The Community of the Future

From Retirement Communities of Care to Communities of Meaning

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.