Housing

HOUSING

Housing plays a vital role in the lives of older adults due to the amount of time they spend at home and their desire to age in place. The features of housing are strong determinants of safety and ability to get out into the community. In addition, the cost of housing is a major expenditure for most older adults. The aging of the population necessitates a broad array of housing alternatives that provide different levels of onsite services, supervision, sociability, privacy, and amenities. These housing options range from single-family homes and apartments to nursing homes. The following sections describe the wide array of housing options available.

Independent housing

Private sector housing. Most independent older persons reside in private sector homes or apartments. Over three-quarters (77 percent) of older adults own their own home. While rates of home ownership decrease with advancing age, 67 percent of adults over age eighty-five still own their own homes. Certain groups, however, have lower rates of home ownership (HUD). For example, home ownership rates are highest for whites and lowest for black (64 percent) and Hispanic households (57 percent) (Naifeh). Older renters differ from homeowners in that they have somewhat lower incomes, have lived in their units for relatively shorter periods of time, and occupy housing in somewhat worse condition.

Accessory units. Accessory units and elder cottage housing opportunity (ECHO) housing (i.e., granny flats), are private housing arrangements in or adjacent to existing single-family homes. These units are complete, self-contained units, usually with a separate entrance. Older adults who are frail and need to be close to their children or other family members can benefit from this option. Another possibility is that older homeowners can rent these units to younger persons at below market rent in return for certain services, such as shopping and meal preparation. Homeowners may also benefit from this situation because it provides an extra source of income to help with living expenses. Zoning in communities designed for single-family housing generally prohibits accessory apartments or ECHO housing, so a special use permit may be needed. Such impediments have restricted the growth of this option.

Shared housing. Shared housing is an arrangement in which two or more unrelated people share a house or apartment. Each person usually has his or her own sleeping quarters, and the rest of the house is shared. Surveys suggest that 2.5 percent of older adult households have at least one nonrelative living in their home, and almost 20 percent of older adults would consider living with someone who was not a family member or a friend. This living situation may occur naturally when individuals decide to form a household, through matches facilitated by an agency, and in small group homes operated by nonprofit or private organizations. In certain cases, agency-sponsored shared housing in small group homes may include services such as meal preparation, housekeeping, and shopping.

However, there are problems and considerations that arise in shared housing, especially in small group homes. Planning and zoning commissions may categorize shared housing with residential care homes, nursing homes, and other types of homes for older adults, all of which are excluded from residential areas zoned for single-family housing. A second problem is that elderly living in shared housing situations who receive food stamp benefits or Supplemental Security Income (SSI) may lose a portion of their benefits or be declared ineligible altogether. Nevertheless, shared housing can provide a source of additional income, reduce housing costs, and provide social, emotional, and physical support.

Government-assisted housing. Since 1959 the federal government has played a major role in increasing the housing supply for low-income older persons through financing housing for the elderly and reducing rents through tenant subsidy programs. Approximately 1.7 million older persons live in federally subsidized housing nationwide. The largest program serving low-income older persons is public housing, in which approximately half a million elderly reside, primarily in special housing for the elderly. Section 202 housing, initially authorized under the 1959 Housing Act to serve moderate-income older persons, has provided the funds for nonprofit sponsors to develop about 325,000 units in which about 387,000 tenants live. Sections 515 and 516 of the Housing Act of 1949 provide housing assistance to rural residents and farm laborers through tenant subsidies.

In addition, older persons live in a variety of housing developed through other federal programs (e.g., Section 236 of National Housing Act of 1968, Section 8 new construction), that have reduced the interest rate on loans for developers. Such programs have generally produced shallower subsidies than public housing. In order to make these programs affordable by low-income persons, many residents receive Section 8 rental certificates or vouchers, which reduce housing expenses to 30 percent of income and can be used to rent units in the private sector.

Supportive housing options

Because frail older persons are likely to need a more physically supportive dwelling unit, greater supervision (e.g., with medications) or services, or more companionship than can be efficiently provided in conventional homes or apartments, a number of supportive housing options have developed since the 1980s. Estimates of the absolute and relative sizes of the populations that live in supportive housing vary considerably because of inconsistent definitions of supportive housing, the difficulty in identifying unregulated facilities, and problems that older persons have accurately answering survey questions about the type of housing they occupy.

Estimates of the number of older persons living in supportive housing settings range from one million to two million. By all accounts, however, the stock of supportive housing is still insufficient to meet the needs of a growing population of frail older persons; much of it remains unaffordable to those with low and moderate incomes, and its quality remains difficult to judge.

Continuing care retirement communities. Also called life care communities, continuing care retirement communities (CCRCs) are unique in that they offer various levels of care within one community to accommodate residents who have changing needs. Most CCRCs offer independent living areas, assisted living, and skilled nursing care. Services that are offered include transportation, meals, housekeeping, and physician services. Some communities provide most of their own services, whereas others obtain many of them through contracts with outside organizations.

