CE Home > Occupational Therapy > OT08 Aging in Place, Part 2

EDITOR’S NOTE: Aging in Place, Part 1, the first in this two-part series, covered barriers and enablers older adults encounter as they experience age-related changes in function.

Beverly moved to a two-bedroom, continued care retirement community with her husband because his needs for physical and healthcare supports were increasing. His health declined, requiring home healthcare and ultimately transition to hospice for terminal care. When her husband passed away, she moved into a one-bedroom apartment in the same retirement community. Over the next several years, Beverly developed a number of chronic health conditions, including coronary artery disease, Parkinson’s disease, and thyroid disease. Her condition was further complicated by a decline in her cognitive functioning, making it more difficult for her to live in an apartment alone. Therefore, she moved from her apartment to assisted living — a change that was challenging even though her friends and family continued to visit her and take her on outings. Her feelings of emotional well-being, quality of life, and health and social engagement were sustained through her ability to stay in the same retirement community, surrounded by friends and healthcare professionals she trusted.

Housing Options

There are a variety of independent to semi-independent noninstitutional community living options available for seniors. They include individual residences, assisted living, continued care retirement communities, home sharing, and senior apartment buildings. The current approach to home building needs to change in recognition of the growing size of our aging population and the physical changes that accompany aging for many people. Incorporating accessible and universal design into new home construction and renovations of personal and commercial properties will go a long way in supporting aging in place. As discussed in “Aging in Place, Part 1,” “Universal design promotes ease of access and use in environments and with products for all people regardless of age or disability.”¹ The following are descriptions of community living options available to seniors in many communities across the United States.

Assisted living is defined by the AARP as: “… aimed at helping residents remain as self-sufficient as possible with the assurance of assistance when it’s needed. These residences usually provide a combination of housing, meals, personal care and support, social activities, 24-hour supervision, and in some residences, health-related services. It’s all conveniently gathered in a homelike setting.”² Assisted living facilities are a “special combination of housing, personalized supportive services and healthcare designed to meet the needs — both scheduled and unscheduled — of those who need help with activities of daily living.”²

Continued care retirement communities have a range of living options available to residents, including independent living in apartments and single-family homes, assisted living, and specialized care units (e.g., Alzheimer’s, dementia, long-term care, and hospice). Residents may enter at different levels, and their entrance depends on their needs and degree of independence. Some communities require applicants to pass cognitive or functional tests to qualify for admission.³

Residents are sometimes challenged by their need to move as their level of functioning changes. Relocation has negative effects on the individual that impact both their physical and psychological health.⁴ Even when a move is required, remaining in a familiar environment with continued access to friends and social opportunities is important. Individuals’ proximity to services and support is important to obtaining their satisfaction and desire to age in place. People need and want convenient shopping, reliable public transportation, and entertainment. Walking is important, and the safety of seniors who walk is enhanced when there are sidewalks, crosswalks, and lights that are appropriately timed for the slower walker.⁵

Home sharing is an evolving option for people who are alone and want to remain in their own homes. Generally an older adult, who owns a home, will enter into an agreement to share his or her home and expenses. This choice is often seen among individuals who are widows and widowers. This type of agreement should include a contract so all expectations are clearly understood. Some agreements will specify that the person entering into the contract will exchange tasks, such as housekeeping, shopping or yard care, for reduced living expenses. The National Shared Housing Resource Center is a good resource for additional information on house sharing.

Individual residences are individually owned or rented houses where the individual is responsible for the care and management of the interior and exterior of the home. This housing option is not restricted to seniors. The homeowner or renter may maintain the home independently, or these duties may be purchased or a part of the responsibilities assigned to an association or management company. In the majority of situations, owners/renters purchase the needed services on their own.

Senior apartment complexes and communities typically are communities that have age restrictions for at least one of the residents in each unit. These apartments and houses offer accessible floor plans and a range of amenities. Seniors who move into apartments or complexes near their homes don’t have to give up contact with their friends, social networks, and access to familiar medical care. Age-restricted communities attract people for a variety of reasons, including living in a community with people of similar ages, less activity and lower expectations for home maintenance.5 Some age-restricted regulations prohibit people under a certain age (e.g., 50) from living in the community for more than a short period of time.

Livable communities possess features and provide access to services that allow seniors to live comfortably. These communities have well-planned land use and infrastructure that integrates an array of transportation, housing, energy, leisure resources, and community businesses that support residents’ needs and the local economy. Their location and the inclusion of health and social services promote independence and quality of life for residents.

