Aging in Place

YOU ARE HOLDING 1.5 CEs IN YOUR HAND! NASW is pleased to offer this FOCUS Homestudy Course. How it works: Read all the articles on these pages, complete the post-test on page 17 and mail it to the Chapter office with your check. Score 80% or better and NASW will mail you a certificate for 1.5 CEs. It’s that easy!

With this format and our HomEd audio programs, the Chapter continues its goal of ensuring that social workers, including those with mobility or other impairments, are able to meet their continuing education requirements. This course of 15,000 words meets the current Massachusetts Board of Registration’s requirements for 1.5 CEs and is appropriate for social workers at all licensure levels. If you have comments, concerns or other questions please e-mail [email protected] or call 617-227-9635 x17. Aging in Place By Stacey Skala, MSW, Curriculum Coordinator, Institute for Geriatric Social Work (IGSW, Boston University School of Social Work with Kathy Kuhn, LICSW, Director, Education & Training, Institute for Geriatric Social Work (IGSW) Boston University School of Social Work Learning Objectives older showed the most rapid growth Course Overview After completing this course, partici- among the older adult population from The majority of older adults and aging baby- pants will be able to: 1990-2000, increasing 40%. The aver- boomers report that they want to stay in their • Defi ne the concept and impli- age life expectancy continues to dra- homes and communities as they grow older. In cations of aging in place matically increase compared to past spite of this, one out of every fi ve older adults • Identify at least three barriers decades, which accounts for the growth faces spending part of or their remaining lives to aging in place of the “oldest old” population. in a nursing home. • Name at least three strategies to promote aging in place Expand Your Aging IQ With the onset of chronic conditions, illness and physical/cognitive limitations, older adults By 2030, the number of people aged 65 are more likely to require assistance with their Core Content years and older in the United States is personal care and household activities as they Aging Demographics projected to be: age. Despite the prevalence of assistive devic- Our nation is facing substantial chang- 15 million es, home modifi cation products, community- es in its age demographics. The number 30 million and home-based services, many barriers ex- of older adults in our society is on the 50 million ist for older adults who want to remain in their rise, and the aging “boom” will only 70 million homes. continue to increase in the coming decades. Answer: According to projections from The concept of aging in place refers to growing the U.S. Census Bureau (2000), the older without having to move to an institution Expand Your Aging IQ number of older adults aged 65 and old- in order to receive supportive services. Aging in er will double from 35 million in 2000 During the 1990s, what percentage did to over 70 million in the year 2030. place spares older adults from the negative ef- the 85+ population increase by? fects of relocation, transition and abandoning 5% their established social networks. In addition to 25% In addition to people living longer, we benefi ting the individual older adult, aging in 40% also are awaiting a vast growth in the place also has considerable economic benefi ts. 15% older adult population due to the aging baby-boomer generation (people born Compared to the costs of nursing home care, between the years 1946-1964). Baby- customized community-based care at home can Answer: According to the U.S. Bureau boomers will begin to reach retirement be a cost-effective aging model. In addition, of the Census (2000), adults aged 85 and ages in 2011, and by 2030 it is estimat- communities with older adult residents benefi t from their role as consumers, investors and do- Figure 1. nors of their volunteer services. 100

Social workers have a vital role in enabling old- 80 er adults to stay in their home and remain independent for as long as possible through their 60 role as clinicians, case managers, educators, 65+ administrators and advocates. This course will 40 Millions 85+ give an overview of the emerging issue of ag- 20 ing in place, a theme that is likely to require further attention as our baby-boomers begin retir- 0 ing and aging at staggering rates. 1900 1950 2000 2050 (projected) 1 ed that people aged 65 and older will account for 20% of the population (Federal Interagency Forum on Aging Related Statistics, Answer: According to the U.S. Bureau of the Census (2001), 2004). Nevada experienced a 72 percent increase in its elderly population between 1990-2000, followed by Alaska (60 percent), Arizona (39 Figure 1. is a visual representation of the upcoming aging boom. percent) and New Mexico (30 percent). As you can see, the number (in millions) of older adults in the 65+ and 85+ categories are expected to increase signiﬁ cantly by the Despite the common belief that older adults head for sunnier cli- year 2050. mates during their retirement years, studies show that the majority of older adult homeowners prefer to remain in their homes as they Expand Your Aging IQ age. If they do change residences, it tends to be in nearby commu- Which state experienced the highest percentage of growth in its el- nities and often in the same county (Golant, 2002). derly population from 1990-2000? Florida Additional data from the U.S. Census Bureau illustrates the follow- New Mexico ing demographics: Nevada • Almost four out of ﬁ ve older Americans own their Alaska own homes • Persons between 65-85 are the least likely age group Institute for Geriatric Social Work to move The rapid aging of our society, and the related increase in the • More than 1.5 million older adults (disproportionately need of older adults for services and care, is one of the major female and over age 85) live in nursing homes or other challenges of the 21st century. The profession of social work residential care facilities is at the forefront of those facing this challenge and is also in a unique position to respond - both to meet immediate needs and also to establish a higher standard of care for the future. Web Resources The Institute for Geriatric Social Work (IGSW) is dedicated to For additional information about aging and housing advancing social work practice with older adults and their families. demographics, please visit: Led by Scott Miyake Geron, Ph.D. and a team of social workers, Administration on Aging: IGSW is located at Boston University School of Social Work and http://www.aoa.gov/prof/Statistics/statistics.asp continues to build upon the School’s historical commitment to Federal Interagency Forum on Aging Related Statistics: the aging field and current strength in gerontological teaching, http://www.agingstats.gov/ research and training. U.S. Bureau of the Census Age Data http://www.census.gov/population www/socdemo/age.html IGSW is committed to becoming a national leader in developing the workforce of social workers to meet the challenges of a Benefits of Aging in Place growing and changing population of older Americans. Through innovative and wide-ranging education and training efforts, IGSW Imagine yourself at 80 years old. Where do you see yourself living? will provide practicing B.S.W. and M.S.W. social workers — the In your own house or apartment? With your children? In a nursing large majority of whom have received little or no geriatric training home? Not surprisingly, most of us probably do not see ourselves — with the core knowledge, skills and tools they require to meet living in a nursing home because we want to remain independent as the needs of older adults and their family members. we get older and grow older in our own homes or apartments.

IGSW is also committed to expanding practice and reimbursement options for geriatric social workers. IGSW has initiated and is A 1996 report from the American Association of Retired Persons conducting research to demonstrate the effectiveness of social (AARP) found that the majority of surveyed older adults (83%) re- work interventions designed to improve the lives of older people, ported that they want to stay in their homes as they get older, yet and will support innovative model programs in geriatric social it is probable that nearly 20% of older adults will reside in a long work practice. IGSW will also inform and seek to influence term care facility for at least part of or the rest of their lives (Ron, policy-makers through the dissemination of pragmatic, timely 2004). information that documents the efficacy, benefits and outcomes of empirically-based geriatric social work practice. There appear to be many benefi ts to older adults staying in their For more information about IGSW and a listing of web-based communities. A recent study compared the mental health of old- CEU courses, please visit http://www.bu.edu/igsw er adults living in the community versus those living in nursing homes (Ron, 2004). Findings from this study suggest that residents The American Society on Aging of nursing homes are considerably more likely to experience high- In order to achieve our primary goal of providing training to B.S.W. er levels of depression and suicidal ideation than their counterparts and M.S.W. social workers across the country, IGSW has formed living in the community. a partnership with the American Society on Aging (ASA). ASA is the largest professional organization in the field of aging, with over 7,000 members and subscribers to its publications and From an economic standpoint, the costs of institutionalized care 3,000-4,000 professionals attending its annual conferences. are higher than the costs of living independently (Wodarski and Selected articles from ASA’s Generations journal appear in this Williams-Hayes, 2002). In addition, older adults have a great deal course. For more information about ASA, please visit http:// to offer their communities. Not only do older adults act as consum- www.asaging.org. ers and investors in their communities, they also donate a consid- 2 erable amount of their time and expertise through volunteer pro- and not homeowners (the majority of older adults own grams. The economic value of the time and expertise donated by their own homes) older adults 65 and over is estimated to be worth $22.7 billion • Health and housing resources are allocated differently (National Association of Regional Councils, 2004). Strategies for Aging in Place According to Experience Corps (2004): In response to the range of barriers to aging in place, social work- • Nearly half of Americans 55 and over volunteered in the ers play an important role in enabling older adults to stay in their past year homes. • 43% of those 75 and older volunteered in the past year • Older adults volunteer over 7.5 billion hours per year The following are strategies to help older adults age in place: • Increasing access to services Barriers to Aging in Place • Care management Older adults require long-term care when a chronic condition, ill- • Home safety ness or physical/cognitive limitations interfere with their ability to • Home modifi cations perform personal care and household activities (Family Caregiver • Assistive devices Alliance, 2004). • Transportation • Community and home-based services While many older adults are able to maximize their independence • Informal networks of support and remain in their homes by receiving assistance in their house, Increasing Access to Services apartment or assisted living community, others are unable to age in place due to a range of barriers, such as: Differences in income, health and social networks have a great • Economic and structural barriers impact on aging in place. Several comparative analyses of older • Access to services African Americans, Hispanic Americans, American Indians and • Navigating resources Asian American/Pacifi c Islanders found that as a whole, these older • Transportation issues ethnic groups face an increased risk of shorter life expectancy, poor • Deterioration of homes health, poverty, malnutrition and poor housing quality (Hooyman • Home safety and Kiyak, 1999). As a result, these are the populations most in • Health care needs need of services to help them age in place. • Economic and Structural Barriers Social workers benefi t by understanding the structural, economic It is important to emphasize that the socioeconomic status of old- and cultural barriers to service utilization and how we can structure er adults greatly impacts their ability to age in place. Older adults programs and services that are accessible to ethnic older adults to with high incomes are more likely to afford costly home-based ser- help them age in place. vices, home modifi cations and the option of living in Continuing- Care Residential Communities that enable older adults to age in Barriers to Service Utilization Among Ethnic Older Adults: place. (Hooyman and Kiyak, 1999) • Lack of knowledge about services On the other hand, older adults with limited fi nancial resources, the • Cultural isolation/language differences majority of whom are ethnic minorities and women, are likely to • Perceived stigma of using services face structural and economic barriers to aging in place. • Confusion/anger/fear of health care providers & hospitals • Lack of trust of professionals and Western system • Location of services In order to age in place, older adults need to have their housing • Lack of transportation and health needs met. Unfortunately these sectors function as two • Lack of services and staff that are oriented towards respec- separate divisions with confl icting guidelines, allocation methods tive minority groups and eligibility criteria. As a result, many older adults may be eligible for some but not all of the services needed to help them stay in their homes. In addition, many older adults who are unable other- Increasing Access to Services by Ethnic Older Adults (Hooyman wise to afford home-based services fall just above eligibility crite- and Kiyak, 1999) ria and do not qualify for government assistance. • Service locations in ethnic communities • Bilingual/bicultural staff • Culture and language appropriate forms and In summary, the following structural and economic barriers to ag- assessment tools ing in place exist for low income older adults (Lawler, 2001): • Culture appropriate foods and activities • The eligibility guidelines for housing programs often • Personalized organizational climate confl ict with the eligibility criteria of health programs • Involve ethnic minorities in program planning and • Medicare does not cover enough services service delivery • Only the sickest and poorest older adults are eligible • Utilizing existing minority-targeted media and community for Medicaid groups (such as civic clubs or churches) to promote and • Housing programs and subsidies usually support renters link to sources of help 3 Care Management Examples of barriers to home modifi cations include (Pynoos, As the number of older adults has increased, so has the number of 2001): services to help older adults remain in their homes and commu- • Costs and affordability of modifi cations nities. For-profi t entities, community-based organizations and lo- • Consumer confusion about funding sources and providers cal, state and federal governments offer a wide variety of services of modifi cations to help seniors age in place. Adult day care, home delivered meals, • Lack of awareness about the problems in the physical home care, transportation and housing services are some of the var- environment ious programs offered. However, without a central point of entry, • Lack of awareness about the benefi ts of home the result can be a complicated maze of services that can be diffi - modifi cations cult for the average older adult to navigate (Yagoda, 2004). One example of a statewide strategy to address the barriers to home modifi cations included a state-wide partnership between local uni- In response to this challenge, many programs support care manage- versities, community-based agencies and retail Lowe’s hardware ment (also known as geriatric care management for social work- stores to offer education about home modifi cation options to help ers who have a specialization in geriatrics) as a core component of seniors age in place (Price, Zavotka and Teaford, 2004). This study their services. Care management is an individualized approach that found that there was a lack of knowledge among consumers and aims to plan, seek and monitor services from various agencies on professionals on strategies for aging in place, including how old- behalf of clients in order to maximize their functioning (Wodarski er adults can modify their homes to adapt to their changing needs. and Williams-Hayes, 2002). The result of this collaboration, which included community work- shops, professional trainings and in-home assessments, was an in- Web Resources creased interest and awareness about home modifi cations to help For more information about geriatric care older adults age in place. and case management, please visit: National Association of Professional Geriatric Care Managers: Another strategy to home modifi cation barriers includes increas- www.caremanager.org ing the use of home-modifi cation specialists. Home modifi cation NASW Standards for Social Work Case Management: specialists are able to assess the homes of older adults and pro- www.naswdc.org/practice/standards/sw_case_mgmt.asp vide cost-effective strategies based on the assessment and consumer input. Home Safety Home safety is a critical aspect of allowing older adults to stay in To find a home-modification specialist in your area, their homes. Social workers often play a part in assessing the safe- please visit: National Association of Home Builders, ty of their older clients’ homes. The following article, published by Database of Certified Aging-in-Place Specialists: the American Society on Aging, analyzes some of the assessment http://www.nahb.org/generic.aspx?sectio nID=126&genericContentID=8484 tools used to measure home safety.