Each community houses between four hundred and six hundred older persons, often in a campus-type setting. CCRCs generally require, as a condition for entry, that new residents be in reasonably good health. Once a person is admitted, however, CCRCs are the most accommodating of all settings because residents can remain and obtain services in the community even if they experience physical or mental limitations.

The typical age of entrants is seventy-nine and the majority are women (75 percent). The primary reason that older persons select CCRCs is security, represented most clearly by the assurance of high quality nursing care and personal care services.

By 1992 there were approximately a thousand CCRCs, housing approximately 350,000 to 450,000 older persons. It is predicted that the number of facilities could double by 2010, though growth may be tempered by an increase in other options, such as home care and assisted living.

Most CCRCs require residents to pay an entrance fee and monthly fee, for which the community guarantees a dwelling unit, services, meals, and nursing care. Entrance fees typically range from $20,000 to $400,000 with an average of $40,000; monthly fees range from $200 to $25,000. Generally, CCRCs are an option affordable only by middle- and upper-income older persons, for most residents must pay out of pocket. Residents generally are required to have Medicare parts A and B. In order to reduce their potential liability for long-term care, some CCRCs offer or require long-term care insurance.

As of 2000, thirty-five states have regulations in place for CCRCs; though they vary greatly in stringency. Government involvement usually takes the form of measures to improve the ability of residents to make informed decisions and to guard against the bankruptcy of these facilities. CCRCs, fearing overinvolvement by the government, have formed their own regulating agency, the Continuing Care Accreditation Commission, which adopts basic standards that focus on finance, residential life, and health care.

Board and care homes. Board and care homes are residential facilities that generally offer on-site management, supervision, a physically accessible environment, meals, and a range of services for physically or mentally vulnerable older people and younger disabled people who cannot live independently. In facilities serving primarily seniors, the average age is approximately eighty-three, about eight years older than residents of government-assisted housing.

Data from a 1991 survey suggest that over thirty thousand board and care homes exist in the United States, more than double the number of nursing homes (Sirrocco). However, owing to their smaller size (usually between five and twenty dwelling units), board and care facilities house only about one-fourth as many residents (about four hundred thousand persons) as nursing homes, and include about two hundred thousand persons under age sixty-two.

The cost of living in this type of facility varies with location and the services provided, but in general the average monthly fee ranges from $450 to $2,000. Many of the older residents in board and care homes are subsidized by state governments, which add an amount to the Supplemental Security Income (SSI) that many residents use to pay for their accommodations and care. Most board and care homes are very modest in nature and require that residents share rooms. Though theoretically licensed and regulated by state governments, many of the smaller board and care homes remain unlicensed and enforcement is lax.

Congregate housing. Congregate housing refers to a wide range of multiunit living arrangements for older persons in both the private and the public sector. Older persons who live in this type of housing generally have their own apartments that include kitchens or kitchenettes and private bathrooms. Most of this housing has dining facilities and provides residents with at least one meal a day (frequently included in the rent). There are common spaces for social and educational activities, and in some cases transportation is provided. Congregate housing generally does not offer personal care services or health services. It is therefore not licensed under regulations that apply to residential care facilities or assisted living.

In line with the physical characteristics of the buildings and the limited provision of services, congregate housing attracts older persons who can live independently. It especially appeals to older persons who no longer want the responsibility of home maintenance or meal preparation, and positively anticipate making new friends and engaging in activities. Problems may arise later, however, as residents age in place and need more assistance than the facility provides.

Residents, who are usually sixty-five to eighty-five years old and widowed, typically live in a one- or two-bedroom unit in a facility with fifty to four hundred units. Units are rented monthly, for from $700 to $2500 a month, and paid for out of pocket. Nonprofit facilities are usually subsidized by government agencies or religious organizations, and therefore are less costly than for-profit facilities. Most Section 202 housing falls in the congregate housing category.

Assisted living. During the 1990s assisted living (AL) was the fastest growing segment of the senior housing market. Assisted living is a housing option that involves the delivery of professionally managed supportive services and, depending on state regulations, nursing services, in a group setting that is residential in character and appearance. It has the capacity to meet scheduled and unscheduled needs for assistance and is managed in ways that aim to maximize the physical and psychological independence of residents (see Table 1). AL is intended to accommodate physically and mentally frail elderly people without imposing a heavily regulated, institutional environment on them (Kane and Wilson).

