Presented at the special invitational conference, Comprehensive Congregate Housing for the Elderly: Advancing Research and Practice, May 11-12, 1984 in Chicago. CONGREGATE HOUSING OVERVIEW: THEORY THROUGH APPLICATION M. Powell Lawton, PhD During all of my 20 years in gerontology, housing has been a major concern in policy, service and research. Every scientific meeting, most continuing education workshops and many issues of professional journals have typically dealt with housing issues. It is thus difficult to understand why so little of this attention has been devoted to the genre of housing that concerns us today, congregate housing. I could think of Wilma Donahue1s conference (1977) and the Boston meeting (Chellis, 1982)as the only predecessors of this meeting. The journals and workshops have devoted very little attention to this topic. I should like today to demonstrate why congregate housing should occupy our attention more than it has. Til begin by looking at the history of congregate housing and then consider where congregate housing fits in the total continuum of long-term care and residential long-term care. Then I shall discuss systematically the needs that can be served by congregate housing and end with some suggestions as to how to improve the congregate housing of the future in its ability to meet these needs. But at the beginning we need a definition of congregate housing. The term "congregate11 was used by gerontologist Robert Kleemeier (1959) to refer to institutional practice of having all residents do the same thing at the same time -- this is one of three essential features of residential care organizations. To my mind, it was an unfortunate choice to apply this term to service-rich housing because it connotes an institution, where we wish emphatically that our environments be homes. Nonetheless the kind of meaning is apt, that one -2- form of behavior is performed in congregate style that is not commonly done in private homes -- eating regularly with others. Eating together is done as part of a larger package of supportive services, whose exact form may vary considerably. My definition, then, is: Congregate housing is a residential environment for older people that offers age-appropriate shelter, one or more communal meals per day, and other services designed to insure a minimal level of satisfaction of basic needs. Congregate housing and the spectrum of services This definition thus makes clear that congregate housing is a package of hard and soft services. Further, its services may be characterized as supportive rather than amenities. This distinction is subtle and doesn't always work, but it is an essential one. Supportive services are provided to compensate for early losses of function. Amenities are services provided for people's convenience and to satisfy their preferences. Both ideally and to some extent in practice, the two types of services imply different users. The distinctive feature of congregate housing, and the most compelling reason for its importance in today's housing scene, is that it provides for the needs of a group of users that may be at risk of institutionalization because their functional capacities are beginning to diminish. There is considerable talk that congregate housing can be a major alternative to institutionalization. In what ways would we expect the consumers of congregate housing to exhibit losses of independence? Some find the burden of keeping up an independent household, including the care of the dwelling unit and the yard, to be the first motivation for seeking new housing. -3- However, the need for easier maintenance is widespread. This need can be served by ordinary new housing as well as by congregate housing. Often, however, the same need occurs in combination with a decrease of energy for such tasks as shopping. The real core change, however, is apt to be more psychological than physical: The realization that the future will bring increased frailty and therefore a growing concern over security. This psychological appraisal is frequently phrased to oneself as, "What will happen to me if I can't take care of everything myself?11. Thus, people may be foreseeing impairments more than reacting to contemporary impairments. In many ways, then, congregate housing is an alternative for people who plan for their future. The picture is clouded, however, by the fact that almost eyery service offered by congregate housing can be an amenity, rather than a support, for some people. There are people who have always hated food shopping and can't wait to be relieved of that task; people who think of being served most meals as the height of luxury; people who are seeking a socially stimulating environment and view the congregate meals as the vehicle for this goal. These people probably show few personal impairments and may even have little conception of the protective quality of the congregate housing environment. Thus the potential clientele for congregate housing will likely be a fairly mixed group, composed of those who have begun to decline, those who see themselves as being at risk of imminent decline, and those in search of the easy life. Thus the character of the congregate housing environment will need to be composed of elements that satisfy the needs of all constituents. -4- The Major Needs of Tenants The proportion of all tenants who move into congregate housing partially to satisfy needs for security is very high -- the amenity-seekers are in a minority. People see themselves as possibly requiring assistance in a wide variety of activities, which should be considered part of the service package. I shall speak a little later about the form of the services. The types of services that are normally provided include, first, the obligatory congregate dining service. Others, though they are not mandatory in the HUD requirements for congregate housing, ought definitely to be present: Transportation, activity programming, major housekeeping and janitorial services and counseling. Another subgroup of in-home services should be available, but optional, utilized only by those whose condition demands it: Daily housekeeping, home health visits, shopping assistance, home-delivered meals and