fl W W M“ l 1 I ll! * ”III I 'l h THS' IIIHIIH’I HOUSING 0913999390919£19599:AN-i'. - w . - 9199mm STATE UNIVERQITY ' GEERTRUIBA HEU‘E ~*',;:9 1999_; " ‘ INFORMATION HANBOUT; FaRFANIL-IEs; : - ‘ ' " ‘ ' A Schoiari y Fméect fer tne Segrfie {if M S N,:"5j'j'-,"}_ft?_7 ‘i‘f-‘J i" ‘r ,- :- LIBRARY Michigan State University PLACE IN RETURN BOX to remove this checkout from your record. TO AVOID FINES return on or before date due. MAY BE RECALLED with earlier due date if requested. DATE DUE DATE DUE DATE DUE 6/01 cJCIRCIDateDuepasop. 15 HOUSING OPTIONS FOR THE ELDERLY: AN INFORMATION HANDOUT FOR FAMILIES BY Geertruida Heule A SCHOLARLY PROJECT Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE IN NURSING College of Nursing 1999 ABSTRACT HOUSING OPTIONS FOR THE ELDERLY: AN INFORMATION HANDOUT FOR FAMILIES BY Geertruida Heule More Americans are now living beyond the age of 65 compared to the beginning of the century, yet the percentage of older adults living in nursing homes has remained relatively constant. Most older adults (96%) choose to live in housing situations other than the traditional nursing home setting. There is a great need to provide guidance to individuals in selecting alternative living arrangements, regardless of their current type of housing, as people are not familiar with the many options available. The Advanced Practice Nurse is in a key position to teach older adults and their families about housing options appropriate for them. This project used Lawton and Nahemow's (1973) model of housing press to construct a teaching tool which the Advanced Practice Nurse can utilize with older individuals. The tool will help older adults and their families plan for current and future housing needs. It may also help families choose an alternative housing option for an elderly relative when the current living situation is no longer suitable. DEDICATION To my parents, Carl and Paula, for their unfailing love and support. iii ACKNOWLEDGMENTS I wish to thank the members of my scholarly project committee: Dr. Laura Struble, chair, for her guidance, support, patience, and encouragement, and for serving as a role model in the art and science of gerontological nursing. Dr. George Allen, and Linda Keilman, MSN, for their time, input, and assistance. I also want to thank my daughters: Theresa, Paula, and Maryann. You bring love and joy into my life, and provide me motivation to keep reaching for my goals. iv TABLE OF CONTENTS Introduction . . . . . . . . . . . . . . . . . . Statement of Problem . . . . . . . . . . . . . . Purpose Conceptual Framework and Definitions . . . . Conceptual Framework . . . . . . . . . . Adapted Model . . . . . . . . . . . . . Definitions . . . . . . . . . . . . . . Literature Review . . . . . . . . . . . . . . . . Functional Ability . . . . . . . . . . . . . Activities of Daily Living . . . . . . . . . Instrumental Activities of Daily Living . . Housing Options . . . . . . . . . . . . . . Single Family Dwelling . . . . . . . . Apartments and Condominiums . . . . . . Assisted Living Facilities . . . . . . Skilled Nursing Facilities . . . . Continuing Care Retirement Communities Project Development . . . . . . . . . . . . . . . Evaluation of Information Handout . . . . . . . . Implications for Advanced Nursing Practice . . . Consultants . . . . . . . . . . . . . . . . Educator . . . . . . . . . . . . . . . . . . Collaborator . . . . . . . . . . . . . . . . Implications for Nursing Education . . . . . . . Suggestions for Research . . . . . . . . . . . . Summary LIST OF REFERENCES . . . . . . . . . . . . . . . APPENDIX A . . . . . . . . . . . . . . . . . . . 12 12 16 16 18 19 20 20 24 25 26 26 28 28 29 30 3O 31 32 32 33 34 38 LIST OF FIGURES Figure 1: Press-Competence Model (Lawton & Nahemow, 1973) . . . . . Figure 2: Adapted Press-Competence Model vi INTRODUCTION In the later part of the 20th century, people live longer, but not necessarily better. In fact, sixty-nine percent of people over the age of 65 live with at least one chronic illness, and nearly half of people 85 years and older require some assistance with at least one activity of daily living (ADL) (Barton, 1997). As people live with gradual physical decline, they need an environment which is easier to navigate, and provides support. Unfortunately, while there are many newer housing options available to the elderly, such as senior apartments and assisted living facilities, compared to the traditional nursing home, the differences between such options, and the advantages and disadvantages of each, are often not clear to the older adult. It is not uncommon for people to postpone making changes in their living environment until an emergency, such as a hip fracture, forces them into a different housing arrangement. Such placements are frequently very stressful for all involved and may cause depressive symptoms and decline in the health of the older adult (Blank, 1988) who had to make the choice quickly, or was too ill to be involved in the decision. Statement of the Problem Four percent of people age 65 and over are living in a skilled nursing facility (SNF), popularly referred to as a “nursing home” (Edmonson, 1997). Therefore, 96% of individuals aged 65 and older live in the community. The overwhelming majority of elders in the United States prefer to stay in their own home as long as possible (Carlin, 1991; Golant, 1992; Pastelan, 1995; Riekse & Holstege, 1996). Considering the cost of institutional care, it seems economically favorable to have older adults remain in their own home (Pastelan, 1995), and out of a nursing home. But because of the increased occurrence of chronic health problems and disability as people age (Fleming, Evans, Weber, & Chutka, 1995), community dwelling older adults may find themselves in housing situations which do not offer the environmental support necessary for safety and well being. Older adults in relatively good health, rarely anticipate physical decline when making housing decisions, (Carlin, 1991; Pastelan, 1995). Even if elderly people plan ahead, they face many obstacles: the options in housing for the elderly are numerous (Staab & Hodges, 1996). The terms to describe services available are vague, confusing and sometimes misleading. These terms are based on marketing principles rather than professional healthcare information. Financial resources vary greatly among older adults, limiting options for some. And finally, people face an increasing aversion to change as they age (Hasselkus, 1978). Thus, while older adults would do well to plan their future housing situation with careful deliberation, while mentally and physically able to do so, it is a task many postpone. A lack of such planning might result in emergency housing changes in case of serious illness, and such a change may not at all be what the older adult wanted, resulting in depression and health decline (Hasselkus, 1978). Fortunately, if housing changes are planned in advance, especially if the older person perceives to have some control over the situation, relocation stress is kept to a minimum (Armer, 1993, 1996). The Advanced Practice Nurse (APN) in primary care is in a position to both assess the older person's need for a change in living environment, and discuss some recommendation (Staab & Hodges, 1996). It would benefit both the APN and the client if information regarding housing for the elderly, and how to make housing choices, were available in an easy to use format. Purpose The purpose of this scholarly project was to construct an information handout the APN can use to teach older adults and their families what facilities call themselves, and how to make an informed consumer choice. In addition, well elderly will be able to use the handout to plan their future housing needs. The goal of this preplanning is to prevent emergency placement, as well as inappropriate housing situations. This scholarly project is meant to give an overview of housing options only, and not of the economics involved with these options, since the financial abilities of elders vary greatly, as well as the cost of each option, depending on locality, and quality of care. Therefore, formulas and recommendations regarding the financial aspect of each option will be omitted except in the broadest sense. Conceptual Framework and Definitions W The conceptual framework for this project is Lawton and Nahemow's model of housing press. Lawton and Nahemow (1973) developed a model to clarify the interaction between a person's functional ability and their environment. The