The typical AL resident is female, age eighty-three or over, and widowed. In 1999 there were approximately thirty thousand to forty thousand facilities in the United States housing approximately one million individuals (ALFA). Costs vary from $383 per month to $6,150, with an average of $2,206 in 1998 (ALFA). Most residents must pay out of pocket for their care (see Figure 1). An individual's health insurance program or long-term care insurance policy is another possible source of funding. As of 2000, there are few governmental funding sources for ALs. Some states and local governments use Supplemental Security Income along with Medicaid to pay for low-income residents, or the Medicaid waiver program to reimburse for services. In addition, the Department of Veterans Affairs and the Department of Housing and Urban Development, and the Independent Agencies Appropriations Act of 2000 allow HUD vouchers to be used in certain AL complexes and provide grants to convert some Section 202 buildings into AL facilities.

Varying definitions of ALs around the nation have produced difficulties with regulation and accreditation. With little leadership from the federal government, states have established regulations on their own. By the beginning of 1999, 25 states had regulations in place, with three more states pending (ALFA, 1999). In 2000, both the Rehabilitation Accreditation Commission (CARF) and the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) developed an accreditation process to promote quality care and outcomes for AL residents.

Aging in place

Although the continuum of housing identifies a range of housing types, there is increasing recognition that frail older persons do not necessarily have to move from one setting to another if they need assistance. Semidependent or dependent older persons can live in their own homes and apartments if the physical setting is more supportive and affordable services are accessible. Indeed, most older adults express a strong desire to age-in-place in their own homes and communities. Yet often, these older adults live in physically unsupportive environments, disconnected from services. Instead of facilitating older persons' ability to grow old safely, independently, and with dignity, many settings have instead become a source of the problem itself. The following section examines various methods and programs that enable older adults to age-in-place.

Home modifications. Home modifications are adaptations to home environments that can make it easier and safer to carry out activities such as bathing, cooking, and climbing stairs. Increasing evidence suggests that home modifications can have an important impact on the ability of chronically ill or disabled persons to live independently (Mann, 1999). In addition, environmental factors such as lack of privacy or insufficient space may impede family and formal caregiving (Newman, 1985; Newman et al., 1990).

Estimates by the National Center for Health Statistics indicate that 7.1 million persons live in homes that have special features for those with impairments (La Plante et al., 1992; see Table 2). In conventional homes and apartments of persons 70 and older, grab bars and shower seats are the most common home modifications at 23 percent, followed by wheelchair access inside the home such as wide hallways (9 percent), special railings (8 percent), and ramps at street level (5 percent) (Tabbarah et al., 2000). However, a large number of older persons who report health problems, mobility limitations, and dependency in ADLs and IADLs (instrumental activities of daily living), live in housing without adaptive features. It is estimated that at least 1.14 million households occupied by older persons need additional supportive features (HUD, 1999).

The overall low incidence of supportive features in the home is due to three major barriers. First, there is a lack of professional and consumer awareness concerning problems in the home environment. For example, several studies have found that many disabled persons, especially among the elderly, have a low level of awareness of the risks that the environment presents or a lack of knowledge of how home adaptations might make living safer and easier. In fact, older persons are often reported as having adapted their behavior to the environment (e.g., stopped taking baths or showers because of the danger of falling) rather than having adapted their environment to their changed capabilities (e.g., installing a handheld shower, adding a grab bar). Among professionals such as doctors, knowledge about home adaptation also is low. Concern has been expressed that even case managers, the gatekeepers for many long-term care services, may overlook home modifications.

Second, some home modifications may be unaffordable. The cost of home adaptations ranges from less than $100 for the purchase and installation of a simple handrail or grab bar to more than $1000 for a roll-in shower or several thousand dollars for a stair lift.

A third barrier reported by individuals and social service agencies in obtaining home modifications has been the delivery system (Pynoos). Simple home adaptations are often made by persons with disabilities and their family members. However, many persons lack the ability to identify environmental problems and make adaptations. Even installing an uncomplicated grab bar on a wall requires the ability to attach it to a stud and locate it at the correct angle and height in relation to the person using it. It is often necessary to employ a provider to assess problems and make changes, especially those that are complex, such as a roll-in shower. Overall, the modest nature of many jobs, the need for specialized skills, the low income of many persons who need adaptations, concerns about the reliability of private providers, and the difficulty of accessing specialists, such as occupational therapists, contribute to service delivery problems in home modifications.

Clustering services. Clustering services involves consolidating fragmented services for multiple clients. This strategy can reduce travel time and costs, enable more efficient worker assignment, and lead to service of more consumers. Since the 1990s, there has been a growing realization that economies of scale, as well as opportunities for peer support, exist in providing services to large numbers of frail elders living in one place. In addition to assisted living, several demonstrations and programs have been carried out in more conventional housing settings to test models of planning, organizing, and providing services.

