Posted on aahsa.org

FutureAge: Looking ahead to the next 10 to 20 years, what issues concern you the most?

Maria Dwight: One is the economic realities of having a large elderly population, both from their ability to cope with the economic situation and society’s ability to serve them. I’m concerned that the workforce needed has not been trained, or wooed [into aging services], and that could be disastrous.

I’m also concerned about the access to health care and the appropriateness of the health care system, whether it can absorb the shock of handling non-acute, chronic health care, and the ability to seriously look at preventive medicine instead of curative medicine.

One thing that blew me away recently was at a meeting of the National Academies of Science, they talked about the impact of stem cell research. They talked about the amazing things that can be reversed or cured or ameliorated, from dementia to chronic disease. What will that mean to us? My hope is that people will live better, and that the technology will be not too long in coming and over the long run, could have huge impact on the quality of life.

I think we may see an absolutely astounding social change, the way we look at our lives, internationally and cooperatively. (I’m talking about those not of the lowest income.) In upper- and middle-income, people, we’ll see a thrust for knowledge and growth, not accepting stereotypes that preceded them, and the way they look at aging. AAHSA members should be looking not at sickness care but how to keep them healthy.

I think we’ll be an anachronism if we don’t change, until we understand that people want far more autonomous lives than we’ve allowed them. Things are going to change radically, and the Internet and technology is pushing that.

FA: Is this more than just the classic wellness model?

MD: Yes. I have problems with models. Everything is local. Those days of, “You like what we’ve got or we can’t help you” are gone. Can we tailor programs for different needs, whether in health, intellectual growth, or other things we haven’t looked at?

Another thing I hope is changing is the [treatment of] the end of life … both for those who are dying and those who love them. As part of the life journey, it is a very important learning experience for everybody. Through personal experience, I hope caregivers can get a deeper understanding of what’s happening. There’s got to be a new way of looking at that. And a new way of looking at multicultural living experiences. We’re living with people with disabilities and not hiding them away—the whole social norm is changing for the better.

One thing I think [is that] as a field and as individuals, we’re so damn serious! You’ve got to put fun back into late life. You have to have a reason to get up in the morning. You have to have some unexpected potential. Everything is so predictable. More spontaneity, more unexpected, unplanned, unregimented opportunities are needed.

FA: If the trend toward aging in place (and away from “institutional” or residential care) continues, is there a danger that those seniors will be isolated? What can we do about that?

MD: Older people will create their own solutions if the institutions don’t. I’m in Boston right now, the home of Beacon Hill Village and 303 Third Street, in Cambridge. I see a lot of co-op housing going up across the country. I think some people will want to live at home, but I see it in the boomers anyway, a great yearning for community, and a search for reconnection. A lot of people look for community. We see niche markets, such as the lesbian, gay and transgendered [community], and I think the search for community is strong in older people. I don’t think it will be what we think of as today’s CCRC. Get all the letters out of that except the “C” for community. I think there will be growth in that area, but don’t think our field is listening to that. There is also a huge imperative to be environmentally responsible and I don’t see our members responding. Among the public, 88 percent think it’s important. One provider told me recently that they were going to start recycling next month. That’s a 20-year-old idea!

FA: Regarding future consumers, there is a lot of conventional wisdom about what baby boomers will want 15 years from now. But do we really understand what they will want or need? Do they?

MD: I don’t think the boomers have a clue what they will want when they are old. I don’t think many people do. It will be a service-oriented society and it will be a two-class society. I think the first time the boomers ever bumped into the health system—the real health system—was with their parents, and they are disgusted. They will create some change in the next 10 years.

Conventional wisdom is also that boomers will have a second career and they will volunteer, and I haven’t seen any evidence of that. When we ask people how important it is to volunteer, they just don’t have the energy. The older cohort, those 70-plus now, are the last of the volunteers. The decline of the service organizations—Rotaries, Lions’ Clubs—will continue. I don’t think they’ll have the time. How are you going to start doing that if you haven’t all your life? This idea of second and third careers is great but you better make enough money in your first career to do so. It’s an elitist way of looking at late life.

But there are a lot of forward-thinking people [among providers] and those who really do get it. They have to be the advocates who change things. It’s got to be a peer thing that says we can do it. We can be successful, we should not hold ourselves back.