Home Modifications The ability to afford home modifi cations may act as a barrier to aging in place for some seniors, as they can be expensive and not Once homes have been assessed for safety considerations, it may always seen as a priority. Financial programs and other resourc- be necessary to make modifi cations to the home. Some of the ben- es may be available to help older adults with low incomes. Social efi ts to home modifi cations include (Pynoos, 2001): workers who are knowledgeable about resources for home modifi - • Promoting independence by making it easier to perform cations in their communities can help educate their older adult and tasks family member clients. • Facilitating caregiving • Reducing accidents To find out about home modification resources in your area, • Enabling older adults to engage in major life activities please visit: • Reducing health care costs National Resource Center on Supportive • Delaying institutionalization Housing and Home Modification, National Directory of Home Modification Resources Examples of home modifi cations that older adults may require http://www.homemods.org/national_directory_homemods/ include (AARP, 2004): For more information about home modifications, please visit the following websites: • No-step entry AARP Home Design: • Ramps or elevators http://www.aarp.org/life/homedesign • One-story living (bathroom and bedroom are located on National Home Modification Action Coalition: the fi rst fl oor) www.homemods.org • Wide doorways • Wide hallways Assistive Devices • Handrails and grab bars Assistive devices are products which are used to increase, maintain • Non-slip surfaces or improve functional capabilities of individuals with disabilities. • Good lighting • Lever door/faucet handles Continued on page 4 To put it simply, an assistive device, wheth- Web Resources Additional Web Resources er hi or low tech, is a tool that is used to ac- For more information about For more information about complish a task. transportation, please visit community-based services, please the following websites: visit the following websites: AAA Foundation for Traffic Meals on Wheels Association Examples of assistive devices include Safety Quizzes of America: (Bodine and Beems, 2002): http://www.aaafoundation. www.mowaa.org • Walkers org/quizzes/index.cfm National Adult Day Services • Wheelchairs AARP Driver Safety Program Association: • Grab bars http://www.aarp.org/drive www.nadsa.org • Reachers Transit Services for Seniors National Association for Home • Identifi cation bracelets www.apta.com/research/info/ Care and Hospice: • Photo-dial telephones briefings/briefing_3.cfm www.nahc.org • Large print clocks and calendars • Laminated checklists Community and Home-Based Services Informal Networks of Support • Automatic pill-dispensing devices Depending on the community, there are In addition to formal services that can help • Listening systems most likely a number of community and older adults age in place, informal net- • Picture cookbooks home-based services that enable older works of support also play a role in the pro- • Wander alert systems adults to stay in their home. As mentioned cess. Informal networks can include family, • Signaling devices before, care management helps to connect friends and neighbors who can help older their older adult clients with resources and adults with home maintenance, shopping, Assistive devices are another solution to coordinate services in the community to transportation, meals and socialization. helping older adults age in place and re- help them age in place. Community groups such as churches, youth main independent. Each state has a desig- groups and service clubs may also be pro- nated assistive technology program that of- Below is a brief list of community-based viders of help to assist older adults in the fers a wealth of information and resources resources as well as links to websites for community (Himes, Oettinger and Kenny, about assistive devices and how to obtain further information. 2004). them. Role of the Social Worker Adult Day Services Transportation Places in the community where older adults Social workers are likely to face the issue of Having reliable, accessible and affordable can go during the day for socializing, ac- aging in place in a variety of settings when transportation is a key factor in allowing tivities, meals and assistance with personal working with older adults, caregivers and older adults to age in place. care and personal safety. family members of all ethnicities and ages. Social workers may face this issue in a variety of roles; as care managers, clinicians, Despite the preference to remain indepen- Friendly Visitors and Telephone support group leaders, program planners, dent and able to drive their own vehicle, Reassurance educators or advocates. nearly 7 million older adults aged 65 and Volunteer-based programs that provide reg- older are not able to drive (AARP, 2002). ular personal or telephone contact for older Although the specifi c skills and duties may Physical, fi nancial and community barri- persons who are homebound or live alone. ers to alternative forms of transportation vary from role to role, social workers who work directly with older adults or their fam- put many older adults at risk for institution- Home Care Services alization, as they become isolated and im- ily members may utilize the following skills mobile. Older adults without transporta- In-home assistance with health care, house- (Yagoda, 2004): tion suffer by losing reliable access to their hold tasks, emergency response systems, • Engagement health care appointments, social activities personal care and respite for caregivers. • Outreach and identifi cation of and other means of feeling independent. clients Nutritional Programs • Relationship formation • Assessment The article on page 11, published by the Home-delivered meals or congregate nu- • Needs assessment American Society on Aging, further dis- trition sites in the community that provide • Functional assessment cusses the transportation issues faced by low-cost, nutritious meals for seniors. • Biopsychosocial assessment older adults. Transportation Services • Strengths assessment (individual and community) Services such as van transportation, taxi • Comprehensive intake vouchers and discounts for public transpor- • Resource/fi nancial assessment tation. • Home safety assessment • Planning For more information about community re- • Intervention sources for older adults in your area, please • Treatment visit the Eldercare Locator website at • Care www.eldercare.gov. 5 • Rehabilitation place as an older adult? When I am next city over from Mrs. J, who lives alone • Strategic 65 years old? When I am 85 years in an apartment in the same city she has re- • Support old? sided in for over fi fty years. After seeking • Crisis intervention • How can I keep my own attitudes out assistance from a fi nancial advisor, they • Implementation/Coordination and preferences from coloring the sold the house Mrs. J and her husband lived • Service brokering way I work with others? in after he passed away. Rather than mov- • Monitoring service delivery • How can I help older adults cope ing in with Mary, Mrs. J insisted on living • Implementation with losing their ability to function in her own apartment in the same area she • Client support independently? has been living in for many years. • Advocacy • When might aging in place no lon- • Systems improvement ger be an option for older adults? Mary reports that Mrs. J has always been • Client well-being and functioning • How have I faced this issue in my a strong and independent woman and has • Liaison personal life? made it very clear that she never wants to • Mediation • How has my community dealt with be dependent on Mary or live in a nursing • Reassessment/Evaluation this issue? home. Mary helped Mrs. J choose an apart- • Monitoring • ment that was close to a bus stop, market • Effi cacy Another helpful way for social workers to and local senior center. Mrs. J used to walk • Effi ciency learn more about the issue of aging in place to the market and senior center, but in re- • Data collection is to learn about local resources for aging in cent years suffered from a fractured hip and • Data analysis place by asking the following questions: infection after falling in her bathroom. • Disengagement • How can I assist my clients with as- • Discharge planning sessing the home for safety issues? Mary has noticed that her mother’s apart- • Transfer Which checklists are available to ment is becoming cluttered and messy. Mrs. • Termination me? J does not leave her apartment and asks her • Where can I refer clients to for daughter to do a weekly shopping trip for Social workers who work directly with old- home modifi cations? What are the her. Mary reports that she is concerned er adults are encouraged to use a strengths- various options and costs? Is there because Mrs. J’s ability to use a walker based perspective, which incorporates the any fi nancial assistance available? is declining and there isn’t a ramp in her strengths of the older adult client, fami- • Where can I locate a home modifi - apartment building. She is also concerned ly, friends and the community to help the cation specialist in my area? How because Mrs. J is unable to leave the house client live independently and age in place much does this cost? What are the or cook for herself. Additionally, she is wor- (Wodarski and Williams-Hayes, 2002). options for using a home modifi ca- ried because on many occasions, Mary has tion specialist? been unable to reach her mother by phone In addition to the diagnosis, problems and • What kinds of assistive devices are because Mrs. J isn’t able to get up and walk functional status surrounding the activities available for older adults? What to it in time. Mary is worried about what of daily living (ADLs) and instrumental ac- are the easiest and most affordable might happen in an emergency situation. tivities of daily living (IADLs) of clients, ways for my clients to order them? • How can I help my clients assess social workers will demonstrate their con- Mary thinks that perhaps moving Mrs. J to fi dence in the abilities and independence of the driving ability of themselves or their older family members? an assisted living community might solve their clients by also including their strengths her problems. She would be safe, have her as part of the assessment process. • What are the transportation options for older adults who are not able to meals cooked for her and would be able drive? to socialize with other residents. Mary re- Examples of a strengths inventory include • What community-based organiza- ports that Mrs. J insists she wants to stay (Fast and Chapin, 2002): tions are available to meet the nutri- in her home. Mrs. J admits to feeling “a bit • Information on personal & environ- tional needs of older adults? blue” over the past year but points out that mental strengths • What adult day centers and home her “mind is still in order” so she can make • Priorities identifi ed by the client care agencies are in my area? What her own decisions. Mrs. J says that she will • Interests, wants and needs are the options and costs? Are there only “go downhill fast” if her daughter • Social supports fi nancial assistance programs? moves her into “one of those homes.” Mary • Religion and spirituality contacts a social worker referred by her lo- • Leisure and recreational interests cal area agency on aging for assistance. Case Study