model is called the:“environmental press model” (Figure 1). It was based on the researchers Ecology of Aging Theory. The researchers proposed that a person's well-being is impacted by the demands of their environment, because person and environment are interdependent. Lawton and Nahemow also theorized that a person's environment should match closely that person's ability. The model is a visualization of the relationship between a persons ability and the demands of the physical structure in which they find themselves. The model shows how this relationship changes as ability decreases. The model has the following components, which will be defined and discussed below: person, environment and interaction. Person. The Ecology of Aging Theory and the “environmental pressWImodel based on it, were formulated to guide planning of housing for the elderly. They can be applied to any age group, but for this scholarly project will be applied to people over the age of 65. Press-competence model. Mgh COMPETENCE low Figure 1. Press-Competence Model (Lawton & Nahemow, 1973). Lawton and Nahemow (1973) viewed aging as a dynamic process in time and space. This process is one of continual adaptation. The adaptation can be from either the person or the environment. Lawton and Nahemow proposed that age related changes, such as sensory and muscular-skeletal changes, impact a person's reaction to their environment. The researchers stated that older people adapt to changes in both physical and mental ways: increased caution, amplification of sensory input (such as standing closer to people in conversation) and increased planning. So, older people can adapt to their changing abilities. They can change either something about themselves, or change their environment. Lawton and Nahemow (1973) also noted that older people are able to make positive changes and adaptations in their living arrangements, if enough information and preplanning is provided. Lawton and Nahemow (1973) named the degree to which a person can adapt.“individual competence”. Individual competence is a fluid concept, encompassing cognitive ability, psychological adjustment, and physical health. Competency varies over time, is specific to the individual, and encompasses both internal and external personal characteristics. When referring to internal competency, competency is not used in the legal meaning of the term. A person can exhibit low competency as defined by this model, while legally fully competent. An example would be someone with a spinal cord injury, who needs a specialized environment to function, but is still legally fully competent. For purposes of this scholarly project, the term competency will be used as Lawton and Nahemow defined it. External competence refers to the level of functional ability a person possesses. This ability is evidenced by how well they function in the physical environment. For example, living in a freestanding two story house in the country may require the physical ability to climb stairs, walk to a mailbox, put in storm windows. In addition, the person needs to have the mental ability to find ways to compensate, if they are not able to personally perform physical tasks. In other words, this housing situation requires a high level of competence. On the other hand, living in a nursing home requires very little competence, since staff are available to help with virtually all aspects of maintaining the physical environment as well as tending to older adults physical and cognitive needs. In the model competence refers to the combined result of internal and external ability to function in the physical environment. Enyirgnment. The physical environment is broadly defined in the Ecology of Aging Theory (Lawton and Nahemow, 1973). It includes both physical and social surroundings as well as societal structures. In the model, environment refers mostly, but not exclusively, to physical structures. Interestingly, the aesthetic aspects of the environment do not seem to influence a person's perception of its .7 desirability to a great degree. Instead, environments which facilitate competent behaviors are rated as higher in quality than those that don't. Thus, an older person may evaluate positively an environment seen as very negative by others, because familiarity with, and orientation to the environment provide a competence that would be lost in a more aesthetic, yet unfamiliar environment. Lawton (1988) also states “the better one knows one's own home, yard and neighborhood, the easier it is to devote time and energy to other activities? (p. 37). Lawton (1988) proposed that stimulation, maintenance and support are elements a person requires from the environment. Lawton (1988) defines maintenance as routine behaviors: ...everyday life is composed of a series of repetitive, well-practiced behaviors in relation to the environment ...these behaviors are routine, such as setting an alarm clock, knowing which bus to take to the store, and so on. Because they are routine, we do not have to spend much energy thinking about them, and can use our energy for other things (p.36). In contrast to Lawton's concept of maintenance/support is stimulation (Lawton, 1988). Stimulation from the environment happens when something non-routine happens, which requires a response from the inhabitant. For example, a fuse blows, rendering an appliance dysfunctional till the problem is solved. According to Lawton (1988), “the person in a stimulating environmental context is thus called upon to respond either emotionally, cognitively, or behaviorally, often in unfamiliar ways. Activity and often autonomy thus 8 characterize the person in a stimulating environment”. Lawton describes a supportive state of the environment as one which reduces demand for response, and affording relaxation. Lawton describes support as "an extended process which is characterized on the one hand by relative lack of variation and on the other by the easy availability of the resources necessary to maintain life”. In the model, the researchers focus on the aspect of “pressdian environment causes its inhabitants. Environmental press is defined as those forces in one's environment which evoke a response (Lawton & Nahemow, 1973) or degree of physical and mental ability the environment demands of its inhabitant. Press is neutral, since it is defined by the individual rather than intrinsic to the environment. By changing the environment, one can change the level of press. This change could be in the physical surrounding, such as installing grabbers in a bathroom, or in the societal environment of a person, such as providing help with bathing. Press is the combined result of the amount of both support and stimulation an environment provides. Interaction. Called adaptation by Lawton and Nahemow, interaction is defined as the result of the individual- environment transaction (Lawton & Nahemow, 1973). People react to their environment in either a positive or negative way. The evaluation of the reaction as positive or negative is made by both the individual and the people around them. 9 For example, while a dementia patient may view publicly undressing as an appropriate reaction to feeling too warm, the caregiver and society may view this action as inappropriate. In the model, Lawton and Nahemow focus on the extent to which a person's adaptation is positive or negative, from the person's point of view. Lawton and Nahemow (1973) propose there is a range of reactive behavior which is a positive adaptation of a person to an environment. People fall on the high or low end of adaptive behavior depending on their personal characteristics of the moment. “Positive affect, a feeling of comfort within one's environment, occurs near adaptation level. This is true for the region in which the environmental demands are both slightly lower and slightly higher than adaptation level". Therefore, zone of maximum comfort does not overlap zone of maximum performance. Lawton and Nahemow (1973) propose that positive behavior and comfort fall somewhere in the middle of the range of comfort and performance: a person needs stimulation as well as support. The model (Lawton & Nahemow, 1973) shows how people with a high level of competence have a large area of positive behavior and adaptation, but even when competence is low, there is still a range. Thus, improvement in comfort may be possible by optimizing the environment. There is a much greater possibility of negative outcomes associated with low competence, than with high levels. For 10 people