Merrill, Hunl / Aging in PI, 61

Aging in Place: A Dilemma forRetirement Housing Administrators

John MerrillMichael E. Hunt

University of Wisconsln-Madison

components: (a) an overview of current knowledge on the subject of agingin place; (b) interviews with 13 administrators of retirement centers in citiesconsidered comparable to Madison about their experiences with aging inplace; (c) an investigation of the market for retirement housing in Madison.Results of this investigation are clearly inappropriate for generalizing to allretirement housing. However, the insight gained from the investigation ishelpful in better understanding the aging-in-place phenomenon. In addition,the three-phased approach taken in this investigation can serve as a modelfor others confronting aging in place in retirement housing.

The phenomenon of aging in place poses fundamental questions lor administrators and planners0/ housing for the elderly. Based on a planning study for one retirement facility in the upperMidwest, we reviewed current knowledge pertinent to aging in place and present the findings 0/interviews with 13 housing administrators and present some limited market analysis of the hostcommunity of 'he subject retirement facility.

Overview of What Is Known

Aging in place is the phenomenon of growing older in the place whereyou spent your earlier years. The phenomenon itself is not new or unusual.Today, large numbers of persons living in housing designed for independentliving are requiring increasing levels of service as they age in place. Thesituation poses fundamental questions for administrators of retirementhousing.

Our purpose is to investigate issues that administrators of housing for. older persons must address as they consider how to respond to aging in place.This investigation is centered around a case study of Retirement House (afictitious name), a retirement village in Madison, Wisconsin. RetirementHouse is a not-for-profit retirement village consisting of a IS-story high-riseapartment building, a six-story gallery apartment wing, a private diningfacility, a chapel/auditorium, and other specialty rooms for crafts, activities,and meetings. Also on site are a skilled nursing facility and an intermediatecare facility.

Retirement House had been experiencing the consequences of aging inplace for several years. The administration sponsored this investigation tohclp it develop an appropriate response. The investigation consisted of three

Of the three basic responses to aging in place in retirement housing,Lawton, Greenbaum, and Liebowitz (1980) identify two. The first is for thefacility to remain static. In such a case, the facility is designed for residentswho meet specific health and mobility requirements. When residents ceaseto meet these standards, they are expected to move to a more supportive livingarrangement. The second response Lawton identifies is for the facility toaccommodate the increased service needs of the residents. A third approachfalls somewhere in between. Ehrlich, Ehrlich, and Woeh Ike (1982) identifywhat they cal1 a balanced model which involves intervention to strengthenthe informal service network. In the balanced model, facilities a11ow residentsto provide their own services and the facility may also increase the level ofservices provided, but only to a limited degree.

The Static Response

The static response raises ethical concerns as well as market concerns.The ethical concerns relate to the controversy surrounding the relocation ofolder people. In some instances populations of frail older persons haveexperienced drastic increases in death rates following moves. Although therehas been an abundance of research concerning the relocation of older people,the results have been apparently contradictory. For example, Aldrich andMendkoff (1963); Killian (1970); Lieberman (1961); Marcus, Blenkner,Bloom, and Downs (1972); and Pablo (1977) have found the manifestationsof relocation to include increased mortality, depression, stress, and decreasedlife satisfaction. On the other hand, Carp (1968, 1977); Lawton and Yaffe(1970); Lieberman, Tobin, and Slover (1971); Miller and Lieberman (1965);

AUTHORS' NOTE: We acknowledge and Ihank Marlene Slum for her assistance in conductingthe research on which this manuscripl is based.

TheJoumal or Applied Gerontology, Vol. 9 No.1. March 199060· 76II.)1990 The Southern Gerontological Society

60

62 ial of Applied Gerontology Merrill, Hunll Agin _ Jace 63

and Wittels and Botwinick (1974) have not substantiated these debilitatingeffects of relocating older people.

In response to this dilemma, Schulz and Brenner (1977) offer a frameworkthat explains these apparently contradictory findings. This framework isbased on the assumption that relocation is stressful. Schulz and Brenner arguethat laboratory research on animals and humans reveals two factors thatmediate responses to stress: controllability and predictability. "In general.thegreater the perceived controllability or predictability of a stressor, the lessaversive and harmful are its effects on the organism" (p. 324).