For social workers who are new to the issue Let’s further explore some of these issues Case Study Discussion Questions in the following case study. Please read the of aging in place, a good place to start is Imagine that you are the social worker and to explore your values about the issue and following example and the discussion questions that follow. Mary is your client seeking out help with how you may face it in your work, personal her situation. Please read and think about life and community. You can start by ask- the following discussion questions. ing yourself the following questions: Mary is 55 and the only daughter of her 82 Question: When working with Mary, she • How will I feel about aging in year-old mother, Mrs. J. Mary lives in the asks you whether or not you agree with her 6 idea to move Mrs. J into an assisted living Home modifi cations Ethnicity & Multicultural Considerations facility. All of the above The older adult population, whose current majority is of European decent, is becom- Take a minute to think about how you feel Discussion: All of the above. There are ing increasingly diverse. Record high im- about this situation given the information many resources that may assist Mrs. J to migration rates indicate that the trend of presented. live independently. For example, a home- a diverse older adult population will only making service could help with the clutter continue in the coming decades (Capitman, How do you respond to Mary? and mess as well as the shopping and regu- 2003). Tell Mary that you think she is right, her lar chores. Since Mrs. J is no longer able to cook, she is a good candidate for home de- mother would benefi t the most from liv- Culture is defi ned as “the way a group lives, livered meals. Home modifi cations, such as ing in an assisted living community the ethnic background, the race, the values a ramp, grab bars, non slip surfaces, emer- Tell Mary that you think she is wrong, and norms of behavior, and ways of think- gency alert systems, cordless phones and her mother would benefi t the most from ing that are passed down through genera- good lighting are examples of options to living in her own apartment tions and make the person an identifi able make the apartment safer for Mary’s moth- Tell Mary that you think her mother group in a society” (Leigh, 1998). Since er. Mrs. J may also need to work with her should move in with her culture shapes the life experiences of each doctor about whether or not she should be None of the above individual, social workers can benefi t by using a wheelchair if she is having trou- understanding the cultural composition of ble with her walker. In addition, the social their older ethnic clients and how it impacts Discussion: None of the above. The role of worker can address the isolation of Mrs. J communication, attitudes, values and the the social worker is not to tell Mary wheth- by suggesting ways of socialization, such presenting problems of clients. er or not you think her mother should live in as adult day services, friendly visitor pro- an assisted living community, despite how grams, or transportation alternatives to the you may feel personally about the situation. senior center she used to attend. When working with older ethnic adults, The role of the social worker in this case is social workers benefi t by having a gener- to build a relationship with both Mary and Question: As the social worker in this situ- al knowledge of the cultural characteris- Mrs. J, to collect information and assess ation, you have come across many clients tics of various ethnic groups they may be which interventions to take. who are facing aging in place issues. Unlike working with. At the same time, it is im- Mary and Mrs. J, many are unable to afford portant to remember that each client comes Question: After the initial meeting with home modifi cations and often do not qual- from a unique experience that may not fi t Mary, what might be the next step when ify for assistance programs. You think that into a predetermined cultural blueprint and working with Mary and Mrs. J? your community needs to make aging in may be dissimilar from the generalizations Assess Mrs. J’s apartment for safety place a priority by improving transportation about his/her ethnic group. Assess Mrs. J’s functional abilities for older adults, educating families and pro- Ask Mrs. J about her desires and fessionals about aging in place options and To learn more about how the culture of the strengths fi nding ways to make home modifi cations individual older ethnic adult affects the is- All of the above and other services more affordable. sue of aging in place, social workers can How might you take action? ask guiding questions about the client’s cul- Discussion: All of the above. Mrs. J and Start a local coalition or task force with tural perspective on matters such as aging, Mary can both provide valuable informa- other professionals and community housing, illness and family systems. tion during the assessment process that will members help the social worker formulate a plan. Raise awareness through editorials, pol- Case Study Since Mrs. J has suffered from a fall be- icy briefs and other publications Joon is a divorced 40 year-old Korean fore, the apartment needs to be assessed Ask clients, family members and other American woman. She has no children and for safety and possible home modifi cations. social workers to write letters or call lo- is a lawyer in Los Angeles. Her parents and The social worker may need to include the cal decision makers as well as testify at two older brothers moved to the United landlord in this process. In order to decide public hearings States from Korea before she was born. which services Mrs. J can benefi t from, the All of the above Joon’s father passed away a few months ago social worker needs to assess her function- and her brothers agreed that their 72 year- al status and ability to live independently. Discussion: All of the above. Social work- old mother should move out of their house Finally, asking Mrs. J about her desires and ers can fi nd many ways to involve them- in Koreatown and live in Joon’s two bed- taking a strengths inventory will demon- selves with advocacy efforts on issues that room condo in a different part of town. Joon strate your confi dence in her abilities. impact their clients and the community. is feeling guilty because she doesn’t want Starting a coalition or task force, raising her mother to move in with her. Although Question: What community resources awareness, using the voice from the com- she feels obligated to take care of her, Joon might help Mrs. J stay in her home? munity (clients and family members) and is very independent, career-oriented and informing decision makers are all examples worries that her mother will be very lone- of advocacy efforts that social workers can ly and isolated living with her. According Home delivered meals participate in. to Joon, her mother has mentioned that she Home care services (homemaking) doesn’t like the idea of leaving Koreatown. 7 As opposed to the area Joon lives in, her mother can communicate Ask Joon about what a Korean daughter might be expected to in her native language in Koreatown and has many friends that she do in this situation socializes with. Joon’s brothers feel very strongly that their mother Tell Joon that she has nothing to feel guilty about should not live alone. They both have children still living at home, Tell Joon about senior living options in her area do not have an extra room in their house and do not understand None of the above why Joon would put her career before their mother. Their mother doesn’t like to argue and says her sons probably know what is best. Discussion: Ask Joon about what a Korean daughter might be ex- Joon has decided to seek help from a social worker but hasn’t told pected to do in this situation. By doing this, the social worker will her family. Joon provided some information to the social work- learn more about cultural norms and get more insight about Joon’s er over the phone prior to making an appointment for the follow- feelings of guilt. Having this knowledge will help guide the social ing week. worker’s interventions. Telling Joon not to feel guilty or suggesting senior housing options for her mother might be inappropriate in Case Study Discussion Questions this situation and could potentially offend Joon. The social worker Question: Before the social worker meets with Joon, he or she can build trust in Joon by asking her to explain her feelings of guilt would benefi t from: and empathizing with the client. Contacting Joon’s brothers to gather some additional information Ethical & Legal Considerations Contacting Joon’s mother to gather some additional informa- Social workers may encounter diffi cult ethical dilemmas when try- tion ing to help their older clients age in place. Learn more about the general characteristics of Joon’s culture All of the above Examples of dilemmas may include: • The older adult wishes to remain independent in his or her Discussion: Learn more about the general characteristics of Joon’s home but the condition of the home is unsafe culture. Prior to meeting with Joon, the social worker in this case • The older adult is no longer able to keep up a will benefi t from having a general understanding about Joon’s cul- deteriorating house tural background and how the characteristics of Korean culture • The older adult does not qualify for resources to help him/ might be affecting this situation. Some issues to learn more about her age in place but is unable to afford necessary services might include immigration patterns, differences in generations, at- and home modifi cations titudes toward utilization of social services, aging, illness, death, • The older adult requires a level of assistance that requires mental health, divorce, family systems and gender roles. Once the around-the-clock care social worker has a general knowledge of Joon’s cultural group, he • The family thinks the older adult will be safer and bet- or she can then learn about Joon’s personal experience as a Korean ter off in an institution but the older adult has expressed American woman and compare this against group generalizations strong feelings to stay in his/her home to individualize Joon’s culture and how it impacts the issue she is • Older adults with cognitive impairment without local facing. family members who begin to require constant care and supervision Question: What are some skills the social worker can use during the fi rst meeting in order to gain Joon’s trust? The following article, published by the American Society on Aging, Follow agency assessment protocol by asking preset questions further explores some of the ethical dilemmas that social work- Start where the client (Joon) is at ers might face when working with older adults and their families Ask Joon to bring her family members and act as a mediator around aging in place. All of the above Policy Considerations Discussion: Start where the client (Joon) is at. Although agency as- In order to make aging in place a reality for many older adults and sessment questions are useful and necessary tools for social work- the increasing number of older adults to come, efforts need to be ers, it may be inappropriate to begin right away with this approach. made on a national, state and local level. In order to have a successful helping relationship, the social worker needs to establish and build a relationship by starting where Joon is at and learning more about Joon’s cultural perspective. When meet- The Joint Center for Housing Studies at Harvard University main- ing for the fi rst time, it may be helpful to get a sense as to how Joon tains that an overhaul of our national, state and local systems needs feels about her present situation and coming to speak with a social to include rethinking the health and housing sectors as two sepa- worker. It may also be helpful for the social worker to explain the rate divisions and to see them instead as two integral parts of one role that each of them play during the helping relationship. In addi- unifi ed service-delivery system (Lawler, 2001). Their recommen- tion, the social worker may be more effective by allowing Joon to dations include: guide the social worker in his or her understanding of Joon’s cul- • Creating a pooling agency to combine health and housing ture and how it impacts her presenting situation. resources at the state and/or local level • Eliminating regulatory barriers that prevent the overlap of health and housing sectors Question: As the social worker in this situation, how would you ap- • Include housing in each state’s Olmstead planning process proach Joon’s feelings of guilt? 8 • Recognize the assets of community-based organizations in differ from person to person in the context of one’s culture, socio- coordinating health and housing services at the local level economic status and family system. This course has offered strategies to promote aging in place as well as an introduction to the Consumer-Directed Care larger social and policy issues surrounding meeting the housing Another policy consideration concerns consumer-directed care. and health needs of older adults. The ability to age in place often relies on the use of home- and community-based programs. As the movement to help older adults References and disabled populations remain independent in their homes has Experience Corps. “Fact Sheet on Aging in America.” Retrieved mounted, so has the concept of consumer-directed care. Consumer- on 12/1/04 from www.experiencecorps.org. Washington, DC: directed care, usually in reference to the use of home- and com- Experience Corps. munity-based services, emphasizes the ability of older and dis- Family Caregiver Alliance. Fact Sheet: Selected Long Term Care abled consumers to assess their own needs, make decisions based Statistics. Retrieved on 11/23/04 from http://www.caregiver. on choices and options, and monitor the quality of their services org. San Francisco, CA: Family Caregiver Alliance. (National Council on Disability, 2004). Fast, B. & Chapin, R. (2000). Strengths-Based Care Management for Older Adults. Baltimore, MD: Health Professions Press. As the number of older and disabled adults who utilize consumer- Golant, S. (2002). “Deciding Where to Live: The Emerging directed home- and community-based programs increases, policy Residential Settlement Patterns of Retired Americans.” considerations arise for both consumers and the government. One Generations. Vol XXVI (2):66-73. San Francisco, CA: policy consideration includes the quality of services, as the quality American Society on Aging. of consumer-directed programs is not regulated by the government. Hetzel, L. & Smith, A. (2001). “The 65 Years and Over Population: Another policy consideration is the experiences of the workers and 2000.” Census 2000 Brief. Retrieved on 11/29/04 from http:// consumers in consumer-directed programs. Traditional home- and www.census.gov. Washington, DC: U.S. Census Bureau. community-based services maintain control of the salaries, poli- Hooyman, N. & Kiyak, H. (1999) Social Gerontology. 5th Edition. cies and supervision of their employees. In consumer-directed care Needham Heights, MA: Allyn & Bacon. however, the consumer has complete control over and directly su- Kercher, B. & Rubenstein, L. (2002). “Home-Safety Checklists for pervises the worker. Elders in Print and on the Internet.” Generations. Vol XXVI (4):69-74. San Francisco, CA: American Society on Aging. A comparison of consumer-directed care programs in fi ve coun- Lawler, K. (2001). “Aging in Place, Coordinating and Health Care tries by Tiller, Wiener and Cuellar (2000) revealed the following Provision for America’s Growing Elderly Population.” Joint lessons learned: Center for Housing Studies of Harvard University. Retrieved • Research indicates that older people are less likely to on 12/10/04 from http://www.jchs.harvard.edu. Cambridge, want consumer direction than younger people, although MA: Harvard University. a signifi cant minority prefers control over their services. Leigh, J. (1998). Communicating for Cultural Competence. Therefore, programs should be fl exible to accommodate Needham Heights, MA: Allyn & Bacon. varying preferences. National Council on Disability. “Consumer Directed Health • Cognitive impairment raises concerns about the capacity Care: How Well Does it Work?” Retrieved on 12/10/04 from of older consumers to manage their own care. However, http://www.ncd.gov. Washington, DC: National Council on persons with cognitive impairment can participate in con- Disability. sumer-directed programs with the assistance of a surrogate Partners for Livable Communities. Aging in Place. The Issue: decision maker (caregiver or family members). Defi ning the Problem. Retrieved on 11/22/04 from http:// • The most controversial issue in consumer-directed care www.livable.com/aging/issue. is the quality of consumer-directed care and how services Price, C., Zavotka, S & Teaford, M.(2004). “Implementing should be monitored. a University-Community-Retail Partnership Model to Facilitate Community Education on Universal Design.” The Gerontologist. Vol 44 (5):697-702. Washington, DC: Independent workers in consumer-directed care are more satisfi ed Gerontological Society of America. than their counterparts in agency-based service environments, al- Pynoos, J. (2001). Meeting the Needs of Older Persons to Age though do not get compensated as well. However, many indepen- in Place: Findings and Recommendations for Action. The dent workers in consumer-directed care are family members. National Resource Center for Supportive Housing and Home Conclusion Modifi cation. Retrieved on 11/29/04 from http://www.usc. edu/dept/gero/nrcshhm/research Los Angeles, CA: Andrus This course has aimed to provide an overview of the issue of ag- Gerontology Center, University of Southern California. ing in place in various social contexts with a specifi c focus on the Ron, P. (2004). “Depression, Homelessness and Suicidal Ideation role of the social worker. As older adults face increasing health Among the Elderly: A Comparison Between Men and and cognitive changes, they may require increasing assistance with Women Living in Nursing Homes and in the Community.” their daily activities and decision making. Social workers are of- Journal of Gerontological Social Work. Vol 43 (2/3): 97-116. ten at the forefront of helping older adults and families deal with Binghampton, NY: Haworth Press, Inc. this issue and face the challenge of fi nding the balance between the wishes, safety and independence of older adults. Often we must Continued on page 17 look inward to understand what “home” means and how this may 9 Moving Along the Mobility Continuum: Past, Present, and Future By Harvey L. Sterns, guest editor, Jon E. Burkhardt, and John W. Eberhard The word mobility refers to the quality of “being mobile, movable, Clearly, then, any consideration of transportation for older people or moving readily.” For older people, personal physical mobility must go beyond issues about driving. However, the primacy of the is infl uenced to a considerable extent by age-related changes that personal automobile in the United States is one of the greatest bar- in combination affect muscle strength, posture, balance, and joints riers to development, or even discussion, of a workable system, (Wagner and Kauffman, 2001; Whitbourne, 2002). Thus, for older and this situation shows few signs of changing. While many peo- people mobility in the community, and the performance of mobile ple who are older adults now did use public transportation when activities like walking, often depends on environmental modifi ca- they were young and may view the use of public transportation tions such as curb cuts, ramps, and signs that help people with mo- more positively, many younger adults have no experience with the tor and sensory defi cits get around (Christiansen and Hammecker, use of public transportation. What is required is that people of all 2001). ages be made aware of the importance of developing and supporting a range of transportation services in our communities, and they This article considers later-life mobility in the broader context of must be made aware of the range of service options that can be transportation (Schaie and Pietrucha, 2000). The private automo- available. bile continues to be the main source of transportation in our society—the primary way people gain access to services and maintain Licensing agencies, safety forces, physicians, service providers, social relationships. Continuing to drive is a major factor in avoid- and families all play a role in a complex process. A modern geron- ing social isolation and maintaining full participation in commu- tologist needs to not only understand individual differences in abil- nity life. With age, changes in abilities and skills related to driv- ity, but to offer interventions and solutions that give older adults ing may require the individual to modify driving behavior or cease choices that maintain their mobility in the community. The devel- driving (Sterns, Barrett, and Alexander, 1985). At age 80-plus, the opment of new professional roles and testing approaches helps us proportion of older adults whose usual means of transportation is to better understand evaluations of normal and abnormal aging-re- their own car falls below 50 percent. Yet, the changes in an indi- lated changes in older drivers. Information from evaluations will vidual’s physical mobility often make it more diffi cult to use mass give older adults the information they need to change their driving transportation systems unless the system makes special modifi ca- and to cease driving as appropriate. tions. Changes in mobility can result in the loss of quality of life for older people (Schaie, 2000). Another major set of issues relates to how older adults who have stopped driving can continue leading full lives by using transpor- The issue of mobility and quality of life for older adults is not new. tation choices as well as mobility support by family. Communities In 1976, Golant emphasized that transportation diffi culties may be that want to be “elder-friendly” need to develop appropriate plan- the fi rst sign that a person is “becoming old” and may no longer ning and coordination of services. be able to carry on his or her life in the same way as in the past. Self-Management and Choices Studies of older adults’ transportation needs and modes have been Sterns and Gray (1999) emphasize the challenges faced by midlife available for more than twenty-fi ve years. However, the dramatic and older adults as they seek to make informed choices about their increase in the number of older adults seen now and predicted in transportation needs, saying that “the individual needs to be in the future demands increased attention. charge, in control, and able to select adaptive options.”

