Empire State Building
350 Fifth Avenue, 23 Floor
New York, NY 10118
The Commission on Affordable Housing and Health Facility
Needs for Seniors in the 21st Century
January 14th, 2002
Fredda Vladeck, CSW
Director, Aging in Place Initiative
Madame Chairmen, members of the Commission, my name is Fredda Vladeck. I'm very pleased to have the opportunity to appear before you today to provide you with some of my perspectives and experiences, grounded in the twenty five years in which I have been working with seniors in need of health care, social services, and other forms of assistance.
In 1983, I went to work for St. Vincent's Hospital in Manhattan as a social worker on a project to address the housing needs of frail elderly clients in the hospital's Greenwich Village and Chelsea service areas. That experience led to my involvement with Penn South Houses, where in the mid-1980s, in conjunction with the Board of Directors of Penn South, UJA/Federation of Jewish Philanthropies, and Selfhelp Community Services, we developed and operated the nation's prototypical Supportive Services Program in a naturally-occurring retirement community, or NORC. Now, having come almost full circle, I direct the Aging in Place Initiative of the United Hospital Fund, which works in partnership with the New York City Department for the Aging, the United Way of New York City, UJA-Federation, and other private funders to support the development of programs based on the Penn South model, and to foster the development of other service delivery models for community-based services for seniors.
Currently, there are 28 NORC Supportive Service Programs operating in New York City in moderate income apartment complexes, public housing developments, and garden apartments in which 46,000 seniors live. These programs are public/private partnerships between government agencies, philanthropy, housing entities, and health care and social service providers to locate a wide array of social and health care services at a housing site. NORC programs are by nature proactive and take a holistic, preventive approach to the health and well-being of seniors.
On the basis of this experience, I have arrived at a number of conclusions, five of which I want to share with you today, elaborating on each slightly: First, under any plausible set of assumptions about housing markets and national housing policy, the overwhelming majority of seniors who will require some sort of health and social services over the next twenty to twenty-five years are already living in precisely the same places they will be when those needs for service develop. In other words, most seniors in need of service will age in place, where they are now.
Second, while Medicare, Medicaid, and the Older Americans Act play an indispensable role in supporting services for the elderly, there is growing consensus that the existing service system is too reactive, too fragmented, and too categorical to optimally meet the needs of a growing population with multiple, interactive chronic conditions. Some new organizational and conceputal bridges must be built to span the gap between the needs of a growing number of seniors and the current capabilities of our service delivery system.
Third, we increasingly understand that the well-being and, indeed, physical health of seniors is highly dependent on their connectedness to a web of social networks, that social isolation, conversely, is itself a major risk factor for bad outcomes. Our existing service delivery systems are not oriented to meet this need at all.
Fourth, in well-functioning communities with considerable concentrations of seniors, much of the "caregiving" occurs informally as interactions between and among neighbors, whether or not members of the community reside in purpose-built senior housing. The challenge before us is to find ways to help foster the informal "caregiving" and web of social networks as the residents of a community get older.
And fifth, these four propositions, taken together, suggest that it is possible to develop service programs that effectively bridge some of the gaps between seniors and existing health and social services. But if early models of such programs are to be replicated, expanded, and modified for the differing conditions of other communities, we need to take several concrete steps soon. We need research to understand more systematically and more scientifically what distinguishes good community-based programs from mediocre ones. We need demonstration projects to test new models of community-building and community services in more suburban and rural single-family home communities, of the sort in which a growing proportion of seniors are likely to live. And we need significant changes in the ways in which we train social workers, nurses, program managers, and other service professionals if we are to adequately respond to growing demographic realities.
Permit me to say some more about each of these points in turn.
Where the Clients Are - and Will Be
Despite the proliferation in recent years of assisted living and independent housing marketed at a narrow band of the senior population, the simple fact remains that aggregate patterns of housing for the elderly have really not changed that much in the last 25 years, and are not likely to change in the future. Even if we had a systematic national commitment to radically expanding the supply of purpose-built senior housing, the simple arithmetic is that the burgeoning population of older people - and especially of the "old old" who are most in need of services - will far outpace any plausible increase in the supply of such housing. More importantly, the data and experience establish the overwhelming fact that, as people age, they tend to become more attached, not less, to the places in which they have lived for a protracted period of time. While there will always be, in other words, some people attracted to the idea of relocating to specialty housing, or relocating their parents to such arrangements, most seniors want to stay where they are.