Written by Maria B. Dwight (President of GSI)

Published in Longevity Rules:  How to Age Well Into the Future, edited by Stuart Greenbaum

I’m old.  I am 75, which through no stretch of the imagination can be considered “middle aged” and certainly isn’t young.  Ergo:  I must be old.  I am not young-old, also euphemistically known as “an active adult.”  I am not “a frail elder” either and probably have a decade before I hit that benchmark.  So, I am just plain old.

There is nothing wrong with being old.  I still work 50 hours-a-week at a career that I love.  I don’t always make my bed before I go to the office, and often leave the dishes in the sink, but I still do the Times crossword puzzle, to keep away the dreaded brain atrophy, as much as for pleasure.  I eat well (sometimes, I must admit to peanut butter-folded over, over the sink).  I kayak, get undressed and dressed in the security lines within the three-minute allotted timeframe, put my own suitcase in the overhead bin, and other miscellaneous exercises.  I am very careful to take my vitamins, eat leafy green stuff and make sure that I drink the prescribed red wine for a healthy heart.

I must look 75 since the only nips and tucks in my body were followed by radiation, none of which are enhancing procedures.  My chin and my neck have slowly become one.  My waist must be somewhere between my breasts and my hips, but no longer invites a glittery belt and only seeks refuge under layers of tunics, capes or sweatshirts left behind by forgetful adolescent grandsons.

I am no longer carded at the movies.

I am old, but I am also very lucky.  I am one of the 12 percent of women over 65 who have a job, so I have health insurance as well as Medicare.  This means it is not a struggle to find a doctor who “will see me now.”  I am in good health, in spite of myself.  I have a good education.  My children are happy with their lives and are self-sufficient.  I have an annual income over the ($16k!) median of a “white,” “widowed” female.  I own a house whose mortgage will long outlive me.  I was frugal and tucked away my savings, only to have them evaporate in the last couple of years.  But I still have enough to live comfortably, unlike many of my age peers.  The early lessons of depression-era childhood have held me in good stead.  “Use it up, make it do, do without” was the mantra, along with “Turn off the lights!”

So now I am working on becoming a female curmudgeon.

I can’t seem to find new movies that interest me.  Spare me the retirement communities’ staples of Fred Astaire and Ginger Rogers.  Save me from the dreary reruns on PBS of passe rockers and crooners, and I couldn’t stand Lawrence Welk the first time around.  Why are movies so dreadfully loud, rude and gratuitously crude?  Who are these young women, like cloned Barbie Dolls, who seem to have forgotten to put on anything over their underwear?  And these wannabes of all sizes, shapes and ages who frequent my supermarket with their tattooed bulges on display?  And their beaus, conversely in clothes that are far too large and hang, often precariously and sometimes unsuccessfully, off their hips, sharing with us the brand of their boxer shorts.

What’s with the compulsion to be on the cell phone?  The plane lands and everyone turns on their phones to tell the world, in a chorus, that they just landed.  So?  People walk through stores and down streets talking to air.  Are they mentally ill or just impolite?

What is with this glorification of “multi-tasking”?  I was taught (often unsuccessfully) to do one thing at a time and do it well.  But I also was taught to save for a rainy day, to stand when older people entered the room, to not interrupt, to make my bed with hospital corners, to write thank you notes, to watch my language, to not take the biggest cookie on the plate and to chew with my mouth closed.

So, I am old.  I am one of the “Silent Generation” that was squeezed between the “Greatest” and the “Boomers.”  Our war was Korea.  We cam from small families and we spawned large ones.  We believed in “togetherness” and “at home moms.”  We volunteered in our communities and behaved… until we didn’t.  Then we led the most pervasive changes for social justice in our nation’s history.  It is our generation that crossed the bridge at Selma; marched on Washington, D.C.; rode the Freedom Buses; opened the doors for the Feminist Movement; fought back at Stonewall Inn; landed on the moon in Apollo 11; and redefined art, poetry and theater.  Elvis Presley was among the “Silents” and that boy could howl and he could rock!

So, keep on howling!  Rock on, all you old people!  Keep changing the world, or at least your part of it.  Don’t forget about the others who are old and keep their needs in the faces of the politicians and the bureaucrats.  Show all the younger generations what it means to be “Old and proud of it!”

