1,749 2,306
Blackb 27,184 3,152 2,847 5,093 5,373 4,853 2,906 1,715 1,243
Alone 4,332 38 249 669 701 958 643 555 519
With spouse 8,555 13 214 1,524 2,199 2,194 1,401 696 314
With other persons 14,297 3,101 2,384 2,900 2,473 1,701 862 464 410
Asianb 9,930 789 823 2,249 2,175 1,707 1,094 645 447
Alone 774 5 52 209 124 79 137 66 104
With spouse 5,732 5 88 1,240 1,681 1,324 748 439 209
With other persons 3,424 779 683 800 370 304 209 140 134
Hispanic originc 29,601 3,378 3,675 7,636 6,242 4,159 2,316 1,316 878
Alone 1,921 14 135 367 300 325 288 255 237
With spouse 13,719 78 821 3,969 3,836 2,535 1,407 733 340
With other persons 13,961 3,286 2,719 3,300 2,106 1,299 621 328 301
Non-Hispanic Whiteb, c 160,084 12,881 12,612 23,651 28,903 30,618 22,814 14,509 14,097
Alone 22,402 80 885 2,447 2,734 3,715 3,780 3,300 5,461
With spouse 89,570 103 2,086 13,281 19,955 21,375 16,381 9,773 6,618
With other persons 48,112 12,698 9,641 7,923 6,214 5,528 2,653 1,436 2,018

Security, Supplemental Security Income (SSI), Medicare, and senior housing act to prevent homelessness.

Among the concerns about homelessness are the inherent health-related issues. The relationship between homelessness, health, and illness is complex. Some health problems precede homelessness and contribute to it, whereas others are consequences of homelessness; in addition, homelessness often complicates access and adherence to treatment. For example, mental illness or substance abuse (dependency on alcohol or drugs) may limit a person's ability to work, leading to poverty and homelessness. Without protection from the cold, rain, and snow, exposure to weather may result in illnesses such as bronchitis or pneumonia. Homelessness increases exposure to crime and violence, which could lead to trauma and injuries.

There are many reasons that homeless people experience difficulties gaining access to health-care services and receiving needed medical care. Lacking essentials such as transportation to medical facilities, money to pay for care, and knowledge about how to qualify for health insurance and where to obtain health-care services makes seeking treatment complicated and frustrating. Psychological distress or mental illness may prevent homeless people from attempting to obtain needed care, and finding food and shelter may take precedence over seeking treatment. Even when the homeless do gain access to medical care, following a treatment plan, filling prescriptions, and scheduling follow-up appointments often present insurmountable challenges to those who do not have telephone numbers, addresses, or safe places to store medications.

Furthermore, because chronic (long-term) homelessness can cause or worsen a variety of health problems, homeless people may not live to old age with the same frequency as their age peers who are not homeless.

LONG-TERM CARE, SUPPORTIVE HOUSING,
AND OTHER RESIDENTIAL ALTERNATIVES

Spouses and other relatives are still the major caretakers of older, dependent members of American society. However, the number of people aged sixty-five and older living in long-term care facilities such as nursing homes is rising, because the older population is increasing rapidly. Even though many older adults now live longer, healthier lives, the increase in overall length of life has increased the need for long-term care facilities and supportive housing.

Growth of the home health-care industry in the early 1990s only slightly slowed the increase in the numbers of Americans entering nursing homes. Supportive housingassisted living, congregate housing, and continuing-care retirement communitiesoffer alternatives to nursing home care. The overarching goal of supportive housing is to enable older adults to receive needed assistance while retaining as much independence as possible.

There are three broad classes of supportive housing for older adults. The smallest and most affordable options usually house ten or fewer older adults and are often in homes in residential neighborhoods. Residents share bathrooms, bedrooms, and living areas. These largely unregulated facilities are alternately known as board-and-care facilities, domiciliary care, personal care homes, adult foster care, senior group homes, and sheltered housing.

Residential care facilities, assisted living residences, and adult congregate living facilities tend to be larger, more expensive, and offer more independence and privacy than board-and-care facilities. Most offer private rooms or apartments as well as large common areas for activities and meals.

Continuing care retirement communities and life care communities are usually large complexes that offer a comprehensive range of services from independent living to skilled nursing home care. These facilities are specifically designed to provide nearly all needed care, except for hospital care, within one community. Facilities in this group tend to be the most costly.

Nursing Homes

Nursing homes fall into three broad categories: residential care facilities, intermediate care facilities, and skilled nursing facilities. Each provides a different range and intensity of services:

  • A residential care facility (RCF) normally provides meals and housekeeping for its residents, plus some basic medical monitoring, such as administering medications. This type of home is for people who are fairly independent and do not need constant medical attention but need help with tasks such as laundry and cleaning. Many RCFs also provide social activities and recreational programs for their residents.
  • An intermediate care facility (ICF) offers room and board and nursing care as necessary for people who can no longer live independently. As in the RCF, exercise and social programs are provided, and some ICFs offer physical therapy and rehabilitation programs as well.
  • A skilled nursing facility (SNF) provides around-the-clock nursing care, plus on-call physician coverage. The SNF is for patients who need intensive nursing care, as well as such services as occupational therapy, physical therapy, respiratory therapy, and rehabilitation.

