The Commission on Affordable Housing and Health Facility
Needs for Seniors in the 21st Century
November 7, 2001
Good afternoon Mr. Chairman, Members of the Commission, and Guests. Thank you so much for the opportunity to speak about Affordable Housing and Health Facility Needs for Seniors in the 21st Century. I am especially pleased to speak with you about seniors who live in rural America.
I am Anne McKinley, and I have lived and worked in Prescott, Arizona, for 20 years. It is the largest town and the county seat of Yavapai County. My professional and volunteer activities during this time have taken me into the smaller communities of this county as well as many small communities all over Arizona and other areas of the country. As diverse as they are, these communities have a common theme that directly relates to the mandates of this commission. They are not well heard and they are not well served.
This testimony will be about those seniors whom I know best, those who live in the rural areas of Arizona, and particularly those who live in Yavapai County in North Central Arizona.
I am using this geographic area as the basis of my testimony for we already have the percentages of seniors living here that the rest of the country anticipates in and after the year 2020. We meet the criteria established by many of the 40 definitions of rural found in federal policy-including frontier and wilderness. (Will the real rural stand up?) What is happening here also reflects the change that is occurring in much of the West and Southwest where so many people are choosing to retire at this time. This region has close ties in terms of demographics, economics and topography. We have relevant issues in housing, health, and economic and social consequence. One alarming social consequence we share is that the Rocky Mountain States have the highest incidence of elderly suicide. This paradise of ours is in trouble.
Over the years of working with the people in small towns and rural communities, my thinking crystallized regarding the dilemma of developing services and programs for seniors who live there. One dilemma is regarding major challenges and barriers that we face. The other area is three interventions that are applicable to resolving some of the dilemma.
Barriers and Challenges: The barriers are isolation, economic deprivation, lack of the ability to use economy of scale, lack of a trained labor pool, lack of a human service and health care infrastructure, cultural antagonism, lack of a well informed and consistent advocacy group. There are two major cross cutting concerns, housing and transportation.
We also find problems with targeting of federal and state funds, the lack of local matching capacity, the lack of "high tech" capabilities, a lack of organized intergenerational networks which are essential in rural communities, and an inability to effectively "get the message out".
Rural areas have an abundance of scarcity and an abundance of strength. As we deal with the scarcity now we will build on the strength for the future.
Three Interventions: The interventions are: strengthening the network of care in rural communities using community organization strategies; establishing an educational direction that needs to be taken if rural seniors and their communities are going to be informed, heard and served; developing and utilizing technology capability to create a way for the people to have more control of their lives as they face necessary losses and strive to maintain independence in the face of dependence. These interventions are connected to the development of a capacity to respond, a campaign for caring and quality of life.
I am currently working to develop an Institute of Applied Gerontology (IAG) at Yavapai College (YC), our community college for this region of Arizona.
When the opportunity was presented to me, it became a different way to explore the identified barriers and "lacks". It is a new set of alliances and a non-traditional avenue for the service providers, community planners and the community members themselves. It would be an opportunity to implement the interventions; and it would be possible to raise consciousness of aging, develop various educational programs in small towns, have technology access and capability and to create an advocacy effort that is long over due.
Yavapai College: Yavapai College is well suited to do this. It has three major campuses in this very large county, the largest elder hostel program in the United States, a 350 member self directed senior learning program (though only operational on the Prescott campus), and an emphasis on retirement and leisure education. The IAG has added a new component that increases the comprehensive efforts to reach seniors, their families, their provider services, and the business community with a variety of educational and service modalities. Communities can help develop the strategies and it would be a method of helping them help themselves move forward.
IAG and the Research Component: In a visioning process with an advisory group in each community, IAG designed a research and resource component into its function. This element of our activities is pertinent to item (4) in the commission mandate, "to establish methods of encouraging increased private sector partnerships." We are working with the Senior Industries Cluster of the Arizona Department of Commerce (ADOC) and the Morrison Institute for Public Policy Research at Arizona State University. We are doing a study to evaluate the impact of seniors on all aspects of our economy-businesses like construction, banking, retail, and especially and including the health facilities industries. A look at work force needs is a primary objective. We are at the same time working on a study with an organization in Tucson, the University of Arizona Center on Aging and ADOC to develop direction and initiatives for support of the direct caregivers who are so important to our health facilities, home care programs, family private hire needs and ultimately a quality of life for our seniors. The first study is Yavapai County directed though it will have implications for other rural areas. In the second study we are a rural site to determine what differences may exist for planning and education for more effective response to the direct caregiver needs in a rural setting. As is so often the case, the issues may be the same; the resolution and problem solving may need to be different.
