providing assistance to older people in a home-like setting

3
Providing Assistance to Older People in a Home-Like Setting by Elizabeth Clemmer and Sun Eun Programs in England and Oregon provide lower-cost alternatives to life in a nursing home. Increasing interest suggests the future for these arrangements is bright. D uring the 1980s, both England and the state of Oregon in the United States developed programs that combine private apartments with personal care services to enable many frail older people to remain independent and to avoid or postpone entering a nursing home. Oregon is the first state to develop a comprehensive program of assisted living in the United States. These programs, termed "very sheltered housing" in England and "assisted living" in Oregon, are a response to people living longer and wanting to remain in charge of their lives, even as they begin to need assistance with daily activities. Despite increasing frailty among older people, many do not need the nursing care provided by nursing homes. These programs also reflect the strong desire of older people and their families to avoid such institutions and the recognition by government that alternatives to institutionalization can be less costly as well as more popular with citizens. In neither country does the high degree of citizen acceptance of these programs indicate that older persons readily leave their homes. In the United States, a recent survey by the American Association of Retired Persons (AARP) showed that 85*70 of older persons preferred to remain in their homes for as long as possible. When living at home is no longer feasible, however, many prefer to live in settings like very sheltered housing and assisted living rather than in institutions. Both of these alternatives enable residents to receive assistance when needed while living in a home-like setting and retaining as much independence as possible. Genesis and Goals England's and Oregon's programs have similar origins and goals. Each developed from the realization that people who moved into apartments reserved for older persons wanted to continue to live in private quarters even when they became frail and needed help with personal care such as bathing, dressing, and managing their medicines. Beginning in the 1960s, England developed "sheltered housing" in response to growing dissatisfaction with the shortcomings of life in hospitals or nursing homes, which had been the only shelter available for many older persons who did not own their homes or who had low incomes. Sheltered housing provided small, specially adapted apartments in which residents took care of themselves and a "warden" acted as a "good neighbor" in emergencies. 1 Frail older persons wanted to continue living in private quarters. As residents aged and increased in frailty, however, some needed more help than wardens could provide. Very sheltered housing evolved under the aegis of private non-profit housing associations and local housing authorities. In addition to the warden, other staff provided help with personal care, meals and other tasks. Throughout this evolution, the explicit intent was to avoid the institutional care and to promote a model that "captures the essence of home" while encouraging self-determination) Currently, about 7,000 residents live in very sheltered housing in England and in Wales, about 88 residents per 100,000 over the age of 65. In Oregon, assisted living originated from the efforts of a gerontologist, Keren Brown Wilson, who worked with a housing developer to find a means of providing intensive services in a home-like environment, s To accomplish this goal, they built 52 Ageing International June 1993

Upload: elizabeth-clemmer

Post on 22-Aug-2016

212 views

Category:

Documents


0 download

TRANSCRIPT

Providing Assistance to Older People in a Home-Like Setting

by Elizabeth Clemmer and Sun Eun

Programs in England and Oregon provide lower-cost alternatives to life in a nursing home. Increasing

interest suggests the future for these arrangements is bright.

D uring the 1980s, both England and the state of Oregon in the United States developed programs that combine private apartments

with personal care services to enable many frail older people to remain independent and to avoid or postpone entering a nursing home. Oregon is the first state to develop a comprehensive program of assisted living in the United States. These programs, termed "very sheltered housing" in England and "assisted living" in Oregon, are a response to people living longer and wanting to remain in charge of their lives, even as they begin to need assistance with daily activities. Despite increasing frailty among older people, many do not need the nursing care provided by nursing homes. These programs also reflect the strong desire of older people and their families to avoid such institutions and the recognition by government that alternatives to institutionalization can be less costly as well as more popular with citizens. In neither country does the high degree of citizen acceptance of these programs indicate that older persons readily leave their homes.

