A patient of mine and I were discussing what options we will have when we are no longer able to care for ourselves. This is a source of much worry and some fear for many Baby Boomers, and with good reason. As we move into our 70s, 80s and 90s, it is quite possible that we will not be able to remain independent and will need to consider alternative housing.
To a person, the most frequent statement I hear is, “I am not going to a nursing home!”
Many of us born at the tail end of the Baby Boomer generation won’t have to worry about going to one because there will be no vacancies. There are not a lot of nursing homes currently being built because that model of care is falling out of favor and is too expensive and difficult to maintain.
Which leaves us with a dilemma: where will we end up?
Typically, older Americans who own their own homes move three times before they die. The first is from the “family home”, to a smaller, more manageable property. The family home was most likely bought specifically to start a family, and now is either too big for Mom and Dad, or not close enough to where the children live. This move is most commonly done when folks are in their mid-60s. When they are still active and are anticipating they will continue to stay that way.
The second move is from the downsized location to either a retirement community or some type of assisted living. The retirement community is typically some form of homeowner association where dues are paid to cover maintenance of the grounds and amenities ranging from golf courses, swimming pools, tennis courts, and other activities. Assisted living is similar, but frequently includes a more communal setting (apartments), shared dining experiences, and possibly housekeeping, transportation, as well as lectures, games, or enrichment activities such as art, music, and exercise. Medicare and Medicaid doesn’t pay a penny for these types of living situations.
The final move is to a hospital and then stepped down to a nursing home or long-term care. Medicare Part A covers the stay in the hospital, and 100 days in a nursing home. Medicare does not cover long-term care.
If you are not in the economic class where you have property as an asset, your options are much more limited. Depending on your income, you may need to get on waiting lists for Federal programs such as Section 8 housing vouchers. This program reimburses landlords and guarantees your rent will be paid if you can find someplace to rent that takes these vouchers.
Many communities have organizations that have built and maintain supported housing for low income renters. Some of these units are reserved for older adults. Typically they are in high demand, as there are fewer units reserved for the elderly than for families.
If you have physical or emotional issues, you may qualify for board and care housing under your State Medicaid program. This is a communal living situation where between four to eight residents share a house (board) and are provided meals by employees (care). These types of homes are subject to restrictions on what can and cannot be provided to the residents in terms of services and are typically licensed by the State. Usually residents are on some form of assistance such as Medicaid in addition to Medicare. Employees do not have to be specially trained or licensed.
The reality is that we do not have sufficient affordable housing for our elders in the U.S. Older adults are living longer. Developers are not building new units. We are already at a critical mass, with more Boomers on the way. Communities are going to need to get creative to meet this need.
There are several initiatives that are addressing this problem, but unfortunately, leadership is in short supply from both State and Federal governments. This leaves solving this problem up to us. AARP Foundation, Archstone Foundation, SAGE-National LGBT Elder Housing Initiative, are but three of many non-profits, private foundations, and local community members who have been looking at and contemplating this problem for several years now.
Co-housing is an intentional community of private homes clustered around shared space. Each attached or single family home has traditional amenities, including a private kitchen. Shared spaces typically feature a common house, which may include a large kitchen and dining area, laundry, and recreational spaces.
The “Tiny House Movement” is actually international, with people from all over the world seeking to downsize (quite literally) in order to leave a smaller footprint environmentally, but also provide affordable housing.
But will this be enough? Historically, government has led the way in addressing the larger social issues that have confronted our nation. FDR addressed the need for providing an income to every American when they were out of work. LBJ saw to it that health care was made available to those who were 65 and older or disabled. Currently there is a void of statesmen and stateswomen who have the legislative acumen and influence to pass a law that would guarantee housing be provided to those who need this key component to insure their safety and quality of life.
I will leave you with a brief story from my private practice. I was working with a woman who had been a professional at one time, who had raised a family, gotten divorced, and then succumbed to alcoholism and depression. She was intelligent, resourceful, and proud. Her circumstances had changed dramatically, and when I first saw her, she was living in her truck. She had recently been discharged from the hospital, where she had been treated for a severely broken ankle. Her rehab consisted of two or three days in a nursing home (which she couldn’t stand) and then her own version of homeopathic care. She was in her late 60s and had only occasional contact with her children. She came to the clinic where I worked for her primary medical care and for therapy with me.
We worked for several weeks on her relationship with alcohol. She was willing to stop drinking, had good pain management from her primary care provider, and was making progress. She managed her hygiene by going to a local State park where there were showers, and she spent her days finding odd jobs (usually some kind of gardening) or hanging out at the library.
We had case management available, and we got her on a waiting list for housing. There are a total of 103 units dedicated to seniors in my small community. The wait list in my County is between two and ten years. Yes – two and ten years. Homeless people get priority.
Over the next several months, my patient and I spent more than one session working with the feelings of hopelessness, shame, marginalization, and anger that her homelessness brought up. Remarkably, she continued to stay clean and sober and her life began to take on some regularity. While she was still without housing, the frequency of our sessions decreased because she was feeling better about herself and was better able to take care of herself. She still lived out of her truck, but she found safe places to park, got a seasonal job at the County Regional Park, and felt productive again.
It had been several months since I had seen her, but one day I saw her name on my schedule. I was concerned because while she had been doing well, she was still vulnerable. She came into my office with a huge smile on her face and a beautiful potted plant. She said, “I’m just here to say thank you and to let you know I finally have a place to live!” She was so excited. We talked about things like decorating, having people over, having a place to cook and do laundry. We talked just like normal people. Just like normal people.
It is my belief that providing housing is possibly the most potent intervention we can provide. In the long run, it is cheaper than all the medications on the market, and more effective than anything Freud or Jung could have done. All it takes is commitment from a community to take care of its own.
Sadly, homelessness among aging Americans is increasing as more older adults are priced out of housing and have no one to turn to. Communities need to affirmatively create support for aging members. This includes finding money to pay for infrastructure changes, housing, and medical care that are unique to the needs of older adults. Communities that do this are far better off than those that do not.