Written by Maria B. Dwight (President of GSI)

Published in Living for the Elderly:  A Design Manual, by Eckhard Feddersen and Insa Lüdtke

Introduction

Every society in every country has its own special considerations and will seek its own appropriate solutions to improve and maintain the quality of life for its older citizens.   Every culture has its very special nuances.  Every individual has a personal set of values and expectations.   But people everywhere are seeking a quality of life that transcends just the need for medical care and shelter.   There is no best or correct model, but rather a multiplicity of appropriate responses which, when thoughtfully combined, will make the most appropriate model for that specific time, in that specific place.

As populations continue to expand and new generations of people enter late life in an increasingly technological and global community, the options and models will need to be flexible to respond to market factors.   The demands for less costly, less institutional responses will continue to drive the private and public sectors toward consumer driven innovation.

We in the United States are finally learning this lesson.  Our systems, fractured as they are, have failed the elderly in many ways.  I ask you please to learn from our mistakes, and move forward to a new, international era of quality caring within a compassionate, accessible and integrated system.

The Traditional Models

In the last 60 years, the major providers of housing and care for the elderly in the United States have focused their energies on emulating two diverse and equally inappropriate models.  The retirement housing segment looked for cues within the collegiate model of campus and dormitory.  The healthcare component, driven by the advent of the federal insurance programs of Medicare and Medicaid, followed the medical model as exemplified by the acute care hospital.  Within the rigid boundaries of such diverse environments, we have tried to develop continua of care, which have historically required the consumers to physically move from living space to health care space, depending upon their level of frailty.

The management concepts developed over this period were based on a hierarchical structure, with a paternal attitude toward residents and families.  Loyalty to the sponsoring organization was assumed, through brand names or religious or fraternal memberships.  The rigidity of the rules and daily schedule was not questioned.  The flow of information was controlled and narrow.  The focus was we are taking care of you.

The New Forces

Within the last decade we are seeing the unraveling of this model.  There has been a dramatic change in expectations and demands among older people.  They are seeking a different philosophy and new policies that encourage and support healthy aging.  They refute the concept that old age is a disease.  There are diseases common to late life and the aging process, just as there are those common in childhood and adolescence.  These geriatric diseases are overwhelmingly chronic, are often multiple and are usually treatable, but not necessarily curable.  This reality means that older people are aware that their lifestyles do and will play an important role in their health and in the quality of life in their later years.  They are looking for the services that will help them to stay mentally and physically active, and not simply for services to care for them when they are ill.

They are also looking for continued control over their lives, maintaining the dignity and autonomy that comes with self-direction and decision-making.  This is true throughout the age spectrum and should affect the operations of nursing centers as well as assisted living and retirement communities.

There is power in information.  Older people are finding access to information through new and varied conduits.  The internet has opened up new avenues .  Alternative and/or complimentary medicine has augmented or sometimes replaced traditional “western” medicine.  The use of vitamins, herbs and hormonal supplements is commonplace among the older population, as is the demand for therapeutic massage, and stress reducing exercise and meditation.  The concept of healing has taken on new dimensions that include spiritual as well as physical manifestations.

There is accessible information about all facets of life besides health care.  The knowledge of where to access reliable and valued services is available, as well as costs, quality measures and consumer satisfaction levels.  Our research shows us that older people are primarily seeking accessibility to, and quality of, services, to help them help themselves.  The old constituent loyalties are gone, having been replaced by the pursuit of quality.

This bursting forth of technology as an information source has had another profound effect on the future of service delivery among the elderly.  Most older people prefer to remain in their own homes until they die.  It is not an unreasonable expectation, which is now made more possible with the plethora of medical procedures that can be delivered in the home setting.  Tele-medicine (or rather Tele-health) has not yet come of age in the US, but its advent will allow people far more latitude in living arrangements, even in an advanced state of frailty or illness.  Adaptive and new technologies are being beta-site tested now, to make the homes of the future into intelligent environments, providing unobtrusive security, health monitoring and safety features.