NURSING HOME RESIDENTS.

Conducted by the National Center for Health Statistics, the National Nursing Home Survey is a continuing series of national sample surveys of nursing homes, their residents, and their staff. The surveys were conducted in 197374, 1977, 1985, 1995, 1997, and 1999. The latest survey was conducted in 2004, and its findings were published in December 2006. Even though each survey has a different focus, all of them offer some basic data about nursing home residents.

The nation's 16,100 nursing homes had occupancy rates of 86.3% in 2004, and housed nearly 1.5 million residents. (See Table 3.3.) Close to ten thousand were private facilities and sixty-two hundred were voluntary nonprofit or government-owned facilities. More than half of the nursing homes (54.2%) were part of a chain of facilities, and the remaining were independent. The distribution of nursing homes varies by geographythe South and Midwest are home to nearly twice as many facilities as the Northeast and West. (See Table 3.4.)

DIVERSIFICATION OF NURSING HOMES.

To remain competitive with home health care and the increasing array of alternative living arrangements for older adults, many nursing homes have begun to offer alternative services and programs. Table 3.5 shows that more than half of all nursing homes offer specialty units or programs such as hospice (end-of-life) care, pain management, and skin wound treatment programs. About fifty-one hundred (32%) offer units for people suffering from Alzheimer's disease or another dementia. (Alzheimer's disease is a progressive form of dementia, characterized by impairment of memory and intellectual functions.)

Collaborating with other providers of health-care services or on their own, many nursing homes also offer services such as adult day care and visiting nurse services for people who still live at home. Other programs include respite plans that allow caregivers who need to travel for business or vacation to leave an older relative in the nursing home temporarily.

INNOVATION AND RECREATIONAL SERVICES IMPROVE QUALITY OF LIFE FOR RESIDENTS.

Even though industry observers and the media frequently decry the care provided in nursing homes, and the media publicizes instances of elder abuse and other quality of care issues, several organizations have actively sought to develop models of health service delivery that improve the clinical care and quality of life for nursing home residents.

In 2004 most nursing homes offered a broad range of activities for residents. More than three-quarters offered evening, weekend, offsite, and outdoor activities as well as pet therapy, gardening, and intergenerational activities. (See Table 3.6.)

THE PIONEER NETWORK.

In response to concerns about quality of life and quality of care issues in nursing homes, leaders in nursing home reform efforts from around the United States established the Pioneer Network in 2000 as a forum for the culture change movement. The culture change in this instance was a focus on person-directed values that affirm and support each person's individuality and abilities and that apply to elders as well as those who work with them. Pioneers commit to the following values (2007, http://www.pioneernetwork.net/who-we-are/ValuesandPrinciples.php):

  • Know each person.
  • Each person can and does make a difference.
  • Relationship is the fundamental building block of a transformed culture.
  • Respond to spirit, as well as mind and body.
Nursing homes Beds Current residents
Facility characteristic Number Percent distribution Number Beds per nursing home Number Occupancy ratea
aOccupancy rate is calculated by dividing residents by available beds.
bEstimates for nursing homes that are not certified are not shown because the sample size was less than 30 and figures are unreliable.
Note: Numbers may not add to totals because of rounding. Percentages and rates are based on the unrounded numbers.
       Total 16,100 100.0 1,730,000 107.6 1,492,200 86.3
Ownership
Proprietary 9,900 61.5 1,074,200 108.6 918,000 85.5
Voluntary nonprofit 5,000 30.8 503,600 101.6 440,300 87.4
Government and other 1,200 7.7 152,200 123.6 133,900 88.0
Certificationb
Certified 15,800 98.5 1,708,900 107.8 1,475,600 86.4
Medicare and Medicaid 14,100 87.6 1,599,600 113.5 1,379,700 86.3
Medicare only 700 4.1 33,100 50.6 28,100 85.0
Medicaid only 1,100 6.9 76,200 69.0 67,900 89.1
Beds
Fewer than 50 beds 2,200 13.9 75,800 33.8 62,200 82.1
5099 beds 6,000 37.3 454,700 75.7 422,600 92.9
100199 beds 6,800 42.5 903,100 132.0 788,500 87.3
200 beds or more 1,000 6.2 296,400 298.2 218,900 73.9
Geographic region
Northeast 2,800 17.4 381,500 136.0 331,300 86.8
Midwest 5,300 33.0 526,600 99.4 448,000 85.1
South 5,400 33.6 585,600 108.3 501,500 85.6
West 2,600 16.0 236,200 92.1 211,400 89.5
Location
Metropolitan statistical area 10,900 67.7 1,290,900 118.5 1,127,800 87.4
Micropolitan statistical area 2,600 16.2 242,200 92.9 202,000 83.4
Other location 2,600 16.0 196,900 76.3 162,400 82.5
Affiliation
Chain 8,700 54.2 939,400 107.9 812,500 86.5
Independent 7,400 45.8 790,600 107.2 679,700 86.0
  • Risk taking is a normal part of life.
  • Put person before task.
  • All elders are entitled to self-determination wherever they live.
  • Community is the antidote to institutionalization.
  • Do unto others as you would have them do unto you.
  • Promote the growth and development of all.
  • Shape and use the potential of the environment in all its aspects: physical, organizational, social, psychological, and spiritual.
  • Practice self-examination, searching for new creativity and opportunities for doing better.
  • Recognize that culture change and transformation are not destinations but a journey, always a work in progress.