Controllability and predictability are easily applied to relocation. In thiscontext, controllabil ity refers to the degree of choice offered to the person,and predictability refers to the degree of environmental change. Thus facili-ties adopting the static response to aging in place need to be prepared tomaximize controllability and predictability of the move for residents. Themarket concern raised by the static response is whether there is a sufficientpool of replacement residents who would meet the facility's independencecriteria and be attracted to the facility. Of several factors to consider inresponding to this question, the first is the age distribution and health statusof the aging population. The second is the array of competing housing optionsavailable to older persons considering a change of housing. The conditionsthat prompt a change of housing by older persons constitute a third factor tobe considered.

Changing demographics of aging. The older population is aging: Thepercentage of persons 85 or older and between 75 and 84 is increasing fasterthan the percentage of persons between 65 and 74 years old. Nationalprojections are that the number of persons over age 74 age will increase by70% by the year 2010, while there will be a much smaller growth in thenumber of persons 65-74 (35%; Warner, 1983).

As persons age, the chances of their having one or more impairmentslimiting their ability to live independently increases. While about- 13% ofpersons aged 65-604 report a functional impairment, over 28% of those overage 79 report an impairment (Macken, 1986). These figures suggest that thepopulation of older people potentially in the market for retirement housingis aging, and may in fact, on average, need more services.

Competing housing options available. An array of housing options isavailable to active older persons. Perhaps the most popular housing optionfor older persons is the naturally occurring retirement community (NORC),defined as a housing development or complex not planned or designed forolder people, but which over time comes to house a preponderance of olderpeople (Hunt & Gunter-Hunt, 1985). NORCs provide an opportunity for

It-

companionship with age peers in an age-integrated setting, as well as conve-nient proximity to services such as a grocery store and other shoppingfacilities- all at a modest cost. For many older people, NORCs may offer allthe support that is needed to live an independent life-style.

Other active retirees may simply want to reduce the home maintenanceburden without sacrificing the privacy, independence, arid space of a single-family home. These persons may find a condominium the best choice. Othersmay prefer to stay in their own homes and arrange to have services broughtin to meet their needs.

Reasons for moves 10 retirement housing. The aging of the old and theavailability of other housing options have caused an apparent shift in thetype of older person who is applying for residency in retirement housing.Applicants tend to be older and more in need of some level of services.Malozemoff, Anderson, and Rosenbaum (1978) asked older persons whatevents would lead them to move to retirement housing and found that olderpersons are not likely to move until some major event occurs, such as areduction in their ability to live independently, or, conversely, an increasedneed for services.

A study conducted by the State Housing Council in Oregon (Niven, 1983)compared residents of senior housing with nonresidents. Niven found theaverage age for the typical resident was 83. Residents placed a high value onmeal service, emergency help, security, and nearness to relatives. Mostindicated no trouble with such self-care activities as dressing and making thebed. Nonresidents were about four years younger. Their ability to manageindependently was the primary reason for delaying a move to retirementhousing. They wanted the housing to which they finally moved to providemedical coverage, suggesting that they intended to delay the move until theywere no longer able to function independently.

In an analysis of a sample of 27 congregate housing facilities across thecountry, Urban Systems Research (Malozemoff et aI., 1978) reports that themost often cited reason for moving to congregate housing was difficulty inkeeping up the house or apartment. A second reason was a desire to remainindependent and not to be a burden on family. The high cost of previoushousing and concern about emergencies were the next most frequently citedreasons.

The Accommodation Approach

The accommodation response to aging in place raises separate issues. Willthe provision of services change the image of the facility and thereby make

64 Joui [ Applied Gerontology Merrill, Hunt I Aging in PI", _ 65

it less attractive to older persons capable of more independent living? Thelogical extension of this concern is that more and more services would beadded and increasingly dependent residents would not only be retained, butattracted as well.

A corollary of the image issue is the response of current residents ifpersons with obvious frailties are allowed to remain in the facility. Theseissues are symptoms of the central concern that must be addressed in theaccommodation approach. What services should be provided? How shouldthey be provided? And once a facility begins adding services, is it possibleto determine at what service level the accommodation should stop?