This combination of forces; a new consumer cohort with new demands and new technologies with innovative applications, is creating cracks of significant proportion in the traditional models of care and service for older people.  However, we see builders and service providers perpetuating the old order, resorting to the comfortable past, controlling the information flow and maintaining systems that discourage consumer participation and decision-making.  To exacerbate the situation, the health insurance industry has another agenda, which is to reduce costs through reduced utilization.  If all of these forces were to come together in a reasoned fashion, we might construct a new policy and an intelligent approach to serving the elders of this country.

The New Models:   Life-long Living and Learning Centers

If the providers of housing for the elderly are to succeed in the future, they must reinvent themselves out of the past.  The college model has some attributes that can be salvaged.  The concept of collegiality and “environment matching” is sound.  People like to live with people who share their values and ethics.  However, most college students spend the majority of their time outside of the dormitory, as opposed to older people, who spend the majority of the time within their private space.  Our research shows that (regardless of income) this generation of elders wants larger dwelling units (a one bedroom apartment with a den is the smallest acceptable unit), more amenities within their units (washer/dryers, microwaves, kitchens, etc.) and less public or communal space.  This quest for privacy and individualism will become even more prevalent in succeeding generations.

The most intriguing part (and its raison d’etre) of the academic model was originally designed out, and now is being reintroduced.  This is the concept of the campus (horizontal or vertical) as a living and learning center.  We have worked with colleges and universities to create life-long learning centers because we have found that many, who are enjoying a longer span of healthy late life, are seeking out opportunities to continue to grow intellectually.  Many institutions of higher learning are seeing numbers of non-traditional students flock to their classes.  In recognizing this trend, and the increasing demand for healthy bodies and healthy minds we have had the opportunity to design integrated university and retirement campuses.  The ancillary services, such as security, maintenance, dietary, transportation, housekeeping, and health care will be amortized over both resident populations.  Academic classes and cultural, sporting and social events will be open to all who wish to attend.  There will be a symbiotic relationship between the young learner and the mature learner.  Some of the academic classrooms will be on the retirement campus, as will dining and hospitality services.  The interplay between the two populations will be self selected, and will not impinge on the privacy of either.  It is anticipated that many retired faculty will welcome retirement in this academic setting, as will many who simply seek an intellectually stimulating environment.

Other models have developed retirement communities that are physically close to universities and are intended to attract alumnae/i.  Our model has integrated the programs of the two campuses, and, I think, offers a more innovative opportunity for inter-generational living, within the boundaries of a retirement milieu.  It also makes efficient use of human and financial resources, which in turn keep costs competitive for the consumer.

However, with the advent of the “Virtual University” and distance learning centers, this model could be initiated in freestanding retirement communities or in the community at large.

Another aspect of college life that is applicable to the future campuses is the interest in healthy bodies.  The health club (a variation of the traditional gym) has taken a dominant place in the demands of the older cohort.  The health club, in fact, has replaced the health (or nursing) center in the hierarchy of demands.  This is expected to be a professionally staffed, dedicated space that includes a weight and exercise room, an exercise pool and lockers with showers.  The focus of these facilities is to improve balance and flexibility, as well as to provide a therapeutic environment and rehabilitation.

Managerial styles are also changing to accommodate these new expectations.  With more men surviving to late life and selecting retirement communities, and with more self-assured women with business and professional experience, there are more questions about management direction, and we are seeing resident participation on all levels of decision-making becoming more prevalent.  Information is more forthcoming.  Schedules are being developed based on the desires of the consumers instead of for the convenience of the staff.  Buildings are being remodeled or replaced, and programs are being redesigned.  Residents are Aging in place in their apartments, and services are coming to them instead of them moving to the services.  The desire to die at home includes a home in a retirement facility.

These shifts in service delivery are beginning to play havoc with other levels of care.  Assisted living has become the nursing home of the pre-Medicare past.  Nursing centers only care for those who are terminally ill, medically needy or in a rehabilitative regimen, or in late stages of severe chronic disease or dementia. But even in the healthcare continuum there are increased demands for consumer autonomy and self-determination.

The Health Care Continuum

Celebration City in Orlando, Florida, a Disney Community, has developed an innovative model with the Adventist Health System, which may well be the precursor of the future.  It is called HealthCompass, which is a personal health management tool that allows consumers to develop a longitudinal lifelong health record for themselves and their family members on the Internet.  The consumer remains in control of the record at all times, and can add to the documentation as well as allowing access to other providers.

