AGE-FORWARD CITIES FOR 2030 Caroline Servat and Nora Super Foreword by Paul Irving ABOUT THE MILKEN INSTITUTE

The Milken Institute is a nonprofit, nonpartisan think tank. For the past three decades, the Milken Institute has served as a catalyst for practical, scalable solutions to global challenges by connecting human, financial, and educational resources to those who need them. Guided by a conviction that the best ideas, under-resourced, cannot succeed, we conduct research and analysis and convene top experts, innovators, and influencers from different backgrounds and competing viewpoints. We leverage this expertise and insight to construct programs and policy initiatives. These activities are designed to help people build meaningful lives, in which they can experience health and well-being, pursue effective education and gainful employment, and access the resources required to create ever-expanding opportunities for themselves and their broader communities.

ABOUT THE CENTER FOR THE FUTURE OF AGING

The Milken Institute Center for the Future of Aging promotes healthy, productive, and purposeful aging. The Center focuses its efforts in three priority areas: Age-Forward 2030, the Business of Aging, and Healthy Longevity.

©2019 Milken Institute This work is made available under the terms of the Creative Commons Attribution-NonCommercial- NoDerivs 3.0 Unported License, available at creativecommons.org/licenses/by-nc-nd/3.0/ TABLE OF CONTENTS

FOREWORD...... 1

INTRODUCTION...... 3 How We Grow, How We Build, How We Care...... 3

Delphi Survey Methodology...... 4

CHAPTER 1. Age-Forward Economic Development: How We Grow...... 5 Integrating Older Adults into Urban Economies ...... 5

Advancing Economic Opportunities for Successful Aging...... 6

Harnessing Data to Demonstrate Age-Forward Productivity ...... 8

Age-Forward Economic Roadmaps...... 10

Promoting Pathways for Public-Private Partnerships ...... 13

Case Studies: New York, Louisville, and Kansas City...... 15

CHAPTER 2. Age-Inclusive 21st Century Design: How We Build...... 19 Understanding the Socioeconomic Drivers of Longevity Disparities...... 19

Designing For Accessibility...... 23

Realizing Age Diversity in Public Spaces, Transit Systems, and Innovation Districts ...... 25

Age-Forward Cities Making a Difference ...... 28

Case Studies: Washington, DC, Los Angeles, and Chicago...... 29

CHAPTER 3: Resilient Networks for Healthy Aging: How We Care...... 35 Strengthening Social Connections for Stronger Communities...... 35

Age-Friendly Health Systems for Age-Forward Cities ...... 38

Digital Networks, Connectivity, and Resiliency for All...... 40

Case Studies: Pittsburgh, Denver, and Tampa...... 45

ENDNOTES...... 48

ACKNOWLEDGMENTS...... 57

ABOUT THE AUTHORS...... 57 FOREWORD

A massive shift is taking place in the makeup of the world population, and societies are already struggling to cope. By 2030, more people worldwide will be over the age of 60 than under 10.1 Realizing the benefits of an older population—while addressing the difficulties and realities—will be one of the great human challenges of the 21st century. Cities are ground zero for the demographic shift—eight in 10 US residents 65 and older already live in metropolitan areas,2 underscoring the need to view population aging with the same sense of urgency as climate change, public safety, homelessness, or any major urban priority. Healthy aging means living a long, productive, meaningful life and enjoying a high quality of life.3 Research demonstrates that older adults who adopt healthy behaviors, use preventive health services, and are involved with their family, friends, and communities are healthier and more independent.4 Aging in a healthy way is closely linked to older adults’ physical, social, and economic environments, and where one ages is a key determinant of how long she or he will live.5 Many Americans expect to celebrate birthdays well into their 70s, 80s, and beyond, but not everyone is experiencing longer lifespans. A widening longevity gap across cities and regions poses troubling questions about how health, prosperity, and environment make an uneven impact across the social landscape. In fact, a difference of 20 years separates US counties with the longest and shortest typical life spans based on life expectancy at birth.6 Globally, a similar gulf exists between longer-living countries like Japan and India.7 To narrow the longevity gap and promote purposeful, productive, and healthy aging, cities can take the lead to integrate older adults into policies and planning across multiple domains. Aging is Diversity

The shifting age demography is an unavoidable hurdle in nearly every aspect of urban life and demands new ideas—from health system pressures and an increasing need for services and supports, to the disproportionate impact of climate change on older populations and the economic impact of gentrification on neighborhood stability. A one-size-fits-all solution is not the answer. Older adults are as equally diverse as the younger population and are a major—albeit complex—driver of economic expansion. Adults over age 60 are expected to account for about half of urban consumption growth by 20308—but that figure includes those experiencing economic stress. By age 65, approximately 40 percent of middle-class Americans will fall into poverty or near poverty.9 For that reason, older adults are working later in life than earlier generations and seeking employment beyond traditional retirement age, but often face ageist bias and high unemployment rates in the fastest-growing US cities.10

