It is an article of faith among many in the elder and disability advocacy communities that aging in place is always the best alternative for someone who needs personal care. I don't believe it, and I recently heard an important panel discussion that confirmed that view.
The panel, sponsored by Washington Grantmakers, was especially interesting because the participants were all supporters of community caregiving. But they agreed that, without a strong infrastructure of family, community, and public support, it is not always possible for people to live at home. Indeed, it can often be lonely and even dangerous.
University of Florida professor Stephen Golant, who has written extensively on housing and care alternatives for seniors, reported that his research finds six major challenges to the frail elderly living at home. They include affordability, physical deficiencies of homes, lack of social supports, neighborhood changes, difficulties accessing community assistance (especially in both inner cities and cul de sac suburbs) and vulnerabilities of old age including greater risks of accidents, poorly trained family and paid caregivers, and even abuse.
Golant concluded that those most at risk staying at home are low-income, very frail, poorly educated women who are 85 or older and either living alone or with a frail spouse. This seems obvious, but these are the very people who have the fewest alternatives. For most, high-quality assisted living or even independent living are far beyond their financial means. Golant says those at most risk are not the very poor but the nearly one-third of seniors he calls "tweeners," who do not qualify for public programs but can't afford to private pay for housing with supportive services.
Golant suggests that addressing these issues requires "changing the aging in place dialogue." Doing this will require society and families to recognize that living at home is not always the answer, and that focusing on group care may make more sense. This can mean thinking about senior villages and other naturally occuring retirement communities where care can be better coordinated and delivered much more efficiently.
Charles Smith of the Montgomery County (MD) department of aging and disability services said that it is increasingly difficult for government to deliver the services necessary to support people aging at home. Budgets are being slashed and physical distances make it tougher to provide assistance, especially in the suburbs. Smith said that in sprawling Montgomery County, it costs five times at much to deliver a meal to a suburban house as it does to buy it. Transportation services, the single most common need for those at home, face the same difficult combination of smaller budgets and greater distances.
"We are creating expectations that you should age in place," Smith says, but government doesn't have the resources necessary to meet those expectations.
Rev. Joseph Williams, executive director of Emmaus Services for the Aging, a private non-profit in the District of Columbia, added that grassroots community support is essential for people to age at home. "It can't all happpen in the department of aging," he said.
None of this means those of us caring for our parents should not do all we can to help them stay at home, if it is appropriate. It does mean that just saying the words won't make it happen. Rather, it will require communities and families to work together to back up the sentiment with real resources, including both time and money. It is a fantasy to believe that assistance will come entirely from government, which will be increasingly strapped for funds in coming years. It will also require us all to recognize that some of our parents will be far better off in a congregant care setting.