with low competence positive outcomes are possible only with low environmental press. For these people, small changes in level of environmental press can cause gross changes in outcome, especially negative. It should not be overlooked, however, that there is still a negative outcome with too low a level of press, even at low competency. Older people who are under stimulated, or given too much support, are not at optimum function either. Giving too much help is as detrimental as giving too little (Golant, 1991). The Press-Competence model emphasizes the uniqueness of individuals, the way this person interact with his/her environment. For example, a physically able person with reduced mental competence (such as a person with Alzheimer's disease), may experience too much environmental press in an environment in which a mentally competent but physically disabled person (such as a person confined to a wheelchair), can adequately function. Applied to housing choices for older adults, this model can help to find the optimum balance between ”environmental pressfrand the functional ability of the older adult. As people age, they may need a lower level of"environmental pressrlbecause of decreasing abilities, but not so low as to inadvertently impair the older adult's health by providing too little stimulation. 11 Adapted_MQdel To adapt Lawton and Nahemow's (1973) model to housing choices for the elderly two concepts will be applied (see Figure 2). The concept of “environmental press” will be defined as “housing option". The concept of “competence” will be defined as.“functional ability of a person”. ‘The result of the interaction between competence and housing choice will be the same as in the original model: the person will be either comfortable and at performance potential, or not. I E' 'l' Person will be defined as an adult over 65 years old. This adult can have any kind of health status (the model can be applied regardless of health), and live in any kind of housing. This person can be the user of the housing guide, or he/she can be the older relative of the reader, or a proxy-decision maker. Competence will be defined as functional ability, which is measured by the ability to perform the Activities of Daily Living (ADLs) as well as Instrumental Activities of Daily Living (IADLs). As in Lawton and Nahemow's (1973) model, competence will be the combined result of mental and physical ability, and will not reflect the legal meaning of the term. Instead, families will determine if the older relative can do ADLs and IADLS independently, with some help, or is completely dependent. 12 Press-competence model. High Competence Functional Ability Low competence strong W80 k Support Offered by Housing . . Skilled Nursing Facrlrty Single Family Dwelling Figure 2. Press-Competence Model (Adapted from Lawton & Nahemow, 1973). By G.C. Heule. 13 Functional ability is chosen because it is the most observable part of competence, and because Lawton used functional ability to-develop the model of environmental press (Lawton & Brody, 1970). ADLS and IADLs are chosen because scales to measure them can be applied to people regardless of their cognitive function. Also, they are relatively easy to discuss with families, since no special healthcare skills are needed to understand them. Finally, by focusing on the abilities of the older adult, families can ensure that considered housing options meet the older relatives needs. Functional ability should be periodically reassessed (Lawton & Brody, 1970). Families should be alerted to reassess when the older adult has a change in health status, and also because people's abilities change as they age. Additionally, people's housing changes: if the bus route is discontinued, or the pharmacy stops home delivery, IADLs may be impacted. Older people tend to minimize their housing problems (Filion, Wister & Coblentz, 1992), or may feel they should be able to cope with a poor housing situation (Wister & Burch, 1989) so families should be alert to potential problems. Housing_gptign is the second concept used to determine housing choice. Housing option will be defined as the place were the older person lives. It will include both the physical structure and the services inherent in the housing 14 choice. Only housing options found in the United States will be considered. Interactign in this scholarly project will be the result of housing choice. This result can be either negative or positive, depending on whether the choice falls in the area were competence and press are balanced. There is a fine balance between keeping the older adult safe and overprotecting the person. Safety can not be the goal in this model, nor should it be (Cookman, 1996). Rather, safety should be the result of the environment as a supportive resource. If safety would be considered alone, one would want to put every older adult in a supervised environment, or at least in one with more support than the older person may yet need. The model shows this would cause too low a level of press for many. However, if one finds housing which balances the older adult's functional ability with level of press, safety will be a positive byproduct. If housing is not optimal, at the very least the model will help clarify what the problem areas are, and families can decide what level of risk they are comfortable with. If the match between the older adult's functional ability and the level of support of the person's housing is one of optimal environmental press the result will be a safe and satisfying housing situation (Lawton & Nahemow, 1973). This housing situation is not static: if the older adult's abilities change, the housing will have to change also. Conversely, if the housing changes (death of a 15 caregiver, neighborhood deterioration, etc.) the housing choice may have to change (Gilderbloom & Rosentraub, 1996, Lawton, Nahemow & Tsong-Min-Yeh, 1980). Therefore this model needs to be re-applied each time a change in the variables occurs. Literature Review As stated, the concepts used in Lawton and Nehamow's (1973) model are person and environment, and the interaction between the two. The concepts reviewed are functional ability, housing options, and optimal housing choice. A literature review of each concept will be discussed. E l' J El'J'l To make an appropriate housing choice, one needs to know the level of functioning of the older adult. Before any housing choices or changes are made, an older adult should be seen by a competent healthcare professional, skilled in geriatric assessment. This professional can make recommendations regarding medication adjustment, physical therapy and other interventions to help the older adult reach optimum level of functioning (Ham & Sloane, 1997). Once the older adult has reached optimal level of health, a functional assessment can be made. This needs to be done separately, because functional impairment cannot be predicted by number and severity of medical diagnoses (Fleming, Evans, Weber & Chutka, 1995). Lawton realized early on that use of the model of housing press necessitated a measuring tool of functional ability; "The inclusion of 16 functional assessment pulls together the various diagnoses to the focal point of appropriate planning. ...A major aspect of treatment is the matching of the particular facility or service to the individual? (Lawton & Brody, 1969, p. 184). The researchers developed an early assessment tool which they called the physical self maintenance scale. It gave an indication of how independent a person is with ADLs, namely toileting, feeding, dressing, ambulation and bathing. Lawton and Brody (1969) also developed a tool for measuring Instrumental Activities of Daily Living (IADLs) which addresses people's ability to shop, prepare food, use the telephone, do housekeeping, take medication, and handle their finances. The scales were further refined by later researchers. The scales have varying shortcomings, in that scoring is not consistent across ADLs, and terms are loosely defined (Morris & Morris, 1997). Therefore the scales may not be precise enough for clinical situations, such as in a geriatric rehabilitation facility (Morris & Morris, 1997). Since these scales are easy and quick to apply (Lawton & Brody, 1969; Morris & Morris, 1997) they can be used to discuss with families how to match an older adult's ability with a housing option. Families can use these scales to guide what should be asked when evaluating services needed by the older adult. 