THE EDEN ALTERNATIVE.

Developed in 1991 by William Thomas, the Eden Alternative is a movement that, like the Pioneer Network, seeks to transform nursing homes. The Eden Alternative strives to create nursing homes that are rich and vibrant human habitats where plants, children, and animals bring life-enriching energy to residents. The philosophy of the Eden Alternative is that providing a stimulant-rich environment will help minimize the hopelessness often felt by nursing home residents. Nursing homes based on this model are being opened across the country.

By providing gardenlike settings filled with plants and encouraging relationships with children and pets, the Eden Alternative hopes to improve the human spirit and dispel loneliness. The ten principles of an Eden Alternative nursing home are (2007, http://www.edenalt.org/about/our-10-principles.html):

  1. The three plagues of loneliness, helplessness, and boredom account for the bulk of suffering among our elders.
  2. An elder-centered community commits to creating a Human Habitat where life revolves around close and continuing contact with plants, animals, and children.
    Facility characteristic Total No specially units One or more speciality unitsa Alzheimers or dementia unit
    aSpecialty units are physically distinct or designated clusters of beds or segregated wings or units that are used exclusively for residents with specific conditions or requiring specialized care.
    bIncludes state and local government owned facilities.
    Note: Numbers may not add to totals because of rounding.
    All facilities 16,100 9,900 6,200 4,300
    Ownership
    Proprietary 9,900 6,400 3,500 2,500
    Voluntary nonprofit and otherb 6,200 3,500 2,700 1,900
    Beds
    Fewer than 50 beds 2,200 1,900
    5099 beds 6,000 4,500 1,500 1,100
    100 beds or more 7,800 4,300 3,500 3,200
    Geographic region
    Northeast 2,800 1,400 1,400 900
    Midwest 5,300 3,100 2,200 1,800
    South 5,400 3,700 1,700 1,200
    West 2,600 1,600 900 500
    Location
    Metropolitan statistical area 10,900 6,400 4,500 3,000
    Micropolitan statistical area 2,600 1,600 1,000 700
    Other location 2,600 1,800 800 600
    Affiliation
    Chain 8,700 5,300 3,400 2,400
    Independent 7,400 4,600 2,700 1,900
    It is these relationships that provide the young and old alike with a pathway to a life worth living.
  3. Loving companionship is the antidote to loneliness. Elders deserve easy access to human and animal companionship.
  4. An elder-centered community creates opportunity to give as well as receive care. This is the antidote to helplessness.
  5. An elder-centered community imbues daily life with variety and spontaneity by creating an environment in which unexpected and unpredictable interactions and happenings can take place. This is the antidote to boredom.
  6. Meaningless activity corrodes the human spirit. The opportunity to do things that we find meaningful is essential to human health.
  7. Medical treatment should be the servant of genuine human caring, never its master.
  8. An elder-centered community honors its elders by deemphasizing top-down bureaucratic authority, seeking instead to place the maximum possible decision-making authority into the hands of the elders or into the hands of those closest to them.
  9. Creating an elder-centered community is a never-ending process. Human growth must never be separated from human life.
  10. Wise leadership is the lifeblood of any struggle against the three plagues. For it, there can be no substitute.

Thomas's initiatives also include the Green House Project. This effort comprises the design and construction of small group homes for older adults, built to a residential scale that situates necessary clinical care within a social model in which primacy is given to the older adults' quality of life. The goal of the model is to provide frail older adults with an environment that promotes autonomy, dignity, privacy, and choice.

Green Houses are designed to feel more like homes than today's typical long-term care institutions and to blend easily into their community or surroundings. The first Green House in the nation opened in May 2003 in Tupelo, Mississippi, developed by United Methodist Senior Services of Mississippi.

In September 2006 Thomas was honored when the Heinz Family Foundation named him as one of six distinguished Americans chosen for their unique contributions to American society. In the article "Six Distinguished Americans Selected as 12th Annual Heinz Award Honorees" (September 25, 2006, http://www.heinzawards.net/articleDetail.asp?articleID=193), the foundation describes Thomas as having sparked a revolution in nursing home care by transforming assisted living facilities from "lonely, hopeless, tedious institutions into vibrant centers of care and companionship." By 2007 more than three hundred nursing homes across the country had been transformed in accordance with the Eden philosophy, with most featuring bright décor, gardens, pets, and on-site day care for children.

