Housing Problems and Options for the Elderly

 

   
   
   

Objectives

  • Understand the housing problems of older persons
  • Identify government strategies to address housing problems
  • Be able to define and critique the continuum of housing
  • Understand the concept of environmental press and accommodating environments
  • Be able to analyze several housing options available to the elderly
   
   
   

Introduction

 

   
   
   

 

Housing is a critical element in the lives of older persons. The affordability of housing affects the ability of the elderly to afford other necessities of life such as food and medical care. Housing that is located near hospitals and doctors, shopping, transportation, and recreational facilities can facilitate access to services that can enhance the quality of life. Housing can also be a place of memories of the past and a connection to friends and neighbors. Housing with supportive features and access to services can also make it possible for persons to age in place. In this session, we will be examining housing problems and options for the elderly. Along the way, we will be testing your housing IQ with a series of questions and exercises. At various points, we will refer to the following case about the housing situation of Beverly and Walter Anderson.

   
 

 
   

Housing Case Study: Meet the Andersons

Beverly and Walter Anderson, ages 73 and 82, respectively, were married in 1945 just after the end of World War II. Their first home was a rental apartment above a restaurant near downtown Detroit. In the 1950s, with two small children and a third on the way, they moved to a small tract home in the suburbs. In 1963, Walter changed jobs, and the family relocated to San Diego, California. The Anderson’s bought a small, two-story ranch style home just large enough to accommodate their three children. It has three bedrooms and two full baths on the second floor and a kitchen, laundry room, powder room and living room on the first floor. Even though the children have grown up, the Anderson’s still live in the same house. Their hallway is a gallery of photographs that chronicle their family’s history. Bev says: " The only change we've made so far has been to accommodate our grandparent status--we bought a used crib. I love this house. We own it free and clear. Up until last year, I couldn’t imagine myself living anywhere else. But recently, Walter has been experiencing physical problems such as balance and can't easily get up the 17 stairs to our second floor bedroom. He has actually fallen several times on the steps leading from the backdoor to the garden where he likes to spend time tending to his special herb collection. He's even slipped in the bathtub. He also seems to be having some memory problems and has wandered out the front door. So far, he has always found his way back but I am worried about leaving him alone. Sometimes, the house seems too large for just the two of us. On our retirement income of about $1,500 per month, it has even become expensive to maintain. Even though we have paid off our mortgage and the house is worth about $200,000, it costs us about $500 per month for items such as utilities, taxes and maintenance. Our daughter wants us to move near here, and my grandchildren are so cute I'm tempted. It seems like a good time to examine our options."

   
   
   

Housing Situation of Older Persons

How typical is the housing situation of the Andersons?  We will begin by examining five areas

  1. Prevalence of home ownership
  2. Length of stay in current residence
  3. Living arrangements
  4. Attachments of older persons to where they live
  5. Moving behavior. 

1.) Prevalence of Home Ownership among the Elderly
2.) Length of Residence in Current Housing 
3.) Living Arrangements

With whom older persons live can influence housing affordability, space needs, and the ability to age in place. About 54% of older persons live with their spouses, 31% live alone, almost 13% live with related persons other than their spouse and about 2% live with unrelated persons. With increasing age, older persons (primarily women) are more likely to live alone or with a relative other than a spouse. Frail older women living alone are the persons most likely to reside in homes with ‘extra’ rooms and to need both physically supportive housing features and services to "age in place". This segment of the population is also the group most likely to move to more supportive housing settings such as assisted living. 

4.) The Attachments of Older Persons to their Current Homes and Aging in Place

Many older persons have strong psychological attachments to their homes related to length of residence. The home often represents the place where they raised their children and a lifetime of memories. It is also a connection to an array of familiar persons such as neighbors and shopkeepers as well as near by places including houses of worship, libraries and community services. For many older persons, the home is an extension of their own personalities which is found in the furnishings and dÈcor. In addition, the home can represent a sense of economic security for the future, especially for homeowners who have paid off their mortgages. For owners, the home is usually their most valuable financial asset. The home also symbolizes a sense of independence in that the resident is able to live on his or her own. For these types of reasons, it is understandable that in response to a question about housing preferences, AARP surveys of older persons continue to find that approximately 80% of older persons report that what they want is to "stay in their own homes and never move." This phenomena has been termed the preference to "age in place."