assistance with personal care. Finally is the yery difficult question regarding the type of health care that should be available within the housing environment. A greater variety of possible forms for health care exists than one would think from reading the literature on congregate housing. Note that to me the issue is what type, not whether such services ought to be part of the service package. Some writing about congregate housing has attempted so strongly to emphasize its independence and growth opportunities that an impression is created that there should be no health-related services. What is meant, however, is usually that there should be no long-term nursing beds or no infirmary in the housing. In fact, some provision for health needs is as essential as the -5- congregate meals. Once more, however^ the psychological aspect may be more important than the actual mechanism. That is, eyery tenant must feel psychologically reassured that a channel to both regular and emergency medical care is in place and dependable. Consider the many possible channels: 1. Many people, especially while they are vigorous and engaged socially, will simply depend mainly on themselves, their local physician, or their closest relative, as they have done all their lives. They require little from the service package. 2. For some people's psychological comfort, and for all people's emergency use, a special mechanism needs to be established whereby someone responsible to management can take charge in an emergency. During the normal work day, management itself can provide such oversight. Off hours, however, people should not have to depend on someone present only during the work day. Therefore, an on-call resident professional is extremely desirable, if not mandatory. A nurse would, of course, be ideal, possibly a nurse who is also a resident, although this person must be on the payroll or otherwise compensated. 3. Active services, rather than only a channel to services, may be more desirable. Again, there are many forms that such services can take. One is simply to maintain a clinical office where regular office hours may be kept by a community physician, a physician's aide* or a professional in the employ of the housing management. Such arrangements may, of course, provide treatment in emergencies. They may also operate as health-maintenance services or as a dispensary of minor clinical services. -6- 4. A formal medical service may be provided by people employed by the housing. This kind of service is expected to be the major out-patient resource for tenants and, of course, would need to operate with regular hours eyery day and have provision for off-hours coverage. A physician and nurse would need to be on the payroll of the sponsor. The really big question is whether nursing-care services should be available as part of the residential package. Before making any suggestion regarding the desirability of long-term nursing services, I shall suggest three forms in which this service might be provided. The first is the on-site nursing unit, which forms one component of a multiple-level care complex. Life care represents one way to achieve the campus arrangement, but there are many other arrangements possible where the financing of the residence and the nursing home are not linked. This might happen where a nursing home decides to build a congregate housing unit on its grounds or when a housing environment decides to expand in the direction of nursing care. The second approach is for the sponsor of the housing to build a nursing-care unit in some other location, while maintaining a single administrative structure for both components. In the third approach, the housing component would, through a combination of a formal agreement with a separate nursing home or active care management, guarantee the housing tenant access to nursing care when and if that should become necessary. I thus suggest there should be no situation where the congregate housing stands alone without a nursing-care component, either a physical entity or a guarantee of assistance. The nursing-care component is an essential aspect of the marketing of congregate housing. It is impossible to overestimate the depth of anxiety -7- that people have of being in acute need without the personal fortitude to procure their own assistance. They fear that a sudden illness or even mental deterioration will leave them unable to make decisions about leaving the residence, helpless in locating aternative care, and unable to make a radical change in household. They also put a high value on relieving close family of the burden of some kinds of care. Finally, a substantial segment of people who live in planned housing of all kinds have no close relatives. Thus we can be certain that everyone looking for congregate housing hopes that this will be the last major housing search she has to make. Whatever are the arrangements to guarantee care or oversight need to be made evident to the prospective tenant, in an unobtrusive way. Life care has been very successful in its traditional form, that is, a nonreturnable large front-end payment combined with monthly charges adjusted only for costs, but not for the change from residential to nursing care. There is no question that the continuity of care guarantee is the major basis for the appeal of life care. Although the preferred mode of financing and payment seems to be changing, the essential feature of continuity on the same campus is being preserved. With such success, one may wonder why there should be any form other than that of the compus that includes both residential and nursing components. There are, in fact, two reasons why other models are needed. First, not every sponsor has the expertise or the motivation to develop and manage a nursing home in addition to housing the problems of congregate housing may be major, but those of delivering nursing-home care are even worse. Therefore, a sponsor must be free to decide on the limits of its expertise. -8- A second indication of a need for something other than the full continuum of care involves the knotty problem of the competence mix of tenants, alluded to earlier in the contrast between security and amenity needs. Although ewery