Assisted Living

Assisted living arose to bridge a gap in long-term care. It is intended to meet the needs of older adults who wish to live independently in the community but require some of the serviceshousekeeping, meals, transportation, and assistance with other activities of daily livingthat are provided by a nursing home. (Activities of daily living are generally considered to include eating, bathing, dressing, getting to and using the bathroom, getting in or out of bed or a chair, and mobility.) Assisted living ideally offers a flexible array of services that enable older adults to maintain as much independence as they can, for as long as possible.

Type of program
Facility characteristic Total No special programs One or more special programsa Hospice end of life Palliative care Dementia care Restorative care Behavior problems Pain management Continence management Skin wounds
*Estimate does not meet standard of reliability or precision because the sample size is less than 30. Estimates accompanied by an asterisk (*) indicate that the sample size is between 30 and 59.
aIncludes any of the programs listed where the facility has specially trained personnel dedicated to the program. Special programs do not include special training that is provided to all personnel.
bIncludes state and local government facilities.
Note: Numbers may not add to totals because of rounding.
All facilities 16,100 3,300 12,800 3,000 2,700 5,100 11,100 3,800 4,100 3,500 8,600
Ownership
Proprietary 9,900 2,000 7,900 1,600 1,400 2,800 7,100 2,400 2,300 2,200 5,300
Voluntary nonprofit and otherb 6,200 1,300 4,800 1,400 1,200 2,300 4,000 1,500 1,800 1,300 3,300
Beds
Fewer than 50 beds 2,200 800 1,400 * * * 1,000 * *400 * 800
5099 beds 6,000 1,300 4,700 1,100 900 1,500 4,200 1,500 1,500 1,400 3,000
100 beds or more 7,800 1,100 6,700 1,700 1,500 3,200 5,800 2,000 2,200 1,900 4,800
Geographic region
Northeast 2,800 *700 2,100 *500 *600 1,000 1,700 *600 *800 * 1,400
Midwest 5,300 1,000 4,300 800 900 2,000 3,900 1,600 1,400 1,200 2,800
South 5,400 1,000 4,400 1,300 900 1,500 3,800 1,200 1,300 1,300 3,200
West 2,600 *600 1,900 * * *600 1,700 *500 *600 *600 1,200
Location
Metropolitan statistical area 10,900 2,100 8,800 2,100 1,900 3,500 7,600 2,600 2,900 2,500 6,100
Micropolitan statistical area 2,600 *600 2,000 *400 *400 900 1,700 *600 *600 *500 1,200
Other location 2,600 *600 2,000 *600 *400 700 1,800 700 600 *500 1,200
Affiliation
Chain 8,700 1,700 7,000 1,600 1,500 2,800 6,300 2,000 2,300 2,100 4,900
Independent 7,400 1,600 5,700 1,400 1,200 2,300 4,800 1,900 1,900 1,400 3,700

Since assisted living refers to a concept and philosophy as opposed to a regulated provider of health services such as a hospital or skilled nursing facility, there is no uniform description of the services an assisted living residence must offer, and as a result there is considerable variation among assisted living facilities. These residences are regulated on a state level, and each state has its own definition of what constitutes an assisted living facility as well as its own set of rules governing them. In Understanding Medicaid Home and Community Services: A Primer (October 2000, http://aspe.hhs.gov/daltcp/reports/primer.pdf), Gary Smith et al. define the term assisted living as "care that combines housing and supportive services in a homelike environment and seeks to promote maximal functioning and autonomy."

Members of the Assisted Living Federation of America (ALFA; 2007, http://www.alfa.org/i4a/pages/index.cfm?pageid=3285), the largest national association dedicated to operating assisted living communities for older adults, subscribe to a ten-point philosophy of care:

  1. Offering cost-effective quality care that is personalized for individual needs.
  2. Fostering independence for each resident.
  3. Treating each resident with dignity and respect.
  4. Promoting the individuality of each resident.
  5. Allowing each resident choice of care and lifestyle.
  6. Protecting each resident's right to privacy.
  7. Nurturing the spirit of each resident.
  8. Involving family and friends, as appropriate, in care planning and implementation.
  9. Providing a safe, residential environment.
  10. Making the assisted living residence a valuable community asset.

