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Paul Willging Says...

November 1, 2005
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Aging in Place Conveys the Wrong Idea

'Aging in place' conveys the wrong idea As long-term care community managers, we really try not to give too much thought to "aging in place." If anything, we have approached the concept more as a threat, as a challenge to market share, and certainly not as a critical part of our own mission. If people age in place, we've contended, doesn't that simply mean they will delay the utilization of our products and services? And where's the benefit in that from our point of view?

There are ways of dealing with that concern. The first, of course, is to ignore it as irrelevant. The customer will do what the customer will do. If Emma wishes to stay at home as long as possible (and if she has the resources to do so), what we think Emma should do is of no concern to her whatsoever.

But I would prefer to deal with the issue from two totally different perspectives. The first is the more practical one: An admission deferred is not an admission denied. Emma might stay home a few months (or even years) longer than we might think appropriate, but if her needs can eventually be met only in a nursing facility or assisted living community, that is likely where she will ultimately find herself "at home." That will become her "place," the place where she will continue to age.

The second perspective has to do with the very nature of the long-term care continuum and the role of facility-based care on that continuum. Nursing homes, particularly, have too often seen the continuum more as a challenge than as a logical umbrella for the services they provide. And other providers along that continuum have perpetuated that stance. First home care and then assisted living have both historically positioned themselves as alternatives to nursing home care. Home- and community-based services in general have tended to justify their existence not in terms of the positives attendant to their product, but more in terms of the negatives attributed to the nursing home. And shame on them!

No wonder the nursing home profession continually sees itself as in a state of siege. But it shouldn't. Its competitors' positions notwithstanding, nursing facilities need to embrace, even more than their competitors, the concept that long-term care is indeed a continuum and that all providers along that progression of increasingly intense services are legitimately partners in service delivery. The profession should embrace with passion and commitment the idea that aging in place is a concept critical to the mission and vision of all of them. It is not the preserve of active adult communities, of home care providers, or of assisted living communities. There are no alternatives to nursing home care when it is needed. If nursing home care is most appropriate for Emma on the continuum of care, that is where she should be.

But what about Emma's own preferences? If her concern is to age in place, shouldn't all of us be oriented toward fulfilling that goal, regardless of whether she is best served in one of our communities?

To effectively address that challenge, I would suggest that we need to address the entire concept of aging in place. I would contend that the very word "place" is the root cause of many of our problems. By its very nature it implies one's "house"-the place where we raised the kids, shared family experiences, and ventured from to walk the neighborhood. I propose we discard the term or at least change its definition.

Aging in place should have nothing to do with physical location. It should have everything to do with self-fulfillment, with personal empowerment. Aging in place reflects an attitude and an environment enhancing the ability of seniors to maintain personal control over their lives, to the extent practicable but in ways important to them.

Aging in place is best seen as a phenomenon reflecting the ability of seniors, to the extent feasible and practicable, to maintain the ability to direct their own lives. Public- and private-sector responsibilities should be less to do things for seniors than to support them in their ability to do things for themselves-to provide the tools enabling them to age in place, wherever that "place" might be. Our goal in encouraging aging in place should be to support seniors in making their own decisions, not to make those decisions for them.

In fact, I would suggest that a much more appropriate term for this might be "productive aging." That's a concept much more prevalent among our European colleagues. In Europe, it is assumed that one can productively age regardless of location. Indeed, it would not be heretical there to suggest (as it might be in the United States) that one might age in place in a nursing facility, if that is the location that best addresses both resident needs and resident preferences and best facilitates senior empowerment.

Easier said than done, perhaps. If what we're really after is the broader concept of productive aging, how do we get there? I would suggest that it is simpler than one might anticipate. It doesn't entail the expenditure of vast sums of additional monies. It doesn't require the enactment of broad new publicly funded programs. It does require the recognition that the greatest barrier to senior empowerment is the dearth of information seniors need to make the decisions that they themselves are otherwise in the best position to make. The issue is not capacity; most seniors are still quite capable of making the decisions required for them to lead productive lives. What they lack is the information necessary to do so.