Appendix I

The Humanitas Foundation in a Nutshell


(Used with permission from the

http:/ website)



Good morning, welcome to Humanitas Woonzinnig, Experts in Apartments for Life

This is not a duplicate of the Dutch internet site, but a brief explanation of what the Humanitas Foundation and her daughter foundation, Humanitas Woonzinnig, do.



   1. The Humanitas Foundation in a nutshell

   2. Short history of the Dutch situation

   3. The changes in housing and care between 1970 and 1990

   4. The present-day practice in Rotterdam

   5. The basic philosophy in a nutshell

   6. The Future

   7. What the Humanitas Woonzinnig foundation does


"The Humanitas Foundation in a nutshell"

Humanitas is a provider of housing and home care as well as nursing and treatment. The Humanitas Foundation is a non-profit organization. We employ about 1.800 people and around 4.000 elderly live in our apartments and residential and nursing homes. It makes Humanitas Foundation one of the largest in this field in The Netherlands.


All European countries are seeking forms of collaboration with primary healthcare and institutional care for the chronically ill and elderly in order to achieve a more comprehensive and integrated service to the population.


The Humanitas Foundation thinks it has found a solution for these challenges and problems the 'levensloopbestendige woning' : an 'Apartment for Life'. This dwelling allows all types of care, including intensive nursing home care (and shortly also hospital-care), to be rendered in one's own home. Important starting-point in this notion is that supply of care is strictly based on the demand. What does the client want? We look at the problems of integrated care from the position of the client as a care demander.

For Humanitas it is evident that in many cases the client experiences more 'well being' from a pet than from a nurse, more from a barkeeper than from a dietist and more from expressions of art than from a strict hygienic regime. In our integrated product we bear this in mind. In practice, it is evidently clear that the client is averse to institutions. He does not like coming into contact with health care institutions such as hospitals, nursing homes or old people's homes. He will not visit them if he can avoid it, let alone live in such a place.

Up to now, however, it was assumed that residing in an institution is inevitable in case of declining physical or mental capacities. Somehow, it cannot be helped that certain physical or mental conditions go together with certain care-facilities, in The Netherlands these are the old people's home, the nursing home and the hospital.


Short history of the Dutch situation

In the beginning of the sixties - 15 years after World War II - there was a substantial housing shortage in The Netherlands. Many young families could not find a place to live in. By housing many, relatively young, elderly people in sheltered flats, homes - a bedsitter of around 12 square meters with complete care - many existing dwellings became available. This 'solution' meant that less new dwellings were needed. In the sixties many people of 65 and over (most of them in good health) were eager to live in these homes. Typical for the way many homes in The Netherlands were built in those years was:

    * large, long flats with inner corridors;

    * mostly single rooms of 14 square meters;

    * some double rooms of 25 square meters;

* o flats for independently living elderly (with sitting room and bedroom)

of 34 square meters;

    * one shared living room and bathroom per floor;

* a large recreation rooms for all residents and complete service and care,  

   regardless of the needs.


These homes showed many 'total institution' characteristics.

The same is the case with the so-called 'nursing homes' that started as imitation hospitals, that were meant for patients to stay some time, after treatment in hospital, before going home.


The changes in housing and care between 1970 and 1990

In the second half of the seventies the elderly's appreciation of the homes for the elderly decreased. The problem of housing-shortage had been solved and new houses were larger and more comfortable. This eventually led up to more and more empty rooms in the traditional homes - they were by now generally called 'henhouses'.

The period between 1975 and 1990 showed an ever-increasing number of square meters for living (up to 50 square meters,) as well as many improvements. In many cases, however, insufficient consideration was given of the changes within the group of elderly themselves. The existing as well as the new population of the traditional homes became more and more dependent on intensive care.

From 1988, the care and service in these so-called 'care homes' is also organized differently. In the old homes, with the overall care and housing, residents left their income with the Social Security Service - which paid the institute - and received an amount of pocket money. These days the residents pay their own rent for their own apartment and expenses for services like the warden, the window cleaner, etc. The help is now given in co-operation between extramural and residential organizations.


We now focus on the specific group of elderly: those living in nursing homes.