Another dramatic example of this new concept in care provision is at the Kameda Medical Center in Japan.  John Wocher, Executive Vice President of the organization, has instituted a technological system that has created a film-less, paper-less hospital, that is patient focused and patient care centered.  Each patient has a computer terminal at bedside, which provides patient and family access to all records, notes, etc. on the patient’s history, as well as documenting patient preferences for the care staff.  The patient may add to the files.  The record goes with the patient upon discharge, and also becomes a part of a permanent longitudinal record of the individual’s health history.

Unique Populations

Developing retirement options for people of modest means has been a creative challenge.  We have worked on a number of innovative, adaptive reuse projects, which utilize existing structures and infrastructures to minimize capital costs.  We have also developed operational program models that integrate a brokered “care management” package for the residents into the existing community network of services, thereby reducing redundancies in service provision and personnel.  It also provides an integrated, cohesive package of services at a reasonable cost.  A concierge (not a social worker) accesses the system for the residents, or they can do it themselves through a personal or community-based computer.  Technology has been a vital component in making this an efficient and responsive management system.   Some of the adaptive reuse projects have included decommissioned military bases, mills from the days of the industrial revolution, schools, convents and hotels.

The increased life span and the increased number of elders have presented other new challenges in providing access to services to specialized populations, each of who has differing needs.  The demographic trends clearly indicate that dementia will continue to be a major health problem, which is difficult to address because of the wide variety of forms that dementia takes and the uneven progress of the diseases.  We have learned a great deal in recent years on how to humanely and sensitively care for people with dementia.  Both the therapeutic physical environment and the operational program have shown positive effects on behavior and quality of life.

We are also involved in a project for adult children who are developmentally disabled and their care-giving parents.  Medical advances have lengthened the life expectancy of many children who have special needs, and as their parents age, new challenges emerge.

We have also worked with populations who, in their late life, seek protective and separate environments.  Some are culturally or ethnically bonded, others are physically similar.  For example, a project for the Deaf elderly brought into focus the very special concerns that this population has.  The need to communicate and to share among peers becomes increasingly important, as one grows more physically frail and dependent.

Conclusion

The evolution in the United States from a post industrial, post technological society into the information age is having a profound effect on how we meet the demands of the elderly. Simultaneously, we are experiencing the influences of the largest, most highly educated, geographically mobile, affluent cohort of older people that we have ever had in our society.  The traditional ways are falling aside, and new models are rising. But the gap between rich and poor continues to grow. There are also many new ethnically and culturally diverse populations within our urban and rural communities, and many have immigrated with their elderly.  They, like many of their counterparts in their homelands, and their age peers here, are finding that the demands of this new society are breaking down the old order, and the traditional family responsibilities are no longer possible to undertake.

There are lessons to be learned from our evolution.  Often wisdom comes from understanding mistakes or misdirections.  Moments in history, political decisions, well-meaning attitudes, lack of knowledge: all have created the complex tapestry of the past.  As other cultures and countries make this transition from industrial or agriculturally based societies, they too will experience the pain of change but, hopefully, they will avoid some of our missteps, and will learn from our collective pasts. We have an awesome challenge before us as a global community.

Examples

Mirabella: Located in a new urbanism development on the Willamette River in Portland, Oregon, The Mirabella will take every advantage of the neighborhood’s extensive amenities, while also providing robust services for its residents.  It is affiliated with the prestigious Oregon Health and Science University, and is situated directly on the light rail line.

The Clare: Sited in the midst of urban Chicago’s most prestigious neighborhood, The Clare is a 55-story high rise, continuing care retirement community.  It first four floors are devoted to Loyola University, and the residents are developing shared learning experiences with the University. It includes a first class spa, dining venues with city views, health and wellness programs and concierge services.

February 2008

Sometimes to really evaluate change you need perspective–and the broader and deeper the perspective, the better. It would be difficult to exceed the long-term care perspective of Maria Dwight, who has had 40 years of consulting experience with gerontological service organizations of every description, including nursing homes and assisted living firms. Her widely known consulting firm, Gerontological Services, Inc., is celebrating its 25th anniversary this year. She and her staff provide expert guidance on all aspects of senior-oriented operations–from feasibility and marketing studies, to project development, to operational guidance, to technology integration, to advocacy for the “computer-innocent” in planning their information technology (IT) systems. During her long career–most notably in recent years, she says–the long-term care and services market has changed so much that were she starting out today, she would adopt a career path more oriented toward direct provision of services. Recently she reviewed her impressions of these changes and what they mean to the field in a conversation with Nursing Homes/Long Term Care Management Editor-in-Chief Richard L. Peck.