17 E l' 'l' E E .1 I' . The ADLs are basic self-care skills. They are bathing, dressing/grooming, toileting, transferring, continence and feeding (Lawton & Brody, 1969). They are written in this order, because this is generally the order in which they are lost (Ham & Sloane, 1997). For each activity, one has to ask if the person evaluated can do the activity independently, needs some help, or is completely dependent. Independence refers to the ability to do the activity without supervision or direction. Since dependence can therefore be due to either physical or mental deficits, older adults with cognitive impairments can be evaluated on this scale as well. It is important to address each ADL separately: dependence in activities which need to occur once or twice daily will require much less intensive assistance than others. In addition, these scales should be reapplied periodically, so any changes in ability can be observed, and increased support obtained (Ham & Sloane, 1997). For purposes of this project, a score on the scale is not needed. Rather, the consumer of housing services should ask the service provider specifically regarding availability of help with each ADL for which the older adult needs help. In the case of family caregivers, the scale can help to divide responsibilities, and indicate how much help is needed. Lawton noted that use of these scales can help “adult children towards a more realistic appraisal of their 18 own capacity to provide the care required by the parent" (Lawton & Brody, 1969). IADLs relate to the more complex activities an individual needs for independent living, and the maintenance of a household (Ham & Sloane, 1997). It includes the ability to use the telephone, shopping, food preparation, housekeeping, laundry, transportation, medication management and management of finances. “IADLs thus are learned skills, and the individual's ability to carry them out depends on the environment itself as well as the individual's characteristics? (Ham & Sloane, 1997, p.54). For example, an older adult who lives alone, has no deficiencies in ADLs, but is unable to shovel snow from the outside steps, will have IADL deficiencies in winter time. Family members using the IADL scale will have to rate the older adults ability to perform the activity under all circumstances, and try to identify which environmental changes (such as weather) require increased support. IADLs lend themselves less to application of the model of housing press, being not unique to either the person or the housing. They do, however, help to define the amount and type of help a relatively healthy older adult needs (one without ADL deficiencies). Therefore, IADLs are useful in decision making regarding adapting housing, especially single family dwellings. 19 H . : l' The housing options available to elders which will be reviewed in this scholarly project are: single family dwellings, apartments and condominiums, continuing care retirement communities (CCRCs), nursing homes, assisted living facilities, and group homes. Also discussed will be various supportive arrangements for elders in independent living settings, namely: adult day care, care management, home health care, community services, house sharing options and accessory apartments, or “granny flats”. Single_£amily_nwelling. Many elderly are very attached to the home they have lived in for many years (Carlin, 1991; Riekse & Holstege, 1996), and the overwhelming majority would like to remain in it as long as possible (Gonyea, Hudson & Seltzer, 1990; Riekse & Holstege, 1996). As long as the older adult is in good health and able to cope with the demands of living in a single family house this option may be a “good fit” according to Lawton's theory, and indeed provide the needed level of stimulation for the older adult (Lawton, 1988). For the older adult who remains in a single family house, there are several options to deal with the problems of increasing frailty, or, in Lawton's terms, to make the housing more supportive. These options are: adult day care, care management, home health care, community services, house sharing, and accessory apartments. Adult day care offers a sheltered, supervised environment for elderly with cognitive impairments, or 20 physical disabilities which prevent them from being home alone. This option is suitable when two adults live in the home, one of whom is disabled. It provides the care giving adult (frequently an elderly spouse) with time to work, rest and tend to household and social activities, while enabling both people to remain in the family home (Carlin, 1991). Places which offer adult day care sometimes also offer respite care, which the care giver can use in times of care giver illness, or during vacation times (Golant, 1992). Care management involves hiring a non-relative specialist, frequently a nurse or social worker, who is familiar with the community resources where the elder lives, and having this person coordinate the care the older adult needs, in the elder's home when possible (Golant, 1992). This option is offered by many home care agencies, and is a good choice for family members who are concerned about their older relative's well-being, but lack the time, or live too far away, to personally coordinate care. Ideally, the care manager will get to know the elder well, and be a trusted liaison between the client and the far away relatives. On the down side, the people hiring the care manager, if they live far away, have few ways to evaluate the managers performance (Golant, 1992). Home health care involves providing services such as skilled nursing care, personal care, homemaking services, shopping, physical therapy and other rehab therapies, social work services and the like, in the elders home. Some of 21 these services, if short-term, intermittent and ordered by a physician, are paid for by Medicare. All of these services can be bought privately. Buying even some of these services on a limited basis can often enable an aging person to stay in their own home longer than would otherwise be possible (Gonyea, Hudson & Seltzer, 1990). They can also increase a family caregiver's knowledge of how to give safe care (Lach, Reed et a1., 1995). However, cost effectiveness of Medicare funded home health care is called into question recently (Collins & Butler, 1997), and it is not sure which services will be covered in the future. Nevertheless, budgeting for the purchase of some home care services is a helpful option for many elders, and may give them time to find long term, more supportive housing when faced with increased housing press. Community services are those services provided in the community where the elder lives, and can be offered either at the elders home, such as home delivered meals, or away from the home, such as meals and social activities offered in a neighborhood senior center. Such services can provide a needed safe place for the elder to spend the daytime hours, an opportunity to make friends, have access to a visiting social worker or nurse, and improve nutrition (Collins, Butler, Gueldner & Palmer, 1997; Kauffman, 1995; Strumpf, 1994). On the other hand, frail elders may be ostracized in senior centers (Kauffman, 1995), and the array 22 of community services can be confusing and involve a lot of bureaucratic paperwork. House sharing involves renting out part of the elders house to either provide added income for the elder, or to provide reduced cost living to a tenant in return for services such as cleaning, yard maintenance, and shopping (Carlin, 1991). If carefully planned these arrangements can be very successful (Carlin, 1991; Schreter, 1985; Teaff, Lawton, Nahemow & Carson, 1978), and provide security and help for the elder. Some communities provide matching services to match elders with their tenants (Carlin, 1991). On the downside, the elder might have to give up some privacy, depending on the house sharing arrangement, and some of their living space. Finally, accessory apartments or “granny flats” enable some elderly to live in an independent dwelling. These “flatsW.are manufactured housing which is put adjacent to the house of a relative and removed when the elder dies, or moves into different living arrangements (Carlin, 1991). Alternately, they can be selfcontained, private living quarters within the dwelling of a family member (Riekse & Holstege, 1996). The close proximity enables the relative to provide care to the elder while each party still has their own, independent, living space. Zoning laws may not make this an option in many communities, and