5.) Moving Behavior of Older Persons

Although most older persons move near their current communities, some seek retirement communities in places with warmer weather in the southwest, far west and the south.

   
   
   

Types of Housing Problems

There are six major types of housing related problems for the older person:

  1. Affordability
  2. Condition
  3. Overcrowding
  4. Suitability
  5. Neighborhood 
  6. Limited Housing Options for Frail older persons
1.) The Affordability of Housing

Chart, Income for Housing

   
   
   

2.) The Condition of Housing

Older persons such as the Anderson’s may live in a home that has appreciated in value and still have insufficient resources to maintain it. In single family homes, the first indications of visible problems are often associated with exterior maintenance such as peeling paint and unkempt yards. But these outward manifestations may only serve to mask other problems such as leaking roofs, equipment such as toilets and heaters that break down frequently, faulty wiring and cracks in the foundation. Low income is the major reason that older persons do not maintain their homes. Poor housing conditions can not only result in unsanitary and uncomfortable living situations, but serious health problems as well. For example, if the heating system is inoperable during a period of very cold weather, older persons can suffer from hypothermia, in which body temperature drops considerably, resulting in loss of consciousness and even death. 

About 8% of older persons live in physically deficient housing as defined by the federal government. Those elderly who live in such housing tend to fall in the following categories:

  • low-income
  • renters
  • women living alone
  • the very old.

Elderly in rural areas are especially likely to live in dwelling units in poor condition.

   
   
   

3.) Overcrowding/Under Utilization

The federal government has set a standard of not more than 1.01 persons per room. According to this standard, less than 1% of older persons live in overcrowded conditions, although persons living with their families or in rooming houses and board and care homes may experience such problems. Approximately one-third of older homeowners reside in homes with at least one extra bedroom and two or more nonsleeping rooms. On the basis of this evidence, a number of experts and policy makers have considered older persons overhoused relative to the rest of the population. Consequently, programs such as shared housing, one model of which involves a person moving into the home of an older person, have been promoted as a means to make better use of the space in the homes of older persons. In addition, policy makers have tried to provide incentives for older persons to move into smaller dwellings through programs such as reduced capital gains taxes on home sales. But generally, older persons do not consider themselves overhoused. They report making use of their spare rooms for family visitors, leisure (e.g. sewing) and other activities, and storage. If older persons own their homes outright, there is relatively little financial pressure to change housing. Research suggests that older people are unlikely to be induced into smaller dwellings unless financial and other barriers are lessened and attractive alternatives are available in nearby areas.

   
   
   

4.) Housing Suitability and Environmental Fit 

Housing suitability refers to the fit between the abilities of older persons and the physical features of their homes. Underlying the concept of suitability is the theory of "environmental fit" which compares a person’s level of competence with the demands of their environment. Competence refers to such factors as health, sensory and cognitive abilities, capacity for self-care and ability to perform various activities of living. If the environment is too demanding for a person’s competence or if the environment puts too few demands on a person's competence, there is a poor fit. 

Housing suitability has received increasing attention in the last decade as the number of persons in their seventies and eighties has increased. Older persons are more likely than younger counterparts to experience problems with chronic health problems such as arthritis, hypertension, heart disease, and hearing and visual impairments. These chronic conditions can translate into limitations in ability to carry out major functional activities such as climbing stairs, bathing and cooking. Almost 20% of the elderly population reports having at least one such limitation. Activity limitations are most prevalent among persons over 80 years of age. Unfortunately, most of our current dwelling units can be termed "Peter Pan housing", designed for persons who never age. They were built for young persons and their families with little recognition that their residents would "age in place". Consequently, a house that met a person’s needs when they were younger may become inaccessible, unsupportive and even hazardous with aging. 

