Research Applied to Congregate Housing

              Research Applied to Congregate Housing M. Powell Lawton, Ph. D. Philadelphia Geriatric Center Although congregate housing is not a new phenomenon, there has been relatively little research devoted to housing of this type, as compared to the more usual housing for the elderly with minimal services. By far the greatest proportion of all senior-citizen housing was designed for original occupants who were still relatively independent. This planning decision necessarily dictated certain physical design features that may he uncongenial to the later addition of some kinds of services. Yet, the original population of independent tenants does age, and over a period of years the characteristics of new occupants may also change. Thus, what may originally have been an appropriate environment for the original occupants may, ten years later, be less appropriate. The 1970 Housing Act also at least legitimated the building of new housing environments of the congregate type. The need to re-think the suitability of older housing and to plan prospective designs for new construction makes it mandatory that we become aware of existing knowledge about the service needs of people in traditional housing, and how present-day congregate housing works. This paper will discuss a series of Issues in these areas, referring wherever possible to research done at the Philadelphia Geriatric Center over a period of years. The topics to be covered are: 1. The expressed service needs of elderly tenants. 2. The characteristics of people who choose congregate and traditional housing. 3. The frequency of different service programs in federally assisted housing. 4. The use of services by tenants. 5. The impact of services on tenants. 6. Environmental design considerations appropriate to congregate housing. 7. Management requirements for congregate housing. The expressed service needs of older people. As might be expected, it makes a great deal of difference whether a person is a community resident, an applicant for housing, or a tenant when one tries to determine his perceived need for the kind of services that might be offered within congregate housing. An even stronger determinant of perceived need is whether the person is actually receiving the service at the time the question is asked. As we all know, older people of todayfs generation have a strong tendency to evaluate positively their current situation unless it is incredibly bad, so that we need to take this current situation into account when ttying to estimate actual need. In two major research projects done at the Philadelphia Geriatric Center we were able to obtain some information relevant to older people's wish for services. One project was an intensive study of about 1700 older people who lived in 12 different age-segregated public housing and 202 projects or in scattered private residences in the community. Some of the housing tenants were interviewed before they moved in and again a year after occupancy, In the second study, a national probability sample of 103 public 202 sites was studied, as well as a sample of 3500 tenants housing sites and 50 currently living in those sites. One of the goals of both studies was to learn about as many of the issues associated with services as possible. Generalizing from the results of both studies, the most striking finding was the very high level of expressed need for some kind of regular on-site medical services among community residents, housing applicants, and tenants who did not currently live in housing that provided them. Almost two-thirds of all tenants expressed such a need, which is especially notable because such a lopsided proportion runs counter to the general tendency to express satisfaction with whatever one has. Conversely, only 3 percent o? tenants in several environments that did have medical services indicated any wish that there not be such services within their housing. It is more difficult to generalize about the type of services wished. critical point is the feeling of security that is conveyed by knowing that assistance is quickly available if one needs it; Therefore, the most generally approved form was an on~site medical clinic, with regular physician houss and with a nurse readily available. There was less general approval of more clearly The hospital-like facilities such as an infirmary or a semi-permanent special-care area within the housing. However, it should be noted that such "heavy" medical services become more acceptable as the health of the housing population declines. In such a case we have a clear instance of a tradeoff situation, where a minority-somewhere between one-fifth and one-third - of tenants express some discomfort at the idea of having visibly sick or disabled people living in close physical proximity to them. Yet, in more extended interviews with some of these people, the idea was communicated that the security of knowing that a service that they themselves might someday need was available was frequently important enough to outweigh the anxiety caused by the presence of a medical service or of visibly frail fellow-tenants. Thus, we concluded that some kind of arrangement whereby a physician could hold regular office hours, and where a nurse could be present for some period every day and on call for emergencies (i.e., a live-in nurse) would be extremely desirable. An infirmary or special-care area is probably best reserved for congregate housing that has both substantial financial resources and also a policy of accepting and maintaining people whose level of functioning ability is considerably lower than those who ordinarily live in housing without services. A very high level of approval was also expressed by tenants for the idea of having personal care services such as help with cooking, housekeeping, and -3- bathing available for tenants who might need them, ? This wish clearly represented \ a security-building mechanism, since relatively few tenants mentioned a current need for such services. With the exception of lilirtTniiMliilfI that explicitly cater to the marginally independent tenant, these services are probably beat provided on call for individual tenants in need, rather than across the board. It is, of course, very important that if personal care is announced as being available that it actually be deliverable. Transportation is, as we know, a vital link to almost all other need satisfactions. While one's own car rides from a family member, and walking account for the majority of most tenants' trip behavior, other transportation can make the critical difference in the case of individual tenants with disability, those without access to a car, those who wish to enrich their lives by utilising distant facilities, and those located In resource-poor or dangerous neighborhoods, Sini it is not surprising that half of our tenants felt that they would be willing to spend some part of a small increase in inconie to pay ; ; for bus service that would connect them with a shopping or business center. About four years