the presence of granny flats is frequently objected to by neighbors, who 23 complain this housing makes the neighborhood look less attractive (Golant, 1992). A Anaztments_and_ggndgmininms. When the house seems too big for an older person to comfortable maintain, the elder may want to move to smaller housing with less upkeep, such as an apartment, or condominium (Carlin, 1991). Not having to worry about outside maintenance (true for both apartments and condo's) and things such as plumbing and replacing worn carpet (true in apartments) will free the elders energy for more enjoyable pursuits. In addition, while the elder may miss familiar neighbors (Carlin, 1991) living in higher density dwelling gives the elder an opportunity to make new friends in close proximity. Also, elderly residents who live in the same apartment complex tend to help each other in times of need, such as short-time illness (Golant, 1992). And apartments marketed to “seniors" are usually located close to services such as bus lines, shopping centers, senior centers, and doctors offices. The disadvantage of such a move to smaller housing is the lack of flexibility it offers for care when the elder becomes frail. Since many of these dwellings are designed to be lived in by only one person, or a set of spouses, the elder will not be able to choose from some care options available to someone with larger living quarters. Also, other residents and the management of these facilities tend to become very impatient with frail residents, since their presence makes the facility appear like a “nursing home” rather than a place 24 for active older adults (Golant, 1992). So, when the resident becomes frail, they may have to relocate, often on short notice. Assisted_Liying_£acilitigs. These places may be the closest to “aging in place” for most Americans (Barton, 1997). They combine a place to live, which can range from a private apartment to a single room, with a variety of services. Such services may be meals, laundry, personal care, housekeeping, help with medication, transportation services, and simple nursing care. The main problem with referring someone to an assisted living facility is that since these are not government regulated the quality of care varies a lot (Binstock, 1996). Staff skill level may range from a skilled nurse on duty at all times, to unskilled high school age hresident aides” (De Young, Just & Van Dyk, 1994, 1995). Another problem with assisted living facilities is that residents can usually not stay if they become too frail for the staff to handle. It is therefore important to ask who decides when a resident has to move, and whether the facility has an affiliation with a SNF the resident can be placed in, so a frantic search for a nursing home bed can be avoided (Golant, 1991). A variation on the concept of'Tassisted living’ is the group home (Harkey & Traxler, 1982). These facilities usually consist of a small number of people and a caregiver, frequently a couple, who provide housekeeping services and 25 meals for the residents, as well as some supervision. Sometimes medication administration is offered as well. Skilled_untsing_flagilities. These residences are really institutions, rather than residences. However, they become the home of the people living in them, and many try to maintain a home like atmosphere with plants, patterned floor surface and color (Moloney, 1997; Blank, 1988). Skilled nursing facilities provide skilled nursing care, 24 hours a day, as well as social, recreational, nutritional, and medical services (Staab & Hodges, 1996). A well run nursing home can be a good option for a very frail or chronically ill elder, providing needed support, structure, and safety (Blank, 1988). Much information is available to enable the consumer to choose a good nursing home. Since the purpose of this scholarly project is to prevent inappropriate housing choices, the consumer will be directed to additional sources of information. Sources which are known to be reputable, are widely known, and are easily accessible, will be chosen (Carlin, 1991). Examples are the American Association of Retired Persons, and the National Institute of Aging (Staab & Hodges, 1996). W The main idea behind a CCRC is that once accepted the resident will receive care till death (Carlin, 1991). This housing option provides all the components of the previously discussed housing. It is the second most favored housing option of 26 most elderly (Gonyea, 1990). CCRC are often sponsored by religious organizations, and will bill Medicare and Medicaid directly for services provided to residents eligible for reimbursement. The caveat in this option is that while the resident will receive care, such care will not necessarily be provided in the room or apartment the resident first moves into when entering the community. Thus a ‘conveyer belt? approach is often used, with residents forced to move through the system as they become increasingly frail (Golant, 1992; Thompson, 1994). If handled with care, compassion, and knowledge of what will cause the least amount of stress to a resident, these changes of residence can be rather uneventful. If not, such changes can be very traumatic for the resident (Binstock, 1996; Feingold 8 Werby, 1990; Feldman, 1996; Grant, Skinkle & Lipps, 1992; Harkulich & Brugler, 1991). The various levels of care are in close proximity to each other, or even under the same roof. This system of bringing care to the resident, rather than moving the person to where the care is, can be built right into the design of the facility (Thompson, 1994). Meals, laundry, medication administration, social activities, etc., are provided at various intensity at the different levels of care. Cost of this housing option are based on the projected lifetime cost of care of the resident, and vary by facility (Staab & Hodges, 1996). 27 In summary, these are the housing options, from single family dwelling to skilled nursing facility, which are available to older adults. A single family dwelling offers the least amount of support to an older adult, a SNF offers a very high level of support, and assisted living facilities offer a minimum to moderate level of support. A CCRC offers all levels of support. Project Development The information handout can be given by the APN to patients and families. The information handout would be used in a primary care setting by an APN. The handout may be presented as result of an inquiry by the patient, or can be used if in the APN's assessment a patient should start considering a change in housing. The handout will include a listing of the various housing options, and what level of support to expect from each. Suggestions will be given on how to choose or adapt housing so the older adult will receive the support recommended. The information handout will have references for the reader to look up more detail, if desired, but will provide enough information for immediate use by families (see Appendix A). Evaluation of the Information Handout It is important to ensure that the handout is practical, understandable and useful. The main outcome of using the handout is to increase an appropriate level of support for older adults, and do so in a proactive manner. Secondly, use of the handout should make it easier for 28 families to evaluate the various housing options, and determine their appropriateness for their older relative. To evaluate if this goal is met one could insert a short questionnaire, asking users if this handout helped them to plan for, and choose, housing for older relatives. One could ask APNs who have used the handout in their practice if they would use it again. Did they find it useful in helping families make housing decisions? Did the handout help in advising families to consider a housing change? Regarding families who use this handout, one could survey families who made a change in housing arrangements. Those who did use the handout should have found the process of choosing housing easier than those do did not. Also, users of the handout may be more satisfied with the housing choice than non-users. Implications for Advanced Nursing Practice Assessment and recommendations regarding housing changes for older people is within the role, as well as the scope, of the APN, and especially the Gerontological Nurse Practitioner (Hamric & Spross, 1989; Staab & Hodges, 1996). APNs, as primary care providers, tend to get to know their patients, and caregivers, over time. The APNs roles of consultant, educator, and collaborator are described because these are the roles an APN will most often assume when dealing with housing issues. 