Carp (1979, p. 127) stated that “unless old people can meet all their An important continuing area of research will focus on the abil- needs within the conﬁ nes of their own homes, their satisfaction de- ity of older people to plan and manage their own retirement. An pends upon their mobility into the wider community, and this, in important aspect of such planning for later life is consideration of turn, is contingent upon the transportation facilities available.” mobility: How will I get around when I am older and my capabilities have changed? Successful planning for later life means mak- In 1971, approximately 46 percent of heads of household age 65 ing choices that will allow the person to live in the style that he or and older had no car. Today, people are keeping their cars and con- she chooses. For many people, maintaining driving skills is clearly tinuing to drive much longer. Even frail older adults are driving important. But even more important is making sure that if they can more and more, and they are thus more apt to be involved in a fatal no longer drive, they live in a location that provides transportation accident. With more people living longer, more people are outliv- services. Retirees often choose to live in an isolated area, but such ing their driving skills (Sterns et al., 2001). A major concern now is a choice may not serve them well in their later years. Part of taking how to enable people to drive as late in life as possible, as long as responsibility for one’s own later life means making choices that they can do so safely, and to get them to stop driving when it is no facilitate mobility in a range of possible conditions. (See adaptive longer safe. The challenge is to facilitate the transition from driv- strategies listed on page 7). ing to the next phase, driving and using transportation services, to the next phase, not driving but using transportation services.

10 Mobility and Safety Sterns, Barrett, and Alexander (1985) have emphasized that old- Focus-group research indicates that older adults are most con- er adults need to continue to live and work as they always have. cerned about the reliability of public transit. Many older people Unless there is compelling evidence to the contrary, people should are not able to wait outside for long periods of time, especially be encouraged to maintain their lifestyle and activities as they age. in poor weather conditions. On-time arrivals are considered very It should be remembered, however, that age-related changes and important. Older adults want door-to-door service, and they want declines in health caused by disease may alter the performance ﬂ exible service that responds to the needs that they may have on a level of critical skills, making older adults less able to meet task particular trip. This service could include help in carrying parcels demands and thus subject to an increased risk of injury. or traveling with other people.