FOREWORD 1 AGE-FORWARD CITIES FOR 2030 Finding solutions to the urban The objective is to spur virtuous jobs longer. Caregiving needs and a challenges of an aging population is a competition among cities to improve shortage of direct care workers will complex issue, particularly because conditions for aging Americans and challenge communities across the older adults can span from healthy, elevate this crucial societal priority. world. Climate change will elevate active, highly-productive members The “Best Cities” publications have the risks of natural disasters that of communities to needing assistance drawn substantial attention in disproportionately threaten older with daily living, being homebound, academic, policy, and media circles populations. or living with life-limiting illnesses and have led to a number of local The United Nations 2030 Agenda like dementia. and regional policy initiatives. for Sustainable Development seeks Slow to Respond In 2014, the Center launched the to define new goals for people, the Mayor’s Pledge, encouraging civic planet, and prosperity, and the World The enormous challenges and leaders to commit to purposeful, Health Organization (WHO) declared opportunities of population aging healthy aging. Two hundred eighteen this the “Decade of Healthy Ageing.” mayors from every US state are require leaders to recognize positive Against this backdrop, Age-Forward pledge signatories.14 aging as an overall community 2030 challenges cities and benefit. Mayors of US cities rarely While the Center for the Future communities to prepare for a new mention older adults in their policy of Aging is proud of its work, era of economic growth, inclusion, pronouncements and priorities. much more can be done. Society and resiliency. It seeks to meet Speaking frequently about economic must push harder to encourage city leaders where they are today growth and development, they action and see faster change. and implores them to focus on the overlook the interconnection Building on “Best Cities,” the World realities of tomorrow. It is a call to between their aging communities Health Organization’s Global action to create a better future for all and their cities’ economic health Network of Age-Friendly Cities residents, investing in solutions that 11 and sustainability. They often fail and Communities, and the AARP deploy the human and social capital to harness compelling opportunities Network of Age-Friendly States and of older adults as community assets, at the intersection of aging, Communities, the Center presents an change agents, and co-creators. 12 urbanization, and inclusiveness. ambitious vision for a better future Our goals? We seek to highlight of aging: “Age-Forward 2030.” While many cities are making notable new ideas and best practices and to strides (this report highlights efforts Why 2030? The next decade will galvanize conversation and action to worth emulating), the stakes are not only see an extraordinary promote shared prosperity. We want high and the overall response to the demographic change, but also to be a resource to those building demographic shift is just beginning. unprecedented advances in cities and communities that are The Milken Institute Center for the technologies and medicine, and vibrant, inclusive places to live for Future of Aging challenges cities and cultural and societal shifts that all ages. We hope that Age-Forward their leaders to move aging to the top would have been unimaginable to 2030 will inspire action and change. of their policy agendas. generations past. —PAUL IRVING Forward to a New By 2030, about three out of every Chairman, Decade five people across the globe will Milken Institute Center live in cities, and older adults will for the Future of Aging In 2012, 2014, and 2017, the Center generate over half of all urban for the Future of Aging published consumption growth in developed the “Best Cities for Successful countries. Artificial intelligence, Aging” report, which uses metro- robotics, and automation will displace level metrics to assess and rank millions of workers at a time when US cities’ progress toward positive an increasing number of older environments for older adults.13 adults need and want to remain in

FOREWORD 2 AGE-FORWARD CITIES FOR 2030 INTRODUCTION

How We Grow, How We Build, How We Care

Age-Forward 2030 was developed with the guidance of nearly 150 subject matter experts on aging, public health, urban planning, and related issues. This Age-Forward 2030 report focuses on three priority areas for city and community commitment and action:

ƒ Age-Forward Economic Development: How We Grow Economic development strategies can keep older adults engaged and help underserved communities flourish. Plans should include age-friendly commercial districts and housing, accessibility, and relevant services, along with job creation and workforce opportunities for older workers, support for older entrepreneurs, and investment in industries that serve older adults.

ƒ Age-Inclusive 21st Century City Design: How We Build By focusing on the built environment where people live, work, play, and pray, age-inclusive cities boost well-being across the life-course through features such as neighborhood design and amenities that encourage walkability, intergenerational public spaces, comprehensive transportation networks, street and home safety, affordable and accessible housing, and flexibility for multigenerational housing and accessory dwelling units.

ƒ Resilient Networks for Healthy Aging: How We Care Interconnected and cross-sector collaboration that fosters healthy aging can enable older residents to withstand physical and economic shocks and unanticipated events, and stay connected to and engaged in their communities. As populations age, incentives must align to create person- centered, integrated care for older adults, especially for those who are marginalized and have complex needs.

The Age-Forward 2030 report proposes 18 recommendations for city and community leadership. These recommendations are categorized under three principal themes, indicated by the icons below.