congregate housing applicant has the need for security somewhere in her consciousness, not all are willing to have that reality facing them everyday in the form of a full view of the nursing home component or repeated face-to-face contact with impaired residents., As long as the channels to obtaining nursing-home care are kept open and guaranteed, some tenants1 needs may be met best by a freestanding congregate housing environment. Thus the campus arrangement may not be the best for everyone. I want to comment at this point on a subvariety of the campus concept, the retrofitting of an acute-care hospital complex with a congregate housing addition. Recent years have seen substantial interest in this type of arrangement among hospitals. The idea is sometimes appealing because land (or even worse, outmoded hospital buildings!) is available. The more usual direction of expansion is in the nursing home, a natural in the face of the new Medicaid reimbursement system involving flat rates for diagnois-related groups (DRGs). It is very possible sheltered, nonlicensed, housing may become useful to hospitals as a temporary placement for longer-recuperating patients. In any case, I have very little enthusiasm either for the physical location of housing yery proximate to a major acute hospital or for the philosophy of housing management that might be espoused by professionals from the medical-model tradition. Thus, where there are ways to buffer housing tenants from a proximate nursing home, so that the proximity is an advantage, there is no way to buffer tenants from the impact of a next-door acute hospital -- this then becomes a negative locational characteristic* Closeness may be desirable, but even at worst, emergency transportation is usually adequate for access to acute hospitals in urban areas. -9- The Need for Activity and Engagement The major emphasis of this presentation inevitably is on security because this seems to be people's most critical need. We need to be very careful that recognition of this fact does not blind us to the importance of maximizing satisfaction of the contrasting needs for activity, independence, autonomy and continued engagement with the larger society. Housing offering high levels of support is at great risk of undermining the motivation to maintain independence. This assertion may seem ridiculous to anyone who has observed the vitality and self-determination of resident life in continuing-care communities. Many of these are notable for their dawn-to-midnight round of activities organized by tenants themselves. One that I visited recently reported proudly that its 50th active committee had just been established. There is no doubt that having a resident constituency with a background of enriching interests and self-directed behavior helps a great deal,. Where the tenant group had such earlier-life advantages, such continued activity is very likely to continue with little active effort by management. Management must be particularly careful not to assume that more direction or participation by administration than is necessary becomes aggressively offered to tenants. Tenant groups with less earlier experience in proactive behavior will be much more vulnerable to erosions of independence. A much finer line between fostering autonomy and doing for the tenant must be tread by management. It is very likely that management may need to launch a resident organization, contribute a nest egg for a resident-planned activity program, and consult - 10 periodically. But they must also know when to get out. The matter of services constitutes another soft spot in the attempt to affirm independence. Viewed in one way, services being offered to people conveys a message of incompetence. Beyond this covert message is the potential desire and decay of skills that comes when everyday tasks are performed for a person by others. Such risks require active planning and effort to counteract. First, the physical environment itself must support the maintenance of skills. Unquestionably the worst possible decision is to build living units without kitchens. Without a kitchen, the environment becomes an institution. My experience has been that when there has been trouble keeping units in multicare campuses occupied it has usually been in the domiciliary section, where rooms without kitchen facilities are offered. Even where the likelihood is poor that the kitchen will get much use, a minimal traditional-looking kitchen is worth the investment for its symbolic value. Unfortunately some reduction in residents1 choice regarding the use of the communal dining room is necessary to produce a large-volume preditable-- enough flow of paid-for meals. With this compulsion taken for granted, how can perceived self-determination be salvaged? One way is to make sure that some choice is maintained. For example, a quota of meals rather than all meals, or the option to pay for one, two or three meals a day. Another way is to make certain that the dining room is treated like a restaurant rather than an institution. This means monitoring carefully the behavior of waiters, the provision of choices at every meal, perhaps a menu or an order card, decor like a restaurant, some flexibility of seating times, open seating, and the avoidance of institutional practices like public address-system announcements at mealtime. - 11 - Another approach to creating an atmosphere of independence is in the physical design of the facilities for medical services. This means a high level of confidentiality regarding people's medical conditions, the furnishing of clinic space as a doctor's office (perhaps with a choice of an entrance from the outside or an exit not through the waiting area). Programming can feature wellness and health maintenance. Advantage may be taken of the general interest in excercise and positive life styles for classes and activities on these themes. Weekly major housekeeping does not seem to cause people to feel incompetent. Help with housework seems to be a function that most people are able to view as an amenity rather a supportive service, as is transportation. More problematic are the services that are appropriate to the genuinely impaired, which are viewed in