Types of services needed. One way to respond to these issues is to look atthe frequencies of the need for various types of services in the population ofolder persons. Each year the National Center for Health Statistics conductsa national survey through the U.S. Bureau of the Census to obtain informationabout health and use of health care. In 1984 a supplement was added to thesurvey to collect information specifically about older persons. The samplefor this supplement included 11,497 persons 65 years of age and over.Dawson, Hendershot, and Fulton (1987) analyzed data in this supplementconcerning functional limitations. People were considered to have a limita-tion if they indicated difficulty performing a task because of health orphysical problems. Respondents were asked about a set of tasks known asactivities of daily living (ADLs) and another set known as instrumentalactivities of daily living (IADLs) (see Tables 1 and 2). The results pertainonly to noninstitutionalized elderly.

These data suggest that a substantial proportion of the very old haveproblems with instrumental activities. However, relatively few have troubleswith personal care activities. The two exceptions are walking and bathing.Altogether only 16% have more than two activities for which they receivehelp.

Another national study looked at the frequency of cognitive impairment.This study by the Health Care Financing Administration (Macken, 1986)reported that only 16% of the population 85 years of age and older demon-strated moderate or severe cognitive impairment, suggesting that most olderpersons can be expected to manage their own affairs even when physicallyimpaired.

Lawton, Moss, and Grimes (1985) found residents in a sample of retire-ment facilities to be less competent than they had been 12 years earlier. Theyengaged in less active activity, did less visiting, and left the building lessfrequently. However, measures of functional health suggest there was only aminor decline in wellness. A total of21 % indicated one or more impairments

\

Table 1. Percentage of Persons 65 and Over with Functionat LImitations

% Reporting Limitation

65·74 75-84 8S & Over

Activities of Daily LivingBalhing 6.4 12.3 27.9Dressing 4.3 7.6 166Using loilel 26 5.4 14.1Walking 14.2 22.9 39.9Eating 1.2 2.5 4.4

Instrumenlal Activities of Daily livingHeavy housework 8.6 28.7 47.8Light housework 4.3 8.9 23.6Preparing meals 4.0 8.8 26.1Shopping 6.4 15.0 37.0Getting outside 2.7 6.9 21.2Managing money 2.2 6.3 24.0

SOURCE: Adapted from Dawson et at., 1987.

Table 2. Percentage of Persons 65 and Over by Number ofPersonat Care Activities for which Help Is Received

Age Group None 1 2 3 4-;-65-74 94.0 2.8 1.1 .6 1.575-84 88.1 4.5 2.4 1.5 2.585 and over 68.9 10.9 6.2 5.1 10.8Total 65 and over 90.4 3.9 1.9 1 .1 2.8

SOURCE: Adapted from Dawson el at. (1987).

in major activities; 7% indicated two such impairments. In general, the mostmarked decline was in mobility.

Studies that look at the demand for services as opposed to the need showsimilarly small proportions. The services most demanded in the UrbanSystems Research study, referred to earlier, were meals and housekeeping.Medical service was desired but primarily as a security feature in case of needrather than as a necessary support service (Malozemoff, 1978)_ When respon-dents in Lawton's study (1985) were asked what additional services they

65 Journal of 1"., •• .ed Gerontology Merrill, Hunt / Aging in Place 6'1

needed, housework assistance was the clear choice, yet only 13% indicateda need for even that.

Conclusion about services needed. It appears from the evidence availablethat the vast majority of older persons with impairments need only limitedservices, if any, and that they are mentally competent to oversee theseservices themselves. Only a few types of services seem to be really necessary.

Methodology

male and female. A total of 13 administrators were interviewed from ninecities in seven states. Information was collected from each administrator bytelephone-focused interviews and mailed questionnaires. It should be men-tioned that three facilities of the initial retirement housing sample did notparticipate because they did not provide services, but focused only in inde-pendent living and attempted to remain constant.

The retirement facilities contacted fell into two categories with regard totheir obligation to provide health care to residents. One category of housingpromises independent-living-unit residents a priority for adrn ission to long-term care accommodations, but has no legal obligation to provide it (n = 5),A second category of housing hasa legal obligation to provide long-termhealth care to independent-living-unit residents (life-care contracts) (n = 8).

Aging in place was found to be occurring in both types of retirementhousing contacted. The extent to which aging had occurred appears to be afunction of the age of the facility and not its obligation to provide long-termhealth care. The longer the housing had been in existence, the more aging inplace had occurred. Of all the facilities contacted, the average age at openi ngwas 76.2, and today it is 82.5. Average ages of those on waiting lists had alsoincreased, but only by 3 years versus 6.3 years for current residents. A typicalwaiting-list individual was 78.5 years of age.

