Bill and Helen, both in their late seventies, live in a two-story brick home that they purchased when their children were in elementary school. The neighborhood has grown older with them but still includes a mix of older and younger families, whom Bill and Helen enjoy very much. They love their neighborhood and the lasting relationships they have developed over the years.
However, their lovely home is causing some problems for the two. First, Bill and Helen no longer need the four-bedroom home for the children, and cleaning the house is becoming more difficult for them. Second, the yard work tires the couple more and more. They no longer look forward to spring planting, mulching, and grass cutting. For a number of years, Bill has paid one of the neighbor’s children to cut the grass, but he and Helen are not willing to let someone else do the landscaping, as they have always prided themselves on the spectacular flowers that bloom throughout the year. Third, the laundry room is in the basement of the house. This means that Helen must carry the laundry up and down two flights of steps to do the laundry. She has sometimes stumbled going up and down the steps and fears falling with a heavy load of laundry in her arms. Bill and Helen are hardly frail older adults, but they are experiencing some “person-environment” fit problems. They wonder if they should consider a move into new housing where assistance is provided if they should need it.
A variety of housing options exists for older adults needing assistance. Many older persons remain in their family homes for their entire adult lives; however, others find that they need to move to other locations. This publication describes some possibilities for living options where older adults may receive assistance: continuing-care retirement communities, assisted housing, nursing homes, ECHO housing, board-and-care homes, congregate housing, and foster care. As you read this publication, consider which housing options, now and in the future, best fit your needs as well as those of Bill and Helen, should health and functioning change.
Considerations for Choosing Living Options Offering Assistance
Like Bill and Helen, people thrive in environments that suit their needs. In other words, the environment and the abilities and preferences of the person must mesh. When the social and physical environments are appealing, quality of life is enhanced. The environment must provide enough challenge to provide stimulation but not so much as to become overwhelming. This is called the “person-environment fit” (Lawton, 1980). When considering living options, it is critical to identify an appropriate fit in order for the living option to be successful.
It is also important to recognize that feeling safe and secure in the new living arrangement is important for a successful transition. Selecting a place in a familiar environment can also help in easing the transition. However, choosing a new home which has staff and residents that one can trust is most important. Before a move takes place, the person moving should always be consulted about whether they sense they will feel safe and secure in their new home (Fonand, Wahlin, Heikkila, and Emami, 2006).
How can Bill and Helen’s housing needs best be met? Which housing options might be best for you?
Continuing-care Retirement Communities
Continuing-care retirement communities (CCRCs) provide a range of living options, from independent living in single-family dwellings to rooms in a skilled nursing facility, in one community setting. As residents find themselves in need of assistance, they move into more supportive living environments within the CCRC. Today, there are more than 2,200 CCRCs in operation across the U.S. (American Association of Homes and Services for the Aging, 2006).
Generally, there are three basic types of CCRC contracts. An extensive agreement contract includes shelter, residential services, and amenities as well as long-term nursing care for a monthly fee. A modified agreement contract is similar but offers limited services in long-term nursing care for a monthly payment. A fee-for-service contract provides the same residential services, but long-term care services are billed at a daily rate (AAHSA, 2006).
Moving to a CCRC requires a significant down payment of money in addition to monthly payments. The decision to sign a CCRC contract should not be taken lightly, as the agreement is in effect for the balance of the person’s lifetime and is not easily broken. Entering into an agreement will also require full disclosure of personal wealth and health-care coverage.
Would Bill and Helen be able to afford a CCRC, and is this option a good person-environment fit for them? How would a CCRC fit into your future plans?
Information on the Internet
For guidance on what to look for when selecting a CCRC, go to HelpGuide.org at www.helpguide.org/elder/continuing_care_retirement_communities.htm.
Accessory Dwelling Units
Accessory Dwellings Units (ADUs) are residential units that provide independent living facilities for one or more people, with designated areas for cooking and sanitation, plus space for living, sleeping, and eating (Liebig, Koenig, and Pynoos, 2006). One type of AUD is the “granny flat” or ECHO housing, which stands for Elder Cottage Housing Opportunity. These units are small self-contained modular houses that are usually placed on the property of a family member. ECHO housing allows an older adult to retain his or her independence while living near a supportive person, who also is able to retain their privacy and independence. Construction is affordable and the unit is moveable. Prior to purchasing a granny flat, local zoning and building codes should be investigated (Hare, 1990).
Similarly, an accessory cottage, also known as guest cottage or carriage house, is a permanent, separate structure placed on the same parcel or lot as the single-family dwelling and provides the same benefits of privacy and support as with ECHO housing. Garage or barn apartments are similar to accessory cottages because they are not part of the primary dwelling; the latter is more popular in rural areas (Liebig et al., 2006). However, when resources are not available to create a separate living unit, an existing room or basement can be remodeled into a living area in which a frail older adult can live (Wacker and Roberto, 2008).
