Housing

Because frail older persons are likely to need a more physically supportive dwelling unit, greater supervision (e.g., with medications) or services, or more companionship than can be efficiently provided in conventional homes or apartments, a number of supportive housing options have developed since the 1980s. Estimates of the absolute and relative sizes of the populations that live in supportive housing vary considerably because of inconsistent definitions of supportive housing, the difficulty in identifying unregulated facilities, and problems that older persons have accurately answering survey questions about the type of housing they occupy.

Estimates of the number of older persons living in supportive housing settings range from one million to two million. By all accounts, however, the stock of supportive housing is still insufficient to meet the needs of a growing population of frail older persons; much of it remains unaffordable to those with low and moderate incomes, and its quality remains difficult to judge.

Continuing care retirement communities. Also called life care communities, continuing care retirement communities (CCRCs) are unique in that they offer various levels of care within one community to accommodate residents who have changing needs. Most CCRCs offer independent living areas, assisted living, and skilled nursing care. Services that are offered include transportation, meals, housekeeping, and physician services. Some communities provide most of their own services, whereas others obtain many of them through contracts with outside organizations.

Each community houses between four hundred and six hundred older persons, often in a campus-type setting. CCRCs generally require, as a condition for entry, that new residents be in reasonably good health. Once a person is admitted, however, CCRCs are the most accommodating of all settings because residents can remain and obtain services in the community even if they experience physical or mental limitations.

The typical age of entrants is seventy-nine and the majority are women (75 percent). The primary reason that older persons select CCRCs is security, represented most clearly by the assurance of high quality nursing care and personal care services.

By 1992 there were approximately a thousand CCRCs, housing approximately 350,000 to 450,000 older persons. It is predicted that the number of facilities could double by 2010, though growth may be tempered by an increase in other options, such as home care and assisted living.

Most CCRCs require residents to pay an entrance fee and monthly fee, for which the community guarantees a dwelling unit, services, meals, and nursing care. Entrance fees typically range from $20,000 to $400,000 with an average of $40,000; monthly fees range from $200 to $25,000. Generally, CCRCs are an option affordable only by middle- and upper-income older persons, for most residents must pay out of pocket. Residents generally are required to have Medicare parts A and B. In order to reduce their potential liability for long-term care, some CCRCs offer or require long-term care insurance.

As of 2000, thirty-five states have regulations in place for CCRCs; though they vary greatly in stringency. Government involvement usually takes the form of measures to improve the ability of residents to make informed decisions and to guard against the bankruptcy of these facilities. CCRCs, fearing overinvolvement by the government, have formed their own regulating agency, the Continuing Care Accreditation Commission, which adopts basic standards that focus on finance, residential life, and health care.

Board and care homes. Board and care homes are residential facilities that generally offer on-site management, supervision, a physically accessible environment, meals, and a range of services for physically or mentally vulnerable older people and younger disabled people who cannot live independently. In facilities serving primarily seniors, the average age is approximately eighty-three, about eight years older than residents of government-assisted housing.

Data from a 1991 survey suggest that over thirty thousand board and care homes exist in the United States, more than double the number of nursing homes (Sirrocco). However, owing to their smaller size (usually between five and twenty dwelling units), board and care facilities house only about one-fourth as many residents (about four hundred thousand persons) as nursing homes, and include about two hundred thousand persons under age sixty-two.

The cost of living in this type of facility varies with location and the services provided, but in general the average monthly fee ranges from $450 to $2,000. Many of the older residents in board and care homes are subsidized by state governments, which add an amount to the Supplemental Security Income (SSI) that many residents use to pay for their accommodations and care. Most board and care homes are very modest in nature and require that residents share rooms. Though theoretically licensed and regulated by state governments, many of the smaller board and care homes remain unlicensed and enforcement is lax.

Congregate housing. Congregate housing refers to a wide range of multiunit living arrangements for older persons in both the private and the public sector. Older persons who live in this type of housing generally have their own apartments that include kitchens or kitchenettes and private bathrooms. Most of this housing has dining facilities and provides residents with at least one meal a day (frequently included in the rent). There are common spaces for social and educational activities, and in some cases transportation is provided. Congregate housing generally does not offer personal care services or health services. It is therefore not licensed under regulations that apply to residential care facilities or assisted living.

In line with the physical characteristics of the buildings and the limited provision of services, congregate housing attracts older persons who can live independently. It especially appeals to older persons who no longer want the responsibility of home maintenance or meal preparation, and positively anticipate making new friends and engaging in activities. Problems may arise later, however, as residents age in place and need more assistance than the facility provides.

Residents, who are usually sixty-five to eighty-five years old and widowed, typically live in a one- or two-bedroom unit in a facility with fifty to four hundred units. Units are rented monthly, for from $700 to $2500 a month, and paid for out of pocket. Nonprofit facilities are usually subsidized by government agencies or religious organizations, and therefore are less costly than for-profit facilities. Most Section 202 housing falls in the congregate housing category.

Assisted living. During the 1990s assisted living (AL) was the fastest growing segment of the senior housing market. Assisted living is a housing option that involves the delivery of professionally managed supportive services and, depending on state regulations, nursing services, in a group setting that is residential in character and appearance. It has the capacity to meet scheduled and unscheduled needs for assistance and is managed in ways that aim to maximize the physical and psychological independence of residents (see Table 1). AL is intended to accommodate physically and mentally frail elderly people without imposing a heavily regulated, institutional environment on them (Kane and Wilson).

The typical AL resident is female, age eighty-three or over, and widowed. In 1999 there were approximately thirty thousand to forty thousand facilities in the United States housing approximately one million individuals (ALFA). Costs vary from $383 per month to $6,150, with an average of $2,206 in 1998 (ALFA). Most residents must pay out of pocket for their care (see Figure 1). An individual's health insurance program or long-term care insurance policy is another possible source of funding. As of 2000, there are few governmental funding sources for ALs. Some states and local governments use Supplemental Security Income along with Medicaid to pay for low-income residents, or the Medicaid waiver Table 1 Services Generally Provided by Assisted Living Facilities SOURCE: Author program to reimburse for services. In addition, the Department of Veterans Affairs and the Department of Housing and Urban Development, and the Independent Agencies Appropriations Act of 2000 allow HUD vouchers to be used in certain AL complexes and provide grants to convert some Section 202 buildings into AL facilities.

Varying definitions of ALs around the nation have produced difficulties with regulation and accreditation. With little leadership from the federal government, states have established regulations on their own. By the beginning of 1999, 25 states had regulations in place, with three more states pending (ALFA, 1999). In 2000, both the Rehabilitation Accreditation Commission (CARF) and the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) developed an accreditation process to promote quality care and outcomes for AL residents.