Peck: What to you have been some of the more striking signs of change in the marketplace in recent years?

Maria Dwight: A good example is Sunrise Retirement Communities’ “Condos for Life,” which bring all sorts of service directly to a resident’s condominium via a concierge service. The concierge may or may not be a MSW (master’s of social work), but he or she does everything from changing the kitty litter to administering IVs–a range of services so that residents can age in place. Sunrise didn’t go into this approach to home-based care out of the goodness of their hearts–they see it as good business.

Another model that fascinates me is the Beacon Hill Village in Boston. The program does not provide services directly to seniors living in their apartments, it acts as a broker for those services–screening them, contracting with them, and monitoring their performance with online satisfaction surveys. This approach makes a lot of business sense to me. From the service provider’s standpoint, association with Beacon Hill is a community’s sign of approval–and if the provider gets dumped, it risks losing significant market share. With this model there is more efficiency, less duplication of services, and more peace of mind. In exchange for knowing that someone providing services in their homes is prescreened, qualified, and bonded, people are willing to pay membership fees. This model is, to me, a cool idea, and if I were young and just starting out, being as entrepreneurial as I am, this is what I would do.

Peck: Some say that service operations like this are making urban revitalization to support senior environments a viable alternative. Do you agree?

Dwight: Yes I do. More and more I’m hearing people say this is what they want for their retirement years. They want walkability, they want ready access to stores and entertainment, they want educational resources and to be able to pursue lifelong interests. And they don’t want to be isolated.

Poor schools were a factor in chasing people out of cities in the past, but for empty nesters this isn’t a consideration. Of course, the neighborhood has to be safe, and transportation has to be good.

Peck: But isn’t this a major obstacle to revitalization efforts these days–the lack of clean, safe, adequate transportation?

Dwight: That’s true, although there have been some ingenious ideas for dealing with this. One is something called “zip cars,” which you see quite a bit of these days in San Francisco. This involves being able to rent a car by the hour, as needed, totally online, and not having to worry about all the responsibilities of owning a car.

Peck: One interesting demographic trend these days is people moving past suburbia into exurban areas, into what have been called “edge cities.” Do you think this demographic shift will figure into senior services trends?

Dwight: Right now I think pull is in the opposite direction, in the direction that we have been talking about. People who have spent their lives in the suburbs say they’re conscious of having missed something. Their lives have revolved around their work and even their friendships are professional. People today are looking for community. As empty nesters, they want to know how to reconnect with society and follow their lifelong interests. That is why the motivations for someone moving into a senior community today are so much different from those of older generations, who were primarily seeking healthcare and physical support. I see this change as very positive.

Peck: What sort of opportunities do you see in all this for facility operators providing skilled care and assisted living?

Dwight: Well, nursing homes these days are very much in flux. I don’t know if the Green House thing will pan out but certainly there will be a change of attitudes regarding senior care. Long-term care is moving strongly now to a residential model and to setting up or working with continuums that provide care and services across the board, including clinical care in the home. There are some interesting opportunities for joint ventures. For example, physical therapists are very hard to find these days so, if you have good physical therapists, why not share them with those providing home care? Why not use them in a way that the market is demanding today and, in that way, reach out to the community? That’s good marketing.

Peck: What about another form of community outreach–the wellness center?

Dwight: I’ve seen some skilled facilities having difficulty with that, probably because people have this innate terror about even getting close to nursing homes. But I’ve seen assisted living and independent living operations having success with this. They’re able to market their spas and specialized fitness centers and even their dietary services to the general community in an attractive, totally nonthreatening manner. This is excellent public relations for the providers who bring it off.

For further information, visit www.gsi.org. To send your comments to the editors, e-mail 2peck0208@nursinghomesmagazine.com.

Interview with Maria Dwight, President/CEO, Gerontological Services, Inc. (GSI)

Maria Dwight, President and CEO

Gerontological Services, Inc., Santa Monica, Calif.