Assisted living residences may be located on the grounds of retirement communities or nursing homes, or they may be freestanding residential facilities. They vary in size and location as well as services. Some are high-rise

Facility characteristic Total Off-site activities Evening activities Weekend activities Outdoor activities Gardening Pet therapy Intergenerational activities
*Includes state and local government owned facilities.
Note: Numbers may not add to totals because of rounding.
All facilities 16,100 14,500 15,300 15,700 15,200 12,200 14,000 13,700
Ownership
Proprietary 9,900 9,100 9,400 9,700 9,500 7,300 8,400 8,400
Voluntary nonprofit and other* 6,200 5,400 5,900 6,000 5,700 4,900 5,500 5,300
Beds
Fewer than 50 beds 2,200 1,600 1,900 2,100 1,900 1,400 1,800 1,700
5099 beds 6,000 5,600 5,700 5,900 5,800 4,400 5,200 5,300
100 beds or more 7,800 7,300 7,700 7,800 7,600 6,400 7,000 6,800
Geographic region
Northeast 2,800 2,500 2,700 2,800 2,700 2,400 2,500 2,600
Midwest 5,300 4,800 5,100 5,200 5,000 4,300 4,700 4,700
South 5,400 4,900 5,200 5,300 5,100 3,700 4,600 4,500
West 2,600 2,300 2,200 2,500 2,500 1,900 2,100 2,000
Location
Metropolitan statistical area 10,900 9,700 10,400 10,600 10,300 8,400 9,500 9,200
Micropolitan statistical area 2,600 2,400 2,500 2,600 2,400 1,900 2,300 2,300
Other location 2,600 2,400 2,400 2,500 2,500 2,000 2,200 2,300
Affiliation
Chain 8,700 8,100 8,300 8,500 8,400 6,500 7,400 7,400
Independent 7,400 6,400 7,000 7,200 6,800 5,800 6,600 6,300

apartment complexes, whereas others are converted private homes. Most facilities contain between 25 and 120 units, which vary in size from one room to a full apartment.

ALFA reports that in 2006 "more than a million Americans [lived] in an estimated 20,000 assisted living residences." Key findings contained in the report 2006 Overview of Assisted Living (Facts & Trends) (2007), which was compiled by the American Association of Homes and Services for the Aging, ALFA, the American Seniors Housing Association, the National Center for Assisted Living, and the National Investment Center for the Seniors Housing and Care Industry, include:

  • Facility types32% of facilities are freestanding, 24% provide assisted living and programs for people suffering from dementia, 17% are continuing care retirement communities, 13% offer a combination of assisted and independent living, 8% combine assisted living and nursing facilities, and 5% are devoted exclusively to care of people with dementia.
  • The median (the middle valuehalf are higher and half are lower) occupancy rate of freestanding facilities is 95%.
  • Median age of residents is eighty-seven for females, eighty-five for men. Residents' median income was $15,668. Residents required assistance with an average of two activities of daily living.

Assisted living licensing regulations vary from state to state. Most states require staff certification and training and all assisted living facilities must comply with local building codes and fire safety regulations.

COSTS OF ASSISTED LIVING.

The cost of assisted living varies based on geography, unit size, and the services needed. According to the 2006 Overview of Assisted Living, the median monthly amount is $2,350 and may cover all services. Most assisted living facilities charge monthly rates and some require long-term lease arrangements.

The 2006 Overview of Assisted Living finds that about half (51%) of assisted living facilities offer tiered pricing for bundled services, and less than one-quarter (22%) offer a single all-inclusive rate. Nearly all free-standing assisted living communities (97%) provide three meals per day in their basic rates; 40% provide assistance with the activities of daily living in basic rates; and 60% offer assistance for an extra charge.

Residents or their families generally pay for assisted living using their own financial resources. Some health insurance programs or long-term care insurance policies reimburse for specific health-related care provided by assisted living facilities, and some state and local governments offer subsidies for rent or services for low-income older adults. Others may provide subsidies in the form of an additional payment for those who receive SSI or Medicaid (a federal and state health-care program for people below the poverty level).

Continuing Care Retirement Communities

Continuing care retirement communities (CCRCs), also known as life care communities, offer a continuum of careindependent living, assisted living, and nursing home carein a single facility or on common grounds. The goal of CCRCs is to enable residents to age in place (remaining in their own home rather than relocating to assisted living facilities or other supportive housing). When residents become ill or disabled, for example, they do not have to relocate to a nursing home, because health-care services are available on the CCRC campus.

Like assisted living facilities, CCRCs vary in location, design, and amenities. They range from urban high rises to semirural campuses and from one hundred residents to over a thousand. Most include common dining rooms, activity and exercise areas, indoor and outdoor recreation areas, and swimming pools.

Typically, residents enter into a contractual arrangement with the facility requiring that they pay an entrance fee and a fixed monthly fee in return for housing, meals, personal care, recreation, and nursing services. Many CCRCs offer other payment options, including both entrance fee and fee-for-service (paid for each visit, procedure, or treatment delivered) arrangements. In the past entrance fees were nonrefundable; however, by 2006 most newer CCRCs had instituted refundable or partially refundable entrance fees.

CCRCs may be operated by private, not-for-profit, and/or religious organizations. Entrance fees in these communities vary substantially, from $20,000 to $500,000, and monthly maintenance fees range from $600 to $2,000, depending on the size of the facility and the extent of services. With few exceptions, none of the costs of CCRCs are covered by government or private insurance.