Naturally occurring retirement communities are neighborhoods that have naturally become composed of older adults who remain in the neighborhood. In a nationwide survey conducted in 2005, AARP found that as many as 36% of respondents (55 and older) were living in communities like that.6 In traditional communities, there is an ebb and flow of families moving in and out of neighborhoods, which maintains a diverse range of age groups. The United Jewish Communities studied these age-clustered communities and received specific funding aimed at Supportive Service Programs, which is part of the Older Americans Act. The components of this model include —

• Coordinated health social services, including group activities
• Partnerships between residents, providers, and government officials
• Health and wellness promotion
• Opportunities and responsibility to become involved in the planning and delivery of services
• Identifying situations where no payment mechanisms exist for services that promote health⁶

When the option for naturally occurring retirement communities exists, the feasibility for aging in place increases.

Funding options: Funding for services and supports for seniors is complicated and varies from payer to payer (e.g., insurance, Medicare Parts A, B or C, or Medicaid). It often has coverage limitations and consequently does not pay for all of an individual’s needs. Individuals “private pay” for many services, although seniors are eligible for Medicare and Social Security, which contribute to the payment of healthcare services and daily living. OTs can investigate these sources for their clients; however, the complexity of the program’s eligibility requirements may warrant enlisting the help of experts to understand and submit applications to the appropriate program. Additional programs or entitlements that may be available are briefly described below.

• The Older Americans Act: This act provides funding for services that benefit seniors, including nutritional services, health promotion, disease prevention, in-home care, and mental health and substance abuse services.⁷
• Money Follows the Person: States can assist seniors and people with disabilities who want to transition from the nursing home back to the community.⁸
• Medicaid: Income eligibility exists for all programs, which vary from state to state. States may establish specific waiver programs, such as funding for environmental assessments and renovations. Qualified individuals may obtain durable medical equipment, personal care services, nursing care, therapy, and payment for assisted living or nursing home care.
• Medicare: Under specific circumstances, Medicare pays for hospitalizations, outpatient doctor and rehabilitation services, prescription programs, in-home care, prevention services, and chronic disease management.
• Long-Term Care Insurance: This private insurance policy helps pay for some long-term medical and nonmedical care, such as help with activities of daily living. Because Medicare generally does not pay for long-term care, this type of insurance policy may help provide coverage for long-term care that is needed in the future.
• Supplemental Security Income and State Rent and Service Supplements: A few states provide a state supplement to Supplemental Security Income recipients to help purchase supportive services in assisted living facilities accredited by The Joint Commission.⁴
• Reverse Mortgages: This government-insured line of credit is only available for people who are 62 or older and whose homes are their primary residences. It allows seniors to access their equity without having to sell their homes. Senior homeowners are never required to make monthly payments, they stay on title of the house, and their heirs will inherit the home without any problems. The funds received from a reverse mortgage can be used to eliminate an existing mortgage payment, pay bills, or supplement income. Funds can be accessed as credit lines, lump sums of cash, or monthly payments. In addition, proceeds from a reverse mortgage are tax-free, and in most cases do not count as payments. There are closing costs involved with reverse mortgages, and they are financed into the loan. The FHA regulates all fees and ensures that a borrower or a borrower’s heirs can never owe more than the house is worth. Lenders are required to disclose the fees up front, and they can never exceed the standards established by the FHA.
• Veterans Administration: Medical, rehabilitation, mental health, and substance abuse services are available to veterans. The VA also pays for car/van modifications, assistive technologies, and home modifications for eligible veterans. Eligibility is based on a determination of disability made by the VA. Detailed information is available on the VA’s website and on the websites of service organizations like the Disabled American Veterans.

Supportive Resources and Services

Communities that promote successful aging in place offer people transportation options; access to home health services, local health centers and hospitals, and local businesses; leisure and social options; and resources, including assistive technologies that support activities of daily living and instrumental activities of daily living. Additionally, communities incorporate hospice care; senior centers; nutrition programs; and educational, recreational, and volunteer opportunities for seniors.

Adult Day Care: These community-based day programs are available to seniors and people with disabilities. They offer structured activities; occupational, physical, and speech therapy; social work; and nutrition services in supervised settings. Typically, these programs serve adults who are frail and require medical supervision, such as those with dementia. Participants also have access to leisure and social opportunities. Fees are charged for participation and may be funded through grants, waiver programs, Medical Assistance, etc.

