Putting Together the Pieces for “Aging in Place”

One of the most common trends facing providers of senior housing is that many of our existing residents have become physically frail. Their mobility might be limited, and they generally do not have much strength and endurance. Some might have impaired cognitive function. They might be somewhat forgetful, react to situations much more slowly than they used to and might not be thinking on a concrete level. These seniors might not require ongoing oversight, but they do have chronic physical and/or mental problems. Age itself has not produced disability, but rather a combination of disease process, poor health and a natural slowing down of bodily functions. "Aging in place"-the process of becoming increasingly frail while still living in an independent living environment-is beginning to pose a challenge for many operators.
For the older adult resident, those promised "Golden Years" are just a bit tarnished. Their progressive frailty impacts their ability to perform at least one of the "activities of daily living" (ADLs) or "independent activities of daily living" (IADLs):

  • ADLs include dressing, bathing, grooming, toileting, eating and ambulating.
  • IADLs include meal preparation, shopping, housecleaning, using the telephone, managing money and taking medication.

Ultimately, the decline impairs their ability to sustain self- and home or apartment care. They might have increased difficulty shopping for groceries and preparing meals. They might have reduced social contacts and a limited ability to participate in the social milieu of the housing community, thus feeling isolated, lonely and often depressed. Their disturbed sleeping habits might keep them and other residents awake later at night because the television is on just a bit too loud. They might have reduced ability to care for their beloved pets. They might be experiencing frequent falls. They might spend time in your public areas and lobbies, just sitting or sleeping. They are increasingly dependent on other residents and staff to help them.

Certainly the challenge to the seniors housing management staff can be evident in increased maintenance and housekeeping problems because of odors, pest infestations and incontinence, for example. Some residents might report persistent knocking on their doors by neighbors requesting assistance or orientation reassurance. Reports might increase regarding "stolen" possessions that later are found misplaced in another location in the apartment, as well as lost keys, accidental lockouts and complaints from other residents. Management might even notice that some appliances require additional maintenance because of misuse or abuse.

The impact of the resident's "aging in place" must also be seen in the context of their families' reactions, e.g., families feeling:

Guilty. After all, they have busy lives. Consider that Mom might be 90 years old and the daughter could be 72 and retired in Florida with her 78-year-old husband. Their own daughter is 44, a single mother raising two teenage children of her own. Sometimes the guilt can be laid upon the family by the resident herself: "How come one mother can take care of five children, but five children can't take care of one mother?"

Angry. "Why should I be spending my time helping Mom? I do all that I can and she doesn't appreciate it or remember that I've been here." Often unresolved conflicts from childhood surface at this stage of life.

Frustrated. "I've tried everything. She won't let in the homemaker I hired," or, "He won't give up his car keys and insists on driving without a license or insurance."

Afraid…of their own aging or death. Watching close relatives functionally de-cline can be scary to family members. So many are afraid that dementia or Alz-heimer's disease will be their fate, as well.

A sense of grief and loss. A serious change in a close relative can produce the same reaction as his or her death-grieving for the person who is no longer there. So often we hear, "I wish you had known my mother before, or when…." Unlike death, a loss of this kind has no set rules or rituals to follow to ease the pain.

In denial or out of touch. "I just took her to the doctor and she's fine." And how often do we hear, "That's why we pay you. You take care of Mom!"

And that really is management's problem. What do we do with residents who have functionally aged beyond the ability of the housing community's service capacity? How do we deliver the additional level of services our residents require and at the same time continue to attract active, independent residents?
Before answering that question, there are several points to consider:

  • How does your organization assess the ability of the resident to live safely in your housing environment?
  • What criteria will you apply consistently and uniformly to each resident?
  • What impact does providing service support have on your staffing, budget, marketing and other residents?
  • What additional liabilities would be incurred if additional services were to be provided?
  • What expectations might be set up by the provision of additional services?
  • Who is going to pay for the services and how much?
  • How much service is too much for your particular setting?
  • Does this provision of service merely postpone the resident's eventual transfer to a more supportive level of care?
Physical Adaptations
Certainly, there are physical adaptations that can be made to the housing environment to permit aging in place, for example:

  • Adding grab bars in bathing and toilet areas
  • Installing lever hardware in place of doorknobs
  • Installing doorbells or flashing lights to signal residents with sensory handicaps
  • Placing benches or chairs in long corridors and next to elevators as temporary resting places
  • Installing corridor handrails
  • Increasing lighting in corridors, dining rooms and public areas
  • Making sure public area furnishings are "geri-designed," with firm seats and backs, armchairs of appropriate height and low-pile or tightly woven carpet
  • Arranging furniture in public areas close enough to improve conversation for residents who are hard of hearing
  • Installing acoustical treatments in dining rooms to reduce noise
  • Providing adaptive eating utensils, clothing, etc.
  • Placing special signage on apartment doors identifying residents by name or placing familiar items on their doors for further identification
  • Printing notices in large, legible print
  • Converting tubs to shower stalls
  • Installing handheld shower heads
  • Installing thermostats with easy-to-read numbers and posted instructions on use
  • Installing "comfort-level" toilets
  • Color coding corridor, doors and elevators
The list goes on, but the question remains: Who pays for these refinements? If the senior housing provider has planned well, many of these adaptations could already be included in a facility set up to accommodate "universal design." If not, you might want to include adaptations of this sort in your annual budget. Many families are more than willing to pay for such adaptations just to keep their relatives in a residential, independent environment.

Some community organizations and foundations have limited funds for these adaptations, and since assistance is provided to individuals and not organizations, for-profit organizations should not neglect to consider these. Check, for example, with Parkinson's associations and organizations serving the blind and visually impaired.

Adding Support Services
If not already provided by your housing community, you might need and want to add supportive services that benefit your entire resident population. These could be either included in your monthly rents or paid for on a "fee-for-service" basis. Some examples:

  • Transportation to physician appointments, religious services and essential shopping. Residents with special needs might require escorted services. If your housing community does not have its own vehicle or if the resident cannot afford the transportation service fees, tap into community resources for older adult transportation, volunteer transport and family assistance. For example, the diabetes associations might have volunteer transportation available for residents who require kidney dialysis. Churches might have an outreach program for assisting seniors. Public transportation might have a "call-a-ride" system for people with disabilities.
  • Flexible dining opportunities and menus, e.g., soup served in mugs, specialized diets or in-apartment tray service.
  • Activities designed for specialized needs, e.g., reminiscence program led by a psychiatric nurse/social worker from a home health agency; water exercises led by a community organization such as the Arthritis Foundation; tai chi classes to promote balance; family support groups; and wellness programs.
  • Additional fee-for-service housekeeping, laundry, chores and grocery shopping.
  • Establishment of a volunteer service corps staffed by high school student organizations or the Boy or Girl Scouts.
  • Emergency call system pendants or wrist bracelets activated by pressing a button.
Tapping Into Community Organizations
As you begin to assemble solutions to meet the ongoing needs of your aging-in-place population, you need to identify and tap into a variety of public services offered within your own cities and counties. Highlights of these include:

  • Area Agency on Aging (AAA). Each state has an Office on Aging, with AAA agencies located throughout the state. Your state's AAA has an information and referral service offering accurate, up-to-date information on all the available services in the community, including transportation, senior dining centers, volunteer agencies, home health agencies, adult daycare services and specialized care resources.
  • Family service agencies, such as Catholic, Lutheran and Jewish Family Services, which are counseling agencies and, in some cases, service providers for homemaker and chore services, transportation and money management. Often their services are available on a sliding scale based on individual income.
  • Hospitals. When a resident has been admitted to a hospital, it is important to work with its social services department regarding a discharge p1an. Usually, there is a small window of opportunity for you because the hospitalization could be very brief. Together you and the social worker might be able to work out a suitable service plan.
  • Home health services provide nursing services and personal care services, and can be contracted with to provide physical, occupational and speech therapy. Of course, reimbursement for these services under Medicare and managed care has been a "moving target" and cannot be relied upon.
  • Financial and legal assistance agencies provide assistance with estate planning, guardianship, emergency funds, fuel purchases, conservatorship, legal counseling and money management on a sliding-scale fee basis.
  • Adult day care. Generally these programs are open five days a week and include a hot lunch and transportation. Some have specialized programs for dementia and Alzheimer's management, therapy, medications, etc. Many accept Medicaid.
  • Nutrition. There are senior congregate dining centers available in most communities. Some communities offer Meals on Wheels, food pantries and grocery delivery services.
  • Support groups. These include groups focusing on bereavement, Alzheimer's, stroke, and widow-to-widow and caregiver support.
  • In-home services provide assistance with household chores, home repair, weatherization, telephone reassurance and emergency response.
Creating Service Packages
Again and again, research demonstrates that helping seniors remain in their own housing environment is the preferred and most palatable option for them and their families. The advent of assisted living has opened up a new world of service opportunity to meet these preferences. Today, the seniors housing provider has many assisted living service models from which to choose. Creating, for example, a continuum-of-care model involves dedicating a specific building or portion of a building to providing a supportive environment. Clustering residents together in small group settings enables them to have more personalized attention and ongoing oversight.

Another model tailors a service package delivered to the residential units either bundled or a la carte. Typically, the resident is assessed initially by a management designee, contracted social worker or licensed professional nurse. Then, a specialized care plan is developed. If the resident needs only medication reminders, for instance, that service is provided by in-house staff or a contracted home health agency, or the resident's family can contract services from a licensed healthcare professional. Under this arrangement, services can be enhanced for a resident's "spell of illness" and then discontinued when no longer needed. Perhaps the service needed is just a "jump start" in the morning and a "fluff and tuck" in the evening. Sometimes residents might appreciate an escort service designed to orient them to their surroundings and the programs and activities offered by the housing community.

No one model of assisted living service delivery is "best" or "perfect." Sometimes combinations of models are necessary to meet specific needs, which places a premium on flexible thinking. Whatever the service or approach, the program allows the resident to "age in place" amidst familiar surroundings.

Admittedly, from a regulatory standpoint in some cities and states, there might be no choice but to transfer a resident to a higher level of care when his needs can no longer be appropriately accommodated in a particular setting. If so, the transfer process needs to involve a clearly defined resident assessment program and careful documentation, and the resident and his family need to be included in this process so that all have a clearer understanding of the situation.

"Changing Cloaks"
As residents of seniors housing communities age in place, it is incumbent upon us to go "beyond the basics" to help brighten those otherwise tarnished golden years. We need to design models that offer creative adaptations of services and environments to enhance residents' function and compensate for their increasing frailty and disability. It is helpful to view this from the resident's perspective, as this journal entry written recently by a male resident in our area enables us to do:

Mimi and I have about completed a change of cloaks. For many years we have lived quite well and happily under cloaks of independence. Within minimum overview from governmental bodies and some timely observations from relatives and friends, we have survived with reasonable independence. Our home was our castle and we could come and go as we wished.

As our years on earth crept up to the high eighties, we noted a corresponding decline in our energy, our activity, our vigor, our ambition, our awareness, and we could feel the cloaks of independence slipping off. We have acquired new cloaks of dependence which we are slowly getting used to. They signify the adoption of a different lifestyle. We are gradually beginning to appreciate these new cloaks. We are truly grateful for the protection they provide. NH

Bonnie Solomon is vice-president of Retirement Living Services, Delmar Gardens Enterprises, St. Louis, Missouri. For further information, call (314) 434-2520, fax (314) 434-4223 or e-mail gvillas@ swbell.net.

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