Including and Leveraging data and Engaging public- prioritizing age- technology to better private partnerships diversity in local understand the needs to integrate population equity and inclusion and desires of aging aging into strategies planning to improve populations and to for economic growth the physical, financial, enable connection to and resiliency and civic health of improve health and urban communities productivity for older adults

INTRODUCTION 3 AGE-FORWARD CITIES FOR 2030 FIGURE 1 Delphi Survey Methodology Profile of Participants: 146 participants completed the survey from the following sectors: Our Age-Forward 2030 experts provided input and ideas through the Delphi survey method. This three-round exercise Academia Government maps future trends by systematically combining opinions and educated guesses 24% 19% from a diverse group of influencers from government, academia, nonprofit organizations, and the private sector. The first Delphi survey round included a web-based survey that asked our survey participants to rate the likelihood of trends in their areas of expertise. While these trends 22% Private are uncertain, our objective is to ascertain whether a particular trend appears to be Nonprofit 35% more or less likely and whether there is agreement or disagreement in the expert community. Participants were also asked to rank particular policy priorities concerning their importance for aging populations, again FIGURE 2 seeking to learn if there is expert agreement on these priorities or whether a topic is Experts Identify Policy Priorities for 2030 subject to debate. The experts received 12 questions (rankings and likelihood projections) and one open-ended short-answer question: “What are the most critical policy interventions that city leaders should ouing prioritize between now and 2030 to better Political 7 Prioritization prepare for the future of aging?”

Figure 2 represents the breakdown of the experts’ responses to our open-ended

Workforce

question. Solutions identified by participants and Economic

I Development

were coded across several categories in Transportation accordance with the experts’ priorities. and obility 9 The chapters that follow integrate the survey results and expert insights and reference the Connected Care in Community approaches some cities are taking to address 7 the realities of changing urban demography. The Center for the Future of Aging looks C forward to furthering ideas, collaborations, and actions to improve lives in the critically important decade to come.

INTRODUCTION 4 AGE-FORWARD CITIES FOR 2030 CHAPTER 1. Age-Forward Economic Development: How We Grow

FORECASTING 2030 Integrating Older Adults into Urban Economies OPPORTUNITY: Mayor Steve Benjamin of Columbia, SC, calls older residents his city’s The 60+ population will generate over “perennials.” Stable and skilled, they are the demographic “opening the half of all urban consumption growth in developed countries between most businesses and funneling the most money into our nation’s economy,” 2015 and 2030.15 By 2050, the global he said in his 2019 State of the City address. population over age 60 will have His comments highlight older adults as a natural resource whose experience doubled.16 and knowledge power thriving cities. “Conversations on livability don’t just CHALLENGE: affect how well a city is prepared for an aging population; they discuss how a city can attract the experienced class as well,” said Benjamin.20 Cities must Between 75 million and 375 million people may need to switch highlight and incorporate these tandem priorities into a comprehensive occupational categories by 2030, strategy for a sustainable urban future. according to McKinsey’s rapid Although often overlooked in 21st century culture, the growing cadre of older automation adoption scenarios. However, more than half of workers adults is vital to the urban economies where they have invested their lives over 50 will lose long-time jobs before and labor. When cities prioritize their participation, older residents become they are ready to retire,17 and they resources for civic, business, and educational life. Their consumption—be it are much more likely to wrestle with for grandchildren, pets, or a wide range of products and services—fills tax and prolonged joblessness than younger retail coffers. Their support of symphonies, galleries, and theater enhances counterparts.18 By 2030, the US will lives for all. These “perennials” heighten economic vitality: also need an estimated 3.4 million direct care workers to provide ƒ As drivers of consumption ƒ As a human capital resource: long-term services and supports, growth: People over 60 are Civic engagement and a 1.1 million increase over the expected to generate annual volunteerism are built on the 19 2.3 million in these jobs in 2015. consumer spending of $15 trillion backs of older adults. Nearly a 21 GOAL: globally by 2020. quarter of people 55 and older volunteer in their communities, ƒ Focus on urban economic growth As service-job creators: Aging is service valued by the Corporation planning that helps underserved a job-creating juggernaut, with for National and Community communities flourish by creating home health aides and personal Service at $77 billion a year.24 jobs, developing the workforce for care aides, the third and fourth older workers, supporting older fastest-growing occupations in the ƒ As family caregivers: More than entrepreneurs, and prioritizing US, projected to grow 41 percent half of unpaid US family caregivers industries that serve older adults. between 2016 and 2026.22 are over age 50.25 Unpaid caregivers’ work nationwide is ƒ As market shapers: The older valued at nearly $500 billion a population’s size drives market year,26 while older adults also are innovation in housing, health, the job-creating engine for the technology, and other sectors. ranks of paid caregivers. ƒ As employees: Workforces ƒ As support for working depend on older workers, parents: More than 2.5 million yet nearly two-thirds of grandparents take care of US workers say they have grandchildren who live with seen or personally faced them—in many cases making it 23 discrimination based on age. possible for parents to work.27