Yavapai County: Physical Description, Demographics, Governance, Culture:
It is important that you have an understanding of the realities of Yavapai County that impacts on the seniors, and the housing and health facility infrastructure needs. It is just as important for you to understand how seniors impact Yavapai County. All infrastructures, not just housing and health, are affected by the rapid growth we are experiencing in senior populations. Whole communities have grown up after a travel trailer parked to enjoy the view of a large open space---followed by another---and another---and another. One such community that began this accumulation of people in the late 70's now has 800 people, a church and two stores. It also has a small Housing and Urban Development (HUD) apartment unit. The unit is available to three surrounding communities.
Beginning with Prescott, this is, indeed, a very beautiful place. Prescott was the first territorial capitol of Arizona, thus has much of the early historical significance of the state. Magazines and newspapers frequently list it as one of the 10 best places in the country to retire, and people have believed what they read and moved here. The rest of the county is also very desirable as a retirement area. It is over 8000 square miles. It has a diverse landscape that ranges from low desert with vegetation and temperatures like Phoenix to the high desert places like Prescott that are over a mile high with pine forests, winter snow and mountain ranges. One mountain range within the county divides it east and west and another divides it "more west". This adds time to travel and gives new meaning to isolation, cultural differences and cultural antagonisms. Prescott is on the West Side of the mountain and is the largest town with 37,000 people, 38 % of whom are over 60. A town in the county that some of you may have visited is Sedona which is on the East Side of the mountain. It is 65 miles away and because of the mountains one needs to plan an hour and a half to get there. In the "more west" there is a town that is 35 miles away and it is necessary to plan more than an hour to get there.
Including Prescott and Sedona there are 7 incorporated towns, 21 unincorporated towns, and many small and scattered hamlets. In the 2000 census the county has 167,000 people. Twenty years ago it took the entire northeast quadrant of the state, a 48,000 square mile area, to have 200,000 people. Populations in the unincorporated towns are from 645 to 6,000, and the percentage of people over 60 can be from 31% to 60%. In one of the towns that has 1700 people the mean age is 55. All of this, the numbers of unincorporated towns, the high percentage of seniors, and the rapid growth have an impact on the economy, the housing and health care needs, the need for social service organizations and the need for volunteer groups to enhance formal services.
The economy of the area was at one time mining and ranching with small pockets of agriculture and produce. It is now tourism and service industries with some ranching still here. Mining is less significant at this time. Many of the older generations of the ranching families are dying or becoming seriously incapacitated. As the younger generations are inheriting, they are selling large acreage for high-end housing developments. One of the results is that these developments are pushing closer to some of the rural communities which is causing further change to their environment and increasing divisions among the people. Annexation of lands by the larger communities for development purposes is also occurring. It's taking a way of life and up to now is giving nothing back. Annexation makes them subject to zoning laws over which they have little control. It makes low income housing an even lower priority for the government planners. Sometimes I wonder how many rural communities will survive, as we know them, and what this will do to the people who can't keep up economically.
Planning and the local economies are closely related. Rural communities are dependent on public funding through government planning. Even the larger towns have a limited revenue base. The smaller, unincorporated rural communities are dependent on the county for safety, roads. public health, and opportunities to develop housing and transit; on small rural fire districts for fire protection and 911 emergency health, and, I might add, for counseling and support when they are sad and lonely. Unincorporated towns have no elected leadership, which can lead to fractious bids for authority and control from disparate factions. Planning occurs within councils of the incorporated towns, within the county structure for the unincorporated towns, within state agencies, and with some coalition building among some towns. When housing, health and transportation planning is done the people in the smaller towns feel they are passed by. They lack a potent advocacy group.
A planning mechanism that is involved and significant to our housing and health facilities development is the Northern Arizona Council of Governments (NACOG). It is in Flagstaff, which is 100 miles away and is responsible for the entire northeast quadrant and 48,000 square miles I mentioned earlier. This is an area about the size of Pennsylvania. Many of the federal funds flow through there. This is where we receive consultation and technical support for housing, transportation, Community Social Service Block Grants, and the Community Development Block Grants; and the Area Agency on Aging is housed there. One of my favorite stories is when the transit planner told me that Prescott didn't need transit funds because we had a shuttle to the Phoenix airport. The shuttle is available if you can get to Prescott to board it, have $50.00 for a round trip, and need to go to the airport. It doesn't function as multiple use on demand transportation.
There is much fragmentation of planning for all services that add to the confusion seniors have about advocacy and to whom to appeal. They become discouraged, give up and accept that they can do nothing. The leadership in the communities frequently shares this discouragement. They become intimidated and fearful of losing the services they have.
Looking for low income housing through private /public partnerships in the smaller towns may not be feasible at this time. I would like to see this encouraged. It could be a part of the future. There are ethical and moral questions that would need to be answered around what the people want the community to be and how much change they are willing to accept. It would take intergenerational planning and buy in. If there were a way to build an interest in co-op housing and a way to fund it, it would offer a whole new way of looking at the place they live.