Cohousing and Shared Housing

Older adults may share living quarters to reduce expenses, share household and home maintenance responsibilities, and gain companionship. Many choose to share the same homes in which they raised their families, because these houses are often large enough to accommodate more than one or two people. Shared housing is often called cohousing, but the phrases are not exactly the same. Cohousing usually refers to planned or intentional communities of private dwellings with shared common areas that include dining rooms, meeting rooms, recreation facilities, and lounges. Cohousing and shared housing are cost-effective alternatives for those who wish to remain in their own homes and for older adults who cannot afford private assisted living or continuing care retirement communities.

The cohousing concept originated in Denmark in the 1960s and spread to North America in the 1980s. According to the Cohousing Association of the United States (http://directory.cohousing.org/us_list/all_us.php), in 2007 there were more than one hundred cohousing communities in various stages of development in North America. Cohousing participants are involved in planning the community and maintaining it, and most cohousing groups make their decisions by consensus.

In contrast, most shared housing consists of a single homeowner taking a roommate to share living space and expenses. Shared housing can also include households with three or more roommates and family-like cooperatives in which large groups of people live together.

Intergenerational cohousing or shared housing may also meet the needs of younger as well as older people. Along with the benefits of cost-sharing and companionship, home sharers and cohousing residents may exchange servicesfor example, help with household maintenance in exchange for baby-sitting.

Matt Thornhill of the Boomer Project anticipates that aging baby boomers (people born between 1946 and 1964) will embrace cohousing. The concept of a community with shared values, care, meals, transportation, and shared homes will likely appeal to many boomers, who enjoyed communes and group-living situations in the 1960s and 1970s. In "Cohabiting to Cohousing" (The Boomer Project Newsletter, June 2005), Thornhill predicts that cohousing communities will even be retrofitted from existing neighborhoods, enabling boomers to age in place.

ECHO Units or "Granny Flats"

Elder cottage housing opportunity (ECHO) units, or "granny flats," are small, freestanding, removable housing units that are located on the same lot as a single-family house. Another name used by local zoning authorities is accessory apartments or units. Accessory apartments are self-contained second living units built into or attached to an existing single-family dwelling. They are private, generally smaller than the primary unit, and usually contain one or two bedrooms, a bathroom, a sitting room, and a kitchen.

Generally, families construct ECHO units and accessory apartments for parents or grandparents so that the older adults can be nearby while maintaining their independence. Existing zoning laws and concerns about property values and traffic patterns are obstacles to both cohousing and construction of ECHO units, but as these alternatives become more popular, local jurisdictions may be pressured to allow multifamily housing in neighborhoods that traditionally have had only single-family homes.

Retirement Communities

Developers such as the industry leader Del Webb (a division of Pulte Homes) have created and constructed communities and even entire small "cities" exclusively for older adults. Examples include the Sun City communities in Florida, Arizona, and Texas. The Florida and Arizona locations opened in the 1960s and the Texas site in 1996.

In 2007 Del Webb (http://www.delwebb.com/Homefinder/Default.aspx) boasted communities in twenty-one states, which are home to more than two hundred thousand older adults. Homes in most of these properties are available only to those families in which at least one member is fifty-five or older, and no one under age nineteen is allowed to reside permanently. Sun City communities offer clubs, golf courses, social organizations, fitness clubs, organized travel, and recreational complexes. Medical facilities are located nearby.

Even though many older adults and baby boomers aspire to purchase new homes in active retirement communities or to relocate, it is likely that only those with considerable financial resources will be able to do so. Depending on location and size, in 2007 Del Webb home prices ranged from $153,490 in Texas to $880,990 in New Mexico.

Board-and-Care Facilities

In Licensed Board and Care Homes: Preliminary Findings from the 1991 National Health Provider Inventory (April 11, 1994, http://aspe.hhs.gov/daltcp/reports/licbchom.htm), Robert F. Clark et al. define the term board-and-care homes as "non-medical community-based facilities that provide protective oversight and/or personal care in addition to meals and lodging to one or more residents with functional or cognitive limitations." Typically, board-and-care residents have their own bedrooms and bathrooms or share them with one other person, whereas other living areas are shared.

Even though many board-and-care homes offer residents safe, homelike environments and attentive caregivers, there have been many well-publicized instances of fraud and abuse. Entirely unregulated in many states, board-and-care facilities have frequently become dumping grounds for older adults.

In an attempt to stem abuses, the federal government passed the Keys Amendment in 1978. Under the terms of this legislation, residents living in board-and-care facilities that fail to provide adequate care are subject to reduced SSI payments. This move was intended to penalize substandard board-and-care operators, but advocates for older adults contend that it actually penalizes the SSI recipients and that it has not served to reduce reports of abuse. With the 1992 reauthorization of the Older Americans Act of 1965, Congress provided for long-term care ombudsman programs designed to help prevent the abuse, exploitation, and neglect of residents in long-term care facilities such as board-and-care residences and nursing homes. Paid and volunteer ombudsmen monitor facilities and act as advocates for the residents.

