Assisted Living
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Assisted Living

Sobering Realities

Benyamin Schwarz

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eBook - ePub

Assisted Living

Sobering Realities

Benyamin Schwarz

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About This Book

Learn how to make elder housing more homelike! Taking an incisive look at assisted living for the elderly, Assisted Living: Sobering Realities is an important book for the professionals who work with aging Americans and their families. This vital book provides a multidisciplinary overview of the world of assisted living for older Americans. With unique insight and a keen clinical perspective, Assisted Living examines a variety of topics: the dilemma of aging in place, the realities of end-of-life care, and the ins and outs of residential care supply. Easy-to-read graphs and charts make the data user-friendly. This book delivers current information on:

  • the housing needs of elderly renters, with case studies of 109 residents in two facilities
  • the need for improved housing and services for low-income elderly, providing an overview of how successful facilities take a comprehensive approach in linking low-income elders with community-based services
  • the advantages and disadvantages of residential care facilities
  • research about aging in place from providers and residents' perspectives
  • the unmet needs of the elderly who qualify for housing assistance
  • how visitation patterns affect the overall satisfaction and quality of life of assisted living residents

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Information

Publisher
Routledge
Year
2014
ISBN
9781135417970
Topic
Medizin
Edition
1
Chapter 1
How Long Can I Stay?: The Dilemma of Aging in Place in Assisted Living
Jacquelyn Frank
Summary. Aging in place has long been a focus for proponents of assisted living housing. However, the reality of life for seniors in assisted living is often tenuous, and this homelike setting repeatedly ends up being a temporary stop for older adults. Residents frequently ask, “How long can I stay?”, only to find that there is no easy answer. Increasing frailty and declining health can mean that an elderly resident may be asked to leave assisted living, reducing aging in place in this housing/health care option to what I have termed “prolonged residence.”
Based on eighteen months of anthropological fieldwork at two assisted living sites in Chicago, Illinois, this article presents the individual struggles providers and residents face in interpreting aging in place. Although grappling with disparate aspects of the same issue, residents and providers both share conflicted feelings about how long one should remain in assisted living and what aging in place actually means. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address: <[email protected]> Website: <http://www.HaworthPress.com> © 2001 by The Haworth Press, Inc. All rights reserved.]
Keywords. Assisted living, aging in place, residents’ realities, providers’ views, prolonged residence, liminality
Introduction
Currently, aging in place is a subject of much discussion and debate among assisted living providers, designers, researchers, and policy-makers (Mollica et al. 1995; Heumann and Boldy 1993a; Pynoos 1990; Sherwood et al. 1990; Callahan 1993). Questions such as who qualifies as an appropriate candidate for assisted living and how long a resident may stay are becoming more complicated with the expansion of this supportive housing option. Should assisted living remain part of the conventional continuum of care or should residents truly be allowed to age in place until they die, regardless of their level of impairment (Wilson 1990)? These questions are of concern not only to researchers, but especially to providers and residents who must face these dilemmas daily in assisted-living communities.
This article focuses on the experiences of residents and providers at several assisted-living sites in Chicago, Illinois. Specifically, questions are raised regarding how providers and residents interpret aging in place and what repercussions these interpretations have on assisted-living policies. The article begins by focusing on the variety of present assisted-living models across the country. Highlighted are the types of services and physical environments offered by each model. Following this, I discuss the variety of interpretations for the phrase “aging in place.” Next, the focus shifts to providers and their explanation of aging in place as it applies to their individual facility policies. Admission and discharge criteria are examined at several assisted living facilities in order to illustrate the complexity of the aging in place issue. Revealed is the fact that most providers interpret aging in place to mean what I have termed “prolonged residence.” Prolonged residence only allows residents of assisted living to stay for an undetermined, vague period of time that is never made clear to the resident.
Next, the viewpoints of residents are examined. How do older adults in assisted living reconcile the tension between their own desire to age in place but not live among an impaired population? The research method used in this project allowed both providers and residents to offer their personal feelings and attitudes on assisted living. Presenting the residents’ and providers’ own words in the article reveals the emotional nature of the aging in place debate. Finally, these various interpretations of aging in place are analyzed in relation to prolonged residence and the goals and principles of assisted living housing.