separated the times of gathering data from our two research projects. This lapse of time was prabably quite significant in explaining the only major disagreement between the two studies in the estimation of a service need. Around 1967 we found that aiiacst one*third of community residents and applicants to housing (prior to occupancyx felt that they would like to have some on~site meal services when or if they moved into housing for the elderly. Y e t , the same applicants, after they had lived in housing without meal services for a year, as well as tenants who had been there an even longer time, ware notably less anxious to have this services provided--about 20 percent. W e interpreted this to mean that some confirmation of the person's ability to live a satisfyingly independent life was given by the year's experience in the n e w housing, so that the perceived need decreased. By contrast in 1971, a larger percentage, almost half, of our tenants expressed a need for some kind of on-site prepared meals. Since both of our samples were very large, it seemed that this change since 1967 reflected some real overall change in need. We can only speculate that part of the increased need may have been due to a possible overall aging of the population, and part of it to tenants1 increased awareness of the realistic possibility that such a program exists, through their knowledge of other housing with meals, the increasing incidence of nutrition programs, and so on. Thus, in the case of meals, we can say that not all tenants need or desire them, but that enough do to warrant serious consideration of modes by which those who wish seals oan have them, hopefully without demanding that everyone be forced to do so. There are, of course, serious economic problems associated with optional meals, a subject that I am not equipped to deal with. However, modes to achieve the ideal situation of individual choice ought to be vigorously pursued. The characteristics of people who choose congregate and traditional housing. All too often, the older person has little choice about where she will live. Seventy percent of the households maintained by older people are occupant-owned and therefore profide the lowest-cost housing possible. For many who would like to move because of the deterioration of their homes*the decline of their neighborhoods, or failure of the energy necessary to maintain a home built for an entire family, there is no housing alternative available within economic reach, and they are forced to remain in a less-than-ideal situation. For the minority who are fortunate enough to have access to purpose-built housing for the elderly - ? I estimate this number to constitute no more than 3 percent of * the older population -- simply having a decent shelter at a modest cost overThus, a person with a housing need may be rides every other consideration. -5- likely to accept the first opportunity afforded to move into any housing environment for the elderly, regardless of whether the non-shelter aspects of the housing suit her or not. Given these major restrictions on choosing what is right for oneself, one can sometimes find a small residue of older people who have the kind of new housing into which they move. some choice as to Looking at the choices made by people in moderate to higher income ranges may tell us something about the bases that the larger group might use if they had the option. Our research addressed this issue in a way that allowed us to compare moderate**income older people who chose congregate housing with those who chose traditional housing for the elderly. The sites that we studied in depth included three whose original occupants were almost entirely Jewish and had lived most of their lives in urban Eastern areas. Two of these sites had central dining rooms and some form of on-site medical services, thus having some characteristics of congregate housing. The third site had neither of these services; it therefore represented the traditional type of housing. We asked the specific question, fiAre the tenants who initially occupied the congregate housing measurably different from those who moved into the traditional housing?11 Our hypothesis was that the service-rich environments In fact, we found that would appeal to those in greater need of such services. those who moved into the congregate housing were, before moving in, significantly older, in poorer functional health, less active in organisations, less mobile, and less happy than those who moved into the traditional housing. I consider these findings exfjremely important for two reasons. First, they indicate that when given 1 choice older people? like the rest of us, assess their 1 needs realistically and choose an environment that has the best probability of meeting their need, The service-poor environment required its te&ants to do all their own shopping, food preparation, housekeeping and to travel to receive medical care. These tenants1 better physical, social, and psychological status -6- presumably would enable them to cope adequately with such demands* The second point to be emphasized is that the sponsorfs original &!?ntiin& ?f the level o F services to be offered seamed t? determine the char act er Is tic s of the j . tenants who would choose to apply. Tt is, of course, possible for a sponsor to apply either rigid or relaxed health standards for acceptance of a tenant's application. Our congregate housing sponsors probably could have excluded the least independent applicants had they tried hard to do so. However* they did not, and the result was that the combination of selective appeal to different ' kinds of people and of differing sponsor admission standards led to measureably different tenant populations, These findings thus demonstrate rather clearly that a range of alternatives is required in order to serve people with differing needs. They also indicate that a sponsor needs to be aware of the implications of Its early planning decisions. The sponsor of a service-rich housing environment might well have difficulty finding tenants should it insist on very high health standards. Even if such people did fill the building^the sponsor might in actuality be forcing the exclusion of those who can benefit most from the services. The frequency of service programs In federally-assisted housing, The Philadelphia Geriatric Center's survey was based on a national sample of 103 public housing and 50 202 projects and thus afforded &n estimate of the frequency of services in these kinds of housing throughout the country. Every 202 and 92 percent of the public housing sites conducted some kind of activity program. Thus3 organised activities are part and parcel of planned housing and thus not In any way specific to congregate housing. The situation is totally different with respect to other types of services. Slightly less than one-quarter of both 202 and public housing sites had any kind of medical services available on the site for its tenants. AMttg this minority of sites, very few had either physicians or nurses who were actually -7.