that way by tenants, such as daily housekeeping, meals served in the dwelling unit from the main kitchen, or personal care. It goes without saying that such services should be applied conservatively to residents of congregate housing. Targeting them only to those in need saves scarce resources at the same time it avoids undermining people's wishes to do these things for themselves. Among people with comfortable incomes, many marginally independent people will hire or have provided for them companions or attendants. The presence of very many such people on a daily basis can change the social milieu considerably. Management would do well to provide some guidance to residents and their families in the form of suggestions about when such a person becomes necessary. This effort would usually result in diminishing the number of aides; my experience is that families will more often move too early in the course of decline to insist on such help. Management should also discourage wearing whites by such outsiders. I have written about the processes of change over time in the character of planned housing environments. Briefly I suggested that although the -12 - average direction of change over time was downhill in a biological sense, housing environments had an option in controlling overall change in their social environments. Housing that accepts marginally competent tenants, allows them to remain during the process of decline, and that increases its services in response to changes in tenants represents an "accomodating environment11. Housing that maintains stringent health standards for admission and continued residence and that does not augment services is a "constant environment".(Lawton et al., 1980). By now we have studied seven such environments over periods ranging from 12 to 24 years. The three congregate housing projects were more likely to have accomodated, a not surprising finding. Since the housing was planned and built with some services in place, it was easy for management to fit in with the growing needs of tenants for services. Not all the sites behaved in the same way, however, whether they were independent or congregate. For the majority of environments, despite the yery significant incrase in age over time, the decline in functional independence was not nearly so great. One congregate housing site had started, in predictable fashion, by recruiting an initially marginally independent population. After 12 years, however, the functional health of its tenants had decreased less than had that of several other projects. Management revealed that they had made active effort to moderate the general decline in tenant health by seeking initially healthy tenants. It is of considerable interest that the slope of change in health was considerably less steep than that of change in chronological age. This clearly means that there is a strong selective factor determining who stays and who leaves. In part, of course, this is because the least healthy die earlier; conversely, the survivors are the most fit. Managers observe, in addition, - 13 that the most impaired residents and their families more often than not recognize at some point, on their own, that continued residence in the housing will become strainful enough to destroy any possibility of a good life. These families seek a change to an institutional environment on their own. The most painful administrative task is to initiate such a change against the wishes of the older person. However, this appears to occur less frequently than has been assumed. Thus, one strong force toward constancy in the environment is the resident's accurate and self-initiated assessment of her own capabilities and the best environment to match these capabilities. The extreme accomodation observed in the other two congregate environments we studied appears to have had more negative results. While there has been no drift toward any of the physical features of an institution, the high percentage of frailty gives a distinct impression of a "sick environment11. One result has been that new applications come only from the very old and often frail, thus systematically compounding the general decline in competence. Marie McGuire Thompson (1978) has suggested an ideal mix of tenant capabilities on admission, one designed to promote a general impression of wellness. My evaluation is that this is too heavily skewed in the direction of high independence; one ought to have more than half for whom the communal meals represent a true supportive service. It is, of course, important to seek actively a steady stream of replacement residents who are unimpaired. Since annual turnover is only five to eight percent, in most environments this may mean that all incoming tenants be screened for excellent health. It will be similarly necessary.to establish criteria for separation that control any buildup of people who are more suitable for institutional care. - 14 - It is easy to see the advantage of having one's own nursing-home component. This unit affords greater flexibility in individual decision-making and more immediate responsiveness to a change in a housing resident's condition. Without such a unit under the same administrative umbrella, extra effort must be made to create a responsive channel. For completeness let us consider the consequences of extreme accomodation, certainly an allowable choice for a sponsor. The only possible outcome would be a slow emergence of a true institution. In terms of our current experience such a change might take 20 to 25 years. Considering that our buildings will be expected to last at least 50 years, the prospect for a 25-year half-life as an institution is a good one. To do so would require planning for that outcome at the very beginning, so that such licensure requirements as hallway width or exiting time could be in place without prohibitively expensive physical reconstruction By some standards, there would be an underuse of resources, for example, the kitchen and some proportion of the living space. For some, the extra space would be very functional for the use of companions or live-in help. This option would be expensive, but conceivably one for which some people would pay in return for the