Approximately one million older persons with health and mobility problems live in houses that lack supportive features such a grab bars in the bathroom, railings on stairs, and ramps that could help them maintain their independence.
Critical Thinking E-mail Exercise I

   
   
   

5.) Neighborhood Issues 

Unlike many other consumer goods, housing has a locational element. Most older persons define their housing as located in a neighborhood, although the boundaries of what is considered the neighborhood vary considerably from person to person as do the elements in the neighborhood that are considered important. For older persons, usage, satisfaction and perceived convenience of neighborhood services such as grocery stores, banks or a senior center is often associated with proximity to where older persons live. In the social area, friendship is highly associated with proximity. Older persons often rate neighborhood problems as more serious than housing problems. Generally at the top of the list of neighborhood problems that bother older persons are street noise, neighborhood crime, street traffic, and trash and litter. However, for most older persons, these conditions are not perceived as so bothersome that a large percentage of older persons desire to move. However, as with housing, many older persons cope with inadequate situations because they consider their options very constrained. 
Critical Thinking E-mail Exercise II

   
   
   

6.) Limited Housing Options, Especially for Very Frail Older Persons

Approximately 70% of older persons live in their own homes, 20% reside in apartments, 5% reside in housing with congregate facilities or services such as meals, and 5% live in nursing homes. Older persons who need a physically supportive setting and services or who have cognitive problems such as Alzheimer’s disease are faced with a somewhat confusing array of housing options, many of which are in short supply or unaffordable for low and moderate income. As will be discussed later, providing housing linked with services has become a high priority on the public agenda and finding such housing has become increasingly important to older persons and their families.

   
   
   

The Federal Government's Housing Programs for the Elderly

The federal government has had two basic housing strategies to address housing problems of the elderly. One strategy, termed the "supply side" approach, seeks to build new housing complexes such as public housing and Section 202 housing for older persons. Public housing is administered by quasi-governmental local public housing authorities. Section 202 Housing for the elderly and disabled is sponsored by non-profit organizations including religious and non-sectarian organizations. Approximately 1.5 million older persons or 3% of the elderly population live in federally assisted housing, with about 387,000 living in Section 202 housing. Over time, the government has shifted away from such new construction programs because of the cost of such housing, the problems that a number of non-elderly housing programs have experienced, and a philosophy that the government should no longer be directly involved with the building of housing. Section 202 housing, a very popular and successful program, is one of the few supply-side programs funded by the federal government, although the budget allocation during the last ten years has allowed for the construction of only about 6,000 units per year compared to a high of almost 20,000 units in the late 1970s. Instead of funding new construction, federal housing initiatives over the last decade have emphasized ‘demand side’ subsidies that provide low-income renters with a certificate or a voucher that they can use in a variety of multiunit settings, including apartments in the private sector that meet rental and condition guidelines. These vouchers and certificates are aimed at reducing excessive housing costs. Some certificates are termed ‘project based’ subsidies and are tied to federally subsidized housing such as Section 202. Because housing programs are not an entitlement, however, supply-side and demand side programs together are only able to meet the needs of about 1/3 of elderly renters who qualify on the basis of income. 

While advocates for housing have been trying to hold on to the existing programs in the face of huge budget cuts at HUD, much of the attention has been shifting towards meeting the shelter and service needs of the frail elderly. This emphasis reflects the increasing number of older persons in their eighties and nineties who need a physically supportive environment linked with services. This group of older persons includes a high percentage of older residents of public and Section 202 housing. Initially built for independent older persons who were initially in the late sixties and early seventies, this type of housing now includes older persons in their eighties and nineties, many of whom have aged in place. Consequently, the government is faced with creating strategies to bring services into these buildings and retrofit them to better suit the needs of frail older persons. A major initiative of the early 1990s, which may be stalled by current budget problems at HUD, has been for the federal government to pay for service coordinators to assess the needs of residents of government assisted housing complexes and link them with services. As of 1998, there were approximately 1,000 service coordinators attached to government assisted housing complexes across the country.

   
   
   

The Housing Continuum: A Range of Options for Elderly

A long-standing assumption in the field of housing has been that as persons become more frail, they will have to move along a housing continuum from one setting to another. As the figure on housing options suggests, along this continuum are found a range of housing options including single family homes, apartments, congregate living, assisted living, and board and care homes (Kendig & Pynoos, 1996). The end point of the housing continuum has been the nursing home. These options vary considerably in terms of their availability, affordability, and ability to meet the needs of very frail older persons.