Exactly what assisted living is remains a question that is answered by individual states and facilities (Mollica et al. 1992). It should be noted here that the ambiguity surrounding a universal definition of assisted living creates both great flexibility and great confusion for providers as well as consumers. Ambiguity allows providers to develop policies and rules specifically geared toward their particular facility or state requirements. At the same time, without a standard definition of assisted living, policy decisions such as entrance and discharge criteria are more difficult for providers and more stressful for residents. There is general consensus, however, regarding the philosophy of care that surrounds assisted living. Scholars agree that the basic philosophy of assisted living includes maximizing privacy, dignity, independence, choice, and autonomy for residents (Regnier et al. 1991; Kane and Wilson 1993; Kalymun 1990; ALFA 1994). This is accomplished through the creation of a homelike environment and supportive services. Exactly how this is carried out varies from one assisted living community to the next.
The data for this article was gathered during eighteen months of research in the Chicago, Illinois, metropolitan area. Two primary assisted living sites were utilized to gather qualitative data. The first facility, Kramer, is a free-standing site housing twenty-nine residents in suburban Chicago. The second site, The Wood Glen Home, is actually a nursing home containing one floor devoted to assisted living.1 The Wood Glen Home is located in the city of Chicago, and its assisted-living unit houses up to eighteen people. Participant-observation fieldwork was conducted for a year and a half at both sites. The research consisted of multiple tape-recorded interviews with residents and providers, informal interviews and discussions, participation in resident activities, and the administration of anonymous surveys.2 I also visited eight other assisted living sites in the Chicago area and conducted interviews with administrators at each facility. Through daily interaction, in-depth interviews, and anthropological analysis, it is clear that providers and residents are both concerned with the future of aging in place in assisted living.
Assisted Living: Evolution and Models
Assisted living refers to a housing/health care alternative for elderly persons who are no longer able to live independently in their own homes but do not require 24 hour nursing care (Regnier 1991). A unique dimension of assisted living is the fact that there is no one standard definition for this residential option. The Assisted Living Federation of America (ALFA), the American Association of Homes and Services for the Aging (AAHSA), the U.S. Health Care Financing Administration (HCFA), as well as various scholars, such as Regnier (1996), Mollica and Snow (1996), and Wilson (1996), have all posed definitions of assisted living. Although the definitions may differ, there are two components present in virtually all definitions. These two commonalties include assisted living as a combination of some kind of housing and services. This is where the similarities usually end. Individual states will then decide what is meant by “housing” and what is meant by “services” for their definitions, policies, and procedures.
In order to clarify some of the confusion, ALFA (1999) has offered two general models of assisted living. The first type of assisted living is referred to as the “Senior Housing with Non-Health Care Services” model. Services that are generally provided in this model of assisted living are non-medical in nature and include meals, housekeeping, transportation, security, and very limited personal assistance with activities of daily living (ADLs). “It focuses on maintaining a strong residential characteristic with little emphasis on health services” (ALFA 1999:7). In other words, services focus on Instrumental Activities of Daily Living (IADLs). The major limitations of the model are that personal care is minimal and nursing care is nonexistent, often resulting in shorter residency for older adults and a high turnover for the assisted living community. This model also poses serious barriers to aging in place because there is no assistance present to help a resident who experiences increasing frailty or health complications.
The Assisted Living Federation of America (ALFA) offers a second model of assisted living called “Senior Housing with Health Care Services.” Residences under this model provide meals, transportation, housekeeping, and security as in the first model. However, this plan also includes significant personal assistance, health monitoring, and often 24-hour on-site nursing staff, and nursing services. One feature of this model is that it offers specialized assisted living communities for people with Alzheimer’s disease. “This model focuses on health services and the concept of aging in place” (ALFA 1999:8). The benefits of this model are that it allows for the possibility of aging in place and results in a lower rate of resident turnover. The major roadblock for this model is licensing. “Even the inclusion of minor health services may trigger a requirement that the facility get licensed” (ibid.). Licensure can result for a provider if the setting supplies services that meet the definition of a licensed level of care for that state, whether or not it is called assisted living.
In a separate work, Hawes (1999) proposes a more detailed division of assisted living models. Based on a national study of 11,500 assisted living sites in the United States, she found that there are four basic types of assisted living that are represented across the country. Although not related to the models proposed by ALFA, Hawes’ four categories fit nicely into the two classifications discussed above.