privilege of total continuity of care. Nonetheless, it is unlikely that this model would become adopted by any large number of sponsors. Our research on the developmental history of housing environments is useful in providing guidelines for long-range planning that ought to be in everyone's minds during the very earliest stages of conceiving congregate housing. Let me first underline our finding that the frequently voiced fear of precipitous general physical decline in initially relatively healthy resident populations has been magnified. There is decline, but a compensating - 15 - tendency for survival of the fittest is clearly evident. We found that about 17T of our tenants 12 to 14 years later had some substantial impairment in the major activities of daily living: ambulation, cooking, housekeeping, and bathing. Only seven percent could be characterized as having major unmet needs in these areas,-and that number verged on zero in congregate housing. Thus housing-based services do truly extend the period of independent living (Lawton et al., in press). Let me end with an interpretation of our data on the social and psychological outcomes in housing over time. Our results were derived from people in relatively low-cost housing serving people with primarily workingclass backgrounds. They would surely be moderated if performed on housing occupied by more affluent people who had had more enriched backgrounds. Nonetheless they are extremely valuable in illustrating a prime concern for longterm management. Briefly, there is a tendency for the social vitality of housing environments to dissipate over time. People named fewer friends and decline notably in the more active form of social behavior, visiting one another's apartments. Even the strong bonds to family showed some signs of loosening. There was less contact with family even when account was taken of marital status and number of living children. A major decline also occurred in the amount of participation in activities away from the housing site and a turn was observed from active toward more passive activities. Corresponding declines in psychological well being and perceived quality of life occurred. We know, of course, that all of these indicators of wellbeing are highly correlated with health; since health declined somewhat, part of the psychosocial decline may be understood in these terms. Interestingly, another portion of the decline was explainable in terms of age but independently of health. It may - 16 - be that a lessening of energy may occur even though disease-related health does not. But even with both of these factors accounted for there was still a measurable decline in most of the indicators of well being over time. Our data contain no direct explanations of why this should take place. One plausible speculation is that a closed community composed of people who spend little time in regular employment has a tendency toward entropy., Without constant vigilance among both tenants and management, the easy, passive alternative in decisions as to how to spend one's time may become more frequent than necessary. One's advice to management in attempting to counter this trend may well conflict with that given earlier in relation to fostering self-determination. How can management attain the best outcomes as it deals with the dialectic between active support and encouraging autonomy? I see the need for new research that would probe in fine detail the daily life of housing environments to try to detect ways in which more opportunities could be offered residents for leadership, decision-making power, meaningful work roles within the housing, and incentives to maintain both social and instrumental skills. I think that management needs more instruction in curbing the natural instinct to help than it does instruction in how to help better. If one provides a supportive environment it is natural to want to help. It is less easy to discriminate when and how the help should be carefully metered. One of the questions requiring most new knowledge and most careful qualitative observation and application is how to tailor the ease of access to specific types of help to particular people's needs. Few people are impaired in eyery sector. Why should all have to have a relatively similarservice package? Even some ordinarily across-the-board services might be moderated in their coverage. A token rebate to people who - 17 - would forego the weekly cleaning might motivate some people to keep up their skills. Transportation may be even more complicated to apportion. People who still drive might be encouraged to drive themselves for daytime shopping, but encouraged to use the van for an evening in town. Special off-site entertainment opportunities should not have on-site activities of very high appeal competing with them. Subtle encouragement may be given to occasions that would place a resident in another's apartment -- a friendly visiting program; small committees asked to meet in a resident's home rather than in a public room, for example. Greatly needed are a whole catalog of such ideas, based on the principle that continued exercise of skills with incremental but significant accomplishment is possible as a counteractant to decline, even in environments whose function is to be supportive. References Chellis, R.D., Seagle, J.F., and Seagle, B.M. (1982). Congregate housing for older people. Lexington MA: Lexington Books. Donahue, W.T., Thompson, M.M., and Curren, D.J. (1977). Congregate housing for older people. Washington DC: U.S. Government Printing Office. Kleemeier, R.W. (1959). Behavior and the organization of the bodily and the In J.E. Birren (Ed.), Handbook of aging and the external environment. individual (pp.400-451). Chicago: University of Chicago Press. Lawton, M.P., Greenbaum, M., and Liebowitz, B. (1980). The lifespan of housing environments for the aging. The Gerontologist, 20^, 56-64. Lawton, M.P., Moss, M., and Grimes, M. (in press). The changing service needs of older tenants in planned housing. The Gerontologist. Thompson, M.M. (1978). Assisted residential living for older people. Washington DC: International Center for Social Gerontology.
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