The concept of a continuum of supportive care is based on the assumption that housing options can be differentiated by the amount and types of services offered; the supportiveness of the physical setting in terms of accessibility, features, and design; and the competency level of the persons to whom the housing is targeted. The figure on housing options indicates how such options generally meet the needs of older persons who are categorized, as independent, semi-dependent and dependent. Semi-dependent older persons can be thought of as needing some assistance from other persons with instrumental activities of daily living (IADLs) such as cooking, cleaning, and shopping. In addition to needing assistance with some IADLs, dependent older persons may require assistance with more basic activities such as toileting, eating and bathing. Although semi-dependent and dependent older persons can be found throughout the housing continuum, independent older persons are very unlikely to reside in housing types such as assisted living specifically designed and equipped to meet the needs of frail older persons unless their spouses require these needs.

Although the continuum of housing identifies a range of housing types, there is increasing recognition that frail older persons do not necessarily have to move from one setting to another if they need assistance. Semi-dependent or dependent older persons can live in a variety of settings, including their own homes and apartments, if the physical environment is made more supportive, caregivers are available to provide assistance and affordable services are accessible. A revised framework has therefore emerged that emphasizes the elasticity of the conventional housing stock in terms of its ability to accommodate a wide spectrum of frail older persons (Lawton, 1986). Accommodating housing is adaptable to a person’s changing physical and mental needs through changes in physical design (e.g., addition of handrails and grab bars) and access to services (e.g. meals, housekeeping, and bathing) that allow persons of reduced abilities to stay in residential settings, including their own homes. 

The elasticity or accommodating perspective suggests that as the needs of older person’s change both services and the housing environment should adapt. Adaptations can take the form of changing the environment (e.g., home modifications), bringing services into a setting (e.g., meals or visiting nurses), and, in the case of group housing arrangements, altering management policies such as adding service coordinators.

Several recent laws provide added support for the accommodating approach. For example, the Fair Housing Act of 1988 requires that new residential complexes of more than four units provide basic accessibility for persons in wheel chairs including wide hallways and doors, raised electrical outlets, and backing in bathroom walls for the later installation of grab bars. Although it doesn’t provide funds, the Act allows tenants to make home modifications in their own units. It requires apartment owners to make reasonable accommodations for persons with disabilities. Although the term ‘reasonable’ is subject to court interpretation, accommodations could include the installation of ramps for persons with mobility impairments, better signage for persons with visual impairments, and direct payment methods to collect rent for persons who may have cognitive impairments (Edelstein, 1994). 

Along with the movement to create more accommodating environments in existing housing, forces are at work to develop new supportive housing settings for frail elders. The development of such housing is driven by two factors: 1) a desire on the part of older persons and their families for residential rather than institutional settings; and 2) arguments that such housing is cost-effective in terms of preventing moves to settings such as nursing homes. In particular, the growth of assisted living illustrates a pent up demand for service enriched residential settings that emphasize privacy, autonomy, and choice. Such settings increasingly house persons with Alzheimer’s disease who can benefit by living arrangements that encompass such features as small scale clustering of residents, the ability to respond to unscheduled needs, environments that accommodate such behaviors as wandering, and small staff/resident ratios. The clustering of residents with similar needs makes it possible to take advantage of certain economies of scale in service delivery. Consequently, it appears that many older persons who might otherwise have been residents of nursing homes can live in less expensive, more residential settings such as their own homes, apartments, and assisted living complexes. There is a concern, however, that there is a shortage of supportive housing that is affordable, and residential in nature.