How would Bill and Helen feel about living in an AUD? How would you feel about living in an AUD? Are granny flats an option in your area?
Information on the Internet
More information on ECHO housing can be found on the website About: Senior Living at seniorliving.about.com/od/housingoptions/a/echo.htm.
Public housing for older adults is often thought of as congregate housing; typical arrangements include individual apartments with shared spaces. The shared spaces may include a living room, dining room, and laundry facilities. Meals may be, but are generally not, communal. Congregate housing offers limited assistance to residents who may require some help or oversight with daily activities, but does not include medical assistance. To help residents remain as independent as possible, the staff of congregate housing usually includes a janitor, activity coordinator, and building manager. Residents pay monthly rent to live in a facility and often benefit from subsidies provided by the government (Heumann, 1990, p. 46; Monk and Kaye, 1991).
Would Bill and Helen be happy living in congregate housing? Why or why not?
For more information, contact your local department of social services for congregate sites in your area.
The term assisted-living facility (ALF) refers to a variety of residential living options that provide support as well as opportunities for independence, privacy, and personal choice. Today, over 33,000 ALFs are in operation across the United States. An ALF provides room, board, supervision, and some assistance with activities of daily living (ADLs; i.e., basic tasks which ensure good health such as bathing, dressing, toileting, transferring from a chair or bed, bowel control, bladder control, and eating/feeding) and instrumental activities of daily living (IADLs; basic tasks which require the use of skills such as reasoning, calculation, and judgment to complete including meal preparation, housekeeping, laundry, and managing money).
A person’s ability to perform tasks of daily living determines the appropriate level of care and services. Services are provided in a home-like setting for a monthly fee. Most ALFs serve a general aging population, while others are designed for individuals with specific physical and mental disabilities (The National Center for Assisted Living, 2006).
ALFs licensed through Virginia’s Department of Social Services may provide up to three levels of care: residential, regular assisted living, and intensive assisted living. Residents in residential living need minimal assistance with activities of daily living, and may only require assistance with medication administration. Residents eligible for regular assisted living and intensive assistive living include individuals needing a little to a great deal of help with ADLs and IADLs and may also be prone to difficult behaviors.
Are Bill and Helen candidates for an ALF? Do you know someone who is a good candidate?
Information on the Internet
To locate a licensed ALF in Virginia, go to www.dss.virginia.gov/facility/search/alf.cgi.
The National Center for Assisted Living provides a cost calculator and consumer checklist to help evaluate the potential cost of living in an ALF. Access the calculator at www.longtermcareliving.com/planning_ahead/assisted/assisted7.htm
Board-and-care homes or private adult residences offer room, board, 24-hour supervision, and limited personal-care services. The names used to identify board-and-care homes, and the nature of the homes, vary considerably. Small private homes may provide for as few as two residents, whereas some institutions may designate all or a large percentage of their beds for board-and-care residents. All states license board-and-care homes, although licensing requirements differ. In Virginia, the Department of Social Services may be involved in licensing of these homes. One common characteristic of a board-and-care home is that residents share communal meals. Half the residents in board-and-care homes pay to stay there using only personal funds; the others use a combination of government and personal funding. Typically, residents are physically or cognitively frail and at risk for further decline (Hawes, Wildfire, and Lux, 1993).
How would Bill and Helen feel about living in a board-and-care home? Would a board-and-care home be an option for you in your future? Why or why not?
Information on the Internet
Washington State Department of Social and Health Services developed the booklet Choosing Care in an Adult Family Home or Boarding Home, which can help you make the decision about selecting a board-and-care home, which may be downloaded at www1.dshs.wa.gov/pdf/Publications/22-707.pdf
Foster care is provided by a host individual or family who provides care for up to three older adults who do not need continual care. No licensing is required to be a foster-care provider for three or fewer individuals, but approval by the local department of social services is necessary. Typical recipients of foster-care services include adults considered disabled, former residents of institutions, and those who have lived in the foster-care setting for many years. Services offered by foster care may include supervision and personal care. Residents are encouraged to be as independent as possible and participate in activities in the family home. The average monthly cost is dependent upon personal wealth and government support such as Medicaid services (Wacker and Roberto, 2008).
When might foster care be an appropriate living arrangement for Helen or Bill? Is this a suitable option for you?
Information on the Internet
For more information about adult foster care, visit Virginia’s Department of Social Services website at www.dss.state.va.us.
