Chapter 4 

Residential Options for Creative Aging in American    

By Bruce Darling

Current Trends in Elderly Housing in the United States

Independent living retirement communities, assisted-living facilities, continuous care communities, aging-in-place -- thoughtfully designed and managed living arrangements such as these with a resident-focused philosophy, contribute to promoting the creative potential of this new generation of older people. This alone helps to raise the quality of life for residents. Moreover, the new “landscape of aging”is providing a variety of options for residential living situations to choose from. This is important. Experiments have demonstrated that people who are given options, who can make choices about their lives, are likely to be more healthy, more positive in their outlook, achieve higher life satisfaction. Today older people are demanding an ever-increasing number of choices for living out the latter half of life in the manner they are accustomed. Creative residential options do not include nursing home facilities, as traditionally conceived, for they do not represent a residential environment. Rather, they are viewed as medical facilities. Certainly nobody wants to move into a nursing home, although the nursing home has a role to play when there is no other recourse. Nursing home facilities are, for example, one component of continuing-care retirement communities, to be discussed further below.

In the United States, the various new residential options being demanded by older people are one reason the nursing home population is decreasing, the number of nursing homes constructed declining. This is in spite of the increasing population of older people who heretofore have been considered prime candidates for such facilities. Europe, where the social welfare philosophy is quite different that in the United States, leads the way in this respect. In fact, in most Scandinavian countries, the construction of nursing homes is illegal. In Denmark officials have placed a moratorium on new construction of nursing homes (circa 1990). “In the future, independent dwellings not resembling institutions are to be built.” This is in keeping with Denmark’s advanced social policies for its older citizens: bringing residential services to older people in independent dwellings, making homes universally accessible, offering continuity to seniors, keeping seniors involved in meaningful activities, maintaining high expectations of their older people, making self-determination a high priority. Sweden has also been reducing nursing home beds by about 900 beds per year. In Sweden the elderly who need care live at home or in sheltered-care houses. Existing nursing homes are considered subacute facilities for severely impaired patients and as such are viewed as inappropriate places for people to live out their later years. In the United Kingdom, most older people are cared for at home, with long term care being provided in three categories. In category 1, services are usually supplied by neighbors; in category 2, wardens offer services; Category 3 is skilled nursing. Institutionalization is only used as a last resort. This movement away from skilled nursing facilities is sometimes termed de-institutionalization or normalization.

As noted above, this trend also can be observed in the United States. For example, the cover story of the 21 May 2001 issue of U.S News and World Report, is entitled “A Better Way to Grow Old: Alternatives to Nursing Home Care,” reports that the number of nursing home residents dropped by about 10 per cent over the past decade_the same period when Americans over 75 grew by 27 per cent. Americans have tended to put their frail elderly in nursing homes. According to a 1989 U.S. Government report, the United States has the largest percentage of people in nursing homes of all developed countries in the world. Yet even in 1989 estimates have shown that as many as 93 per cent of Mediaid nursing home residents in Oregon were inappropriately placed. Nursing homes, then, have been serving as a solution to a housing problem, not as a health care remedy. And as a solution to a housing problem, such a medical facility is an inappropriate place for people to make their residence. It is first of all much too costly and secondly its sterile regimented atmosphere is inappropriate for creating a supportive healing environment. Hence, the move away from medical facilities and the appeal of residential environments for long term care can be readily understood.

This move away from nursing homes appears to be at odds with the ideas held by social welfare policy makers in Japan from whom we hear an incessant call for the construction of more nursing home facilities, for the need for ever more beds, to meet the supposed needs of the ever growing frail elderly population. This is not to say that a movement towards de-institutionalization is not being advocated in Japan, but in practice it is not as advanced as in the West. Perhaps aspects of this new landscape of residential living options for the elderly in the United States, and Europe, may provide hints for improving the living situation for Japanese seniors. Japanese social welfare policy seems to fall between those of the United States and Europe. With respect to national health insurance, Japan is closer to Europe; with respect to support for retirement pensions, Japan may lag behind even the United States. With respect to finding work for older works, on the other hand, Japan may well be ahead of both Europe and the United States. However, with de-institutionalization of long term elderly care facilities the United States seems to be moving in the European direction faster than Japan with de-institutionalization of long term elderly care facilities

Returning to the issue of the decrease in nursing homes and nursing home residents in the United States, the question that naturally arises is where are these older people living if thy are not in nursing homes? The answer, of course, is that they are deciding to take advantage of some of the creative innovations in residential lifestyle options that Gene Cohen mentions.

Retiring in the United States

Before discussing in more detail these senior residential lifestyle options, let us look at how two middle class American couples, now both in their eighties, have decided to retire and spend their later years, one aging at home and the other aging in a retirement community. We should remember that this is likely to be different from what we would hear from a comparative European or Japanese middle class couple. Nevertheless, their stories may help us to understand why the particular choices mentioned above have become so popular in the United States.