Senior Centers: These centers provide recreational, educational, and social activities to individuals age 50+ whose cognitive and physical functioning do not require more than minimal assistance. They also offer daily lunch programs, health screenings, and information and referral services to all seniors.⁹ Senior volunteers provide program and administrative support at many centers. Although many programs are free, fees are associated with some activities. Senior centers with specialized social programs for the frail elderly are sometimes called Senior Center Plus programs. These programs provide a social model day care program that serves the needs of people age 55+ who have limited functioning. Participants typically need assistance with activities of daily living, such as toileting and eating, and must be supervised during their attendance at the center. High staff ratios ensure safety and allow staff members to assist participants. The activities are structured to facilitate the functional independence and cognitive awareness of participants.

Transportation and Community Mobility: Community mobility (including transportation) is a critical element to community participation. As seniors age and their level of function changes, it is important that they have knowledge about and access to OTs and others who can evaluate the skills necessary for safe driving. Driver safety screenings are available online and through specialized community-based programs. Clinical evaluations may be available from OTs in rehabilitation settings and freestanding programs. Consumers can locate driving experts through The American Occupational Therapy Association. The Older Driver Safety portion of the website has information for professionals and consumers, including educational materials, a database of driving specialists, and self-assessment tools. Consumers may also contact the Association for Driver Rehabilitation Specialists for help locating their certified driver rehabilitation specialists. AARP’s 55 and Alive educational programs are offered in many senior centers to help seniors renew their driving knowledge. Graduates of this course may be eligible for reduced car insurance rates.

When individuals retire from driving, they often need assistance learning about and using other transportation options. Some communities have ride-sharing programs and low-cost transportation that is supported through the area agency on aging (often in collaboration with departments of transportation). The Americans with Disabilities Act has mandates that focus on transportation access for older adults under certain circumstances.

Health and Wellness: Maintaining one’s physical and emotional health is an important component to aging in place. If one isn’t healthy, it is more difficult to maintain independence and quality of life. Therefore, health, prevention, and rehabilitation services should be available to older adults in their homes or communities. Health screenings are often available through local health departments, senior centers, gyms, and other locations where seniors congregate. Some community providers offer medical care visits in the home and mobile treatment teams who intervene in the homes of seniors and others who may be homebound. According to the National Institute of Mental Health, between 2% and 10% of community-dwelling elders are either abusing or at risk for abusing medications and other substances, and 5% have a significant mental illness.¹⁰ Therefore, OTs who consult with seniors and their families should provide education regarding substance abuse and mental illness. They should also screen for signs and symptoms of depression or substance abuse.

Leisure, Recreational, and Social: These areas of occupation are central to an individual’s well-being and are attained by balancing work, rest, and play. These components are needed across the lifespan. Older adults need access to leisure, recreational, and social activities, which can be found at senior centers, through department of recreation and parks, and leagues (e.g., golf, tennis, bowling, and bridge). Disabled Sports USA is a nonprofit organization for individuals with permanent disabilities. The organization provides a wide range of recreational, educational, and social activities.

Advocacy: The Occupational Therapy Practice Framework specifically recognizes self-advocacy as an outcome of occupational therapy services. Therefore, whenever possible and clinically appropriate, OTs should promote universal design in programs and services, and they should educate clients, be they individuals, organizations, or populations, regarding successful aging in place. Advocacy is also addressed in the Occupational Therapy Code of Ethics. Principle 1 states: “Occupational therapy personnel shall … make every effort to advocate for recipients to obtain needed services through available means.”¹¹

Potential Partnerships

A variety of organizations provide information to the public about aging in place, assessing the home environment, and identifying support systems. The Eldercare Locator provides information and links to websites detailing services and funding programs beneficial to older adults. When researching the availability of community-based senior services, the Eldercare Locator is a good place to start. The AOTA, the Administration on Aging, and the Agency for Healthcare Research and Quality also provide information about the role of occupational therapy in aging. OTs who provide services that support aging in place should inform the relevant organizations about their services and determine if there are new opportunities that would expand their service delivery.

OTs can establish partnerships with a multitude of organizations and agencies. Area agencies on aging and county governments, including health departments, may be open to partnering with OTs to develop driving screening programs, fall prevention screenings and classes, and low vision and other support groups. Additionally, these agencies may also find occupational therapy’s approach to health, wellness, and prevention useful as they develop community outreach initiatives to support older adults who want to age in place. Funding for these programs and services may come from programs previously mentioned in Funding Options; through traditional third-party payment; from federal, state, or local governments; and through grants from nonprofit organizations. Many innovative services have developed thanks to OTs’ initial volunteer participation. Once the programs have demonstrated success, funding may become available to continue them. Converting successful occupational therapy-run programs to fully funded services requires a planned and assertive OT-driven advocacy effort.

