A Guide to Independent Living

William Chandler
Certified Aging-In-Place Professional

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What is Aging-In-Place?

Quite simply, Aging-In-Place defines a people’s ability to remain in their home to the fullest extent possible by planning and implementing modifications to their homes which promote safety, mobility, security and functional use. Too often, seniors and persons with disabilities or impairments are placed in group homes or assisted living quarters unnecessarily. A recent study predicted over 70 million Americans will require “assisted living” by 2020. Many seniors are placed in assisted living quarters by their children who may not fully understand the options available to make the home secure, functional and safe for their loved one.

Considerations for Aging-In-Place

Your ability to remain in your home depends greatly upon your current and future care needs. You may need to consult with your physician to discuss any medical condition and how it may relate to your future care needs and your ability to manage your daily activities. Do you need daily assistance from a health professional or caregiver? How many hours daily do you require assistance? Are you lonely or get depressed when alone? Can you call for help? Do you have physical impairments which prevent bathing or toileting without assistance? Can you manage your impairment with design changes to your home such as a walk-in shower, grab bars, clearance for a scooter or wheelchair, lower countertop heights, ramps instead of stairs or auto-on lighting? If you have greater mobility in your home, would you prefer to remain at home?
As we age, health issues can become chronic and require daily medical treatment and management. Episodic issues require short-term enhanced care such as physical therapy following hip replacement. Progressive conditions may necessitate the need to plan for enhanced care at a later date. Aging-In-Place is about promoting a person’s choice to maintain an independent lifestyle by utilizing assistive technologies, economic use of resources and managed service providers to allow the seniors to remain in their home of choice to the greatest extent possible.

How can an Aging-In-Place Professional benefit you?

A Certified Aging-In-Place Professional is trained to evaluate your senior lifestyle needs and facilitate effective use of your resources. They coordinate relationships with leading providers of assisted living technology, home designers and contractors who specialize in senior living and community resources. Without competent decision making, family members will struggle trying to navigate and organize providers, services, assess needs and estimate costs. Though all these services may be available, they are not organized into an easily managed, systematic whole. Programs and services are managed through different agencies, each with its own criteria, and they are not cohesive. Aging-In-Place means just that – you plan to remain in your home and make your home, external care providers, and technology work for you. Service needs change so the service package needs to change according to the need. Without a plan, it will be a challenge to employ different service providers, coordinate care, maintain the home and manage your health. Dedicated programs and providers are not designed to coordinate easy management by the individual or family. Due to this lack of coordination, generally the senior is forced into an “overcare” or “undercare” situation:

Overcare – housing and care is connected to facilities such as a Medicaid sponsored nursing home. If you have hip replacement surgery, you get assigned 27 days of in-facility care. One program fits all.

Undercare – You are not eligible for the care you may actually need via Medicare or private insurance. Therefore you fall through the crack and must figure out how to obtain the assistance you actually need. There is no single designated and funded service coordinator.

Aging-In-Place works when the demand (senior needs) is met by supply (functioning resources and providers) in a seamless relationship. People live in the home of choice equipped with the tools and design which support independence. Care, meals, supplies, transportation and social interaction are managed easily. I refer to this as a “Care Hub”. The home is the core of the hub and everything needed is mapped within a care circle. Everything which is available within a nursing home or assisted living home is equally available to the seniors within their care hub. Instead of the services being within the confines of a single building, they are spread over the local community.

Evaluate Your Home

Most homes were not designed to accommodate the needs of an aging resident. Most home designs, even today, are based on design basics implemented in the years following WWII and were based on the need of a growing family. Designers have labeled this as “Peter Pan” housing – housing for people who never grow old. The USA lags most of the developed world in this regard. Homes in much of Europe, the Far East and the Middle East are designed to add floors above to accommodate generational needs. Some of this “forward thinking” is the result of economic factors rather than their consideration of aging-in-place due to significant land cost (they simply have to put more people in less space due to geographic boundaries). Nonetheless, they anticipated the need to house up to three generations on the same lot. Grandparents live on the first floor, parents on the second and adult children may live on the third or even fourth floor. As each group ages, they matriculate down. We do not have this, even in our urban cores, as townhomes or row homes were not designed for multi-family with a kitchen on each floor. With the expected increase in the over 65 age group over the next decade, homes built as recent as 2000 will likely have a senior occupant at some point. To function and promote aging-in-place these homes will require modifications to support the occupant.
How does the home work for you now? How do you think it will work in five years or ten years? Do you like your neighborhood? Is any form of public transportation available? Are your hallways or doorways wide enough for a walker or scooter? If you live in a two story home, could you live on the first floor only? If you have front or side entry steps, do you have enough room for a ramp if needed? Is your bathroom large enough to accommodate a walker or scooter?

A Certified Aging-In-Place Professional can evaluate your home, assess your expected needs, and provide an estimate of costs to address modifications to the home.