The term safety may be defi ned as the state of being free from Older adults also indicate that they want comfortable vehicles and danger or injury, or the use of various methods and devices to re- waiting areas. They want to be able to have access to service on duce, control, or prevent accidents (U.S. Offi ce of Technology less than a twenty-four-hour notice. Older travelers want to be able Assessment, 1978). In discussing safety and risk, W. T. Singleton to travel more hours of the day and days of the week than many (1979) points out that we are often better able to specify the degree public transit authorities currently offer. As travel consumers, they of hazard or risk than to specify the degree of “safety.” Our de- want control, autonomy, and choice. scriptions of danger presented by an environment are likely to be more precise than our descriptions of the lack of danger. Our understanding of the needs of the future comes at a time when there is lack of funding, lack of interest, and reluctance to begin the In carrying out their daily activities, individuals are exposed to a process of changing our transportation approaches. number of risks. Their level of skills, their exercise of these skills, and the resulting level of safety are variables in a complex cost- Perspectives on Transportation Modes: benefi t equation. People make judgments regarding activities to Independence-Dependence determine whether the risk of injury is suffi cient to be a deterrent. At every level of capability, older adults desire to maintain inde- Since some older adults may not be aware of their changing levels pendence, decision making, and choice. Sterns and Sterns (2000) of skill, they may be unrealistic in their judgments. have emphasized that, traditionally, transportation choices have been studied in the framework of a transit-centered continuum, Experience provides the opportunity to develop and maintain which emphasizes the modes of transportation. This bipolar con- skills, and in many situations, it may be the only way to acquire tinuum begins with drivers of a private vehicle, considered by and maintain the needed knowledge and performance capabili- transportation planners to be most desirable because it provides ty. Assessment and training can provide the needed feedback and the greatest degree of independence, and ends with riding a public training. If necessary, the individual may need to be counseled to fi xed-route bus or train, considered by transportation planners to stop an activity, such as driving. be the least desirable because it results in the greatest degree of dependence (Figure 1). By placing private and public transportation Maintaining Personal Mobility modes on the same continuum, the transit-centered approach dis- regards the fact that anyone using public modes must have certain Public transportation options for older adults have been recent- capabilities. Further, the approach does little to recognize or sup- ly addressed by the Transportation Cooperative Research Program port those older adults who use more than one mode to travel. Report 82 (Burkhardt et al., 2003) “Improving Transit Options for By emphasizing the bipolar anchors of personal independence and Older Persons.” Looking to the future, it is clear that trips out of dependence instead of discrete points along the continuum, geron- the home by older adults are increasing dramatically. Most trips by tologists offer another way to consider decisions about using trans- older people are now made in private autos. Today’s older adults portation modes. use public transit for about 3 percent of their trips—fewer than 12 percent of all older adults have used public transit in the past twelve months. It should be noted that 34.3 percent of older adults This person-centered approach recognizes the relationship be- have no public system available. tween an individual’s capabilities and the environment in which those capabilities must fi t and leads to a categorical division in assessing degrees of personal independence in using private versus Many older adults now live in communities that are highly auto- public modes. The market-centered continuum (Figure 2) focuses oriented, and many more will do so in the future. Most people now on the highest levels of personal independence and decision mak- in the generations of future older adults now living will have been ing available in the private modes, such as walking and driving a confi rmed auto users all of their lives and are “high mobility con- car, and in public modes, such as using fi xed-route transportation sumers.” It is apparent that demands for all kinds of transportation services. In the most independent mode, public or private, the indi- services will increase. vidual chooses where, when, and how to travel. In both instances, the person must display high level of capability and independence In the future, older adults will expect to be able to make more in travel ability for system use. and different types of trips that are not currently available because of various limitations. People will expect high levels of consumer The market-centered continuum emphasizes the individual us- choice and fl exibility. It is clear that we are not ready to meet the er’s independence of choice and action in using various modes of forecasted changes. transportation and the complexity involved in making choices of 11 which modes to use. Research indicates that older adults, especial- Singleton, W. T. 1979. “Safety and Risk.” In W. T. Singleton, ly those with limited functional capabilities, do not rely on a single ed., The Study of Real Skills, Vol. 2—Compliance and transportation mode for all trips. They tend to choose among a va- Excellence. Baltimore: University Park Press. riety of transportation modes for specifi c trips, depending in their Sterns, H. L., and Gray, J. H. 1999. “Work, Leisure, and Retirement.” capability for making a particular trip and mode availability. Older In J. Cavanaugh and S. Whitbourne, eds., Gerontology. adults prefer the independence afforded by fi xed routes and de- New York: Oxford University Press. mand-responsive public transportation to the dependence on fam- Sterns, H. L., and Sterns, R. 2000. “Commentary: Social Structures ily or friends for a ride (Burkhardt, 2000; Burkhardt et al., 2003; and Processes in Public and Private Transportation.” Nelson and Sterns, 1996). In K. W. Schaie, and M. Pietrucha, eds., Mobility and Transportation in the Elderly. New York: Springer. Conclusion Sterns, H. L., et al. 2001. “Family and Friends Concerned About The importance of mobility through transportation options is cen- an Older Driver.” NTIS Publication No. dot hs 8090307. tral to the concept of independence. One of the lessons of later Washington, D.C.: National Highway Traffi c Safety life is to accept, when necessary, help from others, including fam- Administration. ily and friends, as part of the informal support system and, when Sterns, H. L., Barrett, ., and Alexander, . 1985. “Accidents and available, the options of the formal transportation support system. the Aging Individual.” In J. E. Birren and K. W. Schaie, The best option is to be able to draw on the formal system, but also eds., Handbook of Psychology of Aging. New York: Van have the informal system available. It is important to remember Nostrand-Reinhold. that 34 percent of older adults are in areas with no formal transpor- U.S. Offi ce of Technology Assessment. 1978. tation services. Even in those areas that have transportation servic- Wagner, M. B., and Kauffman, T. L. 2001. “Mobility.” In B. R. es, the real issue is how accessible and acceptable the services are Bonder and M. B. Wagner, eds., Functional Performance to older adults. in Older Adults, 2d Edition. Philadelphia: F. A. Davis. Whitbourne, S. K. 2002. The Aging Individual—Physical and Psychological Perspectives, 2d Edition. New York: Harvey L. Sterns, Ph.D. is professor of psychology and director, Springer. Institute for Life-Span Development and Gerontology, University “Moving Along the Mobility Continuum: Past, Present, and Future,” of Akron, Akron, Ohio, Jon E. Burkhardt is senior study director, Reprinted with permission from Generations, Summer WESTAT, Rockville, Md., and John W. Eberhard, Ph.D., is a re- 2003, Volume XXVII, Number 2: 8-12. Copyright 2003 search psychologist and consultant on transportation and aging is- American Society on Aging, San Francisco, California. sues, Columbia, Md. www.asaging.org.

References Burkhardt, J. E. 2000. “Limitations of Mass Transportation and Individual Vehicle Systems for Older Persons.” In K. W. Schaie and M. Pietrucha, eds., Mobility and Transportation in the Elderly. New York: Springer. Burkhardt, J. E., et al. 2003. “Improving Public Transit Options for Older Persons,” tcrp Report 82, Cooperative Research Program, Washington, D.C.: Trans- portation Research Board. Carp, F. M. 1979. “Improving the Functional Quality of Housing and Environments for the Elderly Through Transportation.” In T. O. Byerts, S. C. Howell, and L. A. Pastalan, eds., Environmental Context of Aging: Life- styles, Environmental Quality and Living Arrangements. New York: Garland STPM Press. Christiansen, C. H., and Hammecker, C. L. 2001. “Self-Care.” In B. R. Bonder and M. B. Wagner, eds., Functional Performance in Older Adults Second Edition. Philadelphia: F. A. Davis Co. Golant, S. M. 1976. “Intraurban Transportation Needs and Problems of the Elderly.” In M. P. Lawton, R. J. Newcomer, and T. O Byerts, eds., Community Planning for an Aging Society: Designing Services and Facilities. Stroudsburg, Pa.: Dowden, Hutchinson & Ross, Inc. Schaie, K. W. 2000. “Preface.” In K. W. Schaie and M. Pietrucha, eds., Mobility and Transportation in the Elderly. New York: Springer. Schaie, K. W., and Pietrucha, M., eds., 2000. Mobility and Transportation in the Elderly. New York: Springer. 12 Who’s Safe? Who’s Sorry? The Duty to Protect the Safety of Clients in Home and Community Based Care By Rosalie A. Kane and Carrie A. Levin First, do no harm. This is a major tenet in the right balance between safety and free- tation than a recommended nursing home medical ethics. It is also the fi rst statement dom. Often, the professional has the pain- placement.) However, some safeguarding of the ethical principle of benefi cence—do- ful sense that he or she is joining the forces procedures and perhaps even some regula- ing good, which holds that ethical profes- pushing unwilling clients toward nursing tion need to be in place to govern any con- sionals act so as to benefi t their clientele homes, yet the push seems to be for their tractual mechanisms for risk-taking among and, at the very least, to do no harm. own good. older HCBS clients.