Aging at Home: Louie and Treeva -

Louie grew up in Wellesley, Massachusetts, and Treeva grew up in Ohio. I'm not sure how they met but they moved to Holliston, a small town west of Boston, a long time ago and took over Fiske's General Store, the heart and gathering place within this small New England town. They posted notices of all birthdays in the window, and there was also a community notice board. They are also always at the center of any fund raising in the town, whether to help out someone with their medical bills or to find a matching donor for an organ transplant. The store always welcomed the school children and had a good supply of the latest fad items. Louie ran the store, and Treeva often helped out. And as the time to retire approached, they gradually handed the store over to their two sons, John and Eddie. Eddie eventually left the store to his older brother who today runs the store. But Louie and Treeva are still familiar faces in the store and even today, 15 years or so after Louie "retired" he can still be seen on occasion to work in the store. They are now both in their 80s and still living in the home in which they raised their family. They have always had a garden - Louie a veggie garden and Treeva a flower garden. And today although they have cut back the scale of the garden, they still garden a little bit. They have a son and daughter who still live in Holliston with their respective families, and their two other children are in New England; only their youngest son left the vicinity and moved to Seattle. They know so many people in town and still, in their old age, I would guess are at the heart of the community.

I don't know what their plans are - they are getting older. I don't know how long they plan on staying where they are or if they've talked at all about moving to an assisted living facility. My guess is that they will stay at home, surrounded by family and friends. They still take care of each other and when I saw them a few months ago they both seemed great. They really hadn't changed since I last saw them 5 years ago.

Aging in a Retirement Community: Bruce and Wilma

Bruce and Wilma grew up in the Rochester, NY, area, went off to college, got married and settled down to raise a family in the same town where they had grown up. Bruce, having earned an engineering degree, worked for the main employer in Rochester. Wilma, along with raising four children, became involved with volunteer work at the local hospital and art gallery. They had a circle of friends from school, work, and the community. Both of their fathers had died while fairly young, though both their mothers lived independently in the Rochester area into their 80s.

After their four children grew up and went off to college, the house where they had raised them began to feel lonely and too large. And many of their friends were moving away. Their children too were now scattered about, only the younger daughter returned to live in the old neighborhood. The others settled down elsewhere, though they did remain in the northeast. So the empty nest couple decided to sell their house and move with their dog to the more pleasant year round climate of Florida.

First, they bought a small apartment in a newly developing resort community in southwest Florida on the Gulf Coast. Discovering that they really did like living here, they then purchased a larger condominium in a small apartment building with a dock for their small power boat. After living here for ten years, and being relatively healthy_still playing golf and tennis, still swimming- but now ready to give up their boat and looking for a place to live that has fewer tourists, they moved to a single story villa in a gated community for active people over 55 a little further north but still on the Golf Coast. Clusters of villas and apartments were set in the beautifully landscaped and carefully groomed grounds with walking paths, ponds, and a boardwalk. Swimming pools were scattered throughout the complex; a club house was available for community activities. They have enjoyed their villa life here very much but after more than ten years here they both were now in their eighties and have begun to see the need for assistance within the next few years. Bruce gave up driving after an accident that totaled the car and has trouble getting around. Wilma is worried she will have problems helping him as his physical condition gets worse. If they stay where they are, Wilma will have to have a helper come to help because she wil not be able to manage all by herself. Again, how well this would work will depend on finances and the availability of help.

When I last saw them several months ago, they both had started to look around at several of the nearby continuous care communities that were being developed. When they find a place they like, and can afford, they will probably have to be put on waiting list until an opening becomes available. Once they move in, they will be able to go about their daily activities worry free about having to move again. In addition to independent living, they also will have assisted living and skilled nursing care all within the same complex. Hence, they will be assured that any future health and care needs. The question is will reality correspond to this idealized scenario.


Several points are worth noting about the retirement choices of these two couples. Louie and Treeva, as they continue to age, have naturally stayed in their family home. They have the familiarity of their home, the security of their family and the warmth of their community. They are able to maintain their independence and autonomy, while continuing to be active in community affairs. They are empowered to make all their important life choices.

With Bruce and Wilma, on the other hand, we see little resistance to moving far away from where they grew up and raised their family. For them, moving was a rational choice based on changed life circumstances_large house when raising family, smaller house or villa after kids leave home, warmer climate for health reasons, and eventually a smaller assisted living apartment in a continuous care community. Finally, if living at home, sometimes termed “aging in place,” is the most desirable place to grow old, for Bruce and Wilma home may be defined as “where the heart is.” Certainly for them home is not a single place. Once again, a far as life choices are concerned, the key words are “independence” and “autonomy.”