In the sixties and early seventies nursing homes were meant for temporary stay of patients - mostly elderly - for physical rehabilitation. After some weeks or months, they returned home. The reasons for building these nursing homes were purely financial. The price of a day in a general hospital had grown so high, that a nursing home for a specific type of patient was far cheaper. However, the nature of this nursing-home patient changed. Nowadays about 85% of the elderly live there permanently until the end of their lives. The nursing homes, however, were built, analogous to general hospitals, with six and four bedrooms. Now that the residents remain in these nursing homes, this is of course no longer sufficient in terms of homeliness, privacy and the continuation of social life. This caused these nursing homes to be less appreciated by the elderly.


A similar development took place in the care and housing of mentally disabled and chronic psychiatric patients. Traditionally the 'asylums' for these categories were massive institutions, cut off from the outside world. Apart from scaling down the buildings and realizing much more single rooms, the normal living conditions set in: houses with communities of up to 12 residents.

The intention of deconcentration of institutions is to find new and replacement capacity for living and care of disabled persons, in smaller units, more integrated in society and more spread out. Therefore, independent living can be a solution for care for many of the elderly as well as the disabled.


The emancipation of the elderly and the more professional approach by pressure groups has contributed to the extensiveness of the debate. Especially in The Netherlands, the result will have great consequences, because of all European countries The Netherlands has the highest percentage of people over 65 that live in institutions (residential home, care home or nursing home).


The desires put forward in the debate by individual elderly and through the pressure groups are:

    * to function as independently as possible;

    * to stay together as partners (or with a child);

    * more privacy;

    * no need to move when more care is needed;

    * separate bills for housing and care;

    * to be able to live in ones own neighbourhood, to maintain social contacts;

    * the demand for care determines the supply;

    * a coherent supply of care.


In the field of housing this means: three rooms' apartments tailored to older people, wheelchair and stretcher accessible, a well equipped kitchen and bathroom. In addition, it should be fit to install future technological developments easily.


The present-day practice in Rotterdam

For many years, Rotterdam led the way in the development of these policies in The Netherlands. Various initiatives were adopted by other cities and then fitted in the national policy. True examples of this are the Humanitas-Bergweg and Humanitas-Akropolis projects that were developed by our Foundation with a lot of support from the municipal services. Humanitas-Bergweg is situated in a district of Rotterdam with a high proportion of elderly people -27% of the 51.000 inhabitants are older than 65 - but few dwellings suited this category. In addition, the care-demand is far greater than the present supply.


The Humanitas care notion

Ever since its foundation in 1959, Humanitas aims at thrusting back the frontiers in the field of care:

    * own responsibility and self-determination; the care is strictly 'made to measure'( we 'help with our hands on our backs')

    * major parts in the care are played by the patient himself ('use it or lose it') and by volunteer aid;

    * separation of housing and care (client is master of the house), the dwellings are Apartments for Life, which means care, up to one hundred percent nursing-home care will be rendered in one's own home;

    * de-institutionalization, fight against disintegration and for reintegration;

    * direct communication with the neighbourhood: interaction with various target-groups and the various social organizations in the community.

    * Well being elements (luxurious restaurants and bars, pets, bridge clubs from outside, art-exhibitions, music groups, wedding parties and stampcollector markets in the sheltered 'village square') are an integrated part of the Humanitas product.


As stated the 'levensloopbestendige' units, together with the starting-points for care, offer maximum opportunities to look after oneself and be independent. Because the patient/client is no longer forced to move, the social networks remain unimpaired. The de-institutionalization, the personal activities and the interaction with the surrounding (outside) community strengthen this aspect.

The sheltered protection offered by the Apartment for Live in the complex, together with the strict application of tailored-to-measure care, the 'use it or lose it' principle and other stimuli, keep up the desire of the elderly to take care of themselves as long as possible and even improve this. Too much care is worse than too little care! The care is provided by several care suppliers. The co-ordination of these care suppliers is an important issue. The attunement of the contribution of the various suppliers must be laid down in a care contract. A central place is created to where the care demands are entered (one entrance for all demands) by a permanent care manager, who looks after the attunement. When drafting the care contract, the client can determine the demands in terms of volume, nature and point of time. This way he keeps in control of (organizing) his own life. Self-management by the client remains the number one priority.