HOW WE GROW 5 AGE-FORWARD CITIES FOR 2030 A parallel reality, however, and purpose. It promotes age Advancing Economic cannot be ignored: Age inevitably integration across urban domains, Opportunities for creates challenges and infirmities. a priority that has never been more Needs for accessible housing and relevant as cities address changing Successful Aging transportation, and health and home demographics, economic volatility, Awareness Deficit: Old Thinking care change and grow with age. environmental pressures, and new Cities increasingly emphasize equity Statistics project a dramatic rise in social dynamics. and inclusion in their economic growth the need for caregivers and services The JPMorgan Chase Institute planning, but age is rarely part of that as the baby boomer generation ages. analyzed shares of consumer paradigm. More than a mantra for The Age-Forward Cities perspective spending in 15 major US metro urban policymakers, reducing barriers recognizes these two faces of areas in 2016 by consumers age to economic and social inclusion is aging and prioritizes economic 65 and older. The table below healthy for local economies. Including opportunities that will build lists the rankings by metro area, older people not only adds to sustainable urban futures. This vision emphasizing the importance of the economic strength but also provides fosters intergenerational engagement shifting demographic landscape that benefits not targeted through other and opportunities for older residents “makes it even more important to inclusivity steps (such as mentorship to enhance the coming decades understand seniors’ contributions to and training of younger workers) and 28 through productivity, engagement, the health of local economies.” has broad consumer impacts. That message has not yet penetrated TABLE 1 for most city leaders. The National League of Cities reports that, Which metro area has the largest share of spending by consumers 65 and older? in 2018, for the fifth year since it began analyzing US mayoral RANK METRO AREA SHARE OF SPENDING speeches, older adults received short shrift. Mayors often mention 1 SAN FRANCISCO-OAKLAND-HAYWARD, CA 23.8% economic development as a 2 PHOENIX-MESA-SCOTTSDALE, AZ 22.7% priority—in 58 percent of mayoral 3 SEATTLE-TACOMA-BELLEVUE, WA 21.8% addresses. However, they mention demographics in 12 percent of 4 MIAMI-FORT LAUDERDALE-WEST PALM BEACH, FL 21.5% speeches, and of those 12 percent, 5 DETROIT-WARREN-DEARBORN, MI 19.7% older adults are a subtopic only 6 SAN DIEGO-CARLSBAD, CA 19.6% 16 percent of the time.29 7 PORTLAND-VANCOUVER-HILLSBORO, OR-WA 18.8% This lapse misses the opportunities - FIFTEEN CITY AVERAGE 18.2% inherent in economic development goals that incorporate older adults. 8 NEW YORK-NEWARK-JERSEY CITY, NY-NJ-PA 17.7% John Feather, chief executive of 9 CHICAGO-NAPERVILLE-ELGIN, IL-IN-WI 16.9% Grantmakers In Aging, posits a 10 DENVER-AURORA-LAKEWOOD, CO 16.6% revealing hypothetical: “Imagine

11 COLUMBUS, OH 16.0% you’re the mayor of a small town (or a city). The economy is slow, and you 12 LOS ANGELES-LONG BEACH-ANAHEIM, CA 15.3% need to do something to improve the 13 HOUSTON-THE WOODLANDS-SUGAR LAND, TX 14.2% quality of life in your town. Luckily, 14 ATLANTA-SANDY SPRINGS-ROSWELL, GA 14.0% you have an opportunity to bring in 1,000 new residents. You can 15 DALLAS-FORT WORTH-ARLINGTON, TX 13.9% choose 1,000 40-year-olds, or 1,000 Source: JPMorgan Chase Institute. 60-year-olds. Who will do more for

HOW WE GROW 6 AGE-FORWARD CITIES FOR 2030 your economy? Ninety-nine mayors Taking on the Age-Segregation Massachusetts Boston’s Elder out of 100 would say the 40-year-olds. Default Economic Security Index for 2016, Unfortunately for them (and their half of Americans 65 and older who These realities call for a vision for towns’ economies), it’s the wrong are living alone “lack the financial 21st century economic development answer.” resources required to pay for basic that upends the devaluation of needs.”35 Nationwide, the number of Why don’t mayors have the right older residents while enhancing age 65+ homeless will nearly triple answer? For the same reason that they overall urban prosperity. To realize from 2017 to 2030, to more than do not tend to list aging among their the benefits of engagement by 100,000, according to projections policy priorities. The issue is not that older adults, cities can promote by university researchers in Boston, they disregard older residents or their intergenerational sites, work policies, New York, and Los Angeles.36 votes. But they are subject to pervasive and environments that negate age The resulting surge in health care societal misperceptions that older segregation. In the process, old and and shelter costs is anticipated to people are a financial burden, are in young adults may find enlightening reach as much as $5 billion a year.37 decline, and have little to offer to build common ground. Both millennials a robust economy and community. and baby boomers cited affordable Even short of homelessness, Mounting evidence challenges these housing, high-speed internet access, economic security for too many hardwired stereotypes. Americans and safe streets in their top three aging adults is precarious. By age over age 50 account for $7.6 trillion in concerns, for example, when surveyed 65, some four in 10 middle-class direct spending and related economic by the American Planning Association Americans will fall into poverty or activity, a figure surpassing the GDP about metropolitan living priorities.34 near-poverty, the Schwartz Center of every nation except the US And strong majorities endorsed for Economic Policy Analysis at the and China. By 2032, the so-called spending on priorities like schools and New School projects.38 Worldwide, Longevity Economy is projected to transportation as economic growth a $70 trillion deficit exists between reach over $13.5 trillion (52 percent strategies, over investing in recruiting retirement savings and need during of the US GDP).30 companies to their cities. These retirement years, according to World Economic Forum estimates; by 2050 Age-Forward policies make economic shared interests can promote cross- that gap will grow to $400 trillion.39 sense. A healthy and engaged older generational understanding and chip Among nations of the Organization population reduces dependency and away at misperceptions. for Economic Cooperation and service costs. Older adults’ work and Development (OECD), some of the community participation support On the Edge: Inequality Among most dramatic income inequality is in economic vitality. And aging adults Older Urbanites the older adult populations.40 who feel purposeful (for example, The road to urban economic vibrancy through volunteerism) experience a faces an especially troubling trend More than 10 million people over heightened sense of well-being and in poverty amongst the elderly. 50 in the US are in poverty, and lower levels of physical and mental According to the University of more than 37 million close to the decline.31, 32 edge, just one life event (a job interruption, natural disaster, or family health crisis) away from We are going to have to be more and more creative about slipping into it, AARP research how we address and come up with solutions that help us keep finds.41 Thanks in large measure to our very valuable employees in the workplace. We need to Social Security benefits (and 1970s make sure that policies that are being put in place—whether changes to the program), the nation it’s at a local community meeting or a state office or at the has made greater strides in reducing elder poverty than poverty across the federal level—that these policies that are being created are entire population. As calculated by ageless, that they are making sure that they’re not being the US Census Bureau, the overall detrimental to either the young or the old.” poverty rate fell only modestly —JO ANN JENKINS between 1964 and 2012, from 19 CEO, AARP, at AARP’s 2019 “Disrupt Aging: The Future of Work for All percent to 15 percent, with a rise in Generations” conference in Washington