Senior Residential Life Style Options

Next, keeping in mind the above summary of how two typical middle class couples have chosen to grow into old age, let us look at the several categories of senior residential life style options for growing old mentioned in the narratives- independent living, assistant living, continuous care communities, lifetime care in one location.

Independent Living

Repeated surveys have shown that living at home, what is usually meant by independent living, is for a majority of people the most desirable way to grow old. But the meaning of home is not a simple concept to define. What are some of the characteristics of “home”? Home is not merely a particular house, as the above story shows. Home means different things at different times. Being in a familiar environment, taking responsibility, having autonomy, making important life choices, accepting challenges and taking risks, making choices, continuing to grow. Rather than a description of a building type, home is perhaps better defined by the psychological state of one “at home.” Home is the center of one’s wellness. One feels most comfortable at home. Economics is an important consideration for most people. An older person’s home is usually paid for so it is less expensive to live there. However, to stay in one’s own home as one ages, to “age in place,” requires that the home be adapted to the changing physical needs of the resident. Supportive architecture and interior design can play a crucial role in enabling one to age in place. “Barrier free” is the term that has been most commonly used to describe this type of design. More recently a better concept is being applied, “universal design.” The premise of the disabled needing barriers removed is replaced by the idea of universal access regardless of age, (mental or physical) abilities, mobility. While certainly architectural and interior design can lend crucial support to those “aging in place,” various other care, health, and social support services are also required. First and foremost is the assistance that one’s spouse, immediate family, friends and neighbors contributes, both in the home and getting out of the home. Isolation as one’s mobility declines leads to accelerated aging. Day Service Centers, public libraries, Christian and Jewish Yong Men and Women’s Associations, churches, etc., provide the opportunity and place for social interaction and creative activities for live at home elders. Access to transportation is a crucial consideration.

For those living at home who need assistance with ADLs and IADLs, various arrangements for home helpers can supplement any family care that is being given. ADLs and IADLs are essential personal daily rituals, “the glue that bonds people to a place called home.” Great care must be taken not to break the bond with home of those needing assistance with these. For example, home service programs, such as Meals on Wheels, have proven to be essential.

Life long independent living also means the introduction of health care at some point. Hospital and nursing home outreach programs for medical interventions are one example. Independent companies have also be established to fill this need. To maintain an “aging in place,” respite facilities for short term stays while family care givers take a rest also must be part of the program. The reader must be wondering at what stage of care requirements does “aging in place” become impracticable. How much skilled nursing can be conducted at home? And what is the role of hospice in “aging-in-place?” In the United States, the answers are not yet clear, though Europe is pointing the way. We will come back to independent living later on when we discuss “Lifetime Care in One Location.”

Retirement Communities for Active Adults

As we noted in the narrative about Bruce and Wilma, moving after the children have grown up from the large family home to a smaller residence, condominium, or apartment in a retirement community can have a certain rationale to it. In the United States such moves have for decades been a very popular way for many retirees to establish new homes. Over 500,00 retires a year move out of state. On noticeable tendency has been for people in the northern states to seek warmer and or drier climates upon retirement. Retirement communities for active retirees have long flourished in such classic sun states such as Florida, Arizona and California. Today, these states continue to be among the fastest growing in terms of population. Residential and vacation communities in these and other states today are continuing to attract older adults, thereby building up new intergenerational communities. Interspersed among these communities are planned retirement communities for active adults. Often these are age restricted and gated. Residents commonly share similar economic status and are racially homogeneous. New social networks develop easily because everyone has moved from somewhere else. Often these retirement communities for active adults have a resort or country club atmosphere. Indeed, not a few have their own golf courses, in addition to swimming pools, tennis courts, activities centers, ateliers, and even country club with restaurant. Amenities such as these continue to be insisted upon by retirees for their new communities. Today, we see new trends in the kinds of retirement communities seniors are demanding; moreover, they are not restricting their choices to sunny climates. Selected locations in the northern states are also proving to be popular destinations for seniors moving to retirement communities. For example, as the title of the cover story for 20 July 1998 issue of Business Week states, “When a Home near the Fifth Hole isn’t Enough: For many, culture, educational offerings, and jobs are as crucial as climate.” Business Weeks lists the following: cultural stimulation, Ashland, Oregon, home of Oregon Shakespeare Festival; educational opportunities, college towns University of Indiana and Meadowood Retirement Community; employment opportunities, Austin Texas, many high-tech companies; and naturally occurring retirement communities(NORCs) in cities that offer all of the above, Capitol Hill in Denver. Note also that creativity, education, and the life satisfaction and economic well being derived from work have all been shown by research studies to make positive contributions to the health of older people.