   
   
   

The Distribution of Older Persons in Different Types of Housing Options

Approximately 81% of older persons live in single family detached dwelling units and 7.2% reside in mobile homes. Mobile homes, frequently referred to now as manufactured housing, have been a rapidly growing segment of the housing supply because of their relatively low cost. About 8% of older persons occupy dwellings and neighborhoods specifically planned for their exclusive occupancy. They range from accommodations that primarily support a post-retirement leisure-oriented life style (active retirement communities) to those that predominately cater primarily to frail persons who need personal assistance and nursing services (Pynoos & Golant, 1995; Golant, 1992). Estimates suggest that about one million elders (or just over 3%) of the total elderly population currently occupy multi-unit supportive housing options which also provide services (500,000 in board and care and assisted living facilities, 350,000 in continuum of care retirement communities and 250,000 in other categories,Lewin-VHI, 1992). The availability of housing options (se appendix for brief definitions of many of the different types) varies considerably across states and within localities. In some areas, for example, zoning either prohibits or makes it very difficult to create housing types such as accessory apartments or ECHO units. Serious gaps therefore exist in the range of housing types available to older persons.

   
   
   

Staying in One's Own Home

InManTubIcon.GIF (15951 bytes)As discussed above, staying in one’s home or apartment is the major preference of older persons as reflected in residential stability. There are several ways that older persons can enhance the possibilities of staying in their own homes.

AssistHouse.GIF (96170 bytes)

1.) Home Modifications

Home modifications are adaptations to homes that can make it easier and safer to carry out activities such as bathing, cooking and climbing stairs. If older persons such as Anderson's face barriers or hazards in the home, they can make changes that increase independence, prevent accidents and make life easier and more convenient. For example, the gentleman in the accompanying slide, similar to Walter Anderson experienced problems getting in and out of the bathtub. He actually had to hold onto the towel rack and soap dish for support, a very dangerous method as neither of these features were designed to support his weight nor are located in appropriate locations. There are many ways to improve this situation such as installing grab bars and nonskid strips on the bottom of the tub. For someone who cannot easily step into a bathtub, it is possible to add a transfer bench. Some older persons can benefit from what is termed a walk-in or roll-in shower such as the one illustrated in the slide. This particular shower has several important features such as non-skid tile on the floor, no lip or ledge to climb over, enough space for a wheel chair to fit in, attractive grab bars custom fit to the user, anti-scald devices, a hand held shower, lever controls, and color contrast between the floor and the walls.
Exercise: Analyzing Envrionmental Fit

   
   
   

2.) Accessory Units

Accessory units are private housing arrangements in, or adjacent to single family housing. There are two types: accessory apartments and elder cottage housing opportunity (ECHO) units.

Accessory apartments, such as the one illustrated in the accompanying picture, are often created out of spaces such as garages that are converted into complete private living units including a private kitchen and bath. Note that an extra door has been added to the accessory unit so it has a private entrance. ECHO units, on the other hand are complete, portable, small homes installed in back or side yards of single family lots. Both of these options may encourage economic and personal support between two households while at the same time allowing considerable privacy.

Older persons who have or create accessory apartments often use them to rent out to another person. Such an arrangement can provide the older homeowner with increased security and companionship. In addition, some homeowners receive personal services from their tenants for which they, in turn, provide reduced rent (Hare & Ostler, 1987). Such support can be extremely beneficial to a frail older person. There are several problems, however, that hinder the development of accessory units. First, the outlay to create an accessory unit can be over $20,000, depending on the work that needs to be done and the building codes. Second, developing an accessory unit can be complicated, involving a contractor and subcontractors.

Third, renting out an accessory unit puts the owner in the position of landlord, which may be uncomfortable for many older persons. Fourth, as in the case of ECHO units described below, accessory apartments often violate single-family zoning and restrictive covenants in deeds and common schemes (Hedges, 1991b). Opposition in the form of not-in-my-backyard (NIMBY) is likely to occur from powerful homeowner associations that fear the effect the units might have in established neighborhoods.

ECHO units differ from accessory units in that they are small manufactured homes that are spatially separated from the main house and can be removed when they are no longer needed. The average cost of a unit is approximately $25,000 including shipping, concrete block foundation and utility hook-up. ECHO units are intended to allow older persons to live along side their relatives but in a separate dwelling.