OWNING AND RENTING A HOME

Data from the Census Bureau's Housing Vacancies and Homeownership survey show the overall home ownership rate in the first quarter of 2007 was 68.4%, close to the highest rate (69.2% in 2004) since the Census Bureau began reporting these statistics in 1965. (See Table 3.7.) In 2007, 80.9% of adults aged sixty-five and older owned their own homes.

Older householders are less likely than those under age sixty-five to have mortgage indebtedness. In A Profile of Older Americans: 2006, the AoA reports that in 2005 approximately 68% of older homeowners owned their homes free and clear. However, even when there is no mortgage remaining on the home, homeowners must still pay property taxes, insurance premiums, and utility bills as well as the costs of home maintenance and repairs.

Renters generally pay a higher percentage of their income for housing than do homeowners. Unlike most homeowners, who pay fixed monthly mortgage payments, renters often face annual rent increases. Many older adult renters living on fixed incomes are unprepared to pay these increases. Homeowners also benefit from their home equity and can borrow against it in times of financial need. In contrast, renters do not build equity and do not get a return on their investment. Also, mortgage payments are tax deductible, whereas rent payments are not.

Reverse Mortgages

To supplement their retirement incomes or pay for health care, many older Americans turn to reverse mortgages. Reverse mortgages allow older homeowners to convert some of their home equity into cash, making it possible for them to avoid selling their homes.

With a traditional mortgage homeowners make monthly payments to the lender. In a reverse mortgage the lender pays the homeowner in monthly installments and in most cases no repayment is due until the homeowner dies, sells the house, or moves permanently. Reverse mortgages help homeowners who are house-richhave considerable equity in their homesbut cash-poor stay in their homes and still meet their financial obligations.

Homeownership rates
Year/quarter United States Under 35 years 35 to 44 years 45 to 54 years 55 to 64 years 65 years and over
*Revised in 2002 to incorporate information collected in Census 2000.
2007
First quarter 68.4 41.7 68.3 75.8 80.4 80.9
2006
Fourth quarter 68.9 42.8 68.9 76.4 80.7 81.2
Third quarter 69.0 43.0 68.8 76.4 80.7 81.5
Second quarter 68.7 42.4 68.9 76.3 81.0 80.6
First quarter 68.5 42.3 68.9 75.8 81.2 80.3
2005
Fourth quarter 69.0 43.1 69.7 76.7 80.6 80.6
Third quarter 68.8 43.0 68.6 76.7 80.9 80.6
Second quarter 68.6 42.8 68.7 76.3 81.3 80.3
First quarter 69.1 43.3 70.1 76.5 81.8 80.8
2004
Fourth quarter 69.2 43.3 70.0 77.4 81.6 80.5
Third quarter 69.0 43.1 68.6 77.4 81.2 81.8
Second quarter 69.2 43.6 69.4 77.0 82.4 81.1
First quarter 68.6 42.3 68.8 77.0 81.7 80.7
2003
Fourth quarter 68.6 42.7 69.0 77.2 81.3 80.8
Third quarter 68.4 42.5 68.8 76.5 81.1 80.7
Second quarter 68.0 41.9 67.8 76.3 81.6 80.2
First quarter 68.0 41.7 67.8 76.5 81.4 80.2
2002*
Fourth quarter 68.3 42.0 69.0 76.4 81.5 80.8
Third quarter 68.0 41.5 68.6 76.4 81.3 80.4
Second quarter 67.6 40.8 68.2 76.3 80.8 80.1
First quarter 67.8 41.0 68.6 76.0 80.9 80.9

Falling Home Prices May Imperil Older Adults

In many parts of the country home prices declined during 2006, and a decline of existing home sales in 2007 was projected. According to Seth Jayson, in "House Price Drop? That's Unpossible!" (The Motley Fool, April 12, 2007), David Lereah, an economist for the National Association of Realtors, predicted a 0.7% drop in home prices in 2007.

Slowing house price appreciation and rising interest rates may pose the greatest threat to older adults with fixed incomes who face unusual expenses and low-income households that depend on their home equity to help finance their spending. Older adult homeowners may face two challenges: the costs of borrowing will increase and the amount of equity available in their homes may grow more slowly than they anticipated or may even decline.

Sale/Leaseback with Life Tenancy

Another option for older homeowners is a sale/lease-back in which the homeowner gives up ownership of a home and becomes a renter. The former homeowner frequently requests life tenancyretaining the right to live in the house as a renter for the rest of his or her life. The buyer pays the former homeowner in monthly installments and is responsible for property taxes, insurance, maintenance, and repairs.