Assisted Living

As active retirees age into their late 70s and 80s, it becomes harder for them to maintain their independence without assistance. If one could no longer depend on a spouse or family members, it used to be that the only choice was to move into a skilled nursing facility, even if constant medical supervision was not required. Medical facilities, however, are not residences, are not places to grow old. Certainly they are much more expensive than living at home (only small Medicaid payments are available). Elderly people do not want to go into nursing homes; nor do the children who have been looking after them want to put them into nursing homes. Their frail health appears to leave caregivers with no choice, at least so the doctor would tell them. Nevertheless, those responsible (whether spouse or children) have a tremendous feeling of guilt. They feel as if they are not carrying out their responsibilities; they think they should be able to do more so that their frail spouse or parent can remain at home in familiar nurturing surroundings. Today, our older citizens who need assistance with multiple ADLs and IADLs are demanding, and getting, options other than moving into a skilled nursing facility. Today the fastest growing option for senior housing in the United States is assisted living, with an annual growth rate over the last few years estimated at 15-20%. "For frail older persons and adults with disabilities who need some assistance to live independently, or who no longer wish to remain at home, assisted living provides an option for meeting their personal and supportive care needs." Note also that successful models of assisted living care serve the cognitively impaired as well. Let's examine "assisted living" more closely. We must acknowledge, though, that a precise definition is very difficult because "assisted living" is a relatively new concept and continues to evolve. Victor Regnier, a longtime advocate for assisted living, gives the following definition:

Assisted living is a long-term care alternative that involves the delivery of professionally managed personal and health care services in a group setting that is residential in character and appearance; it has the capacity to meet unscheduled needs for assistance, while optimizing resident's physical and psychological independence.

To add clarity, here is a list of nine specific qualities that assisted living facilities should ideally have:

  1. appear residential in character
  2. be perceived as small in scale and size
  3. provide residential privacy and completeness
  4. recognize the uniqueness of each resident
  5. foster independence, interdependence, individuality
  6. focus on health maintenance, physical movement, mental stimulation
  7. support family involvement
  8. maintain connections with the surrounding community
  9. serve the frail

The problem is, as Regnier states, that "assisted living" means different things to different people. To some people "assisted living" is a philosophy of care; to others it is a type of building; and to still others it is a regulatory category. Reviewing "assisted living" from these three perspectives may be useful.

Assisted Living Philosophy of Care

Assisted living distinguishes itself fundamentally from other forms of long- term care by its philosophy of care. The focus is on individual attention and needs. "The care philosophy of "assisted living" emphasizes personal dignity, autonomy, independence, and privacy. The objective of assisted living is to maintain or enhance the capabilities of frail older person and persons with disabilities so that they can remain as independent as possible in a homelike environment.” Unlike a nursing home facility mandating that frail elders receive particular services in certain ways, the assisted living philosophy of care advocates choice and independence. Residents' privacy is protected, their dignity supported, their spirits nurtured. Family and friends are encouraged to be involved in care planning and implementation. Providing a safe residential environment always has to be balanced against the implementation of the least restrictive environment, balanced against resident physical independence, freedom of mobility, choice of options, and risk taking. Another aspect of this care philosophy has been to nurture ties between the assisted living residence and the community; by offering respite or day care programs the assisted living residence becomes an important community resource; making services available in the community accessible to residents will encourage additional interaction. In addition, the assisted living residence should serve the community as a place for social and cultural interaction on an intergenerational level between people in the community and those living in the assisted living.

The intention of the philosophy of care in assisted living has been to support "aging in place," though many administrators make a clear distinction between the roles of assisted living and nursing homes. The issues of risk and responsibility weigh very heavily on providers with respect to extending aging in place in order to avoid the placement of frail residents in an institutional nursing home setting. Furthermore, some states regulate the policies for discharging or retaining residents, while others leave such decision to the providers' discretion. Another factor is that certain government reimbursements for health care mandate institutional settings. On the other hand, assisted living has been largely unregulated because of a lack of government financial support. Though thirty-eight states pay for some assisted living, programs are very small, covering less than 100,000 poor people. People who live in states like Oregon and Washington, where experimentation with innovative programs in long-term care are being carried out, have more options. Many older people have decided that they do not want to end up in a nursing home and, even if they have to pay out of their own savings, they decide to move into assisted living residences. These places are not for the poor. Although costs vary depending on the services provided, average costs are estimated to be $2,000 per month. And because they are paying on their own, they do not welcome interference by state regulators telling them that because of their care needs they have to be moved to a skilled care facility. In fact, they sometimes fight such moves in the courts. Once they have moved into and have gotten settled, they do not want to move again. Forcing them to do so often has dire consequences.

Of course, people do not at all want to grow old in a medical facility,

and your typical nursing home has been traditionally built on the medical model.

Today's older citizens want to grow old at home; but if the level of care required does not allow that, then they want to grow old in a home-like environment. The natural and built environment is a big component of this. The role the environment plays in every day health, health care and, especially, in the health care of the aging population is at last being given the attention it deserves. Next, let us examine assisted living from the perspective of a type of building.