Following is an example of a public/private housing idea that didn't work regarding housing development. I was visiting in a senior center in a town of 645 people where 43% of the residents are over 65. It is an economically deprived area. It so happens that in this community there is a closed gold mine that a Canadian company wants to reopen. A man came in and wanted to know if the senior center director thought an apartment complex and a gated community would be acceptable in the community. He was interested in "new economic development that was proposed." He thought that with the cooperation of the senior center a variety of funding could be tapped. The senior center director told him that it might work if they first built low income housing for the seniors. He feigned interest and promised to return to talk about it. The mine hasn't reopened and the man hasn't returned.
Housing and health facility needs by any definition in our rural areas are huge. If you are looking only at home ownership and rental property it's huge. If you add assisted living it becomes huger, and if you add health facilities which includes skilled nursing home care, it is overwhelming. Also, except perhaps in a population center of about 10,000 people, you reach levels of care that are unavailable. Assisted living is difficult to sustain in towns of less than 2000-3000 people because the room and board can't be reimbursed by Medicaid and the cost can be prohibitive for seniors with incomes that are just above Medicaid levels. With low population density and many of the people with limited incomes, there are serious limitations for developing alternative housing options. A housing option that is effective in some of our small communities is adult foster care. More could be done to look at this for refinement in program design so that the focus would be intergenerational learning and mutual support. This would be a shift in direction that might work. It might take a new name to allow this shift. There are practitioners and planners who use the terms adult foster care and assisted living as synonymous terms though there are differences in concept, delivery and reimbursement mechanisms.
It would be helpful to have more small, subsidized housing units. I say this knowing it is problematic because of the cost of building out here. There is an inability to use economy of scale. Materials have to be trucked in, labor force has to be brought in and housed in mobile units or perhaps 35 miles away. This slows things down and gets us behind in completion deadlines. With these economic realities, contractors are reluctant to bid on and develop multi-family units in rural areas. Many of them are no longer willing to build within what they describe as inflexibilities of Housing and Urban Development (HUD) 202 housing.
One contractor who is with a not for profit contracting company told me that HUD restrictions did not allow an inner hall in a 20 unit apartment complex in one of our commentates. He was concerned because he felt the restriction totally negated the promise of attention to quality of life and socialization. The apartments are in an area of harsh weather, the terrain is uneven and rocky, and people have to go outside to reach even a next door neighbor. Since it is for seniors and designed to include seniors with disabilities, he felt he had enabled social isolation.
More than one person spoke to the details and multiple restrictions, like roofing materials. There seems to be a general feeling, even from those contractors who like federal monitoring, that in an assessment of housing and construction policy, there needs to be more consultation with the people who are out here doing the work and trying to implement policy in a way that is sound for the people and the communities.
Other Complicating Housing Factors:
Any housing in the rural communities is complicated because of water and sewer systems. Most of the communities purchase water through a water district, or through private businesses with wells. Individual wells are expensive to drill when water is a speculative commodity, and ensuring a clean water supply can be expensive. The communities and individuals in the small towns have no sewer options, only septic systems. When something goes wrong, the repairs are expensive, and help for the repairs, both with finding workmen and with any public funding is limited. Replacement systems are sometimes not possible because of the terrain. Mary, who was 79, lived alone with a minimal social security payment. She was toileting outside because her septic system was overflowed. The neighbors didn't notice anything for two weeks. Mary was too proud and embarrassed to tell any one. The nutrition site director, Jane, who the people trust, was notified. She, in turn, called the weatherization program and the Area Agency on Aging for help. Help was unavailable for two more weeks. Jane sighed as she told me the story. She asked, "Why are we told there are programs for our seniors when they are unavailable when we need them?" I learned that the weatherization funds for this region are used within a very short time after being received and there is a two-year waiting list for the service. The HOME program requires that if one repair is made the entire house must be brought to standard at the same time. This makes it difficult to use the funds in a critical situation to repair one offending feature, and has the potential to leave people with unsafe environments. These things need to change.
Home repair and rehabilitation are programs are desperately needed for rural people. The low-income energy programs are the compatible supplements to the rehabilitation programs. They are necessary for people's health as well as their comfort. This is especially true for the seniors with heart and respiratory illnesses.
Again, funding cannot keep up with the need, and without transportation it's not possible to get to the office to complete the application. The most vulnerable go unserved.
There are communities that sit in close proximity that when brought together to form coalitions to develop their identified need for housing, transportation or health service cannot work together. They talk of their long time animosity yet unable to identify when it began or why. The people work together in a most cooperative way if planners who are trying to bring them together respect their differences and their naturally formed community alliances. If we are going to have housing and access to health facilities, advocacy and community networks need to be developed and in a thoughtful way that is sensitive to all of the cultural issues.