Nursing homes provide 24-hour services to frail persons who cannot care for themselves due to physical, mental, and emotional conditions. Residents of nursing home do not need the level of care that a hospital would provide but need more care than home care, community-based care, or care provided in an assisted-living facility. Two levels of care are usually available in nursing homes in Virginia: personal care and skilled nursing care. Personal care includes assistance with ADLs and is provided by certified nursing home aides and licensed practical nurses. Skilled nursing care includes activities such as therapeutic treatments, ventilation, injections, and wound care after surgery. All services provided in a nursing home are overseen by a physician and a registered nurse (RN) who is on site at all times. Nursing homes in Virginia are licensed by the Virginia Department of Health. Payment for care usually comes from Medicare (for short-term, rehabilitative care only), Medicaid, and personal funding (Wacker and Roberto, 2008).
Would Helen be a good candidate for nursing home care now? In the future?
Information on the Internet
To locate a nursing home near you go to www.medicare.gov/NHCompare.
A Checklist to Help in Choosing a Nursing Home can be found on the Virginia Dept on Aging website at www.vda.virginia.gov/pdfdocs/Nursing%20Home%20Checklist.pdf.
Comments about Living Options
Making decisions about living arrangements means that you make the best possible fit when considering the person(s), their ability to pay, family circumstances, and the appropriate housing environment available. While many housing options for older adults are in place, some may not be available in your area. Locating suitable arrangements can be facilitated by contacting the local Area Agency on Aging or accessing the housing locator provided through The American Association of Homes for the Aging website at www.aahsa.org or the Senior Navigator website at www.seniornavigator.com. Additional information about how to select an appropriate housing option can be found in the booklet “Long-term Care: A Consumer’s Guide” available through the Virginia Department of Aging website at www.vda.virginia.gov.
If you have questions or are interested in other human development information on older adults and their families, contact your local Virginia Cooperative Extension office. Family and Consumer Sciences agents offer a variety of educational programs related to family life, personal fitness, nutrition, and food safety.
If you would like further information on topics concerning older adults, please see:
Elder Abuse Alert - Considerations About a Hidden Problem, Virginia Cooperative Extension publication 350-251, http://pubs.ext.vt.edu/350-251/
Choosing Community-based Services for Older Adults and Their Families, Virginia Cooperative Extension publication 350-252, http://pubs.ext.vt.edu/350-252/
Substitute Decisions by and for Older Adults and Their Families, Virginia Cooperative Extension publication 350-253, http://pubs.ext.vt.edu/350-253/
American Association of Homes and Services for the Aging. (2006). Aging services in America: The facts. Retrieved December 31, 2006, from www.aahsa.org/aging_services/default.asp
Fonand, E., Wahlin, T.R., Heikkila, K., and Emami, A. (2006). Moving to and living in a retirement home: Focusing on elderly people’s sense of safety and security. Journal of Housing for the Elderly, 20, 45-60
Hare, P. (1990). The echo housing/granny flat experience in the US. Journal of Housing for the Elderly, 7(2), 57-70
Hawes, C. Wildfire, J.B., and Lux, L.J. (1993). The regulation of board-and-care homes: Results of a survey in the 50 states and the District of Columbia: National summary. Washington, D.C.: American Association of Retired Persons
Heumann, L.F. (1990). The housing and support costs of elderly with comparable support needs living in long-term care and congregate housing. Journal of Housing for the Elderly, 6, 45-71
Lawton, M.P. (1980). Housing elderly: Residential quality and residential satisfaction. Research on Aging, 2, 309-328
Liebig, P.S., Koenig, T., and Pynoos, J. (2006). Zoning, accessory dwelling units, and family caregiving: issues, trends, and recommendations. Journal of Aging and Social Policy, 18(3/4), 155-172
Monk, A., and Kaye, L.W. (1991). Congregate housing for the elderly: Its need, function, and perspective. Journal of Housing for the Elderly, 9(1/2), 5-20
National Center for Assisted Living. (2006). Assisted living facility profile. Retrieved January 9, 2007, from www.ncal.org/about/facility.htm
Wacker, R.R., and Roberto, K.A. (2008). Community resources for older adults: Programs and services in an era of change. Thousand Oaks, Calif.: Pine Forge Press
This publication is based on a previous one by Pamela B. Teaster and Karen A. Roberto.
Reviewed by Novella Ruffin, Extension Specialist, Virginia State University
Virginia Cooperative Extension materials are available for public use, reprint, or citation without further permission, provided the use includes credit to the author and to Virginia Cooperative Extension, Virginia Tech, and Virginia State University.
Issued in furtherance of Cooperative Extension work, Virginia Polytechnic Institute and State University, Virginia State University, and the U.S. Department of Agriculture cooperating. Edwin J. Jones, Director, Virginia Cooperative Extension, Virginia Tech, Blacksburg; M. Ray McKinnie, Administrator, 1890 Extension Program, Virginia State University, Petersburg.
May 1, 2009