How have the service needs of the residents changed over ti me? Everyfacil ity contacted reported increases in the demand for personal ca re services(bathing, dressing). An increase in the demand for home health due was alsoreported. Even the administrators of life-care facilities where a continuum ofcare is provided, reported an increasing need for a housing opt ion fallingsomewhere between independent-living units and nursing care. Many facil-ities already provided group meals (7), homemaker/chore help (6), transpor-tation (5), and clinics and emergency responses (5) so that these basic needscould already be serviced. Those facilities not providing the basic meals andhomemaker services found them to be most in demand, followed by healthand personal care services. Also mentioned as changes were less participationin activities by residents, declining mobility, and an increase in the level ofconfusion.

How have tire facilities responded to the change? Responses of theadministrators to the changing needs of residents have varied. The mostextreme response has been to add additional assisted-care units. Of the eightlife-care facilities contacted, two reported having already built additionalassisted-care units and two others reported plans to build more such care unitsin the near future. It is interesting to note that none of the five facil ities withno legal obligation to provide long-term care had built new assisted-care

I. Hotel type services thai reduce the effort of daily living, for example, house-keeping, laundry, transportation, and food preparation.

2. Services that provide a sense of security that someone will be there if erner-gency care is needed - a call system and 24·hour staffing.

3. Assurance of additional care should it be needed in the future- priority for abed in a health care facility.

It would seem appropriate from the literature review to resist providingmore extensive services than those listed above for several reasons. Theseservices would meet the needs of the vast majority of persons who can beexpected to seek housing in a retirement housing facility. Second, theseservices could be provided without substantial physical changes in thefacilities. Third, providing such services would not require licensing in moststates.

Administrator Interviews

In the second phase of this investigation, directors of retirement housingsimilar to Retirement House were interviewed to learn of their experienceswith aging in place. These interviews were expected to provide insight intothe prevalence of aging in place, how facilities are responding to it, and howsuccessful the responses have been.

To approximate the environment of Retirement House, the sample ofretirement housing was drawn from cities that were, like Madison, service-rich midwestern college communities. These communities were Ann Arborand Lansing, Michigan; Columbus, Ohio; Lafayette, Indiana; Columbia,Missouri; lowa City and Ames, Iowa; and Lincoln, Nebraska. Marinette,Wisconsin was also included because of a desire to learn about a specificfacility in that community. Census data gathered for each community sup-ported the similarities to Madison in the percentages of elderly householders,

I

68 Journal of At J Gerontology Merrill. Huntl Aging in Place 69

units. However, one of these facilities indicated an interest in adding assisted-care units in the future and another had definite plans to do so,

It should be noted that there was a consensus among facilities that hadadded assisted-care units, that the major attraction to the housing was theindependent-living units, but that the demand was for assisted care, Thusresidents seem to be attracted to retirement housing by the life-style offeredby the independent-living units, but soon need more assistance than appro-priate in such a setting.

A second response to aging in place has been for the facility itself to beginproviding services to residents of the independent-living units (ILU). Fourof the five facilities with no legal obligation to provide long-term care hadcJecided to follow this course, These added services included meals, house-keeping, and health care. Only one of the life-care facilities decided toprovide more services to the independent-living units,

A third response to aging in place has been to allow ILU residents tocontract personally with independent service providers to bring services tothem, The only retirement facility without an obligation to provide long-termcare that did not begin providing services to ILU residents themselves, didallow residents to contract for services independently. One life-care facilityalso followed this course of action.

A fourth and very different response to aging in place has been to buildadditional ILUs to attract younger residents. One of the five retirementfacilities with no legal obligation to provide long-term care had plans to buildadditional independent-living units. These plans were to build condomini-ums to attract younger retirees (70- 75 years old). Likewise, three of the eightlife-care facilities have plans to build additional independent-living units,The plans of these three facilities range from luxury townhouses withgarages, and duplexes with kitchens, to large luxury apartments.

The final response to aging in place that we identified relies on marketing.One life-care facility reported that they chose to use marketing to overcometheir "old" image and attract younger residents.

