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Get ready for community-based long-term care

March 1, 2006
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Get Ready for Community-Based Long-Term Care
    I guess I had best admit to my bias at the start: I am-and am proud to be-a Howard County resident. I have been for as long as I've lived in Maryland, now more than 30 years. Beyond that, I'm an appointee to Howard County's Commission on Aging. So when, five years ago, my county was named by the National Civic League as an All-America City, my excitement was understandable. But that wasn't the sole reason for my enthusiasm. According to the sponsoring organization, "the fifty-two year-old award is given in recognition of communities that triumph over partisan politics to improve the quality of life for their citizens by finding solutions that achieve uncommon results." And among the programs highlighted by the league was Howard County's "Aging in Place" initiative.

Now there's something worth discussing. We all talk about aging in place. Some of us even write about it, perhaps even skeptically (as per my own article, "'Aging in Place' Conveys the Wrong Idea," in the November 2005 issue). But to actually see a community take this on as a key priority-that's noteworthy.

Especially in Howard County. The county is perhaps best known as the location of Columbia, Maryland, a planned community developed by urban planning pioneer (and shopping center mogul) James Rouse. He was going to create an environment that learned from (and thereby avoided) all the mistakes that characterized similar developments in the past. Columbia certainly didn't achieve all of Rouse's goals. But it was successful enough to attract well over 100,000 highly enthusiastic residents, most of them young. A 1999 survey by the Columbia Association, the entity that governs the "new town," pointed out that "the planned community of Columbia began with virtually no seniors."

Well, times have changed. Seniors in Howard County (defined by the county as those over 60 years of age) now constitute 10% of the population and have made it the second most rapidly aging county in the state. While still below the figure for Maryland (15%) and the country as a whole (16%), it clearly reflects the degree to which residents of the county (with Columbia at its center) chose to make it their home for life.

At the outset, I need to admit that Howard County is a very well-to-do community-among the ten most affluent in the nation, with a median annual household income of nearly $80,000. In that respect, it certainly doesn't mirror most U.S. counties. But the increasing frailty that comes with age is no respecter of affluence. Howard Countians face the same obstacles as most Americans do when it comes to exercising a preference to productively age in their own homes as they get older. Surveys by AARP in 1989, 1992, and 1996 all reflected a consistent desire on the part of seniors (more than 80% of them) to "stay in my own home and never move."

But the desire to stay at home runs afoul, in most communities, of an inherent bias toward facility-based care for the elderly. That bias is reflected not just in the tendency of financing systems to focus on it, but in the absence of both infrastructure and referral mechanisms designed to support alternatives. This is a status quo that readers of this magazine may want to cheer for-but read on.

Howard County chose to confront this issue head-on. With seed money from the Horizon Foundation (one of Maryland's largest philanthropies), the county's Office on Aging became one of only a limited number of American communities with truly seamless, comprehensive programs designed to facilitate aging in place. (Others that come to mind are the Philadelphia Corporation for Aging and Multnomah County's Aging and Disability Services programs in Oregon.)

The particular needs of seniors require services totally unlike those provided to other populations in our society. Most healthcare, for example, is typified by acute interventions designed largely to address singular episodes of ill health. Seniors, however, pre-sent a preponderance of chronic conditions, increasing frailty, multiple comorbidities, and decreasing cognitive capacity. Additionally, social concerns are often more of an issue for seniors because of decreasing physical and cognitive capacities, compounded by limited financial and social resources. And mental illness-especially depression and mental illness associated with dementia-is widespread among the elderly. Indeed, a survey conducted among Howard County seniors as part of its aging in place initiative showed a large proportion (63%) admitted to having experienced some depression over the 30 days preceding the survey.

These are not people for whom a compartmentalized single episode, a single practitioner, a single focus for service delivery is appropriate. Their need is not for discrete and individual interventions, but for long-term and coordinated management of multiple services. And that means management, focused as it must be on the myriad factors attendant to the individual, must itself bring to bear the various specialties and functions appropriate to those concerns. Anything short of that is a disservice to the client.

A team approach, therefore, is key. It is critical at every stage of the process-from needs assessment through service planning, delivery, and follow-up. It is as relevant to the overall management of the service and care program itself as it is to the specific needs of the client. And managing productive aging is no exception-particularly any effort designed to allow productive aging in one's own home.