In the United States, a recent survey by the American Association of Retired Persons (AARP) showed that 85*70 of older persons preferred to remain in their homes for as long as possible. When living at home is no longer feasible, however, many prefer to live in settings like very sheltered housing and assisted living rather than in institutions. Both of these alternatives enable residents to receive assistance when needed while living in a home-like setting and retaining as much independence as possible.

Genesis and Goals

England's and Oregon's programs have similar origins and goals. Each developed from the realization that

people who moved into apartments reserved for older persons wanted to continue to live in private quarters even when they became frail and needed help with personal care such as bathing, dressing, and managing their medicines.

Beginning in the 1960s, England developed "sheltered housing" in response to growing dissatisfaction with the shortcomings of life in hospitals or nursing homes, which had been the only shelter available for many older persons who did not own their homes or who had low incomes. Sheltered housing provided small, specially adapted apartments in which residents took care of themselves and a "warden" acted as a "good neighbor" in emergencies. 1

Frail older persons wanted to continue living in private quarters.

As residents aged and increased in frailty, however, some needed more help than wardens could provide. Very sheltered housing evolved under the aegis of private non-profit housing associations and local housing authorities. In addition to the warden, other staff provided help with personal care, meals and other tasks. Throughout this evolution, the explicit intent was to avoid the institutional care and to promote a model that "captures the essence of home" while encouraging self-determination) Currently, about 7,000 residents live in very sheltered housing in England and in Wales, about 88 residents per 100,000 over the age of 65.

In Oregon, assisted living originated from the efforts of a gerontologist, Keren Brown Wilson, who worked with a housing developer to find a means of providing intensive services in a home-like environment, s To accomplish this goal, they built

52 Ageing International June 1993

"congregate housing" with separate apartments for each resident (or couple) and extensive common areas, and included the capacity to deliver a wide range of services that residents could choose as needed. Recognizing that some of the persons about to enter or already in nursing homes might receive more appropriate and less expensive care in assisted living settings than they would in nursing homes, Oregon state officials obtained both federal and state government funds to permit low-income residents who were eligible for nursing home care to choose assisted living if they wished.

Both programs serve people with levels of impairment similar to those

found in nursing homes.

In 1989, Oregon licensed assisted living and encouraged developers to build more facilities that would promote privacy, dignity, and autonomy. Currently, the state has 1,011 such units with the capacity to serve 1,315 residents, or about 335 places for every 100,000 persons over age 65.

Living Arrangements

Both in England and in Oregon, residents have private apartments with locking doors, private baths and alarm systems. They usually eat in communal dining rooms. The buildings are similar in size, averaging 31 residents in England and 46 in Oregon. Meals are typically furnished, as are housekeeping and laundry. In Oregon, every apartment has a small kitchen while in England, reflecting the range of housing stock, some apartments are "bedsitters," which lack cooking facilities.

Residents and Their Need for Assistance

Oregon and England serve different kinds of residents. In England, residents enter very sheltered housing at a younger age and stay longer than do residents of assisted living in Oregon. Very sheltered housing residents, on average 74.5 years old when they move in, remain for about five years. The most frequent reason for leaving is death (64%) or admission to a nursing home (14%) or a hospital (1007o). The residents are most likely to need help with walking (54%), bathing (40%), dressing (22%), and continence (18070) and

feeding (1207o). About one-third of them have memory problems and two-thirds need assistance when they leave the building. 4

In Oregon, residents are on average 85 years old and are likely to stay about nine months (these numbers are preliminary since most programs have opened in the last 18 months). 5 As in England, death is the most frequent reason for leaving (35%), but residents in Oregon are more likely to leave for a nursing home

(2007o) or to go to other supportive housing (20%) or to improve enough to return to their own homes (15%). Overall, Oregon's residents are more likely than England's to need assistance from staff--63% with bathing, 46% with dressing, 43% with walking, 4207o with behavior management, 39% with toileting, and 32% with feeding.