One of the earliest of these demonstrations, the Congregate Housing Services Program (CHSP), authorized under Title IV of the Housing and Community Development Act of 1978, provides a service-enriched setting for frail older persons. Advocates for the CHSP promoted it on the basis that it would prevent "premature" institutionalization of elderly and handicapped residents of federally subsidized housing. The CHSP was carried out initially in sixty-three public housing and Section 202 sites, using HUD funds to pay for services such as meals, homemaking, and transportation to select groups of tenants with three ADL and/or IADL needs. A service coordinator and professional assessment team oversaw eligibility for and organization of the services. Between 1979 and 1985, approximately $28 million was spent on services to 3,500 residents of sixty-three public housing and Section 202 projects.

Because of controversy about whether the CHSP actually prevented institutionalization and HUD's continued reluctance to pay for services, the program did not expand until the early 1990s (Redfoot and Sloan) with the passage of the National Affordable Housing Act of 1990. By this time the CHSP, initially funded solely by HUD, required a significant state and local match that discouraged many sites from applying. Nevertheless, by 1994 the program had grown to more than one hundred sites.

The concept of clustering services has been the basis of several other innovative delivery systems. For example, the New York City Visiting Nurses Association (VNA) has used Medicaid waivers to provide services to groups of residents living in government-assisted housing. Personnel and health care staff are assigned to clusters of frail residents in senior housing. Staff can therefore move from one resident to another, performing various tasks, rather than spending long blocks of time with individual residents. An evaluation of the VNA project found that it saved money, although residents were somewhat less satisfied because individually they received less service (Feldman et al.).

Service coordination. The concept of service coordination is an outgrowth of the CHSP and the Robert Wood Johnson Foundation's Supportive Services Program in Senior Housing demonstration. Through the Housing and Community Development Act of 1992, Congress authorized expenditures for a service coordinator program. Service coordination is often described as the glue that holds a program together or the linking mechanism between residents of housing complexes and services. It is a less intensive model than the CHSP and relies more on linking residents up with services rather than providing them directly.

Services coordinated for residents include meals-on-wheels, in-home supportive services, hospice care, home health care for those who eligible for Medicare or Medicaid, transportation services, on-site adult education in areas of interest, and monthly blood pressure checks. There is also assistance with locating other living arrangements, such as an assisted living facility or a nursing home, when it becomes necessary, but the primary focus is on assisting residents to continue living in their current apartments.

Though the coordinators in this program do not have budgetary authority for services, they can serve a broad group of frail older residents. By 1999 there were approximately a thousand service coordinators connected with public and Section 202 housing complexes across the country. An evaluation of the program revealed that service coordinators successfully marshal a number of new services for residents, who report high levels of satisfaction with the program.

In 1999 HUD acknowledged responsibility for adapting its stock of housing for the elderly into more supportive settings linked with services. HUD's Housing Security Plan for Older Americans, approved by Congress as a part of its 2000 budget, includes $50 million to expand the service coordinator program and $50 million to convert some existing Section 202 housing for the elderly into assisted living.

A comprehensive system of community-based care. The Program of All-inclusive Care for the Elderly (PACE) is a major health care– based demonstration project that provides a range of services to older adults in the home. PACE, which is expected to include approximately fifty sites and ten thousand participants by 2005, attempts to replicate the On Lok Senior Health Services Program in San Francisco, which integrates Medicare and Medicaid financing and provides medical and long-term care services to frail persons who are eligible for a nursing home in a daycare setting. Participants in the program are assigned to an interdisciplinary team for regular needs assessment and care management. PACE's purpose is to address the needs of long-term care clients, providers, and payers. The comprehensive service package allows clients to continue living at home while receiving services, rather than in institutional settings. Nevertheless, many PACE sites have added housing, having found that a number of participants live in deficient settings or need more supervision and help with unscheduled needs than can be provided in individual home settings.

The challenges to incorporating housing into an integrated continuum of care are evident. Much must be done to develop housing as an environment that supports health, particularly as people age and/or become disabled. Conversely, health care providers and payers must recognize the impact that housing situations can have on health. Then, efforts can be made to integrate housing and health services. Housing settings can begin to develop informal affiliations and strategies that enable services to be coordinated on a client-specific as well as a buildingwide basis, taking advantage of the economies of scale inherent in delivering or "clustering" services for groups of older people living together. The organizations that have integrated housing with health care should be examined as models of how such integration works and what the potential would be to increase the integration in the future.

Conclusion

It is increasingly becoming recognized that housing plays an important role in the lives of the elderly. While new strategies and approaches have been developed to increase housing options, a range of affordable supportive housing choices for older persons remains an elusive goal. Progress in this area necessitates the recognition that housing should be an integral part of long-term care policy, and that more can be done to encourage aging in place.

Jon Pynoos Christy Matsuoka

See also Aging In Place; Assisted Living; Board and Care Homes; Congregate Housing; Continuing Care Retirement Communities; Government-Assisted Housing.

BIBLIOGRAPHY

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