Considerations in Modifying a Home

The two biggest considerations are condition and design. The home should be energy efficient, structurally and mechanically sound, and promote safety. The design needs to be aesthetically pleasing and accommodating to the occupant.
Typically, the single biggest obstacle to senior living is steps or lot elevation. If your home is perched on the side of a steep hill the front entry most likely has several steps. A side entrance through the garage or carport may provide the best entry/exit choice. However, emergency exit must also be considered through the front, rear or side of the home.
Interior stairs can be a problem if the laundry is located in the basement or needed rooms such as the bathroom are located upstairs. Stair glides are available for just about any stairwell configuration. Depending upon the total height and number of turns (landings), stair glides range from a low of $3,000.00 to $18,000 or even higher. This cost should be compared to options such as relocating laundry facilities (carrying a basket of laundry in your lap on a stair glide is not an exciting prospect), making the first floor an inclusive living quarter or considering hiring in-home assistance. A Certified Aging-In-Place Professional can guide you through all options and help you plan accordingly.

Evaluate Outside Connections

There are many providers of assistive technologies to complement aging-in-place. Some examples of assistive technologies are Personal Emergency Response System (PERS), pill dispenser monitors, security systems which also provide medication monitoring, medical alert and telephonic or email check-in service. Home health aide services provide an array of services from visitation to nursing assistance. Adult Day Services provide an outlet for socializing or health supervision. Meals On Wheels deliver meals to your home on a daily or as needed basis. Most counties provide transportation services for needy seniors. Most churches are available to assist senior members with transportation to church or church events, counseling, and other assistance. Most communities have some form of a Senior Center or a Senior Outreach Program and most do a good job of providing information concerning you or your community as well as assistance and a social network.

Develop a Care Plan

First determine your physical assistance needs and then list all the resources available to assist you. Do you need assistance in performing daily routines such as bathing, cooking, laundry or housekeeping? If so, think of available options and resources. Do you have a family member close by who can assist? Do you have insurance or funds to cover the cost of a home health aide? If you had a curbless shower which does not require lifting your legs, would you be able to bath unattended? If you are in a wheelchair, could you prepare meals if the countertops were lower in height or if you had a wheelchair which had a pneumatic lift? Would a front load washer/dryer allow you to do laundry? If you need assistance in managing medications, do you think an automated dispenser or a subscription to a medical monitoring plan would work for you? Many security companies such as ADT offer complete medical alert/monitoring plans under $50.00 per month which include wireless alert pendants should you become incapacitated and which will call you daily to discuss your medications. This is a very effective tool for aging-in-place and can provide peace of mind to your extended family. If you plan to rely upon a family member or friend, make sure you have a back-up in case they become unavailable due to illness, emergencies or other reasons. Be honest about their availability and long term ability to assist you. Remember, aging-in-place is about independence and not about dependence.

Smart home technology is revolutionizing our ability to age-in-place. Computer based controls can operate window blinds, control the furnace or A/C, control door locks, security and lighting. All can be monitored, controlled or operated centrally within the home or remotely by service. Cameras can be installed to allow visitors entry into the home by remote control. Emergency assistance can be summoned at the push of a button or by a sensor. Programmable thermostats can alert caregivers when extreme temperature variations occur which may signal a faulty heating unit. Sensors can alert caregivers if the occupant is changing lifestyle patterns such as not entering the bathroom in a set period of time or if the television has not been turned off.

Develop a Budget

An assisted living condominium with amenities such as pool, spa, recreation rooms, recreation staff, nursing staff, doctor on call, chartered bus trips, fine dining and all the frills can cost $10,000 to $20,000 per month, or more. If you can afford this level of retirement, sell the house and go have a ball. Obviously, the majority of retirees cannot afford this level of living. A medium level retirement home with nursing staff will cost between $4,000 to $7,000.00 per month. Medicare will only assist with short term nursing home care. Medicaid will provide long term care in state-run facilities only and you can only qualify if you do not have any assets. Most seniors deplete all their savings and assets within six months of enrolling in an assisted living facility and are then forced into a Medicaid funded facility. This is a depressing transition for most.

Medicare will cover some home health care services but only if the individual has a need for skilled care that meets Medicare criteria for reimbursement. A typical situation would be physical therapy for a short period following surgery.

Medicaid covers long term care services for certain individuals with very limited income and assets.

Long term care insurance is intended to provide benefits for long-term care such as home care, assisted living and nursing home. This insurance can not be purchased if you are in need of long term care. This insurance can be expensive depending upon the level of benefits you desire and the amount of time you “own” the policy.

The National Council on Aging (NCOA) developed a website which helps you determine benefits and services available in your area and can be found at www.BenefitsCheckup.org.