This most basic goal of doing no harm has The problems are exacerbated by the pro- The Right to Take Risks been extended in the view of some people found ambivalence that so many people One ethics sourcebook defi ned a risk as to mean that the care and service plans de- feel about tradeoffs between their freedom “an adverse future event that is not certain veloped for home- and community-based and safety. Older people—like people of all but only probable” (Shöne-Seifert, 1995). services (HCBS) for older people should be ages—want to be both free and safe. Older People who are competent decision-mak- designed to maximize physical safety and HCBS consumers, who often are aware of ers ordinarily make autonomous decisions protection and to minimize the likelihood their increased risks and diminished capa- about the risks they wish to take based on of preventable negative events, such as bilities, can have great diffi culty making a the magnitude and the likelihood of expect- falls, injuries, or relapses. The social work- necessary choice between the two values. In ed harms and benefi ts associated with each ers, nurses, and others who hold up safety one study of more than 800 elderly clients course of action. There may, of course, be as a goal may be doing so as part of their in these settings, about a third chose free- limits to a person’s right to take informed commitment to do no harm. But such pro- dom, a third chose safety, and a third vacil- risks. Obviously, one should not implicate fessionals may have lost perspective on the lated between the two (Degenholtz, Kane, other parties in one’s risk-taking. For ex- nature of their appropriate role in helping and Kivnick, 1997). Professionals express ample, the emphysema patient who wish- individuals plan their lives; they may be as- similar ambivalence. One study (Kane, es to risk smoking around her oxygen sup- suming too much responsibility. They may 1995) showed respondents overwhelming- ply improperly endangers others in a living have also lost perspective on the facts— ly agreeing with the proposition that older setting. On the other hand, the insulin-de- that is, what actually constitutes safety and HCBS clients should be free to act against pendent diabetic who fails to stick to a diet what actually constitutes risk. With “do no advice of a professional from an agency or may be said to risk injuring only himself. harm” as the overriding goal, protecting program regarding risk-taking without the Yet, some would argue that this noncom- clients ultimately may mean declining to agency or program withdrawing from the pliant individual has no right to repeated- serve them in their own homes because the scene. When asked to elaborate the circum- ly drive himself into diabetic coma, if, in plan may be unsafe. Protecting clients ul- stances under which such client risk-taking so doing, he harms others by drawing re- timately may mean reshaping assisted liv- would be permissible, almost all responded sources away from them. Without getting ing settings through regulations until they with a variant on the phrase “when it does into the more abstract arguments about fi - mirror more restrictive settings like nursing not jeopardize their own safety and that of nite resources for healthcare, we could cer- homes. Paradoxically, the desire to do no others.” Professionals endorsed informed tainly argue that a person who has a week- harm and to achieve safety above all oth- risk-taking, but apparently only when it ly health crisis in an assisted living setting er goals may actually result in harm for the was risk-free! takes valuable and often limited staff time consumer. away from others. In this article, we examine the concept The most exquisitely diffi cult ethical dilem- of consumer risk-taking and profession- Let us assume a consumer’s desired risk- mas that arise in home- and community- al responsibility in home- and communi- taking is likely to cause no harm to others. based services concern the proper bound- ty-based services. We then turn to possible Let us further assume that the consumer aries between promoting freedom for older ways for professionals to negotiate these has decided, after much consideration, that people and avoiding interference with their ethical minefi elds, including an exploration the benefi ts of following the risky course life goals, on the one hand, and acting re- of the relatively new concept of managed of action outweigh the potential harms to sponsibly to promote their health and safe- risk contracting, or negotiated risk. We ar- herself. She may still not be free to follow ty, on the other. These are anguishing situ- gue that active steps need to be taken to her preferences. Care providers might still ations for professionals. The case fi les of preserve and promote the right of compe- argue that they cannot allow people under ethics committees that have sprung up in tent older people to make decisions about their care to assume certain risks because HCBS are littered with examples wherein their care in general, not just narrow deci- they, themselves, would then be negligent professionals wrestle consciously and con- sions about specifi c procedures. (Currently, in their duties. For this reason, homec- scientiously with the problems of striking it is easier to refuse a recommended ampu- are agencies or case managers sometimes 13 choose to terminate a case rather than pro- Whether a client is “better safe than sorry” vices are notoriously diffi cult to quantify. vide a lower level of service than they think is a complicated question, and at present, In contrast, the risks of medical procedures proper (Kane and Caplan, 1993). For cer- no common language is available to dis- are almost easy to measure and describe. tain technical procedures, like administra- cuss risks and risk taking. The following Although science is far from exact, it is of- tion of intravenous fl uid or treatment of elements should be considered in any ap- ten plausible to provide the potential con- wounds, the consumer has no privilege to praisal of potential risk to an HCBS consumer with information about death and waive technical standards. The provider is sumer. complication rates associated with a sur- not off the hook for negligence because the gical procedure or a drug intervention and consumer has consented to, say, reuse of Type of risk. Risks may be physical, psy- even to elaborate on the circumstances that a needle. But what about the quadriplegic chological, or social, including fi nancial. exacerbate or minimize the likelihood that client who cannot take his own medicine For the most part, physical risks are the the particular person will experience a bad and prefers to have his housekeeper admin- ones that care providers bring to the atten- outcome. Similarly, it is often possible to ister the medications rather than eat up the tion of consumers, while tending to dis- provide information about the likely course resources for his HCBS plan by expensive count psychological and social risks. But of action if the surgery is rejected or the visits from a licensed nurse, which regu- even physical risks, to health and well-be- medicine not taken. lations require? Such issues may become ing, should be evaluated based on specif- hotly debated by providers struggling to ic characteristics—some risks are certainly In contrast, long-term care typically deals defi ne where appropriate deference to the more potentially grave than others. with many small consecutive or repeated client’s informed risk-taking ends and pro- decisions rather than one big decision. For fessional negligence begins. Or, the ethi- Risks in the psychological or social sphere example, the likelihood of falling, diffi cult cal tension may be at least temporarily re- are not usually taken as seriously, but they to predict at best, is related to each decision solved at a policy level by rules that require are often far from trivial. For example, some involving independent ambulation or trans- certain training to perform certain tasks. To care plans may be accompanied by a high fer in a variety of circumstances. The con- take another example, regardless of a resi- risk of painful depression. Usually, howev- sumer who is advised to curtail activities dent’s informed choice, staff of an assisted er, care providers are only in the business to prevent falls may adopt a partial strate- living program often obsess over whether of identifying risks to physical health and gy, perhaps with more risk than providers they would be negligent to retain someone safety. Rarely would they review social or would prefer but with more caution than in their setting whose needs seem to exceed psychological risks and advise people, for the consumer would normally adopt. The the service capability in the setting. Such example, to avoid a nursing home because likely consequences of such highly individ- a problem typically involves a risk, not a they seem at high risk for human misery. ualized strategies to avoid risks are almost certainty. The resident might fall, and if he impossible to calculate with any precision. were to fall at night, the staff would be in- suffi cient to transfer him back to bed. The What about the risk of death, to some the ultimate harm? Viewing death as the result Negative effects of avoiding the risk. These resident might wander out because of in- potential effects are also not a certainty, but suffi cient staff supervision and, if so, might to be avoided at all times belies the fact that many people receiving home- and commu- merely a prediction. They too can be clas- sustain an injury, which might be serious. sifi ed in terms of type of effect—for exam- However, in jurisdictions where assisted nity-based services are very old and have shortened life expectancies. ple, physical, psychological, social, fi nan- living programs are legally required to eject cial. They too can be examined in terms of anyone who reaches a certain level of need, Severity of consequences. The potential their likelihood and their potential negative the consumer’s prerogative to take certain consequences. risks has been preempted. The great variety consequences of some risks are even life- of prohibitions and permissions that gov- threatening, whereas others are relatively ern licensed HCBS entities suggests con- trivial. Surely, the nature of potential con- Role of providers. Homecare providers, fusion about how much protection should sequences of the risk must be taken into ac- care coordinators, or assisted living provid- be required. count. ers are often present on an almost daily basis with much more intensity and intima- Likelihood of consequences. Some poten- cy of involvement than is usually the case Thus, the right of a consumer to take in- between patient and physician. Homecare formed risks is modifi ed by the moral, le- tial negative consequences of behavior or actions deemed risky may actually be quite providers may fi nd themselves still active gal, and regulatory responsibilities of in a case after their advice has been ignored health professionals and care organiza- unlikely. Often, professionals and family members of the older person with the dis- and may feel compelled to renew the sub- tions. However, the moral foundation for ject of their concerns regularly. the legal and regulatory constraints on con- ability concentrate on the severity of conse- sumer risk-taking needs constant examina- quences, say, if an older person with some Ingredients of Informed Risk-Taking tion. Professional orthodoxy, aversion to dementia is alone in the home and becomes risk, and motivations to protect the guild prey to a dangerous criminal, rather than Informed risk-taking of course requires may all in effect serve to reduce the free- concentrating on the likelihood of such an a source of trustworthy information. The dom of the consumers to take chances in event actually occurring. consumer may also require time to digest the interests of their own goals. that information and consider the implica- Diffculty of predicting risk. Risks associat- tions. At issue is whether and under what Deconstructing Consumer Risk-Taking ed with home- and community-based ser- circumstances care providers are a good 14 source of information about the riskiness consumer and other parties relevant to the as a failure in care planning. We also iden- of various courses of action. And, if not the agreement. tifi ed a small subset of providers who were care provider, who should be the source of using the mechanism to clarify the risks such information? Should it be provided Managed risk agreements in Oregon have providers were willing to take. For exam- in writing? With a witness? Will all those evolved in the assisted living setting, ple, the managed risk agreement might trappings create an aura of dread and fear which, by law, is a congregate care set- read that the consumer would be permitted that will unduly infl uence the deliberations ting that is expected to maximize privacy, to smoke in a defi ned area of the building of the consumer? Yet, without such a pro- dignity, choice, independence, and normal but, if he dropped the cigarette, he would cess, how is it clear that the consumer has lifestyles. The setting is structured so as to thereafter be required to smoke outside. been informed, and how do professionals encourage people with nursing-home lev- Certainly, the establishment of the progres- and care organizations protect themselves els of disability to live in their own self- sive steps in a provider’s willingness to tol- from legal liability? contained small apartments with features erate the risky behavior and the ultimatum and amenities that encourage independence approach (three strikes and you’re out!) Informed risk-taking also requires a com- but have elements of danger—for example, distorts the original consumer-empowering petent individual who is capable of un- roll-in showers, refrigerators, and cooking intent of managed risk contracting. derstanding the tradeoffs and making the appliances, lockable doors. Assisted liv- choices. Many long-term-care consumers ing programs in Oregon charge less than When Things Go Wrong suffer from some degree of impaired mem- do nursing homes and receive less in pub- All concerned can congratulate themselves ory or judgment that may render them inca- lic payment. They are not staffed for con- on being sensitive to consumer preferenc- pable of making a decision to take chanc- stant attention even if the environments es as long as no untoward events occur. es in the name of autonomy. It still may be are conducive to such surveillance, which But when things go wrong, especially in feasible to develop a process by which an is seldom the case. As individual residents publicly funded programs, there is a nat- agent weighs the benefi ts and harms of var- are perceived to be at some risk because of ural tendency to seek someone to blame ious courses of action on behalf of the in- their own behavior—not waiting for bath- (Kapp, 1997). The true test of an approach dividual with impairment, but the rationale room assistance, violating special diets, go- whereby consumers can make decisions to for such a process is based on a different set ing out on their own, imperfectly managing take chances comes after a negative event. of assumptions. a self-medication regimen—formal man- After a fall occurs, does the consumer get a aged risk contracting is sometimes consid- chance to fall again? And in the worst pos- Managed Risk Contracting ered. At times, the managed risk contract is sible scenario, when the consumer dies as Managed risk contracting is a concept that put into effect because the consumer’s pref- a result of the course of action pursued, has come into vogue in the 1990s as many erence counters that of the provider. For ex- will providers be held culpable? Even state HCBS programs have given explicit ample, the provider might prefer to admin- if they are not blamed, will they feel re- recognition to such notions as “dignity of ister all medications, whereas the consumer sponsible in a way that detracts from their risk” in their supporting legislation or pro- prefers to take them independently, either effectiveness? gram rules. In the state of Oregon, managed to keep independent or to avoid extra costs risk contracting has had the most wide- associated with accepting more help. At The more long-term care mirrors nor- spread application. As developed there, it other times, the managed risk contract clar- mal life, the more things can go wrong. is an orderly process for examining and re- ifi es what kind of assistance can and cannot Depressed people will have more access solving issues that arise when providers be- be expected in the setting. For instance, the to weapons with which they could harm come concerned about the risks that their consumer might be content to be accompa- themselves, for example. Die-hard smok- clientele are assuming (Kapp and Wilson, nied on all walks, but the provider may not ers on oxygen will have the opportuni- 1995). Managed risk contracting as it has have the staff to provide this service. ty to become human torches (an event that evolved in Oregon has several steps: is more likely to kill them than injure oth- 1. Defi ning risks and provider concerns. In an ongoing study, we asked about six- ers nearby). People may leave their homes 2.Defi ning probable consequences of the ty assisted living providers to comment on or assisted living settings, suffer a fall or consumer’s behavior or condition. their views of managed risk contracting as a stroke, and die unattended. Should care 3.Identifying the preferences of everyone a mechanism for clarifying and perhaps re- providers be held responsible for such neg- involved, which could include the at-risk solving some of the ethical confl icts arising ative events? Should it make any difference consumer, one or more care providers, and over safety-freedom tradeoffs. Few people that an event was unlikely or that the possi- one or more family members. say they believe that a managed risk agree- bility had been discussed with the consum- 4. Identifying possible solutions. ment is a legally binding document, and, er? 5. Choosing a solution. indeed, we have not identifi ed any case law that is directly on point to clarify the top- Cognitive Impairment and Surrogate Risk- Ultimately, the person incurring the risk ic. Proponents of managed risk contracting Taking say that the very act of identifying the is- is perceived as the ultimate decision-mak- The most diffi cult situations concern cog- sues is salutary and may in fact lead to cre- er (assuming competency and no inordi- nitive impairment, and these situations are ative compromise solutions. Some oppo- nate risks to others), but the search is al- where most risks occur. Some family mem- nents contend that managed risk contracts ways for compromise solutions. The plan bers express confi dence that they know are meaningless documents, while others is documented in writing and signed by the what kinds of risks their relative would pre- say they see formal managed risk contracts 15 fer to take, and some lay claim to greater freedom for their rela- The work that led to this manuscript was supported by the tive with Alzheimer’s disease. Do family members have the right Retirement Research Foundation. to assert that Mother would rather be at home, even if at times alone and unsafe, than in an unfamiliar institution? Do they have References the right to assert that they would rather have that independent ex- Degenholtz, H. B., Kane, R. A., and Kivnick, H. Q. 1997. “Care- perience for Mother? Do they have the right to say Dad should re- Related Preferences and Values of Elderly Community- main in an assisted living setting, where he might at times wander Based ltc Consumers: Can Case Managers Learn What’s out, and accept the consequences—for example, that the assisted Important to Clients?” Gerontologist 37(6): 767–76. living setting could check his whereabouts at intervals and call 911 Kane, R. A. 1995. Quality, Autonomy, and Safety in Home and if he was found missing? What if family members appear to have Community-based Long-term Care: Toward Regulatory a confl ict of interest? and Quality Assurance Policy. (Report of a minicon- ference for the White House Conference on Aging, Toward Clarity Washington, D.C., February 11 and 12.) Minneapolis: Resolving the problems that arise when perceived safety and free- National ltc Resource Center, University of Minnesota dom confl ict will require new organizational and perhaps legal ve- School of Public Health. hicles. It will be necessary to determine who has a stake in the out- Kane, R. A., and Caplan, A. L. 1993. Ethical ConXict in the come and who deserves to be part of the deliberations. It will be Management of Home Care: The Case Manager’s necessary to develop better ways of engaging consumers in gen- Dilemma. New York: Springer. uine and ongoing consideration of the risks they want to take and Kapp, M. B. 1997. “Who Is Responsible for This? Assigning Rights the way they want to live. We will need to learn how to distinguish and Consequences in Elder Care.” Journal of Aging and between negligent care and care that respects autonomous risk- Social Policy 9(2): 51–65. taking, between protecting consumers and coercing them into con- Kapp, M. B., and Wilson, K. B. “Assisted Living and Negotiated forming lifestyles. Most ethical problems in HCBS revolve around Risk: Reconciling Protection and Autonomy.” Journal of the safety-protection tradeoffs, and consumers and providers alike Ethics, Law, and Aging 1(1): 5–13. are anguished about what to do. We have already tried making Shöne-Seifert, B. 1995. “Risk.” In W. T. Reich, ed., Encyclopedia safety (in the eye of the provider) the default position without of Bioethics, Vol. 4. New York: Macmillan. guaranteeing either safety or other sorts of well-being. A cautious effort to develop a new approach seems worth the risk. “Who’s Safe? Who’s Sorry? The Duty to Protect the Safety of Clients in Home- and Community-Based Care,” reprinted Rosalie A. Kane, D.S.W., is professor, and Carrie A. Levin is a with permission from Generations, Fall 1998. Copyright doctoral student and research assistant, both at the Institute for 1998 American Society on Aging, San Francisco, Health Services Research, School of Public Health, University of California. www.asaging.org. Minnesota, Minneapolis.