The first type described by Hawes is termed “Low Service/Low Privacy.” Nationwide, this form represents 59% of the places that call themselves assisted living. In the low service/low privacy model, the majority of rooms are shared and offer ADL assistance only with bathing and dressing. Most of the services provided here would be for IADLs.
The second type of assisted living community Hawes refers to as “Low Service/High Privacy.” Approximately 18% of the 11,500 assisted living sites in the United States represent this model. Here, residents would likely have a private room (or apartment) and a private bathroom but not much in the way of ADL assistance. Hawes has also referred to this model as the “cruise ship” model because of its emphasis on luxury, privacy, and hospitality services. Of my two research sites, Kramer’s assisted living community would fit into this category.
The third type of assisted living described by Hawes is “High Service/Low Privacy.” In these assisted living settings, two-thirds of residents live in rooms rather than apartments, and slightly over 20% of the rooms are shared. All of the high service/low privacy sites in Hawes’ study had an RN on staff, and the respondents for these sites all claimed that they would retain a resident who needed nursing care. Nationally, only 12% of assisted living communities fall into this category. Assisted living at Wood Glen conforms to the High Service/Low Privacy category.
The final model Hawes presents is called the “High Service/High Privacy” model. This group offers both private dwellings for residents as well as a high level of services to meet both ADL and IADL needs. Approximately 11% of assisted living sites nationwide qualify for this category.
The Low Service/Low Privacy model and the Low Service/High Privacy model both conform to the first ALFA category above, Senior Housing with Non-Health Care Services. Hawes’ two models could be seen as a subcategory of the ALFA classification because both of these models have a lower emphasis on services, and virtually no emphasis on health-related care. The High Service/Low Privacy and the High Service/High Privacy models qualify under the second ALFA model because both are geared toward meeting the health needs of residents. This second set of models offers a greater possibility of aging in place because they can supply the needed health care and advanced ADL assistance that a resident may need to remain in assisted living. However, even the high service models do not guarantee that residents will be permitted to fully age in place.
The distinctions between these four models are critical to detail because several of the models Hawes presents do not adhere to the basic philosophy of care that is so central to assisted living. “Assisted living’s philosophy is to provide physically and cognitively impaired older persons the personal and health-related services that they require to age in place in a homelike environment that maximizes their dignity, privacy, independence, and autonomy” (Wilson 1996:10). Three of the four assisted living models outlined above would not qualify as complying with the philosophy of care stated by Wilson, and would therefore lack the essence of what assisted living strives to be. Presently, it will be useful to flesh out the various meanings of aging in place in order to provide a framework for providers’ and residents’ experiences in assisted living.
What does it Mean to Age in Place?
Aging in place is defined in the Dictionary of Gerontology as “the effect of time on a non-mobile population; remaining in the same residence where one has spent his or her earlier years” (Harris 1988:18). This strict definition of aging in place refers only to changes that occur to the occupants over time; it does not address the changing nature of the environment itself. In fact, several definitions of aging in place offered by scholars in recent years focus almost exclusively on changes in the inhabitants, overlooking changes in the environment (Mangum 1994; Callahan 1993; Merrill and Hunt 1990). Nevertheless, housing is not static.
In contrast to these narrow definitions, Lawton (1990) describes aging in place as a much more multi-dimensional phenomenon for seniors. “Aging in place represents a transaction between an aging individual and his or her residential environment that is characterized by changes in both person and environment over time, with the physical location of the person being the only constant” (Lawton 1990:288). Lawton’s definition clearly illustrates the dynamic nature of aging in place for both person and environment. Lawton also explains that three types of changes occur as aging in place happens. First, there are psychological changes in the individual over time. Next, the residential environment itself will change due to physical wear, the natural environment, and the behaviors of other people in the environment. Third, changes occur in the process of aging in place based on alterations the resident may make to his or her housing in order to create a more supportive, private, and stimulating milieu. Change is thus a critical notion to bear in mind when discussing aging in place.
More recently, elders are wanting to age in place in environments other than their long-time homes. Many older adults who move to senior housing settings want to remain in these environments and avoid any subsequent moves. Residents hope that services and the physical environment can be altered to meet their changing health needs.
Housing providers have responded to elderly persons’ desires to remain in senior housing in one of two ways. One response has been the “constant approach” and the other has been the “accommodating approach” (Lawton et al. 1980). The constant model tries to preserve the original character of both the tenants and the physical environment, to have both remain constant over the years. Within this model, residents are ...

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