An adequate accessibility and the multi functional facilities stimulate other target groups from outside to visit the complex. The presence of people from the arena in the complex stimulates the mental vitality of the client and the will to be active. Without these district-visitors contributing largely to the bonding with the neighbourhood, there is a danger of hospitalization.


The basic philosophy in a nutshell

    * Rigorous separation between housing and care: from care to housing.

    * De-institutionalization: from intramural to sublimated home care.

 * Mixed occupation: rich and poor, sick and in good health, young and old,

   migrant and native.

    * No separation from partner.

* 'Use it or lose it'; the care is strictly suitable and advising; too much care is worse than too little care.

 * 'Give a hand with your hands on your back': stimulate independence and

  self-reliance (up to pain threshold);

    * Corporate yes-culture: meetings cost money, enthusiasm produces!


All this has consequences of course. First of all for the client, but also for the subsidizer or investor, the authorities and the care management.


Our experience since the introduction of the first 300 Apartments for Life in December 1995 (at present we have over 1.000) is that, together with the Humanitas philosophy, they link on closely to the wishes and desires of today's elderly.

The up to one hundred percent nursing-home care appears to have been realistic as well. Alzheimer patients, for instance, can live perfectly independent in such an environment, provided they arrived in an early stage of dementia. In the Humanitas Apartment for Life no client gets any assistance where not needed. Subsequently the care is far from censorious or patronizing. This boosts self-respect and dignity and thus attributes to happiness in the evening of one's life.


Is this care affordable? This amount of individualization and the extra square meters must surely be terribly expensive? Old age pensioners and people on social security surely cannot afford to live here? As expected and now confirmed in practice: the Humanitas notion turned out not more expensive than the traditional approach. Some visible advantages:

* Our rented three rooms apartments are not more expensive than a place in a

nursing home with its affluent space for general purposes and its expensive medical inventory.

   * There is a maximum benefit from the assistance of partners, relatives and


   * Keeping their own household is much cheaper with regard to meals and

   housekeeping in an institution, not in the least because it is based on the client's  

    own choices.

    * Staying is an institution has negative effects on the well being and welfare of the

       client. This results in the need for extra-specialized psychosocial help, which is

       not requested under normal conditions. This saves many hours from

       psychologists, welfare workers and occupational and other therapists.


The care is organized differently from before. The strictly tailor measured care is non-institutional. The staff is not wholly responsible or accountable for the client, because the client is, comparatively speaking, largely responsible for his own well being. This new notion means a great change in attitude for the staff, who have been trained to be always helpful, regardless of the circumstances. They now have to learn to teach the client to do as much as possible for himself: 'give a hand with your hands on your back'. This demands a certain amount of flexibility, which not everyone can manage.

Research at an earlier Humanitas project, where elderly returned from total, full care to made to measure care, shows that the elderly were much sooner accustomed to the new situation than the staff. This is only logical: the clients soon experienced that running their own households (including finances) and activities made them more self-reliant and therefore independent. The corporate 'yes'-culture (everything is possible, unless the contrary is apparent) contributes to an atmosphere in which changes can be accomplished more comfortably. Apart from that we must not forget the total ambiance must be activating and inviting to enter from outside and it should have a cheerful and gay radiation (bars, restaurants, animal farms with cuddly animals, art exhibitions, music theatre, etc.).


The future

One remark we still have to make: what to do for the future. Age proof dwellings with cure and care to the level of nursing care is not enough. Humanitas has already started to deliver real hospital functions in the Apartments for Life. In the Netherlands hospitals are becoming more and more specialized in intensive treatment. In the future they will have almost only intensive care beds.

Humanitas already started an experiment to fulfil the less complicated hospital treatment for diabetics, asthmatics and patients with fractures, hernia, cerebral haemorrhage, kidney dialysis, eye or ear disorders, heart conditions and stomach and intestinal complaints. The experiment also comprises psychiatric patients with disorderly behaviour, terminal patients and generally bedridden patients.

Of course this requires the latest technical novelties (made to measure per dwelling)

To establish real hospital functions in one's own home is not easy, but it goes well with the Humanitas slogan Never a dull moment with the yes-culture!