HOW WE GROW 7 AGE-FORWARD CITIES FOR 2030 the percentage of poor adults under ƒ Young cities that are aging RECOMMENDATION #1 64. Among those 65+, the poverty slowly: These cities need to rate dropped from 28.5 percent in include preparation for aging in 1966 to just 9.1 percent by 2012. their long-term priorities. They must build public awareness Nonetheless, disturbing local about aging and can learn from patterns remain. In Philadelphia, the experience of cities with where the citywide 26 percent Encourage planners and local the other two characteristics. poverty rate is highest among the policymakers to apply tools such 10 largest US cities, the years 2013 to as the Elder Economic Security A 2016 Milken Institute report 2017 saw the number of poor adults analyzed cities’ dominant economic Index to identify areas where age 60+ jump three percentage characteristics and categorized points, to 23 percent, according to older adults in (or at risk of) their economies: knowledge-based, the nonprofit Philadelphia Corp. poverty are concentrated and manufacturing and resource-based, for Aging. But the poorest—living far inform policy interventions that service-based, or economies in 45 below the federal poverty level, improve access and affordability. transition. Each city’s strengths in “deep poverty”—increased from and economic qualities can serve 6 percent of the older population as a pathway for the inclusion of to 10 percent.42 older people. The coming years will only Age-Forward Development as Florida’s capital city of Tallahassee, increase economic stress for aging Sustainable Development for example, has not been growing cohorts, their savings eroded How can cities include older as fast as the rest of the state. It is by the recession, housing costs, adults in their plans for economic campaigning to attract retirees as an and disappearance of traditional sustainability? Solutions are not one- economic benefit, with their greater employee pensions. Rising income size-fits all. Aside from differences reliance on health and hospital inequality among younger adults in geography, economies, and size, services offset by their lower worldwide predicts a growing gap for urban areas fall into three main costs for public education, prisons, 46 future retirees—worrisome news for types, as identified by the OECD:44 and peak-hour roadways. the United States, where economic Tallahassee launched a citywide inequality among retirees is already ƒ Aging cities with slow growth: social media campaign to promote higher than in all OECD countries The older population, a large its new senior center and used 43 except Chile and Mexico. percentage of residents, will targeted marketing aimed at Tallahassee residents whose parents As ground zero for demographic continue to grow, then peak and live outside the city to “showcase change, cities need policy agendas to decline. Facing numerous social the advantages of having your address inequality early and across and economic challenges and parents live there, such as free the lifespan. Effective strategies for opportunities, these cities must babysitting,” explains Amanda aging societies call for collaborative consider which demographic Hadley of the public relations action to incorporate age-forward structures to anticipate before agency BowStern, who manages the economic policies across city and after the peak. campaign.47 agencies, education, social services, ƒ Young cities that are rapidly and the private sector. aging: The younger population Harnessing Data to is still the majority as the older Demonstrate Age- generation grows. Here, the Forward Productivity demographic change raises issues of intergenerational What is “Old”? What We balance and equity. Younger Measure Matters people could be an asset in The prevalent measure of overcoming challenges ahead. population aging, the “old- age dependency ratio,” has a