W!rat impact has tire response had on resident satisfaction? Residentsatisfaction with accommodation by allowing supportive services to beprovided in ILUs has its Iimits according to most respondents, Administratorsreport that curre nt residents are advocates of keeping the independent focusin the apartments. Residents express disapproval at seeing supportive carefor long periods of time, and clear policies on assistive devices are desiredby residents, Resident councils are strong forces in all facilities and influencepolicies regarding the degree of accommodation that they consider appropri-ate but that still maintain the independent focus of the facility. In the

nonlife-care facilities, the addition of meals, homemaker chore services, andmeeting temporary care needs of individuals seems to be acceptable andmakes residents happy that they do not have to relocate and move to suchservices. However, in the life-care facilities, the security provided by alife-care contract was considered to meet residents' needs and providesatisfaction because they know where and how their needs would be met asthey aged.

Marketing an independent-living facility with an average resident in hereighties was frequently mentioned as a challenge, especially if supportiveservices were allowed in the apartments. Many administrators were feelingthe demands from older individuals in need of personal care but theypreferred to market to and cater to the healthier independent market.

What is the intent of admission and retention policies, and have theychanged to deal with aging in place? Each facility had an admission com-mittee that dealt With determining whether an incoming resident met itsdefinition of "independence." Being mobile or ambulatory, mentally alert,and having the ability to take care of their daily needs was the key to mostindependence definitions. No facility was willing to accommodate mental oremotional problems by bringing in supportive services. Variations existed inthe type of mobility aides that were allowed.

Retention was a function of negotiation among the staff, family, resident,the resident's physician, and the administrator of the facility, Some facilitieshad established assessment committees to determine when the residentneeded an increase or decrease in services and to determine when relocationwas needed. Working through what they could and could not provide inservice was a continual process for many. Most found the ir case-by-caseapproach working well. Residents and their families typically recognized theneed to add services or to move to a more supportive environment. Therefore,relocation seemed to be an appropriate response if it were to be accompaniedby communication, assessment, and allowance for a transition period,

Conclusions: Trends in the Aging-in-Place Responses

Accommodation is the predominate response to aging in place by theadministrators interviewed in this investigation.

One finding from this analysis concerns the means by which the retirementfacilities implemented their accommodation to aging in place. Life-carefacilities tended to move residents to the services by building new assisted-care housing units or converting nursing beds to assisted care. These facilities

70 Journal ot . .ied Gerontology Merrill. Huntl Aging in Place

also report that these relocations pose no problems if accompanied by propercounseling involving staff, family, and resident.

The retirement facilities with no legal obligation to provide long-termhealth care tended to bri ng services to residents of ILUs. This approach hasbeen successful in meeting the service needs of residents. However, thisstrategy may negatively affect the facility's ability to attract younger, lessfrail residents and may affect the satisfaction of ILU residents not needingmore services.

Another major finding of the analysis is that there are two very differentmeans of addressing the problem of attracting younger residents. One hasbeen to add more assisted-care units and move frail people to them. The otherhas been to add more independent-living units to attract the younger andhealthier elderly (those in their seventies), such as townhouses, condomini-ums, and luxury apartments. These two strategies would seem to have verydifferent effects on the image of retirement housing. The choice of which toselect would have to be considered in the context of the housing optionsavailable in the host community.

An instrument was developed that included questions about events thatwould lead the respondent to consider moving to retirement housing, expec-tations of retirement housing, and images of it. The instrument was pilotedwith focus groups developed with the aid of local churches.

Responses were received from 278 households, a 45.4% rate of return.Respondents tended to be younger than the study population, but otherwiserepresentative.

The waiting-list survey was conducted by sending each person on theretirement facility's waiting list a questionnaire (n = 109). The instrumentcovered the same subjects as the instrument sent to potential residents. A totalof 74 questionnaires were returned for a 67.9% response ratc.

Findings

Methodology

How many respondents anticipated a move to retirement housing? Nearly89% of the respondents to the community survey had no plans to move. Thosewho were not planning to move were likely to be younger, married, and livingin a two-person household. An interest in moving to housing more suitableto their needs, but not specifically for older persons, was indicated by 20.8%of the respondents. Fewer respondents (18.4%) expressed interest in retire-ment housing.

What events would cause respondents to look for retirement housing?Decl ine in health was the most frequently cited reason for looking forretirement housing (61.9%). The second most frequently mentioned factorwas the desire to reduce the burden of housework and home maintenance(48.2%). Loss of spouse and loss of the ability to drive were mentioned byover a third (35.2%) of the respondents. Only slightly less common amongthe responses was the desire for assistance with daily activities (32.0%).Positive reasons for moving, such as easier access to services and leisureactivities and the increased availability of companionship, were mentionedless frequently (17.4% and 13.8%, respectively).