Primarily, there are six choices available in choosing a care setting:
1. An assisted living facility – A residential housing and care facility which combines independent apartments, private or shared rooms and typically provides health monitoring, dining, wellness programs, social activities and medication management. Typical cost: $4,000 to $10,000 per month.
2. A nursing home – A residential housing unit which provides room, meals, nursing, rehabilitative care, medical staff and supervision. Typical cost: $7,000 per month for a private facility.
3. Elder co-housing – Some residential communities have been developed exclusively for seniors and provide apartments, townhomes and small, zero lot line homes designed for mobility and social interaction. Most of these communities are gated for security and a Homeowners Association provides for all groundskeeping. Most developments include an activity center, community pool and other adjacent activities such as golf, boating, tennis, and parks to name a few. Typically, these homes sell for around $300 per square foot and HOA fees of about $400 per month.
4. Manufactured home communities – There are many over 55 communities which offer a senior lifestyle with manufactured homes. These communities vary in price and amenities offered. A typical home sells in the range of $125 per square foot with a monthly lot rent of $300 to $500 per month. Common maintenance and lighting, garbage and sometimes water is generally included in the lot rent.
5. Aging-In-Place or staying in your home – For those who enjoy their community and social network, want to be close to family or friends or church, and are generally not interested in extreme downsizing or an active, open social setting. Also, if your home is fully owned, many seniors can live comfortably on social security, pension benefits and government sponsored health care.
6. Living with family members – Some find it necessary to move in with their children or relatives or increasingly, children are moving in with parents.

Some General Statistics

The number of seniors over the age of 75 who are living in nursing homes is declining. Many factors such as assistive technologies, medications, senior support groups and professionals play important roles in this decline.
As of 2006, 13% of our population are 65 and older. That is about 42 million people. Of the 13%, about 4% live in nursing homes or 1.8 million. About 625,000 live in assisted living facilities. The over 65 population is expected to reach 70 million by 2020 due to post WWII baby boomers.
There are 1,813,665 beds available in nursing homes. There are 16,995 nursing home facilities for an average population of 107 people per facility. 66% of the facilities are for profit, 27% are run by non-profits and 7% are government owned/funded. Of the nursing home population, 7.4% are over 75 and 16% are over 85 years old. If we maintain the residency rate of 4% , we will need over one million new beds or 9,346 new nursing home facilities over the next nine years to meet the expected demand for nursing home care due to the aging of the baby boomers.
The average cost for a private nursing home is $7,000 per month or $230 per day. Medicaid spends an average of $2585 per month or $85 per day to support its facilities. The cost for a non-medicaid facility is expected to rise to over $11,000 per month or $367 per day by 2020.
Let’s take another look at these statistics:
In the next nine years, we will need an additional 9,346 nursing home facilities or 1,038 new facilities per year. The average time to plan, permit and construct a facility is 2.5 years. 654 of these facilities would be opened by the government (7% of all facilities). Allowing for the planning/construction cycle, roughly 3,115 need to open in 2014; 3,115 in 2017; and 3,115 by 2020 to meet the expected demand. If the market does not meet the demand (an increase of 54%), demand will exceed supply and costs will most likely escalate considerably. A likely scenario, is the market will supply about 40% of the needed increase and some 600,000 seniors will struggle to find placement. Many will turn to charitable organizations, most of which are already overwhelmed and underfunded. A good parallel to this prediction is the shortage of public or assisted housing. Currently, over 50% of working adults do not pay income tax as they qualify for low income tax breaks. The US Treasury is in deep debt and there is no funding in the pipeline to support the needed increase in funding for our baby boomers. If your plan is to simply give away your assets, qualify for Medicaid nursing home care and move into a government funded facility, you may not find a bed.

Look Into The Crystal Ball

None of us can foresee the future but we can assess our situation and make an educated prediction. The first priority is to assess our known medical condition. Consult your physician and open a frank discussion about your ability to live independently in your senior years. Consult your accountant or financial advisor and analyze your financial options. Weigh your options, develop Plan A (desired) and Plan B (fall back) and make peace with your decisions. Implement your plan(s). The rest, as they say, is in God’s hands.

If your desire is to live gracefully in your home, consult a Certified Aging-In-Place Professional who will guide you in making your home work for you. Regardless of your decision, please start planning now.

Telephone Website
US Administration on Aging 800-677-1116 www.eldercare.gov
Family Caregiver Alliance 800-445-8106 www.caregiver.org
Area Agencies on Aging www.n4a.org
AbleData 800-227-0216 www.abledata.com
Disability Resources www.disabilityresources.org
Disability.gov www.disability.gov
National Assoc of Certified Home Inspectors www.InterNachi.org
The Building Inspector www.TheBuildingInspector.net
ADT Home Health Security Services Kshotwell@adt.com

Code of Conduct
InterNachi Certified Aging-In-Place Professional (ICAPP)
1. Every professional will encourage clients to discuss aging-in-place issues with family members or trusted advisors before making any decisions to modify their home or purchase any products.
2. Every professional will provide their consultation with the utmost integrity and honesty.
3. Every professional will provide their best effort to resolve any conflict or address any concern relating to their service.
4. Every professional who endorses any product, service or third party provider will ensure those providers operate in a manner consistent to this code of conduct.
5. Every professional will protect the client’s privacy and not disclose any information to any external parties.
6. Every professional will strive to make recommendations consistent with the client’s best interest.
7. Every professional will maintain competence in the industry.

Author's Bio: 

William Chandler is a Certified Aging-In-Place Professional. He has over 35 years of building construction, building inspection and indoor air quality experience. He is available for consultation.