Assisted Living: Needs, Practices, and Policies in Residential Care for the Elderly

Foreword

Foreword My age peers and I experienced the beginning of age-targeted housing for older people. It was a time for excitement over the idea that a new form of community had been created to fill a niche of need that fell between the healthy elder able to live in the community and the frail elder who required an institution. The new housing form, often referred to as independent senior citizen housing, though targeted to the independent older person, in fact provided a “silent buffer” for people who aged in place in terms of declining health. That is, even though most builders and administrators of independent housing were careful to avoid the look of an institution and emphasized the vigor of its resident population, the fact was that all such housing provided safety nets. Friends were easy to make, if one wished. Near neighbors were available to help or to notice new signs of frailty. Every administrator either actively or passively picked up knowledge about growing signs of frailty and local referral resources. Even though administrators and residents fought the idea that residents were in a social service environment, they did have access to some of that expertise when in need. This covert knowledge on both sides that some protection was available may be thought of as a first-level assurance of security in time of need. “Congregate housing” began almost as early as did independent housing, in recognition of the need of some sectors of the older population for more than a minimal degree of support. Congregate housing was always in short supply because of its additional cost, coupled with its all-ornothing service mode—that is, the philosophy that services had to be supplied for and bought by all residents, to make it cost effective. Even when HUD, in its Congregate Housing Services Program (CHSP), attempted to target services to only those most needy, costs became so great that the CHSP remained tiny. Congregate housing thus remained a scarce commodity . Assisted living in some ways seems like a reconstitution of congregate housing. I see an essential difference, however, one that ought to ensure that assisted living flourishes. Congregate housing was a graft to independent housing, with the intent to extend the independent housing model another notch in the direction of support. In contrast, assisted living is a graft to the nursing home, with the intent to extend this highsupport model in the direction of greater independence. In other words, assisted living recognizes and addresses deficiencies of the nursing home, namely, frequent provision of excess care and independence-undermining features of everyday life. Along with the excess of care came many features of the physical and social environment whose primary purpose was to protect the physically ill patient. The medical model on which the nursing home is based is particularly inappropriate for many people with dementia , specifically for those with stable medical conditions. In its earlier history and up to the present, the nursing home has been overused in this respect because there was no other alternative. The social model of care that is possible when the major reason for nursing home residence is not health care allows much easier introduction of humanistic concerns for higherorder needs such as dignity, autonomy, self-growth, and privacy. Assisted living is growing because there was such a large segment of people needing an enhanced sense of security but not needing to relinquish total control over their lives. From society’s perspective, the graft away from the excess care of the nursing home has the potential for reducing the burden of care on the taxpayer . As of the beginning of the new century, this consideration is only a goal, not an achievement. The excitement of the early days of age-targeted housing was also enhanced because of these programs’ intent to serve the poor. The sad fact is that an unfortunate proportion of the growth in assisted living comes from its appeal to the most solvent sector of the older population. Right now, assisted living is less expensive than nursing home care primarily for the aging family who might be subject to full-pay nursing home care. Some states are moving toward subsidy programs that can open assisted living to low-income and lower-middle-income elders. This deficit in the financial aspects of the current assisted living scene should be viewed as the impetus for private sponsors, researchers, and governmental policymakers to identify those especially appealing and effective features...