Pertinent Questions and Answers:
Assumptions continue to be made that what works for one, works for all, that rural seniors don't want subsidized housing apartments (there are two -five year waits for all existing units in this county. An altercation occurred one day because a man thought someone was given housing before him.), that they are satisfied with their housing. Questions always arise when these issues are discussed with colleagues who have not worked directly with the people in these small towns, " Why are you concerned about housing and health care for rural areas? Research shows that they are more satisfied than their urban counterparts." I certainly agree that the people with whom I work are glad they live where they do. Are they satisfied with the condition of their housing? Of their lack of transportation? Of the separation from their family and other support system when they become ill and must be in a hospital 40 or 70 miles away? Or in a health care facility of equal distance? The answer is "no." Are families disrupted, and saddened by the separations that are incurred? Are they institutionalized for a longer time after an acute health episode that requires rehabilitation services? Do they experience earlier permanent institutionalization when they have seriously compromised health and cognitive disjunction? The answer is "yes." Do they have access to home care and home health services? Do they have access to private hire caregivers? The answer is on a very limited basis, if at all. Do they have access to Older American Act Services like senior centers and nutrition services? The answer is "same as above."Another question is "why don't you integrate services in your low income housing complexes?" The answer is that where we can, we try. In some areas there are just no services to integrate---or they are limited and intermittent.
In a crisis neighbors try to help, if they know about it. It is a myth, however, that neighbors know one another and all of everyone else's personal business in small towns. With the rapid growth, new people are moving in and the lives of the long-term residents are disrupted. The new residents are frequently there only part of a year and do not become integral to the community activities. There are social integration problems that hearken back to Durkheim's theories and the community organization theories that include the gemeinshaft and geshellshaft of rural communities.
Home and Community Based Care, A Matter of House and Home:
Home and community based care is the care of choice with our primarily home ownership and rental economies. The geographic distances, lack of transportation, the lack of workforce, the lack of federal money that finds it way into rural areas for this purpose makes it difficult. The workforce issue may be the major concern in this service as it is for the health facilities. It is also a concern for people who can pay privately, for the workers are not there.
There are other concerns that are sometimes left out of the discussion: road safety for personnel as well as personal safety when working in remote houses and trailers, automobile hazards on dirt roads that need repair, snow and ice in the winter and flash floods when we have very heavy rain.
For people to be safe at home and for quality of life, we again raise the transportation factor. It is a factor in people trying to be together when one is ill in a hospital or long term care facility in town that is far away. It's also a factor when all services and government offices are so far away. For seniors who may have compromised mobility and eyesight, getting outside the house may be difficult indeed. They may be able to walk down the hill, but getting back up the hill may not be possible. For transportation interest, I will mention the need for ambulances and the problems associated with cost and rules and regulations that exist.
This county has 10 skilled nursing homes and many assisted living facilities. All are clustered in the population centers. Both are plagued by workforce and reimbursement issues. For the people in the small towns, availability and access to these facilities presents problems and the inability to pay for them compounds their situation.
We reviewed challenges and barriers to developing programs and services in rural areas, looked at interventions to try, defined some difficulties in existing housing policies, and recognized that housing and transportation are cross cutting issue for rural people.
While we focus on need and change for now, let's accept that the future needs a new vision. Jonathan Swift said that,"Vision is the art of seeing the invisible." Our vision for housing and health facilities change shall include recognition of the differences in rural communities and people.
Housing is a basic need. It is the basis for independent functioning for all seniors. HUD says we will have safe, decent, affordable housing---including health facilities.
Let us insist that it happen.
My set of "ifs and wishes."
If I had to choose an overriding issue, it would be the lack of ability to use economy of scale. It impacts the cost of housing, the cost of services, the cost of health care---everything.
If I had to choose the most important element for success, it would be developing interventions that include the people themselves in planning and implementation.
If I had to choose a single ingredient that is needed to make it happen, it would be dedicated funds.
If I had to choose the option for rural people that holds the most promise, it would be technology.
If I had to choose an immediate fix, it would be toward more weatherization programs, a change in the details of the HOME program, more for low-income energy assistance, and more attention to all home rehabilitation programs.
If I had to choose a housing option to develop, it would include co-op housing or other options that promote mutually supportive environments for intergenerational living.
If I had my way, I would do a total system review including HUD and the Department of Health and Human Services. I would assess how they could integrate service and planning. I would look at the cooperation that exists at all levels of planning from the federal to the local. The outcome would keep what is working and determine how and where it should be placed in the broader policy scheme. I would look at where and whether integration of services might most helpfully begin.
If I have a hope, it is that this information is helpful.