HOW WE GROW 8 AGE-FORWARD CITIES FOR 2030 fundamental weakness. It compares could result in sweeping societal workers age 55 to 64 were unable numbers of people 65 or older to and policy changes. Just one to find jobs in the 10 cities with the the “working age” population—age example—a subject of current highest gross metropolitan product.55 20 to 64. It assumes that a 65th political conversation—is that More than half of workers over birthday triggers dependency—a people are barred from contributing 50 lose their jobs before they are blunt instrument to some retirement savings plans ready to leave—they are laid off at and an outdated misperception. beyond age 70½. But with longer life least once during the remainder of expectancy and delayed retirements, Labor market numbers provide more their paid employment years or are they may want to contribute relevant estimates of “dependency” effectively pushed out, analysis by longer. Currently, Americans born by enabling comparison of the the Urban Institute and ProPublica between 1943 and 1954 are entitled number of adults not working found.56 After that happens, nine to full Social Security at age 66, and not seeking jobs with those in 10 never reach their pre-layoff with benefits increasing 8 percent employed or seeking work, without salaries when they find new work— annually to age 70 if application for the assumption that a specific cut-off reduced earnings thus becoming a payment is delayed. However, after age is the end of a “working” life.48 way of life for which they have never age 70, those increases stop, even Importantly for city projections about planned.57 Out of work, older adults if a beneficiary continues to delay future productivity, the 65+ group are much more likely to wrestle with drawing benefits.53 The age-inflation has been growing as a percentage of prolonged joblessness than younger perspective could alter many policies the overall working- age population— workers are, according to the Bureau involving services, employment, and from 19 percent in 2015 to a of Labor Statistics. On average, more. projected 29 percent in 2060, a 54-year-old job hunter will be approaching the share of younger unemployed for nearly a year.58 RECOMMENDATION #2 age segments.49 Today, Pernicious ageism continues to play more than 20 percent of adults over an exclusionary role; older workers’ age 65 are either working or looking strengths are often overlooked. for work, a near doubling since Experienced adults are relegated 1985.50 to roles beneath the abilities they A data perspective providing even Measure productivity have honed through years in the more insight as to how people comprehensively in the workplace—and in life. actually live and work in the 21st more realistic context of the Despite their significant labor- century is embedded in the concept projected extended working force participation, the boomer of “age inflation,” coined in 2008 by generation’s size means retirements the National Bureau of Economic lives of older adults. also are contributing to a lower Research.51 This term defines people overall labor-force participation rate, not by chronological age (i.e., years a slide that is projected to continue lived) but in terms how many at least until 2026.59 Some industries additional years they are expected Labor Realities: The Truth About already feel the pinch. In both to live, a meaningful distinction Older Workers developing and developed nations, when considering that people at Although many aging workers fewer than four in 10 corporate 75 today have the same remaining want or need to remain in the executives surveyed expressed life expectancy as 65-year-olds in workforce—in one study, half of confidence they would have the the past.52 Essentially, age inflation US baby boomers said they would talent needed for their strategic goals assumes that a particular age has continue working even if they won a few years out.60 The outflow of older a different “value” associated with 54 the lottery —they have the highest workers, the Baxter Consulting Group it over time, given ongoing and rates of unemployment in the nation’s predicts, could create a “potentially expected longevity gains, which the fastest-growing cities. In 2014, when crippling talent crisis,” considering traditional dependency ratio does metropolitan average unemployment that working adults over 65 number not capture. was at 4 percent, the Department of nearly 9 million people, double the Applying an age-inflation approach Labor reported that 5.6 percent of number of teens who work.61

HOW WE GROW 9 AGE-FORWARD CITIES FOR 2030 A global survey of companies by Deloitte paid and disproportionately filled by immigrants. (Immigrants account indicates the extent of the untapped for about a quarter of the home health-care workforce, a number that opportunity: Only 18 percent of respondents could change depending on US immigration policies).67 said that age is viewed as an advantage Aging adults may need assistance with daily living tasks to fulfill their in their organizations.62 Some leading desire to remain in their own homes. It is estimated that 52 percent companies, on the other hand, are starting to of Americans turning 65 today will one day need a high level of help look at this talent pool as a competitive asset, with basic daily activities, like walking, eating, and bathing.68 Experts with more than eight in 10 US employers have warned for decades that demand for caregivers is outstripping saying workers 50 and older are a valuable the workforce. From 2016 to 2026, employment of home health and resource for training and mentoring and an personal care aides will increase 41 percent, far outpacing the average important institutional knowledge source.63 of all occupations.69 Who will fill these roles? In the UK, employers are encouraged by the government to recruit, retrain, and keep older US cities with the most rapid growth for in-home senior care jobs are workers.64 Providence, RI; Rochester, NY; Portland, OR; Minneapolis, MN; and Raleigh, NC, according to Care.com.70 Still, a significant proportion of workers approaching traditional retirement age look Age-Forward Economic Roadmaps forward to retirement—72 percent of US workers overall, including 81 percent of baby Investing in an Age-Diverse Local Workforce boomers.65 And more workers, particularly “Rank the following workforce investment strategies according to in lower-wage professions, are not afforded their relative importance for workers 65 and older: Providing more the same opportunity to continue working opportunities for flexible work arrangements; broadening access to as those with higher educational attainment, employment programs targeted at low-income and minority populations; suffering from more work-related health responding to advancements in technology, for example through skills conditions as a result of physically demanding training; and supporting and scaling pathways through apprenticeships 66 and vocational programs.” jobs. Equally important to recognize is FROM THE EXPERTS the importance of other unpaid work and Asked about the best way to shape employment opportunities for volunteerism, which imparts significant value older people, half of the 150 experts in the Center for the Future of to urban economies. Aging survey cited flexible work arrangements. Just over one-third ranked skills training as second most important; 28 percent cited Instead of retirement-age mandates and broader access to employment programs as second. uninformed attitudes that diminish older workers, James Anderson of Bloomberg Central to workforce efforts is the need to eradicate ageism Philanthropies suggested a new approach that maligns older workers as less capable. Enforcement of age- when he spoke at the 2018 Milken Institute discrimination rules must be prioritized, the surveyed experts Global Conference: “We often talk about the emphasized, to level the playing field for employment and to access productivity drain; what if we flipped that training and promotion opportunities. on its head and think of it as a productivity opportunity? Cities can be the ultimate platform. The vulnerability mindset is Never before have we had to re-educate and important and making sure the safety net is retrain so much of the middle-aged and older there, but an asset-based mindset is a very workforce. In order to achieve a sustainable, different way to approach this population, and I think that’s the future.” globally competitive economy that provides good jobs and wages for Americans, business, Care Workers: A Local Workforce labor, local government leaders, education Development Opportunity leaders, and citizens must mobilize to drive The aging population doesn’t just provide the solutions forward.” workers, it also creates jobs. Today’s fastest- —ART BILGER growing occupations include personal care Founder and CEO, WorkingNation, in an interview with and home-health aides, jobs that are poorly the Milken Institute