Both accessory apartments and ECHO units are relatively low cost housing alternatives that can allow frail older persons to stay in residential settings. They were both strongly supported by the President’s Commission on Housing in 1982. Nevertheless, the growth of these options has been very slow partly due to consumer reluctance, the physical difficulty of placing units in many areas such as inner cities and inner suburbs, and neighborhood opposition that is reflected in restrictive zoning codes. In the case of accessory units, opposition is reflected in single family zoning that attempts to preserve property values, insure aesthetics, and control traffic. Opposition to ECHO units has an added layer associated with the newness of the concept and the misperception that its assembly built modular or panel construction makes it a form of mobile home (Hedges, 1991b). Several states have issued model zoning codes that allow for accessory units and ECHO units and a number of localities have drafted their own codes. Nevertheless, the growth has not been as great as advocates of these types of arrangements had hoped.

   
   
   

Developing New Forms of Service Enriched Housing

In part owing to the difficulty of implementing many of the programs that make existing housing more supportive and the reality that there are limits to aging in place in conventional housing for very frail older persons, a range of service enriched housing types has evolved. While there are a number of housing types that fall into this area, the discussion will focus on assisted living, the fastest growing segment of the housing stock for older frail persons. A brief description of other options can be found in the readings for this week.

   
   
   

Assisted Living

Assisted living (AL) is a housing option that involves the delivery of professionally managed supportive services and, depending on state regulations, nursing services, in a group setting that is residential in character and appearance. It has the capacity to meet unscheduled needs for assistance and is managed in ways that aim to maximize the physical and psychological independence of residents. AL is intended to accommodate physically and mentally frail elderly without imposing a heavily regulated and institutional environment (Kane & Wilson, 1993; Redfoot, 1993; Regnier, 1994; Regnier, Hamilton, & Yatabe, 1995). Because AL is still in its formative stage, advocates have an opportunity to impact the policies that determine who it serves, the nature of the living environment, the quality of care and how it is regulated. 

The phenomenal growth of AL over the last five years is due to several factors. First, AL is viewed by individuals and many states as an alternative to the high cost and institutional lifestyle associated with conventional nursing homes. As illustrated in the state of Oregon, it can house many residents who are nursing home eligible (Kane & Wilson, 1993). AL residential environments appeal to both older adults and their families. Second, AL emphasizes privacy, autonomy and control. Residents usually live in their own units that include bathrooms and small kitchenettes. They can lock their doors and have choices about the types of activities in which they participate. Some residents of government assisted housing complexes who live in their own apartments receive services that approximate those that are delivered in settings now called AL. Third, the demand for assisted living has been market driven, emanating primarily from the middle class who can afford to pay its costs (Regnier, 1996). In turn, the corporate sector has responded aggressively by constructing new buildings and converting existing ones into AL facilities. New publicly financed companies such as Sunrise and Assisted Living Concepts and hospitality organizations such as Marriot are developing national programs. Even some traditional nursing home providers are shifting their inventory towards AL. Fourth, many states themselves, concerned about the costs of nursing home care have been experimenting with placing Medicaid enrollees in assisted living facilities, hoping to save money and provide residents with a better environment.

There is some disagreement about the uniqueness of assisted living. Some analysts argue that AL is not a new concept but an outgrowth of board and care homes or residential care facilities which are group settings for frail older persons. Nevertheless, increasingly state policies and regulations distinguish assisted living from board and care (Mollica, 1997). According to a study conducted by the National Academy for State Health Policy, thirty states had by 1966 created an AL licensure category, passed legislation authorizing such a category or covered AL as a Medicaid service (Mollica & Snow, 1996).

AL presents two major public policy dilemmas: what types of regulations are necessary to protect residents, the average age of whom are over 82 years, and how to make it affordable for low-income persons. Part of the regulatory dilemma is that states have used a variety of definitions of AL. AL raises a number of regulatory dilemmas for advocates. On the one hand, a residential setting based on a social rather than a medical model in which tenants have a considerable choice, privacy and control is highly desirable. On the other hand, there is a tradeoff in terms of risk because of the high acuity level of many residents, most of whom need assistance in several activities of daily living and many of whom have cognitive limitations, including Alzheimer’s disease . 