Glossary or customized, that is used to increase, maintain, or improve the functional capabilities of individuals with disabilities. Activities of Daily Living (ADLs) - Activities usually performed for oneself in the course of a normal day including bathing, Baby-Boomer Generation - A sudden increased post-war birth rate dressing, grooming, eating, walking, using the telephone, taking between 1946 and 1964. medications, and other personal care activities. Case Management - Case managers work with family members Adult Day Care Centers - Adult Day Care Centers offer social, and older adults to assess, arrange and evaluate supportive recreational and health-related services to individuals in a efforts of seniors and their families to remain independent. protective setting who cannot be left alone during the day because of health care and social need, confusion or disability. Care Management - Geriatric Care Managers specifically trained in geriatric care management, and provide case management Aging in Place - The ability to grow older and have your health services on a fee-for-service basis to individual clients. and housing needs met without having to move to an institution in order to receive supportive services. Congregate Meals - These meal programs provide older individuals with free or low cost , nutritionally sound meals served five days Assisted Living Communities - Residential communities for older a week in easily accessible locations. Besides promoting better adults who need assistance on a daily basis but do not need health through improved nutrition, meal programs provide daily constant nursing care. Assisted living provides help with personal activities and socialization for participants which help reduce the care activities while maximizing independence. Assisted living isolation of old age. facilities may stand alone or be part of a retirement community or nursing home. Accommodations range from single or double Consumer-Directed Care - Emphasizes the ability of older and rooms to suites and apartments, depending on how much the disabled consumers to assess their own needs, make decisions older adult resident can afford. based on choices and options, and monitor the quality of their services. Assistive Devices - Any item, piece of equipment, or product system, whether acquired commercially off the shelf, modified, Continuing-Care Retirement Communities - Expensive residential

16 communities for older adults with different levels of housing and Instrumental Activities of Daily Living (IADLs) - Daily activities services across the continuum of care, from independent living, other than personal care or household chores such as money to assisted living to skilled nursing care. Residents sign a life-care management, medication management and administration, meal contract that allows them to age in place by accommodating their preparation, transportation and employment. changing needs and care for the rest of their life. Long-term Care - A general term that describes a range of medical, nursing, custodial, social, and community services Culture - The way a group lives, the ethnic background, the race, designed to help people with chronic health impairments or forms the values and norms of behavior, and ways of thinking that of dementia. are passed down through generations and make the person an identifiable group in a society. Managed Risk Contracting - Referring to the use of home- and community-based services, an orderly process between the agency Ethnicity - A group that shares common characteristics such as and clients for examining and resolving issues that arise when religion, traditions, rituals, culture, language, and tribal or national providers become concerned about the risks that their clients are origin. assuming.

Home and Community-Based Services - A variety of supportive Nursing Homes - Institutions that are licensed by the state and services delivered in community settings or in an older person’s offer round-the-clock care for residents who are unable to live home are designed to help older persons remain living at home independently and care for themselves. Nursing homes provide and avoid institutionalization. the full range of personal and medical care.

Home Delivered Meals - Sometimes referred to as “meals on Senior Housing - Apartments for rent that are designed specifically wheels,” home delivered meals are hot and nutritious meals for older adult residents who are able to live independently. Senior delivered to homebound persons who are unable to prepare their apartment complexes may offer home modifications, emergency own meals and have no outside assistance. call service, assistance with chores, social activities and a range of transportation and social services. Home Modification - Adaptation and/or renovation to the living environment intended to increase ease of use, safety, security Strengths-Based Approach - A model that operates on the premise and independence. that older adults have a tremendous capacity for continued growth and autonomy by focusing on their individual experiences, talents, Informal Support Network - Non-paid persons (family, friends, interests and aspirations. The strengths approach assumes that neighbors) and community groups (churches, neighborhood each person is the expert in defining his/her own needs or will associations, civic groups) that provide assistance to older adults and what he or she needs to achieve well-being. in the community.

References from “Aging In Place” Continued from page 9 Straight, A. & Gregory, S. (2002). “Transportation: The Older Yagoda, L. (2004). “Case Management With Older Adults: A Social Person’s Interest.” AARP Public Policy Institute Fact Sheet. Work Perspective.” NASW Aging Practice Update. Retrieved Retrieved on 12/1/04 from http://www.research.aarp.org/ppi. on 11/29/04 from www.socialworkers.org. Washington, DC: Washington, DC: American Association of Retired Persons National Association of Social Workers. (AARP). “Who’s Safe? Who’s Sorry? The Duty to Protect the Safety of Tilly, J., Wiener, J. & Cuellar, A. (2000). “Consumer-Directed Clients in Home- and Community-Based Care,” reprinted Home- and Community-Based Services Programs in Five with permission from Generations, Fall 1998. Copyright 1998 Countries: Policy Issues for Older People and Government. American Society on Aging, San Francisco, California. www. Generations. Vol XXIV (3):74-83. San Francisco, CA: asaging.org. American Society on Aging. Wodarski, J. & Williams-Hayes, M. (2002). “Utitlizing Case Management to Maintain the Elderly in the Community.” Journal of Gerontological Social Work. Vol 39 (4): 19-38. Binghampton, NY: Haworth Press, Inc.