29 Ccnsnltant Families who are confronted with changing abilities of an older relative may consult their healthcare provider. APNs, as primary care providers, will be able to do a thorough assessment of the older adult, which should yield information regarding the functional ability of the older adult. The APN can than make recommendations regarding a course of action. If a change in housing is likely needed, the APN can provide the family with information regarding available options. EdnCatQI The APN can further help families by educating them about the options available, and whether they would be appropriate for the older adult. As educators, APNs are able to assess a family's level of understanding of housing needs, and apply appropriate interventions. The APN will be able to teach families in a proactive way. In other words, make people for whom a move will probably be necessary in the not-so-far future think about their options while there is still time to plan adequately, but not so early in the disease process as to alarm or overwhelm the patient. This is especially important in the case of diseases of the brain, such as Alzheimer's disease, and disabling diseases such as Parkinson's or Multiple Sclerosis. Of course, not every older adult will be able to find housing which provides an optimum fit. Financial constraints will prevent many from paying for services to make a dwelling more 30 supportive, especially if those services involve extensive personal care. But planning ahead will at least allow families and their relatives to examine the options, and will give them a change to evaluate how important the pros and cons of each option are to them. APNs educational role can also be applied in community settings, such as in presentations to churches and community education courses. APNs may want to direct such teaching to middle aged people, who are the emerging old of tomorrow (Grand/Kent Community Consortium, 1999), since many of them will have to make decisions about both their own and their elderly parents housing. Finally, APNs can educate staff in housing for the elderly about the importance of promoting independent functioning while providing needed support. CQIIQDQIQLQ: The APN as collaborator can actively assist families as they go through the process of adapting the housing situation of their older relatives. Families can receive feed-back from the APN about housing plans. The APN can “walk next to” the families and enable them to make changes. The APN can encourage families during the process, and help the family find available resources. Since primary care should include the element of continuity, the APN can continue to assist the family over time, and help them to explore anticipated housing needs. 31 Implications for Nursing Education Changing demographics necessitate that all APN's, regardless of area of specialty, have some knowledge of the issues confronting older adults. The handout can be used to teach APNs with specialties in areas other than gerontology about housing issues of older adults. The handout may also be used to begin discussion and education about older adults' housing issues in general nursing programs. Suggestions for Research Future research should include evaluation of the usefulness and applicability of Lawton and Nahemow's (1973) adapted model in primary care. First, research on the handout itself could be done. For instance, is a general understanding of the concept on ADLs and IADLs sufficient for families to assist in housing choice? Should some sort of measurement of outside support be included, for instance information about caregiver stress? Secondly, an intriguing study would be to find out how applying the adapted model would impact the “aging in place” movement, especially as it pertains to the present tendency to provide services at home, rather than in an in-patient setting. Primary care practitioners are the ones most likely to provide care for people in the community. Therefore, they are the ones who will encounter most of the problems and advantages of’“aging in place’. The adapted model could be useful to help people stay in their home, or a close approximation of it. This would take place because 32 the model would help families determine what type and how much help an older relative needs. Families can than find creative ways of providing such support. Another study would be to see which teaching format would be most effective: a video showing housing options in detail, versus the brochure suggested in this scholarly project, versus Web based information. Each teaching format would likely reach a somewhat different audience, and may be appropriate for various groups and family structures. Summary As people age their abilities change. Lawton and Nahemow's (1973) model shows that even small changes in environment can have large consequences, especially for a frail older person. Housing decisions of older adults are therefore too important to be guided by advertisement slogans and marketing gimmicks. APNs should be prepared to take a proactive role in housing issues, and teach the consumer to choose housing options carefully. Concrete questions regarding help with ADLs and IADLS will render advertisement slogans and vague service statements used to market for profit housing options unimportant and inappropriate in the housing decision making process. Teaching and assessments conducted by the APN will be augmented with use of this information handout, and help consumers to be more sure services meet expectations. 33 LIST OF REFERENCES LIST OF REFERENCES Armer, J. M. (1996). An exploration of factors influencing adjustment among relocating rural elders. IMAGE; Icnrnal_Qf_Nnrsing_Sctharshin1_2&(1). 35- 39- Armer, J. M. (1993). Elderly relocation to a congregate setting: Factors influencing adjustment. Issues_In_Mgntal Health_Nnrsingl_11(2). 157 172- Barton, L. (1997). A shoulder to lean on: Assisted living in the U S American_nemggranhicsl_12 45- 51. Binstock, R. H. (1996). Shelter and care for the elderly population: Reasons for cynicism. The_§etgntglggist+_1§(3), 410- 413. Blank T (1988) Qlder_nersgns_and_their_hensin§1 Today_and_tgmgztgn. Springfield, Ill: Thomas Books. Carlin, V.F. (1991). can_mgm_IIyg_aIQng2 Lexington, Massachusetts: D.C. Heath and Company. Collins, C.E., Butler, F.R. Gueldner, S.H., & Palmer, M.H. (1997). Models for community based long-term care for the elderly in a changing health system. Nursing_9ntlggkt 55(2), 59-63. Cookman, G. A. (1996). Older people and attachment to things, places, pets, and ideas. IMAGE1__JQurnal_Qf_Nnrsing SCtharShiDI_Zfl(3)r 227' 231- DeYoung, 8., Just, G. & Van Dyk, R. (1994). Assisted living: Policy implications for nursing. Nursing_and Healthcare1_15(10), 510- 513. DeYoung, 8., Just, G. & Van Dyke, R. (1995). Assisted living: Challenges for nursing practice. fig:ia§zig_fl§l§ing+ 15(4), 165-168. Edmonson, B. (1997). A better change for healthy old age Egrecast_19n_linel Available: ' 4.1. O‘ueo «or an 0 .0 on ' ' 0- _ _ Feingold, E. & Werby, E. (1990). Supporting the independence of elderly residents through control over their environment Icurnal_9f_H9using_fcr_the_Elderl¥1_§(1 2). 25- 32. 34 Filion, P., Wister, A. & Coblentz. E.J. (1992). Subjective dimensions of environmental adaptation among the elderly. A challenge to models of housing policy. Jenznnl_ef HQnsing_fcr_the_Elderl¥1_1Q(1-2). 3- 32- Fleming, K. C., Evans, J. M, Weber, D. C., & Chutka, D. S. (1995). Practical functional assessment of elderly persons: A primary care approach Ma¥Q_Clinic_Erncednresi_2l70). 890- 91o. Gilderbloom, J.I. & Rosentraub, M.S. (1990). Creating the accessible city- Amer1can_lcnrnal_nf_Ecnnnmics_and SQQ1QIQQ¥1_12(3). 271-282- Golant, S. M. (1991L Matching congregate housing settings with a diverse elderly population: Research and theoretical considerations. IenzneI_ef_HensIng_fet_the Elderl¥1_2(1\2): 21 33 Golant S M (1992) H9nsing_America_s_Elderlx NewburY Park, CA: Sage Publications. Gonyea, J. 6., Hudson, R. B. & Seltzer, G. B. (1990). Housing preferences of vulnerable elders in suburbia. 19urnal_Qf_Housing_fcr_the_Elderl¥1_l(l). 