Renting Is Often Unaffordable

The National Low-Income Housing Coalition (NLIHC) report OutofReach2006 (December 2006, http://www.nlihc.org/oor/oor2006/?CFID=11115107 CFTOKEN=24009248) documents income and rental housing cost data for the fifty states, the District of Columbia, and Puerto Rico. For each area, the coalition calculates the income needed to be able to afford the fair market rent (FMR) of the housing. The coalition's report also calculates the number of full-time minimum wage jobs necessary to afford the FMR, which highlights the hardships faced by many families of different sizes with varying numbers of wage earners.

The report observes that the median hourly wage in the United States is less than $15 and that average renters earn less than $13 an hour. The national median housing wage, based on each county's housing wage for a two-bedroom unit at the FMR, was $16.31 an hour in 2006. Because the median hourly wage and renters' average hourly wages are less than the national median housing wage, the NLIHC observes that even when workers are employed at prevailing wages they will find it challenging to obtain affordable rental housing.

The average monthly SSI payment was just $603 for adults aged sixty-five and over in 2006. Older adults relying solely on SSI payments cannot afford rental housing anywhere in the United States. The NLIHC report describes those people relying only on SSI as being "at the greatest disadvantage in today's housing markets."

ADDITIONAL HOUSING CHALLENGES
FOR OLDER ADULTS

Physical Hazards and Accommodations

Home characteristics considered desirable by younger householders may present challenges to older adults. For example, the staircase in a two-story house may become a formidable obstacle to an older adult suffering from arthritis, heart disease, or other disabling chronic conditions. Narrow halls and doorways cannot accommodate walkers and wheelchairs. High cabinets and shelves may be beyond the reach of an arthritis sufferer. Even though houses can be modified to meet the physical needs of older or disabled people, some older houses cannot be remodeled as easily, and retrofitting them may be quite costly. Owners of condominiums in Florida, whose young-old (aged sixty-five to seventy-four) residents once prized second- and third-floor units for their breezes and golf course views, are now considering installing elevators for residents in their eighties and nineties who find climbing stairs much more difficult.

Older adults, as well as advocates on their behalf, express a strong preference for aging in place. Much research confirms that most people over the age of fifty-five want to remain in familiar surroundings rather than move to alternative housing. To live more comfortably, those older adults who have the means can redesign and reequip their homes to accommodate the physical changes associated with aging.

Simple adaptations include replacing doorknobs with levers that can be pushed downward with a fist or elbow, requiring no gripping or twisting; replacing light switches with flat "touch" switches; placing closet rods at adjustable heights; installing stoves with front- or side-mounted controls; and marking steps with bright colors. More complex renovations include replacing a bathroom with a wet room (a tiled space that is large enough to accommodate a wheelchair and that is equipped with a shower-head, a waterproof chair, and a sloping floor for a drain), placing electrical outlets higher than usual along walls, and widening passageways and doors for walkers, wheel-chairs, or scooters.

Anticipating the increase in the older population in the coming years, some real estate developers are manufacturing houses designed to meet the needs of older adults and prolong their ability to live independently. These houses feature accommodations such as nonskid flooring, walls strong enough to support the mounting of grab bars, outlets at convenient heights, levers instead of knobs on doors and plumbing fixtures, and doors and hallways wide enough to allow wheelchair access.

PUBLIC HOUSING

Congress passed the U.S. Housing Act of 1937 to create low-income public housing, but according to the Milbank Memorial Fund and the Council of Large Public Housing Authorities, in Public Housing and Supportive Services for the Frail Elderly: A Guide for Housing Authorities and Their Collaborators (September 2006, http://www.milbank.org/reports/0609publichousing/0609publichousing.pdf), by 1952 only a small percentage of available housing was occupied by older adults. After 1956, when Congress authorized the development of dedicated public housing for the elderly and specifically made low-income older adults eligible for such housing, the situation began to improve. During the 1960s and 1970s many developments, specifically for low-income older adults, were constructed. Initially, these apartments were sufficient for most residents, but they were not designed to enable residents to age in place. They lacked the flexibility and the range of housing options necessary to meet the needs of frail older adults. The residents who entered public housing as young-old aged in place and are now the older-old (aged seventy-five and over) and more in need of supportive and health services than they were two decades ago.

Public housing itself has also agedmuch of it is more than thirty years old. Many developments are badly rundown and in desperate need of renovation. Most are unequipped to offer the range of supportive services required by increasingly frail and dependent residents. Absent supportive services, the bleak alternative may be moving older people into costly, isolated institutions. Older adults may suffer unnecessary institutionalization, and nursing home care is far more costly than community-based services.

Public Housing and Supportive Services for the Frail Elderly includes case studies describing the provision of supportive services that enable public housing to better serve older adults. For example, beginning in 1993 the Lapham Park Venture in Milwaukee established an on-site medical clinic and installed a billiards room, crafts room, barber and beauty shop, gym, movie theater, and therapeutic whirlpool to permit its frail, low-income African-American residents to remain in their homes without sacrificing access to needed care and community services. In 1999 the Miami-Dade Housing Agency opened the nation's first licensed assisted living facility in public housing, allowing its residents to age in place with supportive services such as meals.

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