17 Home-Safety Checklists for Elders in Print and on the Internet By Barbara J. Kercher and Laurence Z. Rubenstein

While the importance of making our homes ty issues, lighting, general assistive devic- possible, we traced each list to its original childproof to prevent injuries is well ac- es, safety devices, emergency preparedness, author. At minimum, a cursory review of cepted, an equivalent attention to home and hazard containment. several checklists of either type is advised safety for our growing older population is prior to using one or more of them and, in only beginning to evolve. The Department Our analysis focused on content and “elder particular, prior to the provider recommend- of Health and Human Services (2001) re- friendliness”—factors affecting the check- ing them for elder use. ports that, in 1998, unintentional injuries lists’ acceptability to older adults. Because accounted for the deaths of 18,538 young of the visual and other physical chang- Discussion persons between the ages of 1 and 24 years, es that occur with aging, larger typefac- This content analysis was intended to pro- and for the deaths of 32,975 Americans age es, easy-to-read graphics layouts, and suc- vide an overview of educational check- 65 years and older. Falls account for ap- cinctness are important characteristics. Out lists for improving home safety for elders. proximately 75 percent of unintentional in- of respect for the older person, the tone of Though intended to be as comprehensive juries among community-dwelling older the guides should be one of presenting ma- as possible, it is inevitable that some sourc- adults, followed by burns (8 percent) and terial to an informed consumer, offering re- es were missed, as new materials are being improper dosages of prescription medica- sources and alternatives, rather than patron- produced constantly. Therefore, this analy- tions and other mishaps (17 percent). Most izingly presenting directives. Further, we sis must be considered a work in progress. of these injuries occur in the home environ- assessed the overall diffi culty and estimat- ment (Roberts and Irons-Georges, 2000). ed costs of implementing each safety rec- Each home-safety checklist served to identi- The majority of home environments are not ommendation based on Bakker’s “Resource “elder-friendly” to individuals with limita- fy home hazards and sensitize its readers to Guide” (1997) and our respective experi- the importance of safe home environments. tions in mobility or perceptual ability as- ences as homeowners. sociated with aging (Lanspery, Hyde, and The majority also offered specifi c suggestions for actions to correct or eliminate the Hendricks, 1997; Houts and Rubenstein, Results 2002). home hazards identifi ed, within the content Our content analysis revealed many extrin- of the checklist itself or within its accompa- sic risk factors that were identifi ed repeat- nying text. These suggestions ranged from A multitude of judgment-based home-safe- edly on checklists—for example, grab bars relatively easy, no-expense home adapta- ty checklists, designed for use by elder- in bathrooms (98 percent overall) and hand- tions (e.g., arranging furniture to ensure un- ly people in their homes, provide practi- rails and stairs in good repair (91 percent obstructed pathways) to home modifi cations cal tools for assisting them in making their overall). Certain risk factors were more that required some skill and low-to-medium home environments safer. The checklists commonly found on Internet lists than on expense (e.g., installing grab bars), to ex- vary in number and severity of risk fac- published lists (e.g., smoke detectors, 74 pensive modifi cations that required hiring tors addressed, practicality and product cost percent versus 31 percent), and some were professionals (e.g., replacing kitchen cabi- of proposed solutions, and apparent over- more common on published lists (e.g., non- nets). Indirect evidence suggests that these all quality. Because of this wide spectrum skid wax, 22 percent versus 61 percent). environmental modifi cations can enhance of available lists, and their potential impor- List recommendations varied widely in both functional ability and lower rates of disabil- tance in addressing this major problem, we the complexity and the expense (e.g., from ity. and, fortunately, many of the most crit- undertook a content analysis of home-safe- arranging a buddy system with a neighbor ical home modifi cations and repairs, such ty checklists for elders available in the con- to hiring a professional help-response sys- as improved lighting and grab bars, are rel- sumer literature and on the Internet. ( See tem). Accompanying texts, including illus- atively inexpensive, permanent, and pro- Appendix.) trative examples, advice, referrals, and tes- vide years of benefi ts (Lanspery, Hyde, and timonials, further enhanced the value of Hendricks, 1997). Many modifi cations that Methods many of these checklists and referred read- exceed an individual’s resources can often We conducted a systematic search of sci- ers to additional nonprofi t resources (e.g., be completed with the help of local, state, entifi c and consumer literature as well as toll-free numbers or websites). Indeed, 65 and federal assistance programs. Internet sites for checklists and itemized percent of the Internet checklists offered hazard lists focused on preventing uninten- searches within the site where the checklist The scientifi c and consumer literature, tional injuries among community-dwelling was located. and the Internet sites, offer a continuum of elders. This project involved an extensive home-safety checklists and corresponding electronic library search and use of sever- Readability of the Internet checklists and text for independent elders and their health- al Internet search engines. Our analysis of their corresponding texts was quite vari- care providers. Several checklists are avail- checklists began with an itemization of ex- able. During the course of our search and able in hard copy at no fee, as well as on the trinsic risk factors, which we classifi ed into analysis of elder home-safety checklists, we Internet for reference and printout. Others six broad categories: physical accessibili- discovered signifi cant18 duplication; when are published as booklets or brochures for providers. No one home-safety checklist and text, even if published markable consistency in content among the better lists. Several are as a reference, can encompass all home environmental issues and clearly superior in formatting and comprehensiveness. It is hoped solutions. Some are clearly better than others. The most compre- that these better lists will be tested for effectiveness in future con- hensive ones are not necessarily the most useful ones to an individ- trolled trials. ual elder. Yet, any of them serve to remind their readers of the importance of environmental issues at home and elsewhere. Barbara J. Kercher, M.P.H., is a health educator, Los Angeles County Department of Health Services; Laurence Z. Rubenstein, The best and the worst features of elder home-safety checklists and M.D., M.P.H., is professor of geriatric medicine, UCLA School of related text may be found on the Internet. The best-designed web- Medicine, and director, Geriatric Research Education and Clinical sites tend to be those with large black text on a white background, Center, VA Greater Los Angeles Healthcare System, Sepulveda, appropriate photos, menus for further specifi c information, an on- Calif. site search option, and an easy way to ask questions by e-mail. The more poorly designed websites feature monochrome text and col- This project was completed as part of Barbara Kercher’s graduate or-fi lled backgrounds which tend to camoufl age the text or inappro- work at ucla School of Public Health. priate pop-up and in-your-face animated ads (which could disturb some elders). Providers would do well to review the preferences References and needs of each elder before recommending a website or provid- Bakker, R., 1997. Elder Design: Designing and Furnishing a Home ing a home-safety checklist to their clients or patients. As with any for Your Later Years. New York: Penguin. Internet source, some websites may contain inaccurate or mislead- Houts, P. S., and Rubenstein, L. Z., eds. 2002. Eldercare at Home. ing information or copyrighted material. American Geriatrics Society. www.healthinaging.org/eldercare/index.html. None of these checklists has been tested as a specifi c intervention Lanspery, S., Hyde, J., and Hendricks, J., eds. 1997. Staying Put: in a randomized controlled trial, so these recommendations are Adapting the Places Instead of People. Amityville, N.Y.: based on judgment alone. Baywood. Roberts, P., and Irons-Georges, T., eds. 2000. Aging, Volume 1 and More attention to safety in the home environment is clearly need- 2. Pasadena, Calif.: Salem Press. ed to maximize injury prevention. Programs to reduce intrinsic risk “Home-Safety Checklists for Elders in Print and the Internet,” factors (e.g., exercise programs, risk-factor assessment and abate- Reprinted with permission from Generations, Winter ment programs) have proven successful, but relatively little re- 2002-3, Volume XXVI, Number 4:69-74. Copyright 2003 search has been devoted to environmental risk reduction. Many American Society on Aging, San Francisco, California. papers suggest that elderly patients should use home-safety check- www.asaging.org. lists themselves or in conjunction with their healthcare professionals. However, such checklists have not been standardized and vary considerably, as seen in our analysis. Nonetheless, there is a re-

Post Test and Course Evaluation on pages 20 - 21.

19 Aging in Place Post–Test Please circle the one correct answer for each question. 1. According to the U.S. Bureau of the Census (2000), adults age 8. Several comparative analyses of older African Americans, 85 and older increased by what percentage during 1990-2000? Hispanic Americans, American Indians and Asian American/Paciﬁ c a) 25% Islanders found that as a whole, these older ethnic groups have the b) 15% same risk of shorter life expectancy, poor health, poverty, malnutri- c) 50% tion and poor housing quality as older non-Hispanic whites. d) 40% a) True b) False 2. The concept of aging in place encompasses: a) Growing older in one’s own home 9. According to the Home-Safety Checklists for Elders in Print and b) Receiving supportive services at home the Internet article, approximately how many older adults died as a c) Maintaining pre-existing social networks though the lifespan result of unintentional injuries in their homes in 1998? d) All of the above a) 5,595 b) 10,625 3. Which age group is the least likely to move or change c) 32,975 residences? d) 58,235 a) 45-64 b) 85+ 10. Barriers to home modiﬁ cations include: c) 65-85 a) Costs and affordability d) 25-44 b) Consumer confusion c) Lack of awareness about problems in the physical environ- 4. It is probable that how many older adults will reside in a long ment term care facility for at least part of or the rest of their lives? d) All of the above a) 20% b) 5% 11. True or False? Research indicates that older people are less c) 15% likely to want consumer direction than younger people. d) 25% a) True b) False 5. Research suggests that compared to older adults living in the community, residents of nursing homes are considerably more like- 12. Assistive devices are: ly to experience higher levels of : a) Any product used to increase, maintain or improve function- a) Depression al capabilities of individuals with disabilities b) Suicidal ideation b) Changes made to the home to allow persons with disabilities c) Satisfaction to live independently d) Both a and b c) Hi-tech products that are used to increase, maintain or improve functional capabilities of individuals with disabilities 6. The economic value of the time and expertise donated by older d) Lo-tech products that are used to increase, maintain or im- adults 65 and over in their communities is estimated to be worth: prove functional capabilities of individuals with disabilities a) $22.7 billion b) $5.5 billion 13. Despite the preference to remain independent and able to drive c) $12.8 billion an independent vehicle, nearly how many older adults age 65 and d) $18.2 billion older are not able to drive? a) 1 million 7. Which of the following structural and economic barriers exist for b) 750,000 allowing low income older adults to age in place? c) 5 million a) Housing programs and subsidies usually support homeown- d) 7 million ers and not renters b) Health and housing resources are allocated differently 14. According to the Moving Along the Mobility Continuum: Past, c) Medicare only supports the very sick or the very poor Present, and Future article, approximately how many older adults d) Medicaid does not cover services for older adults age 65 and do not have access to a public transportation system? older a) 15% b) 20% c) 35% d) 5%

20 15. Adult day centers are places in the community where older Please indicate whether the stated learning objectives were adults can go during the day for: achieved: a) Socializing with others b) Assistance with personal care Participants will be able to identify the concept and implications of c) Screening for cognitive impairment aging in place. d) Both a and b Achieved in full 5 4 3 2 1 Not Achieved 16. Immigration rates indicate that the trend of a diverse older adult population will decrease in the coming decades. Participants will be able to identify at least three barriers to ag- a) True ing in place. b) False Achieved in full 5 4 3 2 1 Not Achieved 17. A strengths-based approach to working with older adults includes taking an inventory of: Participants will be able to name at least three strategies to pro- a) Functional capacities (ADLs and IADLs) mote aging in place. b) Medical and mental health history of the client Achieved in full 5 4 3 2 1 c) Leisure and recreational interests of the client Not Achieved d) All of the above Please evaluate the course content: 18. According to Leigh (1998) the defi nition of culture is: This course expanded my knowledge and understanding of the a) The way a group lives topic. b) The race and ethnic background of a person Achieved in full 5 4 3 2 1 c) The values and norms of a person Not Achieved d) All of the above The course material was clear and effective in its presentation. 19. According to the Who’s Safe? Who’s Sorry? The Duty to Protect Achieved in full 5 4 3 2 1 the Safety of Clients in Home- and Community-Based Care article, Not Achieved older adults who choose to stay in their homes may encounter the following risks: This course was relevant to my professional work/interests. a) Physical risks Achieved in full 5 4 3 2 1 b) Psychological risks Not Achieved c) Social risks (including fi nancial) d) All of the above As a result of this course, I learned new skills, interventions or concepts. 20. The Joint Center for Housing Studies at Harvard University Achieved in full 5 4 3 2 1 maintains that an overhaul of our national, state and local systems Not Achieved needs to include rethinking the health and housing sectors as: a) Two separate divisions The resources/references were comprehensive and useful. b) One unifi ed service-delivery system Achieved in full 5 4 3 2 1 c) None of the above Not Achieved d) Both a and b This course addressed issues of diversity and/or the social justice implications of the topic. Complete and return Post-Test and Course Evaluation after reading the CE course in this issue of FOCUS. Achieved in full 5 4 3 2 1 Not Achieved A score of 80% or better is passing and we will send a certifi cate of completion for 1.5 CEs to you. Please provide comments on current course and suggestions for future courses. ______Members $15 Non Members $25 ______Please enclose check payable to NASW ______(Sorry, credit cards not accepted for this offer.)

Name ______NASW Membership # ______Address ______City ______State_____Zip ______Day Phone ______Email ______Send to: NASW, 14 Beacon Street #409, Boston, MA 02108 21