HOW WE GROW 10 AGE-FORWARD CITIES FOR 2030 A level playing field transcends aware of the credit, which could mean Cities are getting involved: 74 ageism alone. Socioeconomic as much as $3,000 for some filers. ƒ The Berkeley Family Friendly status also figures heavily into job San Francisco, in particular, has led and Environment Friendly opportunity, research shows, and the way in incorporating an older Workplace Ordinance of 2017 older residents of wealthy areas worker strategy in its workforce gives employees the right to are the most likely to be working. development priorities through request part-time, flexible, US Census figures make the point: the city’s Work Matters Senior and or predictable working hours, In Beverly Hills, 30 percent of age Disability Employment Initiative, or flex arrangements such as 65+ adults are employed, compared championed by Board of Supervisors telecommuting. Employers to fewer than 10 percent in lower- President Norman Yee. Cities and must provide a business reason 71 income areas like East Los Angeles. regional employers can learn from San to deny the requests.76 Francisco’s example by investing in An analysis by the Associated and tracking age diversity and creating ƒ New York City’s “Fair Work Press-NORC Center for Public campaigns around the future of work Week” bills of 2017 provide Affairs Research also found that that emphasize the importance of age fast-food and retail workers Americans age 65 and older are diversity in the workplace. more schedule predictability most likely to stay in the workforce and stability and a path to in big cities, especially in the RECOMMENDATION #3 full-time hours.77 Northeast and around Washington, DC, where jobs in academia, ƒ In a novel initiative launched in government, finance, and law are 2018, Tulsa’s “Tulsa Remote” plentiful. Their participation is initiative is luring full-time greater in cities where they are remote workers to the city with more highly educated, better Develop a shared platform for an offer of free shared office compensated, and less reliant on cities and regional employers to space, a subsidized furnished labor-intensive blue-collar work, track age diversity within the local apartment, and $10,000 cash analysts say. The fact that educated workforce and create campaigns to relocate and work in Tulsa adults are healthier than less educated for at least one year.78 counterparts also may factor into their around the future of work that To be sure, flexible arrangements longer working lives.72 emphasize the importance of age have cross-generational appeal, diversity in the workplace. Work opportunities are especially especially to parents of young meaningful for some low-income children and employees who older workers who have been denied shoulder family caregiving duties. the federal earned-income tax credit Flexibility at Work: Strategic since Congress increased the age for Workplaces Benefit All Ages RECOMMENDATION #4 full-benefits Social Security eligibility. The tax credit’s eligibility cut-off at To retain older workers and gain the age 65 arguably made sense when benefits of their continued employment, flexible schedules it was established in 1993: People could collect their full Social Security rank highly as a strategy. Some older Create and expand local benefits at 65 and transition from adults may not want as many hours the tax credit program to full Social on the clock, but many are not eager workforce development Security. With the higher eligibility to retire fully. About half of “retirees” programs that provide training age, workers over 65 are denied follow non-traditional paths: They seek updates and new skills for older temporary or part-time work instead those extra dollars while waiting to workers and expand volunteer become eligible for full benefits.73 of full exits, and a majority of baby boomers say they plan to work past age programs that connect multiple California stepped up with its own 65 or not retire at all.75 For employers, generations. California Earned Income Tax Credit flexibility provides the benefits of extending to workers over age 65 and experienced workers’ expertise and launched a campaign to make workers mentoring capabilities.