FutureAge: Looking ahead to the next 10 to 20 years, what issues concern you the most?

Maria Dwight: One is the economic realities of having a large elderly population, both from their ability to cope with the economic situation and society’s ability to serve them. I’m concerned that the workforce needed has not been trained, or wooed [into aging services], and that could be disastrous.

I’m also concerned about the access to health care and the appropriateness of the health care system, whether it can absorb the shock of handling non-acute, chronic health care, and the ability to seriously look at preventive medicine instead of curative medicine.

One thing that blew me away recently was at a meeting of the National Academies of Science, they talked about the impact of stem cell research. They talked about the amazing things that can be reversed or cured or ameliorated, from dementia to chronic disease. What will that mean to us? My hope is that people will live better, and that the technology will be not too long in coming and over the long run, could have huge impact on the quality of life.

I think we may see an absolutely astounding social change, the way we look at our lives, internationally and cooperatively. (I’m talking about those not of the lowest income.) In upper- and middle-income, people, we’ll see a thrust for knowledge and growth, not accepting stereotypes that preceded them, and the way they look at aging. AAHSA members should be looking not at sickness care but how to keep them healthy.

I think we’ll be an anachronism if we don’t change, until we understand that people want far more autonomous lives than we’ve allowed them. Things are going to change radically, and the Internet and technology is pushing that.

FA: Is this more than just the classic wellness model?

MD: Yes. I have problems with models. Everything is local. Those days of, “You like what we’ve got or we can’t help you” are gone. Can we tailor programs for different needs, whether in health, intellectual growth, or other things we haven’t looked at?

Another thing I hope is changing is the [treatment of] the end of life … both for those who are dying and those who love them. As part of the life journey, it is a very important learning experience for everybody. Through personal experience, I hope caregivers can get a deeper understanding of what’s happening. There’s got to be a new way of looking at that. And a new way of looking at multicultural living experiences. We’re living with people with disabilities and not hiding them away—the whole social norm is changing for the better.

One thing I think [is that] as a field and as individuals, we’re so damn serious! You’ve got to put fun back into late life. You have to have a reason to get up in the morning. You have to have some unexpected potential. Everything is so predictable. More spontaneity, more unexpected, unplanned, unregimented opportunities are needed.

FA: If the trend toward aging in place (and away from “institutional” or residential care) continues, is there a danger that those seniors will be isolated? What can we do about that?

MD: Older people will create their own solutions if the institutions don’t. I’m in Boston right now, the home of Beacon Hill Village and 303 Third Street, in Cambridge. I see a lot of co-op housing going up across the country. I think some people will want to live at home, but I see it in the boomers anyway, a great yearning for community, and a search for reconnection. A lot of people look for community. We see niche markets, such as the lesbian, gay and transgendered [community], and I think the search for community is strong in older people. I don’t think it will be what we think of as today’s CCRC. Get all the letters out of that except the “C” for community. I think there will be growth in that area, but don’t think our field is listening to that. There is also a huge imperative to be environmentally responsible and I don’t see our members responding. Among the public, 88 percent think it’s important. One provider told me recently that they were going to start recycling next month. That’s a 20-year-old idea!

FA: Regarding future consumers, there is a lot of conventional wisdom about what baby boomers will want 15 years from now. But do we really understand what they will want or need? Do they?

MD: I don’t think the boomers have a clue what they will want when they are old. I don’t think many people do. It will be a service-oriented society and it will be a two-class society. I think the first time the boomers ever bumped into the health system—the real health system—was with their parents, and they are disgusted. They will create some change in the next 10 years.

Conventional wisdom is also that boomers will have a second career and they will volunteer, and I haven’t seen any evidence of that. When we ask people how important it is to volunteer, they just don’t have the energy. The older cohort, those 70-plus now, are the last of the volunteers. The decline of the service organizations—Rotaries, Lions’ Clubs—will continue. I don’t think they’ll have the time. How are you going to start doing that if you haven’t all your life? This idea of second and third careers is great but you better make enough money in your first career to do so. It’s an elitist way of looking at late life.

But there are a lot of forward-thinking people [among providers] and those who really do get it. They have to be the advocates who change things. It’s got to be a peer thing that says we can do it. We can be successful, we should not hold ourselves back.