Assisted Living Building Type

Building type itself is a basic architectural concept in architecture and is associated with categories of use or construction. Building type is used here to classify by function or structure. Building types for long term elderly care are typically classified as "congregate housing," "shared housing," "board and care," "assisted living," "continuing care retirement communities," "nursing homes. " In these cases, the function of the building defines the type of building it is. The building type in each of these categories represents a very generalized idea of function that is open to various interpretations based, to give but one example, on cultural context. Hence, one's understanding of a building's intended function may result in a different usage for that initially foreseen. The physical properties of a building, as well as the method of construction, represent more concrete attributes for classifying building types. Transcending building function, construction and physical properties, the essence of a building, however, may well lie in the spiritual and poetic dynamics arising from the interaction between those inhabiting the building and the building itself.

Our definition of assisted living noted that the facility be residential in character and appearance. The term residential is used to make a distinction between this and the institutional building label. Furthermore, discussions of the care philosophy of assisted living speak of the intention of the architects and designers of these facilities to provide a "homelike environment" rather than an institutional setting for residents. They see this as a warm and more personal homelike environment as a great improvement over the cold sterile environment of the typical medical model-based long-term care. We see personal resident―friendly care as in contrast to staff-centered, impersonal care so found in medical facilities. Family involvement is encouraged rather than discouraged. Homelike contrasts with institutional "because home environments, unlike traditional institutions, encourage independent action and stimulate continuing growth on the part of the resident." We will examine the concepts of "home” and" "homelike" more fully below.

Residents and their families show a clear preference for residential settings that give tenants' dignity and empower them with choice in their daily lives. Care providers are clearly aware of this preference and are striving to provide a more homelike setting in existing facilities to attract and keep residents. Those developing new assisted living facilities are continually conducting experiments in how to give their new buildings a homelike ambience. The problem is that few objective criteria for determining residential or homelike characteristics have been agreed upon. But before being able to point to characteristics that can help make an institutional environment homelike, the amorphous concept of home must be explored. This is very important because the concepts of "home" and "homelike" bring us to the essence of what assisted living is all about. Schwarz refers to home as "the conceptual foundation of assisted living."

The term "home" brings to mind the place you live, the close relationships you have with the people you share this place with, the base for your daily life/activities. Home is a place you return to again and again over period of time to restore yourself because it is a place you have grown used to, a place with memories, and place where you are comfortable.

The term or concept "home" should be distinguished from "house." A house is a building, a physical form, a part of the environment; home, on the other hand, is more of a "experiential phenomenon" that cannot always be clearly delineated. According to Schwarz, "A home in its essence breaks away from the physical properties of house into the psychological territories of identity, memory, habits, and culturally conditioned reactions and values." Pallasmaa concurs: "Home is an individualized dwelling, and the means of this subtle personalization seem to be outside of our concept of architecture. Dwelling, or the house, is the container, the shell of the home. The substance of home is secreted, as it were, upon the framework of the dwelling by the dweller. Home is an expression of the dweller's personality and his unique patterns of life. Consequently, the essence of home is closer to life itself than to an artefact." Home then conveys a sense of identity, of self, of stability, of continuity, of safety, of community. These aspects of home are above and beyond any particular formal architectural and design elements. Nevertheless, the physical attributes of the home environment (outward appearance, spacial layout, interior decoration, furnishings), supply the setting for these essential qualities of home. These are not the same as those found in a typical institutional environment. Yet it is these same physical attributes of home that architects and designers striving to bring homelike qualities to assisted living must identify and try to incorporate into an institutional type of facility. Studies of patterns that convey homeyness and surveys of how older people perceive efforts to make assisted living facilities look like home support these efforts.

Some of these physical attributes of the home environment that architects and designers are bringing to assisted living facilities in order to try to give them a homelike ambiance include, without going into specifics, familiar appearance, human scale, natural materials, residential spacial arrangements, privacy, personal furnishings. Friends and family members visiting assisted living facilities with this homelike environment find it so much more inviting and livable than the institutional ambiance of so many nursing homes. The architects and designers involved also see this as a tremendous improvement in livability over typical institutional environments. There appears to be a gap in perception as to the effectiveness of these architectural and design elements in creating a homelike environment between the architects, designers and providers on the one hand and the residents on the other. For example, residents themselves, while appreciating the homelike features, view an assisted living facility as little different from a nursing home. For them, a "homelike" physical environment is not the same as "home." Architects, designers and providers compare assisted living to nursing homes. Residents, however, compare it to their own homes.

