Paul Willging Says…


‘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.

Whether we’re talking about economics or one’s own life choices, information is key. If a senior, likely retired, wishes to productively age, how does he or she go about finding the necessary information? How can anyone be expected to make empowered decisions, absent data? That’s what has stimulated the development of any number of projects, private and public, designed to meet just that need.

The Boomerang project in Phoenix, for example, is designed to respond to the unique aging trends of seniors and assist them with the transition to another life stage, that of meaningful retirement. The programs and services provided for by Boomerang are there to help the generation born between 1946 and 1964 answer the question “What’s next?” by providing links to local resources on lifelong learning, second careers, and wellness.

Pathways to Living, Learning & Serving, sponsored by Central Florida Community College, serves a similar purpose. Its life-planning programs feature counselors, one-on-one coaches, seminars, and other resources to help people create a plan for their future and locate the resources they will need to implement it. It offers adults ages 55 and older an opportunity to work with a trained coach in making decisions regarding lifelong learning, wellness, work opportunities, and volunteer services.

The North Carolina Center for Creative Retirement (NCCCR) (part of the University of North Carolina at Asheville) was established in 1988 with the threefold purpose of providing today’s accomplished adult with opportunities for lifelong learning, leadership, and community service, each involving the fellowship of peers sharing a common quest for continued growth and service to others. The university’s goal is to encourage the development of an age-integrated society. In response to the aging of America, NCCCR serves as a laboratory for exploring creative and productive roles for a new generation of retirement-aged people, many of whom will blend education with post-retirement careers.

The federal government also became involved when it announced some two years ago a $9.3 million grant for the development of aging resource centers in 12 communities across the country. One of those communities happens to be Howard County, the Maryland community in which I live. Called MAP (Maryland Access Point), the resource center is designed to serve as a single point of reference for seniors and others looking for information they might need in planning for a productive retirement. The program is part of a federal initiative aimed at overcoming barriers to community living for people with disabilities of all ages. A joint program of the Administration on Aging and the Centers for Medicare & Medicaid Services, it takes an important step toward meeting a senior’s potential need for long-term care by stimulating the development of:

  • affordable choices and options that promote independence and dignity for individuals;
  • consumer control and meaningful involvement in the design and delivery of the programs and services that affect their lives;
  • information that empowers people to make informed decisions;
  • easy access to a range of health, long-term care, and environmental supports;
  • support for family caregivers; and
  • assurances that people are getting the highest-quality care available.

While the federal program is oriented more toward the various forms of long-term care available to seniors, its Howard County site is reflective not just of healthcare concerns, but of the broader issue of information as a prerequisite for empowerment. Its Web site ( offers information regarding an entire array of support services and information, from financial planning to housing, from healthcare to transportation.

All these programs, public and private, reflect a basic premise: Productive aging stimulates and encourages healthy aging. Productive aging reflects an empowered consumer, but the empowered consumer can function as such only with the requisite information. So, as a society, why don’t we stop worrying exclusively about the care of seniors only after that care becomes necessary? Rather, let’s work with seniors to live healthier lives by empowering them to make their own decisions. The place they should be aging is within themselves, and helping them with that will benefit all of us.

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Paul R. Willging, PhD, was involved in long-term care policy development at the highest levels for more than 20 years. For 16 years as president/CEO of the American Health Care Association, Dr. Willging went on to cofound the successful Johns Hopkins Seniors Housing and Care postgraduate program (cosponsored by the National Investment Center for the Seniors Housing & Care Industries), and later served as president/CEO of the Assisted Living Federation of America. He has enjoyed an equally long-lived reputation for offering outspoken, often provocative views on long-term care.

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