OTs who have expertise in aging services and wish to expand their practices should consider the opportunities in community settings as consultants and direct-care providers. OTs can help seniors and their families to identify safety features that will support independent living. If there is a question about an individual’s ability to be safe when at home alone, the OT can assess the individual’s safety, and if needed, provide information about remote alerting systems like Lifeline. Learning about the evolution of home monitoring technologies will expand the opportunities for independence and safety within the home and community. Examples of occupational therapy consultation services may be directed to individuals, families, retirement communities, area agencies on aging, departments of transportation, and state agencies on aging.

Productive Aging: The time has come for greater partnerships with employers regarding worksite modification and job simplification to support the older worker. OTs can help the older employee and the employer meet their needs through training, worksite modification, job simplification, integration of assistive technologies, and other techniques. The Job Accommodation Network offers help for individuals, employers, and others in identifying solutions to worksite accessibility and productivity. Below are additional partnership ideas that could be pursued to develop or expand occupational therapy services that support aging in place.

Partnerships with the American Automobile Association, American Occupational Therapy Association, and senior centers to sponsor CarFit programs are opportunities to promote occupational therapy visibility and community safety. The CarFit program is geared toward adults 50+ to make sure that drivers obtain the optimal fit with their vehicles. OTs and technicians show seniors how to maximize the adjustments to their vehicle and, when needed, use assistive devices to make getting in and out of the car easier and the driving experience safer.

Easter Seals: The organization currently provides a range of services to seniors living in the community, including senior employment, the needs of aging persons with developmental disabilities, mental health and substance abuse program needs focused on older adults, transportation, and fall prevention and low vision programs and services. Easter Seals and similar organizations may benefit from occupational therapy partnerships in building intergenerational programs.

Rebuilding Together: This volunteer-driven organization identifies individuals and families in need of free home modifications and repair. They serve persons with disabilities, older adults, and veterans. OTs are invited to be part of the team to conduct environmental assessments and make recommendations.

U.S. Department of Veterans Affairs: The VA contracts with a variety of companies to conduct environmental evaluations, car and van modifications, driving evaluations and on-the-road training, in-home and clinic-based rehabilitation, assistive technology and prosthetics, and other services for veterans. The VA also supports services that assist veterans with community reintegration. OTs who provide these services, particularly in rural areas, may be able to set up partnerships with the VA. To explore this partnership area, review the items on the Office of Small and Disadvantaged Business Utilization, Small Business Points of Contacts, and Small Business Liaisons pages.

National Association of Home Builders: NAHB is a trade association focused on the housing industry. Members (builders, contractors, OTs) can be found through local builder associations. The NAHB’s Research Center studies sustainability, affordability, and special-needs housing. The organization offers certification programs, including Certified Active Adult Specialist in Housing (CAASH) and Certified Aging-in-Place Specialist (CAPS). OTs can take courses to obtain one or both of these certifications to increase their self-marketing and develop partnerships with remodelers and contractors with these designations.
 
Area Agencies on Aging: These agencies are committed to serving the needs of adults age 60+. Their programs are mandated under the Older Americans Act and focus on home- and community-based living. Rather than provide direct services, they contract with others to provide nutrition and social/support services. OTs have successfully partnered with local agencies to expand service delivery to seniors.

International Longevity Center — USA: This not-for-profit, nonpartisan, research, education, and policy organization’s mission is to help individuals and societies address longevity and population aging in positive and productive ways, and to highlight older peoples’ productivity and contributions to their families and society as a whole. The organization is part of a multinational research and education consortium; it has centers in 11 countries that work autonomously and collaboratively to study how greater life expectancy and increased proportions of older people impact nations around the world.¹² Occupational therapy’s focus on function and productive aging may make OTs ideal partners for the center’s research and educational activities. OTs’ commitment to advocacy on behalf of individuals we serve allows us to help develop and influence public policies.

MetLife Foundation: OTs who have well-formed business plans focused on aging in place may find a partner with the MetLife Foundation. The foundation funds programs that promote healthy aging and address issues of care giving, intergenerational activities, mental fitness, and volunteerism.¹³

Real Estate Professionals: Real estate offices and realtors are always looking for ways to expand their businesses. OTs can help inform buyers and sellers about accessibility features and recommend modifications that are appealing and functional to the older homebuyer.

OTs can work with a wide variety of organizations as consultants, direct care providers, and researchers to support seniors who wish to age in place. Some of these roles are traditional, and others may evolve. Our knowledge of funding sources and our ability to identify future partners will advance our individual practices and the role of occupational therapy in aging services.

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