79- 95- Grant, P.R., Skinkle, R.R. & Lipps, G. (1992). The impact of an interinstitutional relocation on nursing home residents requiring a high level of care. The_§ezenteIegIetI 12(6), 834-842. Grand/Kent Community Consortium on Successful Aging & Heart of West Michigan United Way (1999). Kent_cgunt¥ ResQnrce_E9admap_9n_Snccessfnl_A91ngo Grand RapidS. HI- Ham, R. J. & Sloane, P. D. (1997). E:Imezy_§eze GerIettIee. (3rd ed.) St. Louis, MO: Mosby. Hamrick, A.B. & Spross, J.A. (Eds.). (1989). The Philadelphia: W.B. Saunders Company. Harkey, P. W. & Traxler, H. G. (1982). Share-a-home: A unique community-based residential alternative for the dependent elderly lQnrnal_Qf_Applied_GergnthQs¥1_1 90-94. Harkulich, J. T. 8 Brugler, C. (1991). Relocation and the Resident Act1xit1es1_Adaptaticn_and_A91n91_15(4). 51- 59. Hasselkus, B.R. (1978). Relocation stress and the elderly. 12(10), 631-636. 35 Kauffman, K. S. (1995L Center as haven: Findings of an urban ethnography Nurs1ng_Research1_11(4). 231-235- Lach, H. W. Reed, A. T., Smith, L. J. & Carr, D. B. (1995). Alzheimer's disease: Assessing safety problems in the home. Geriatric_Nnrs1ngi_1§ 160-164. Lawton, M. P. (1988). Three functions of the residential environment Ionrnal_of_Eons1ng_for_the_Elderl¥1_§l1). 35- 50. Lawton, M.P. a Brody, E.M. (1969). Assessment of older people: Self-maintaining and instrumental activities of daily living- The_Qerontoloeisti_2(3). 179-186. Lawton, M.P. & Nahemow, L. (1973). Ecology and the aging process. In C. Eisdorfer & M.P. Lawton (Eds.), The ' (pp. 619-674). Washington, D.C: American Psychological Association. Lawton, M. P. ,Nahemow, L. & Tsong-Min-Yeh. (1980). Neighborhood environment and the wellbeing of older tenants in planned housing. Dexelopmenti_11(3). 211-227- Moloney, M. F. (1997). The meanings of home in the stories of older women Hestern_Jonrnal_of_Nnrsing_Eesearsh1 19(2), 166- 176. Morris, J.N., & Morris, S.A. (1997). ADL assessment measures for use with frail elders. lenznel_ef_nentel_fleelth and_A91n91_3(1). 19-45. Pastelan, L-Ao (1995). Honsing_necisions_for_the ,EIdetIy. Binghampton, NY: Haworth Press. Riekse, R.J., & Holstege, H. (1996). QzeeIng_QIdez_In AmetIee. New York: McGraw Hill. Schreter, C. A. (1985). Advantages and disadvantages of shared housing Jonrnal_of_Housing_for_the_Elderl¥1_3(3\4). 121- 138. Staab, A. S. & Hodges, L. C. (1996). EeeentIeIe_efi Gerontological.flnrsing Philadelphia: Lippincott- Strumpf, N. E. (1994). Innovative gerontological practices as models for health care delivery. aneIng_end Healthcarei_15(10). 522 527 36 Teaff, J.D., Lawton, M.P., Nahemow, L., & Carson, D. (1978). Impact of age integration on the well-being of elderly tenants in public housing. JenzneI_e£_§ezenteIeg¥I 11(1), 126-133. Thompson, I. (1994). Woldenberg village: An illustration of supportive design for older adults. Exper1mental_Ag1ns_Research1_29(3l. 239-244- Wister, A.V. & Burch, T.K. (1989). Attitudes of the elderly towards living arrangements. Jenzne1_e£_flensIng_ier the_Eldezl¥1_5(2), 5-18. 37 APPENDIX A HOUSING CHOICES FOR THE ELDERLY: A GUIDE FOR FAMILIES 38 HOUSING CHOICES FOR THE ELDERLY: A GUIDE FOR FAMILIES OUTLINE Introduction Housing should be matched to the older adult Activities of daily living Instrumental activities of daily living Before you make changes Housing options What to ask when showing for housing Conclusion For more information 39 INTRODUCTION More people live longer today than at any time in the past. Many older peOple find it very difficult to keep up their household, and yet it becomes harder to move as one gets older. The terms used to describe housing for the elderly are sometimes vague. And how much help do you really need? This guide attempts to help you and your family discuss housing needs, so you can plan ahead and make wise decisions if you need to move. HOUSING SHOULD BE MATCHED TO THE OLDER ADULT People fimction best when they live in an environment which closely matches their abilities. The housing situation should not be too difficult. For example, someone who has trouble climbing stairs will find it very hard to live on the 5th floor of an apartment that does not have an elevator. It is possible to adapt a person’s housing situation to their ability: if the person who has trouble climbing stairs would have an elevator, the problem would be solved. This adaptation does not just refer to the house it self, but to the whole living situation. If you need help taking a bath, or making meals, and some one is available to help you, your living situation is adapted. People also do not function well if their living situation is too easy. You may become bored or depressed if you get more help than you need. To 40 lead a satisfying, balanced life, it is important to find the right amount of help. Sometimes it is difficult to decide what it is an older person needs help with. Daily life consists of many tasks, and not all of them are equally important for living. To make it easier to plan, you can use the lists at the end of this booklet. They are called activities of daily living and instrumental activities of daily living. These lists are developed to help find out where the problem spots are in taking care of yourself and your household. ACTIVITIES OF DAILY LIVING Activities of daily living are what you need to do to take care of your body. As you can see in the list this includes bathing, getting dressed, transferring, continence, and feeding. Bathing means taking a full bath, including washing your hair. It does not matter if you take a shower, or use a tub, as long as you can safely clean your whole body. This is usually the first task older people may need some help with. Getting dressed means putting on clothing, and taking care of your hair. To dress without help also means you are able to make safe decisions on what to wear depending on the weather, and on what you need to do that day. 41 Transferring means to move from one place to another. For example, from a chair to a bed, or from the toilet to a chair. You can be independent even if you need help from a cane or a walker, as long as you are able to use these devices safely. Continence means taking care of urine and stool so you stay clean and dry. Feeding means eating and drinking. This could be food you have prepared yourself, or food and drink some one else has brought you. To be independent with these tasks, means to be able to do them without any help or reminders of another person. Many older people need some help. This help can be hands-on, such as helping to put on clothing. The help can also take the form of spoken reminders or supervision, such as reminders to go to the bathroom. To be considered independent with a task it means you can do them without reminders or “a helping hand”. 42 INSTRUMENTAL ACTIVITIES OF DAILY LIVING Instrumental activities of daily living are the more complex skills needed to live and to maintain your household. These are: the ability to use the phone, to shop, to prepare food, to do housekeeping and laundry, and to manage transportation, medication, and finances. These are broad categories, and are not just dependent on the housing situation. For example, the weather can make a difference in being able to do some of these tasks. Nevertheless, it is helpful to look at these tasks of keeping house to decide what type of help you may need. Ability to use the phone includes both dialing out and answering the phone. If you need a phone with large numbers, and have one available, and can use it without help, you are still independent in using the phone. Shopping includes shopping for food and medicine. Weather and transportation changes can really affect an older person’s ability to shop for important items. Preparing food'can be food that someone else has brought in, or that you bought yourself. It refers to food that has enough nutrients in it for a healthy body. 43 Housekeeping and laundry refers to doing all the housework and laundry yourself. Many older people need some help with heavy housework and large laundry items. If you do, you should check the “needs some help” column. Transportation refers to transportation to places outside your home, such as to a doctor’s office, or a store. You are independent if you can drive or walk by yourself, or use public transportation by yourself. Medication refers to being able to remember when to take your medication, and how much. If you take your medicine from a “reminder” box someone else has made ready for you, check the “needs some help” column. Finance refers to all financial matters. This can be writing checks, making a budget, keep track of and pay your bills, deal with the bank, etc. BEFORE YOU MAKE CHANGES Before an older person makes changes in their housing situation, they should visit their healthcare provider. Your healthcare provider