Although residents of very sheltered housing in England tend to be younger and need less assistance than residents of assisted living in Oregon, some programs in England serve mainly older and more dependent residents. In both countries the programs serve many residents with levels of impairment similar to those in nursing homes.

Programs in both England and Oregon also stress the importance of residents' making choices and being involved in their own care. Very sheltered housing is viewed as a home in which the residents have freedom of choice over their own activities and contacts. As in private apartments, residents can come and go as they please. Staff encourage residents to do as much for themselves as possible. Similarly, assisted living empowers residents to take as much responsibility as possible, including the right to share in decisions about the services they need. Residents or their families meet with staff to determine the level of risk that the resident will take (e.g., walking instead of using a wheelchair). In both England and Oregon, this emphasis on self- determination is, along with separate apartments, a major feature distinguishing these programs from nursing homes.

Costs

Because of changes in the exchange rates and data collection at different times, direct cost comparisons are very difficult to make. In both England and Oregon, however, these programs cost less than nursing homes even though they provide separate apartments for residents. Much of the savings is gained from lower staff costs because residents do not need or pay for the

nursing care provided in nursing homes. In Oregon,

Providing Assistance to Older People in a Home-Like Setting 53

total costs per resident are at least 20~ less than nursing home costs while in England, total costs are 8~ less.

The Future

In England, residents, management , and staff all report high levels o f satisfaction with very sheltered housing. The number o f programs has grown from a few in the mid-1970s to about 225 in 1985 and is expected to increase. The expansion o f assisted living in Oregon,

f rom two programs in the mid-1980s to 22 (with about 1,200 residents in 1992), parallels the increased interest

in such arrangements across the United States. According to a recent issue o f C o n t e m p o r a r y L o n g -

T e r m Care, assisted living is the fastest growing sector o f the retirement housing industry in the United States. Private developers, some using models from other nations, such as the Netherlands, have responded to the desire o f older persons to live in home-like surroundings while receiving assistance when needed. State governments, responding to citizen aversion to nursing homes, are looking for less expensive

arrangements for low-income persons who need

assistance but not nursing care and are developing

programs with many features similar to Oregon 's . With growing enthusiasm by state governments and citizens,

programs such as very sheltered housing and assisted living will play an increasingly important role in housing and care for frail older persons.

Elizabeth C. Clemmer, Ph.D., coordinates policy research on consumer issues in the Public Policy Institute at AARP. Her own research focuses on residential care for older persons. Her graduate training is in social and organizational psychology and she has published studies on service quality issues

and on domestic violence.

Sun Eun is a Research Assistant in the Consumer section of Public Policy Institute at AARP. She has a bachelor's degree in Economics and has written articles on eider abuse and board and care.

References

1Clapham, David. Housing Policies for Frail Older Persons in Great Britain, paper prepared for Conference on "Housing Policy For Frail Older Persons: International Perspectives and Prospects," at the University of Southern California, Los Angeles, 1992.

~Peace, S. and Willcocks, D. Changing the Environment in Old People's Homes, London: Her Majesty's Stationery Office, 1986, quoted in Tinker, AIthea. "An Evaluation of Very Sheltered Housing," London: Her Majesty's Stationery Office, 1989.

SKane, Rosalie, and Illston, Laurel H., et. al. Meshing Services With Housing: Lessons From Adult Foster Care and Assisted Living in Oregon, Minneapolis: Long-Term Care DECISIONS Resource Center, University of Minnesota, 1990.

(Tinker, Anthea. "An Evaluation of Very Sheltered Housing," London: Her Majesty's Stationery Office, 1989.

SKane, Rosalie and Wilson, Keren Brown. Assisted Living in the United States: A New Paradigm For Residential Care For Frail Older Persons? Draft Paper, Washington, D.C.: American Association of Retired Persons, Public Policy Institute, 1993.

54 Ageing International June 1993