Under certain circumstances, specialty senior housing can provide the setting for highly successful service delivery programs, but so can naturally occurring retirement communities; there is certainly no evidence that, on average, services are significantly better in one type of community than another. From the point of view of getting people the services they need when they need them, then, significant capital investment in new housing, in and of itself, is largely beside the point. People of all ages need safe, comfortable, and affordable places to live, but this is just as true of seniors as it is of anyone else, not more true.
The Service Mismatch
The recent expressions of interest by policymakers, researchers, and foundations in the disjunction between the health care delivery system and the Medicare and Medicaid programs which underlie it, on the one hand, and the needs of seniors with significant problems of chronic illness, on the other, validate and emphasize what many of us involved in direct delivery of services have known and felt for a long time. Our clients need a service system which is proactive, flexible, responsive, continuous, and well-integrated. Instead, we provide services in a way which is reactive, categorically rigid, disparate, and fragmented. A concrete case example, extracted from many actual cases, may help to illustrate these problems:
The dreaded "fall" is usually the event that starts the access to services. A case in point is Mrs. Smith, who is 77 years old and lives alone. She suffers a fall; breaks her hip; and, is hospitalized. During her stay it is discovered that her thyroid level is dangerously low. She is discharged home with Medicare-covered intermittent home care and Meals on Wheels from her local senior center, so that she will have a hot meal on the days the home health aide does not come. Before the fall, Mrs. Smith had been a regular at her local senior center, but eight months earlier, had stopped going due to increasing confusion. Mrs. Smith had no idea that she was having a thyroid problem. She just hoped nobody else saw that she was having a hard time keeping it together. She did not want to go to a nursing home or have a stranger in her house taking care of her. The center staff had called her a few times to encourage her to return, but did not succeed. Six weeks after she left the hospital, Mrs. Smith was discharged from Medicare home care, but the meals continued. After being discharged from home care, she still had difficulty ambulating which made it hard to get to the drug store to fill her thyroid prescription, which led to further confusion and decline. Six months later, after a fall and another hospitalization, Mrs. Smith had become a daily Medicaid home attendant client.
Medicare, Medicaid, and the Older Americans Act have a number of characteristics in common that define who gets what services, when, and for how long. Each is targeted to a subset of the older population. For Medicare, you must have a covered medical or skilled care need that requires a specific intervention for a limited period of time. For the long term care or medical services covered by Medicaid, you must be poor and able to prove it going back a number of years before you can qualify. And the basic services of the Older Americans Act are for those older people in need of a bare bones budget hot meal to be eaten while "socializing" in the echoing caverns of cement-block senior centers or alone in your own home if you are homebound. If you do not fit one of these categories based on service type or income, you do not get what you need. (You may get served, but it may not be what you need - sometimes we put in a homebound meal when we don't know what else to do or in lieu of providing a home attendant because the client doesn't qualify for clinical, financial, or bureaucratic reasons.)
What is most needed in many communities is not a laundry list of new services or new types of providers to improve access to Medicaid funded and Medicare covered services, but rather some straightforward mechanisms to insure that care providers get to know their clients and potential clients before the event of an acute crisis, to provide basic case management services, and to insure both primary and secondary prevention of emergency episodes in a population that is frail but also highly protective of its autonomy and independence. Such services need not be enormously complex or expensive, but they must be available where the clients and potential clients are, in the communities in which they live, and they must be sufficiently a part of the fabric of those communities that the act of crossing the threshold of a service provider can occur easily, without advance planning, and even without formally seeking services. Senior housing may often provide a sufficient density of people in need of service to foster economies in the provision of such services, but there are many other communities of more mixed housing in which the density of potential clients is more than sufficient for efficient service provision.