can decide if you need any health care to make it easier for you to take care of your self. For example, maybe it would help you to see a physical therapist. Or maybe your medication could be changed so it helps your body work better. Also, some diseases are likely to make it necessary to have more help in the future, 44 for example diseases which affect the memory. It is helpful in planning housing to know what to expect. You can also ask your healthcare provider for advice about housing arrangements. Your healthcare provider will be able to help you and your family decide what would be a good housing situation for you. See your healthcare provider first. HOUSING OPTIONS Most older adults in the United States live in one of these types of houses: A single family house, an apartment or condominium, an assisted living facility, a skilled nursing facility, or a continuing care retirement facility. A single family home offers the least support, and a skilled nursing facility (nursing home) provides help with all the tasks of daily living. Apartments and condominiums and assisted living facilities fall somewhere in between. Continuing care retirement facilities offer a range of support, from independent living to skilled nursing care. Ilrefiinglefiamilxflnms A single family home may be a comfortable place to live for a healthy older person. When some help is needed, consider the following options: 45 community services, adult daycare, home health care, house sharing, and acceSsory apartments. Community services are services provided in your home, such as meal delivery, handyman services, and transportation services. Some community services are offered away from home, such as meals and activities at senior centers. Adult day care offers a safe, supervised environment for older people who can not be home alone. This way family caregivers have time to work, run errands, rest, or do other needed tasks. Adult day care facilities sometimes also provide respite care in case of illness or vacations. Home health care involves having healthcare services provided in your home. These could be visits of a social worker, nurse, nursing assistant, physical therapist or other healthcare workers. Under certain conditions Medicare will pay for such services, or you can pay for it. Some home health care agencies will also offer companion services, help with transportation, and home making services. Home health care services can be very helpfirl when you are ill, or have been in the hospital. They can also be useful as a temporary solution, to give you time to decide how to solve housing problems. 46 House sharing involves renting out part of your house to others. You can charge rent, or receive help with household chores. Ifcarefully planned, these arrangements can be very successful. Accessory apartments refer to temporary housing for older adults, next to the house of a relative who will care for them. Both sides maintain their privacy, but it is easy for the older and younger family members to look after each other. ! | | l C I . . Living in an apartment or condominium means you do not need to take care of the outside of your home. The apartment or condominium staff will mow the lawn, shovel snow and do repairs. Some apartments are especially for the elderly, and offer services for older people. This housing option can be very plush or very basic. Assisted living facilities usually will provide meals and housekeeping. They may also offer help with laundry, baths, and getting dressed. There may be help with medication. Assisted living facilities may be much like a “regular” home. They are not institutions, like skilled nursing facilities. Because they are so home-like, the staff may not have much special training in taking care of older 47 people. This may not be a problem, as long as they are able to give the care YOU need. Assisted living facilities may not be able to take care of people who become very ill or frail. Some assisted living facilities have arrangements with a nursing home in their area. If a resident of the facility needs nursing home care, a spot will he promised them in this home. In this case the residents of the assisted living facility may have to move when they become too ill or frail to safely stay, but they do not have to wony about where they will move to. This is a traditional nursing home. They may be a good option for very frail elderly. Skilled nursing facilities provide 24 hour skilled nursing care, and help with all activities. The quality of skilled nursing facilities varies a lot. If you or your family member needs this option, check out the addresses below. These organizations have lots of information about what to look for in a nursing home. Since good nursing homes are not easy to get into, and may have a waiting list, it is important to plan ahead. i in This option is really three types of housing. When you move into a continuing care retirement center the facility promises to take care of you 48 until you die. In exchange you may have to pay an entrance fee. Part of the facility is usually for people who need little or no help. Part of the facility offers assisted living type help. Part of the facility offers nursing home help. You may have to move to different rooms in the facility if you need more help. These moves do not have to be a problem if the staff knows how make these moves the least stressful for the resident. Some facilities will offer more help as you need it, instead of asking you to move. And if you move with a spouse, some facilities will give more help to the person who needs it, while you can both stay in the same room or apartment. WHAT TO ASK WHEN SHOPPING FOR HOUSING Before you make housing decisions, fill out the chart at the end of this brochure. You can do it by yourself, and with your family. This will give you an idea of how much help you need, and what kind of help. Then you and your family can make plans on how to get the help. . Maybe you need some changes in the house itself, such as grab bars in the bathroom, or extra lamps. - Maybe family members could arrange to help. - Maybe outside help can be hired. 49 - Or maybe you decide you need to move. 0 If you need to move, make sure your new home will offer you help with all the tasks with which you need help. Especially if you plan to move to an assisted living facility. You and your family should ask: 0 If the staff can give the help you need, and if they can give it every time you need it? o What happens if you get ill? 0 Who decides when you have to move? - Does the facility have an agreement with a nursing home, so you know where you can go? Remember that assisted living facilities can be very nice, but that they vary a lot in what they offer. CONCLUSION Sometimes changes in an older adults housing situation may make it necessary to move. For example: the death of a spouse, a helpful neighbor who moves away, the bus route is changed, the local pharmacy does no longer deliver to the house. 50 Sometimes there are changes in the older person’s health which may make it necessary to move. For example after an illness or surgery, or if a chronic illness becomes worse. If you and your family are aware of your needs, it will be easier to plan. You can then make sure your housing situation provides the right amount of help. 51 FOR MORE INFORMATION There is much information available about housing. Not all of this information is reliable. The agencies listed here are reputable, and give out good and reliable information. The addresses below are all for Kent County. For other areas check your local Yellow Pages, or ask your librarian. Area Agency on Aging of Western Michigan 1279 Cedar NE, Grand Rapids, MI 49503 456-5664 American Association of Retired Persons local office: 453-0293 (local president) national office: 601 E Street, Washington DC 20049 1-800-424-3410 Citizens for Better Care 2130 Enterprise SE, Grand Rapids, MI 49508 281-3433 1-800-782-2918 First Call for Help (Heart of West Michigan United Way) 118 Commerce, Grand Rapids, MI 49503 459-2255 Senior Neighbors 50 Weston SW, Grand Rapids, MI 49503 456-6019 52 ACTIVITIES OF DAILY LIVING ACTIVITY CAN DO ALONE CAN DO WITH SOME WW BATHING DRESSING TRANSFERRING CONTINENCE FEEDING INSTRUMENTAL ACTIVITIES OF DAILY LIVING ACTIVITY CAN DO ALONE CAN DO WITH SOME HELP CANNOT Dql USE PHONE SHOP PREPARE FOOD HOUSEKEEPING LAUNDRY TRANSPORTA- TI ON MEDICATION FINANCES DIRECTIONS: Think about each activity. Put a check mark in the column which best describes the current situation. 53