For an assisted living facility to be home, the more subtle personal and psychological qualities of home have to be experienced. This is a far more difficult if not impossible matter because of the potential contradictions of home that are basic to an assisted living . Brummett lists the following: 1. resident dependence on staff for provision of their needs, 2. compromises of privacy and territoriality resulting from living with other people in a group, 3. staff and caregiver needs, 4. higher levels of safety standards with regard to well being of residents. In other words, life in an assisted living facility inherently requires 1. a reduction of autonomy and independence, 2. incursions on privacy and reduction of personal space, 3. less focus on resident or owner centered needs, 4. reduction of ability to make choices due to attempts to minimize of risk. Moving into an assisted living facility means giving up your home. And even with a homelike ambiance, this would mark the start of a gradual thinning out of many of the special though difficult to define qualities of home. Moreover, the older one becomes the more likely that additional assistance with activities of daily living (ADLs) will be needed, further lessening one’s independence.

People chose to move into assisted living because they need help with ADLs. Yet, physical capabilities are often the only criterion for defining independence. If too much help is required, this ADL assistance is used as a yardstick to remove people from assisted living, usually transferring them to a nursing home or hospital. This common scenario may be explained when one realizes that for both people moving into assisted living as well as for the providers assisted living is intended as a way station between independent living in a community and skilled care in a nursing facility. Interviews with residents of assisted living indicate that they do not want to be mixed with people who are severely incapacitated mentally or physically. An underlying premise, although they may not realize it, would be that when they reach that degree of frailness they would agree to being moved elsewhere. Providers are also very much concerned with the safety issue involving frail and mental incompetent elderly. A crucial question concerning long term care of the elderly is the issue of whether the elderly should be shuttled from one facility to another as they become progressively older and weaker and require more medical care. Or should the elderly be allowed to age-in-place until they die? This reflects the current debate regarding continuum-of-care model versus the aging-in-place model of assisted living. The continuum-of-care model of assisted living emphasizes health care and nursing services. Advocates of this model believe that assisted living serves as a bridge between independent living in a community and living in a nursing home. Under this medical model, it is inappropriate for residents to remain in assisted living if their health shows significant decline. The continuum-of-care model the current standard in the United States.

Advocates of the aging-in-place model believe that elderly people should be allowed to remain in assisted living until they die. Prolonged residence alone does not live up to the possibilities of the aging-in-place model. Proponents believe that residents will have a better quality of life by staying in the same residential environment. When older people first move from their home to assisted living, though forced due to the need for assistance, they are still rather independent with a sense of autonomy. Often, they are involved in the decision to move. The older and weaker they become the more dependent and less autonomous they turn. Moreover, each move they then make is to a progressively medicalized facility that brings them increasing disorientation, loss, loneliness, liminality. This is the argument for residents to remain in assisted living and not move again. If this is to be the case, the question to be addressed is whether assisted living can take on the additional health care role of skilled nursing as well as the palliative care role of hospice. However, a compromise of the continuum-of-care model of assisted living has also become very popular for long term elder care in the United States, continuing care retirement communities (CCRCs).

A Brief Comment on Regulations

Assisted living is a new form for long term care; as a consequence currently federal regulatory standards are not in place. Instead, the states have stepped in to grapple with issues of licensure and reimbursement standards. The piecemeal fashion in which is done has resulted in the various states developing their own requirements as they seek ways to incorporate assisted living into their existing housing and long-term care systems. Here is the situation as of June 1998:

22 states had assisted living licensure regulations;

11 states had drafted or revised assisted living regulations;

11 states were studying assisted living;

22 states were planning to reimburse or were already reimbursing for

assisted living as a Medicaid service (this total includes states with and without a separate assisted living licensure category);

6 states reimbursed for assisted living as a service in board and care


States are using three common licensure and regulatory mechanisms to oversee assisted living facilities :

    1. Some have classified assisted living as a new, separate type of residential
    2. housing with its own licensure category and regulatory standards.

    3. A few have combined regulatory classifications governing various types of
    4. supportive housing into a new assisted living category.

    5. Some others have licensed assisted living as one category under their residential housing or board and care regulations.

Because there is no national definition of assisted living with respect to building codes and health care regulations, various standards have been developed throughout the United States. Assisted living philosophy of care, meanwhile, is being applied to various senior long term care environments: freestanding buildings, communities for cognitively impaired, residential care centers, hospice environments, aging at home. What this means is that the blurring of distinctions between institutional care and other long term care options means that care services are not linked to a specific environment and that regulations regarding removal due to disabilities become subject to interpretation.

Regulatory categories fall into three main areas: Zoning laws, building design requirements, and licensing regulations that govern health care, personal care, and food services. Zoning laws hinder the integration of long term care facilities into the their surrounding neighborhoods. Nursing homes usually fall within the institutional zone categories. This makes them not compatible with commercial or residential land uses because zone laws specify separate land uses. The result is that housing for the frail is cut off from the community; its residents isolated from people in the neighborhood. Once again, with regard to housing for older people and its relation to the surrounding community, the encouragement of mixed-use facilities that include health centers, rehabilitation services, restaurants and creative activities centers in Europe offer a glimpse at what is possible.