While people are living substantially longer than they did in the past, they are often doing so in a way more physically isolated from their friends and neighbors. The very increases in the quantity of the nation's housing stock and the tools of telecommunication have made it likelier that frail elders will live alone, literally out of sight. And the evolution of our service delivery systems has, if anything, exacerbated this problem; as more and more clients are served in their own homes, their interaction with anyone other than individual caregivers is reduced. As an eligibility criterion in Medicare, for example, the status of "homebound" may become self-reinforcing. One older person eloquently described to me her fear of becoming "entombed" in her apartment as the services she might need for a specific illness - that would trigger eligibility in Medicare or Medicaid - serve to keep her locked behind her apartment door, separated from the community in which she lives.
As a growing body of evidence identifies the health effects of social connectedness among the elderly, and describes a web of strong interpersonal relationships as an essential contributor to healthy aging, we need to become substantially more creative about developing service models that provide people more opportunity to interact with their neighbors and others of like interests - before they become irretrievably disabled. Highly-skilled professionals often look down their noses at social and educational programs and simple socialization for the "well" elderly, but the availability of such programs may often be part of what keeps them well. And their participation in such activities permits adequately-trained and motivated professionals to encourage other preventive health activities, and to keep an informal eye on changes in clients' status and well-being. Again, the necessary precondition for such services is a large enough population of seniors, whether that population is recently relocated to specially-built senior housing, or has simply aged in place.
Taking Care of One Another
One of the things that happens as successful communities evolve is that people increasingly take care of one another, and community residents, in either organized or individual form, begin to work more closely with professional service providers. Again, a large part of what frail elderly people need is for other people to keep track of them, look out for them, become aware when something appears to be wrong or changing unexpectedly, and help prod often reluctant or resistant people to seek help when they need it. Even in settings such as purpose-built elderly housing, one cannot assume that such community practices and mores will appear spontaneously, although they sometimes will. But in all cases they should be intentionally fostered and maintained, in ways that promote respect for the dignity and privacy of everyone, and that insure that the role of neighbors will not only be helpful, but perceived as helpful.
Lessons for the Future
Our experience with NORC Supportive Services Programs in New York City, and what we've learned about other communities that have addressed the issues arising from the aging in place phenomenon, has taught us a few important lessons. First, successful programs require a partnership among community residents, housing sponsors, health care providers, community service agencies, and government. Each plays an essential role in the development and maintenance of successful community-based programs. Second, successful programs must have a preventive orientation, and must engage the community's seniors before they have an acute medical emergency or other personal problem. Third, while successful community-based programs rely very heavily on the informal roles of community residents themselves, both individually and collectively, that reliance must be accompanied, ironically enough, by especially skillful professionals. Working effectively with communities, and thinking in terms of prevention at the level of a whole community, rather than a single individual, are skills which can be taught, but which rarely are in contemporary educational programs for social workers, nurses, and other health and human services professionals.
We therefore have a very significant educational agenda. The current shortage of nurses and other health professionals has focused attention on the need to increase the number of trained social service and health care professionals. But we need to focus as well on the content of that training. Our aging population will require not only more nursing and social work and therapy and case management services, but better community-organized and -defined services than we are now often able to provide.
But while the educational agenda is clear enough, there are other things we need to do if our communities are going to be able to respond effectively to growing service needs for seniors. If we're going to focus our efforts on the development of community-based services, we still need to answer some very basic questions about the most effective and realistic way to define "community" in terms of total population, population of seniors, characteristics of the senior population, and geographic boundaries. We need a systematic program of research to understand why effective services develop in some communities but not others. And we need to think hard and work creatively to extend service delivery models that have proven effective in dense, high-rise urban communities to more suburban and rural communities dominated by single-family housing, low population densities, and different patterns of interaction among community residents.
We should not consider these challenges overwhelming. Indeed, it is my strong belief that our experience has already shown us the direction in which we need to move if this society is going to enable its growing number of elderly members to live in the kinds of communities that can meet their needs in the years ahead. We have successful models. But those models are, at the moment, too few and far between to inspire much confidence in their widespread replication. To make sure that it happens, we need strong national leadership and a clear sense of national direction.
Again, I very much appreciate the opportunity to appear before you today. I'd be pleased to answer any questions any of you might have.