The overwhelming majority (91.7%) of those on the waiting list wereprompted to apply to the retirement facility for security in case of futurehealth changes. A desire to reduce the burden of housework and homemaintenance was also an incentive for half (50.0%) of the respondents.Nearly one-third (31.9%) of the respondents indicated a desire for easieraccess to services and leisure facilities, a more positive reason for such amove. Slightly less common incentives for a move included the advice offamily and/or physician and loss of a spouse.

Investigation of Aging in Place in Retirement House

The investigation of aging in place in Retirement House included a surveyof potential residents of the retirement facility living in Madison, and a surveyof persons on the facility's waiting list. The purpose of the investigation wasto look more closely at the nature of demand for this retirement housing andthe implications of demand for the facility's responses to aging in place.

To leam more about the retirement housing needs and expectations ofpotential residents a mail-out survey was undertaken. A structured samplewas developed using a mailing list supplied by a local financial institution.The mailing list consisted of persons who were 55 or older who had beenwilling to make a substantial deposit in the institution in return [or certain"club" benefits. This population was of sufficient age and had the financialresources to make a retirement community a realistic option for them. Weselected a sample of 62] persons from this group, constructed so that onlypersons over 60 were included, and the mix of couples and men and womenliving alone approximated the proportions of Madison in general.

Homeowners were influenced more than renters to move to retirementhousing by the loss of a spouse, loss of ability to drive, and the desire toreduce the burden of housework. In comparison, renters were prompted toapply to retirement housing for security reasons in case of a health decline,access to services and facilities, and on the advice of family/physicians.

What features were respondents seeking in retirement housing? Respon-dents to both surveys were presented with an extensive list of possiblefeatures of retirement housing, and asked to check the ones that would appealto them. Two types of features headed the list. One type is illustrated by "agarage," which suggests an expectation of continued independence and goodhealth. The other type of feature is represented by "assurance of care shouldhealth deteriorate" and "transportation options." These features suggest adesire to have some insurance against future need. The emergency caIIsystem may also be part of this "insurance package." See Table 3.

Several retirement housing features attracted very little interest, amongthem a unit without a kitchen, three meals a day, and three bedrooms. Fewerthan 10% of the respondents selected those three features. A "unit in a largeapartment building" and "assistance with personal care" were part of this listfor the community sample and were nearly as unpopular with the waiting-listrespondents. The resistance to the large apartment building on the part of thewaiting-list group was surprising because they had placed their names on awaiting list for a unit in a large apartment building.

Because the responses to these preference questions arc "nominal data,"the best technique for searching for natural groupings among the responsesto these questions was a cluster analysis using Ward's method (Norusis,1985). In the first stage of the procedure each variable is considered as acluster. Means are calculated for each variable. Then the squared euclideandistance between cluster means is calculated. At each step in the clusteringprocess, the two clusters that are merged are those that result in the smaIIestincrease in the overall sum of squared distances within the clusters (Norusis,1985).

In Table 4, we show the resulting cluster analysis when four clustersremained. Cluster A was the last cluster to remain separate, suggesting thatthis cluster of items is least related to the remaining items. This clusterdescribes are latively independent-living setting. Cluster B describes a muchmore supportive setting with the emphasis on availability of health care.Cluster C, on the other hand, emphasizes non health-related services thatreduce the effort of daily living. There is no ready description to characterizeCluster D.