The most difficult regulatory issues involve unit and building requirements, admission/retention policies, services, (including who can provide them) and the nature of the regulatory process. For example, a number of states require private apartment units although some allow sharing if it is by resident choice. In states where AL is defined as a service or applies to board and care, sharing is more common. Admission and retention policies also vary widely among states and even individual programs and places. In some states such as California where AL is licensed as residential care facilities, tenants must be ambulatory, have stable medical conditions and can not receive twenty-four hour skilled nursing supervision on an on-going basis. At the other extreme, New Jersey allows the residence to care for people who require twenty-four hour, seven-day-a-week nursing supervision, are bedridden, dependent in four or more ADL’s, and cognitively impaired. According to Mollica (1997) all states require that facilities identify the services they will provide. The most common services are personal care, housekeeping, meals, transportation, and assistance with self-administration of medications. Most states go farther in that they allow facilities to administer medications and provide some nursing. The type of person who can administer the medications and provide nursing care also varies. In Oregon, for example, the Nurse Practice Act permits non-nurse and non-relative staff to perform specific nursing functions such as administering medications and taking blood samples if trained on-site by a nurse and certified. Given the strength of the nursing lobby, such a procedure may be difficult to implement in many other states. 

Affordability of AL remains a problem in most states. According to Redfoot (1993) "though assisted living is the fastest growing segment of the senior housing industry, the costs associated with this type of service have generally been out of reach for older persons with low or moderate incomes."   Some policy makers are concerned that if states subsidize the costs of services in AL for low-income persons, state long-term care costs will increase. Consequently, the government would be providing incentives for older persons to leave their homes and enter assisted living, thereby avoiding less attractive options such as board and care, foster care or nursing homes. Nevertheless, Oregon has made AL available to low-income persons using a statewide Medicaid waiver. In 1996, Oregon had five levels of payment for services ranging from $553 to $1586. Each level corresponds to categories of ADL impairment with the lowest representing needing assistance in one critical ADL and the highest dependent in 3-6 ADLs. SSI usually covers room and board fees. Mollica and Snow (1996) found that Medicaid covers or plans to cover AL services in twenty-one states, indicating the extent to which AL is considered a possible substitute for nursing home care. AL is therefore likely to remain high on the public policy agenda.

   
   
   

Conclusions

Housing plays a critical role in the lives of older persons. Most older homeowners who function independently express a high level of satisfaction with their dwelling units. However, high housing costs, especially for renters, remain a financial burden for many older persons and problems associated with housing condition persist especially for low- income renters and persons living in rural areas. Federal housing programs such as public housing, Section 202 housing, and Section 8 housing certificates have only been able to address the basic housing problems of only about one-third of eligible older persons because of limited budgets. Moreover, a shortage of viable residential options exists for frail older persons. Up until the last decade, housing for the elderly was conceived of primarily as shelter. It has become increasingly recognized that frail older persons who needed services and physically supportive features often had to move from their homes or apartments to settings such as board and care or nursing homes to receive assistance. Over time, however, the concept of a variety of housing types that can be linked has replaced the original idea of the continuum of housing. It is possible for frail older persons to live in a variety of existing residential settings, including their own homes and apartments with the addition of services and home modifications. Consequently, the last decade has seen a number of efforts to modify homes, add service coordinators to multi-unit housing and create options such as accessory and ECHO units. Although these strategies have been enhanced by a somewhat greater availability of home care services, Medicaid policy still provides incentives to house frail older persons in nursing homes. The most visible development in the field of housing for frail older persons has been the growth of private sector assisted living which is now viewed by many state governments as a residential alternative to nursing homes. The AL movement itself has raised a number of regulatory and financing issues that cross-cut housing and long term care such as what constitutes a residential environment, insuring that residents can age in place, accommodating resident preferences, protecting the rights of individuals and insuring quality of care. Nevertheless, the emergence of AL along with a wider range of other housing options holds out the promise that older persons will have a larger range of choices among living arrangements.

Quiz #3
   
   
   

Key Points

  • Over half of all older persons live with thier spouses.
  • With increasing age, older persons are more likely to live alone or with a relative other than a spouse.
  • Most older people have very strong psychological attachments to their homes.
  • About 8% of older persons live in physically deficient housing as defined by the federal government.
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