Building design requirements are premised on the building type and the intended residents. Forethought must be give to the building design if it is to serve mentally or physically frail people. If certain fire exiting requirements are not met, the law dictates that these people move. Although building codes vary from states to state and municipality to municipality, fire codes always play a central role because of safety, often to the detriment of quality of life. For example, use of residential materials and design elements such as fireplaces are restricted in institutional settings. Instead, institutional elements such as extra wide corridors and doors, solid walls, built in fire extinguishers, distance of rooms from nurse station, etc., are mandated by building regulations.

Licensing regulations that govern health care, personal care, and food services focus on the competency of the people providing the service and how the service is provided. As far as maintaining a residential ambiance of assisted living facilities is concerned, regulations that restrict family involvement in providing care and prevent residents from practicing everyday activities of living (ADLs) do the most harm. Such regulations reduce resident autonomy, take away choice, undermine self-esteem. Elder abuse has been a serious problem in nursing homes. But the introduction of laws and regulations that narrow responses and discourage promising treatments in group living situations are not he best cure for this problem. The approaches to both these issues by Scandinavian countries such as Sweden and Denmark provide us with helpful models for improvements. Nursing home regulations must be strictly adhered to and applied evenly across the board. There is little room for adjusting enforcement to individual requirements, rather than the other way around. Furthermore, changing the type of service can trigger stricter building code requirements. If the future of the nursing home is assisted living then, with the increasing dependence and frailty of residents that would otherwise be in nursing homes, the typically small scale assisted living residences are going to have to meet the stricter regulations that govern skilled larger nursing facilities and hospitals. In other words, the residential character of assisted living is going to be lost due to increasing institutionalization. To prevent this, regulators and health care agencies must understand the difference between skilled nursing care and assisted living.

Basically, the issue of regulation of assisted living concerns two main view points. Many believe that assisted living regulations are essential to protect consumers; this means consumer protection regulations as well as health, care and safety standards. Unquestionably, many residents of assisted living would agree. Others, however, worry, that mandated government regulation will harm creativity and innovation in assisted living and alter its very nature. They believe regulation restricts experimentation and progress. Cinelli gives the successful example of Heritage House, a facility built in a “non-licensed environment, using common sense and consumer input as guidance,” that over regulation would have prevented from being built in its present form.

Continuing-care Retirement Communities (CCRCs)

Continuing care retirement communities (also called continuing care communities) combine different levels of care in a single community setting. Healthy seniors can move into one of these communities, live independently as long as possible, then move into assisted living when care needs arise, and even switching to nursing care if necessary_all within the same community. This means that whatever level of care becomes necessary, the resident remains in the same community with the same social network. Also, all types of long term health care are assured and located close at hand. Once you move into a CCRC, you won’t need to worry about moving again. Health care costs are either covered by up front charges, or by agreements where you agree pay for care as needed in return for lower entrance fees. As with retirement communities for active seniors, life in a CCRC is made attractive for residents by homelike atmosphere, cultural activities, sports, excursions, in house continuing education programs, ready access to banking, travel, investment services, convenient transportation for shopping, and always ready access to health and medical services. Because self care is so important, the emphasis on is prevention through exercise, nutrition, safety, etc., programs run at the wellness center.

Often, an elderly couple chooses to move into a CCRC when both members realize that one of them may need added care that their spouse may not be able to handle. Many recommend, however, that you move in while relatively young and healthy_entry fees are lower and you can take complete advantage of the full spectrum of activities. A broad range of communities is available from which to choose, from a single apartment building set in an urban environment to a broad countryside complex with garden apartments, attached villas, and independent houses to choose from. You can select from country club environments to academic communities, from year round boating environments to mountainous ski recreation areas. Generally, there are two types of pricing arrangements, the more common high up front payment arrangement or a monthly rental arrangement. In the first case, move in costs are generally about the same as to buy a house, though remember you are also paying for peace of mind. You are making an investment for life. However, no matter how long a period you live there, if you decide to leave (and ten per cent do), you forfeit your initial fee. In addition you have to pay monthly fees, again similar to what you might pay monthly to rent an apartment. The monthly rental arrangement means that you do not have to make a large initial investment while you try the community out. If you then decide to move, you will not incur a big financial loss. Additional peace of mind comes from accreditation by the Continuing Care Accreditation Commission, which reviews consumer protections, quality of health care, and financial background. The greatest attraction the CCRCs have for residents is the relief of knowing that all their health care needs for the rest of their lives will be met and that they will not have to move again.

Several aspects of continuing care retirement communities may give people pause. As mentioned above, initial costs can be quite expensive, particularly when you must make a large payment up front, as is most common. You must have sufficient saving at available. The requirement that you forfeit your entire initial fee in return for lifelong care is another stumbling block for many people. Cultural diversity is also generally lacking. As with retirement communities for active seniors, CCRCs are typically age restricted, with a relatively homogeneous economic and social mix. Entry may be controlled for safety, though this may contribute to the CCRC’s isolation from the surrounding community. However, with respect to this discussion, perhaps the most crucial aspect of CCRCs concerns achieving the sought for goal of aging-in-place. For even in a CCRCs residents are still shuttled from one place to another, to ever more medically focused facilities, as health and care needs dictate.