Merrill, Huntl Aging in Place 73

Table 3. Desired Features In Retirement Housing

Potential Residents Waiting ListResponses % Rank % Rank

Garage for car 56.9 1 52.8 13Two bedrooms 54.7 2 61.1 9Assurance of care should health deteriorate 54.4 3 86.1 1Transportation options 50.0 4 68.1 6Emergency call system 47.8 5 75.0 3Apartment in building with people of own age 45.3 6 54.2 12One meal a day 42.3 7 76.4 2Recreation/exercise facilities 39.8 8 47.2 14Laundry facilities 37.6 9 69.4 5Housekeeping services 34.3 10 56.9 1124-hour staff for emergencies 32.1 11 73.6 4One bedroom 31.8 12 65.3 8Planned activities 26.6 13.5 58.3 10Units for 20 or fewer people 26.6 13.5 27.8 17.5Acceptance of walker, cane, wheelchairs 25.6 15 36.1 15Health clinic 16.8 16 65.3 8Private outside entrance 15.7 17 20.8 19Two meals a day 15.0 18 27.8 17.5Duplex or condo 13.9 19 19.4 20Other(s) 9.1 20 5.6 24.5Large apartment building 7.7 21 29.2 16Assistance with personal care 7.3 22 13.9 21Private room and bath. no kitchen 3.6 23.5 6.9 22.5Three meals a day 3.6 23.5 5.6 24.5Three bedrooms 1.3 25 6.9 22.5

" N = 274; respondents could give more than one answer.

. i 2 Jourr. •. ~•.Applied Gerontology

Conclusions from the Case Study

The findings of the case study are consistent with the literature survey andthe survey of administrators, Most older persons are not planning a move.When they do move, they are being pushed out of their previous homes ratherthan pulled to the retirement housing. Declining health and the burden ofhome maintenance are the leading reasons given for being pushed out of aresidence. Increased availability of companionship and leisure facilities arementioned much less frequently as forces pulling them to retirement housing.

Both potential residents and persons on the waiting list preferred featuresin a retirement facility that allowed continued independence but provided

74 Jourru .pplied Gerontology

Table 4. Desired Clusters of Features In Retirement Housing of a Community

C/usterA C/usterC CiusterDClusterB

Private outsideentrance

Duple)( or condoTwo bedroomsGarage

One mealTransportationPlanned activitiesEmergency callHealth clinic24-hour staffAcceptance of

mobility aidsAssurance of care

Age·segregated20 or fewerresidents

One bedroomTwo mealsHousekeepinglaundry

assurance of additional care if needed; for example, a garage was an ex-tremely popular feature. "Assurance of care should health fail" is an exampleof a feature in the other category. Features suggesting a high level ofdependence such as a unit without a kitchen were not popular.

Conclusion

This investigation of aging in place was undertaken to help a particularretirement facility (Retirement House) develop an informed response to theagi ng of its residents. Three st rategies were used 10 shed Iight on the subject:a review of existing literature, focused interviews with t 3 retirement housingadministrators, and some limited market analysis of the host community forRetirement House. The results indicate several recurring themes.

1. The attraction to retirement housing is for independent-living units while thedemand is for assisted care. This conclusion reflects one of the main reasonswhy people are choosing continuing care retirement housing - the availabilityof health care if it becomes needed. However, these residents desire to remainin the independent-living units as long as possible. This desire leads toconclusion number 2.

2. The people who do not need or foresee a need for health care do not tend tomove to retirement housing offering such services. There are other lessexpensive housing options available to such people. These people may be ona waiting list for continuing-care retirement housing, but the actual move willprobably be delayed until an actual or imminent need for health care develops.

3. Conclusion 1 and 2 imply that the independent-living units of retirementhousing offering a continuum of care could actually be assisted-care housing

.:" -,"" ,

Merrill, Hunt / Aging in Place 75

"disguised" as independent-living units. In such a case, assistance, such ashomemaker services, meals, and transportation could be provided as needed.

4. Conclusion 3 suggests an upper limit to the level of assistance that would beappropriately provided in the independent/assisted-living units to retain their"independent" image. Health care services that detract from the independentimage of the housing tend to alter the market for the housing. People desiringmore independent-living units will delay their moves to the facility evenlonger-until they need the health care being provided.

5. If a retirement housing facility decides to build additional living units as aresponse to aging in place, there seem to be two predominant strategies. Oneis to build more assisted-care units and move people to them. The other is tobuild more independent-living units to attract younger and healthier residentswhile continuing to accommodate the aging in place of other residents.

No attempt has been made here to prescribe a solution to aging in placefor all retirement housing. In fact, the results of the study reveal that such asingle "best" solution is nonexistent. Rather, the study has attempted to revealtrends that lead to and result from aging in place and to evaluate responsesto aging in place. Other housing administrators may also find the three-phased methodology employed in this investigation useful in developingplans to address the aging-in-place phenomenon in the ir own facil ities,

References

Aldrich, c., & Mendkoff, E. (1963). Relocation of the aged and disabled: A mortality study.Journal of American Geriatric Society, 11. 185.194.

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