So, if “the future of assisted living is lifetime care in one location,” as Leibrock states, it has not yet been achieved in this type of CCRC. Certainly assisted living in its social model with homelike ambience shows a great improvement over the medical model-based nursing home. Yet assisted living even in the continuous care community setting does not completely fulfill the desire expressed by seniors to age at home. True aging-in-place with assisted living means growing old at home with the necessary level of care and health services. And if the future of the nursing home is assisted living, the future of assisted living may be said to be “lifetime care in one location,” that is aging-in-place. In other words, “lifetime care in one location” may be viewed as a further development of the merging of the two models of assisted living, the continuum of care model and the aging-in-place model. However, the question to be addressed, as we asked with regard to assisted living, is whether aging-in-place in the residential setting of home, can take on the additional health care role of skilled nursing as well as the palliative care role of hospice.

The Dream of Future Senior Residential Living:“Lifetime Care in One Location”

Lifetime care in one location can be viewed as an extension of assisted living philosophy of care to “aging-in-place.” Three main areas must be developed for any policy of lifetime care in one location to be effectively implemented: supportive or therapeutic physical environment, health care access, and social support. And as far as public social welfare policy implementation is concerned, persuasive budgetary viability is crucial. Room for optimism can be justified. First, Europe has a long established successful record in this regard; second, we have successful models even in the United States, though the United States is not going to become a welfare state. For example, Friends Life Care at Home, based in Blue Bell, Pa., is a unique not-for-profit Quaker organization that provides in home care and services for those that prefer to live out their lives at home; third, increasingly seniors are demanding and getting just such care. Innovative HMO’s are providing in-home aids and medical supplies.

The natural and built environment has a great affect on the health of us all, including the elderly. We know that nature heals. We know also that many long term-care services can be reduced or eliminated by making changes in a person’s dwelling. Implementation of universal design can be encouraged by tax breaks, loan interest rate deduction, etc. Making housing accessible through design intervention enables consumers to care for themselves without staff intervention. And, as the Swedes has discovered, design intervention is less expensive than staff intervention and care in the home is less expensive than institutionalization. How is this design intervention being implemented? For example, the Stein Gerontological Institute, a subsidiary of the Miami Jewish Home and Hospital for the Aged, has a full-size one bedroom, one bathroom apartment demonstrating assistive technology. SGI also has a program to remodel homes to make them more accessible. For those with Internet access, help is also available on the AARP Website. As Leibrock notes, “The introduction of universal design elements influences the ease with which long term care services can be provided in the home.”

“Health care is now portable.” Care service suppliers visit the home to help with ADLs and IADLs. Meals on Wheels is well known successful example. Health and wellness is emphasized, with people being given responsibility for their own well being. As with CCRCs, prevention receives priority_nutrition, exercise, safety, security. Today the kind of assistance provided at assisted living facilities is being brought to the home by such service organizations as “At Home” Assisted Living by Sunrise. Arrangements can also be made to have visiting nurses can bring skilled nursing care to the home. How is this possible? Increased knowledge in the fields of gerontology and geriatics, medical advances both contribute. In addition, the new technology is also making contributions. For example, there are many reports of the usefulness of distance monitoring to check on at home seniors.

Social support groups, respite care, art and art therapy, neighbor care participation, medical and care support services--all help the elder who needs assistance; and if family members are deeply involved, these services enable family members to carry on their own lives while still helping. The role of family and friends is very important for loneliness can have a very detrimental effect on the elderly. As mentioned earlier, it can lead to a hastening of dementia. The realization that care of the elderly is more than a medical issue led to the establishment of Social Health Maintenance Organizations, to supplement the regular HMOs and to meet better the needs of the elderly.

It would appear that the nursing home, at least in its traditional medical model, has become outmoded; it is not the place for life care in a single location. That place is home (with family, friends, and memories), within a supportive and healing physical environment, and if necessary with assistance in personal and health care to the level required. Hence, we return to the first of our creative options for senior residential living. One other important point should be emphasized. The greatest support for aging-in-place comes from the recognition by people who are aging that quality of life is of central importance; having independence and the ability to make choices means that some risk must be accepted in return. Today’s seniors recognize this and accept it has giving meaning to their lives. Home, to paraphrase Bachelard, is a place for dreaming, of what was, what is, and what will be.

Note: This chapter is an expanded English version of「アメリカにおける高齢者の居住環境の選択肢」。 In 『社会福祉の動向と課題』 西尾祐吾、塚口喜夫編, 296-315. 東京: 中央法規, 2002