HOW WE GROW 11 AGE-FORWARD CITIES FOR 2030 Clustering Around the Business A deliberately created ecosystem Preparing an Age-Forward Home of Aging can provide structured support for and Health-Care Workforce innovators. “An aging innovation Urban innovation districts are also ecosystem brings together all the Preparing an Age-Forward Home emerging as an environment to necessary players to make change and Health-Care Workforce develop entrepreneurial, investment, happen in aging and senior care—the “By 2030, the US will need an and employment opportunities. startups, industry, investors, older estimated 3.4 million direct care These working and living areas have adults, governments, and academia— workers to provide long-term services leading-edge anchor institutions and supports, a 1.1 million increase with the tools and ability to make connecting with startups, business over the 2.3 million who filled these change happen and get things done jobs in 2015. What is the likelihood that incubators, and accelerators. FROM THE EXPERTS at scale,” Johnson says. this demand will be met by 2030?” Typically designed near transit and technically wired with mixed-use Often typecast as domains of the Our 150 experts were dubious housing, office, and retail space, young, innovation districts are that the booming home-health and they encourage creative synergy equally a fit for older adults: They home-care field would find workers and trust through personal and appreciate the proximity of work to fill the coming need.Less than a third believe the demand will be professional networks.79 Fort Worth, and home; they contribute to local met by 2030. TX, tapped its Near Southside consumer spending, housing revenue, neighborhood for designation as a and business investment; and local medical innovation district, with the businesses and startups have access Particularly worrisome is the potential for thousands of medical to their expertise, mentorship, and deterrent of low pay. The median and technology-related jobs, as part entrepreneurial endeavors. annual wage for home-care aides was just over $23,000 in 2017, of an economic development plan in To avoid increased economic an area that already houses health the lowest of all occupations the stratification, however, these districts 84 80 government categorizes. Often it’s and hospital facilities. need to incorporate age-friendly the poor taking care of the poor. In Edmonton, Canada, Health City features like home and building One in five home-care workers lives serves a similar role. The city-funded accessibility; intergenerational in poverty, compared to 7 percent of economic development initiative engagement opportunities such as all US workers.85 seeks to support innovations to mentorship programs and technology enhance local health, with the education; and pitch sessions and That outlook should set off alarms. possibility of scaling them for global networking events designed to Low pay is a problem in both rural export. In one collaboration of encourage older entrepreneurs.83 areas and expensive urban settings. physicians, local companies, and the Officials in Montana and Oregon pharmaceutical company Boehringer RECOMMENDATION #5 blamed low wages for contributing to Ingelheim, Health City announced a shortage of home aides who assist an artificial intelligence project to with daily living tasks. Workers could examine data predicting patient frailty earn more in fast-food restaurants, and its impact on chronic diseases the US Government Accountability 81 Office noted in a 2018 report on such as heart disease and diabetes. Integrate older adults into the Medicaid-supported, home-care To address older adults’ needs, planning and development programs.86 Minimum-wage Stephen Johnson, co-founder of of innovation districts and increases could make a significant Aging 2.0, urges cities and tech incentivize the development difference for low-paid caregivers. startups to collaborate on “aging innovation ecosystems.” “Tech of startups and commercial To build the caregiving workforce, startups are already making progress enterprises focused on age- professionalizing and supporting the introducing new services for older friendly products and services in field will be increasingly important, including through community college adults in cities, such as transportation, underserved neighborhoods. food delivery, social inclusion, and certification programs. One support care coordination,” he states.82 model, championed by Jobs with

HOW WE GROW 12 AGE-FORWARD CITIES FOR 2030 Justice, is universal family care, which Promoting Pathways Leveraging Development for involves an insurance fund to help in for Public-Private Affordable Mixed-Use Living family caregiving, with people sharing Housing for older adults will in the risks and drawing on the benefits Partnerships become more common in mixed- when they need them. It would Multi-Sector Strategies for use development projects, predicts provide portable insurance that Age-Forward Economic Shankh Mitra, chief investment officer workers could hold across different Development of Welltower, a prominent senior- jobs, with flexible use including asset owner that is redeveloping a caring for an aging parent, providing “Which economic development former shopping center in Charlotte, financial support to hire a care worker, strategy is most critical to address NC, to include ambulatory care and or paying for maternity leave and the challenges of population aging in cities? Rank the following options: multifamily housing, adjacent to an

childcare needs. The fund would FROM THE EXPERTS Expanding age-friendly commercial acute care facility.89 “support a living wage and access to districts and housing developments benefits for care workers in addition Luxury housing is an appealing entry for older residents; developing to training and career mobility, point for some developers. The products and services to respond to offering a path to the middle class.”87 Brightview West End senior living the needs and wants of older adults; community, part of Rockville Town States have begun to take the lead. stimulating local job creation in Square in Rockville, MD, includes a Hawaii’s Kapuna Caregivers Program industries that serve older adults; “club level” top floor with penthouse helps family caregivers maintain implementing workforce development units, a concierge for transportation their jobs outside the home by programs for older adults.” arrangements, and other amenities.90 providing subsidies for adult day When the Center for the Future of The Heartis Buckhead project care, home aides, transportation, Aging asked experts this question, in Atlanta promises amenity- and meal services.88 44 percent ranked “expanding rich “resort-style” living, with In April 2019, Washington became age-friendly commercial districts independent living, assisted living, the first state to approve publicly and housing developments” as and memory care apartments in a funded long-term care through its most important. They split across luxury tower. An adjacent medical Long-Term Care Trust Act, providing the other categories for the second office building is being renovated as lifetime benefits of up to $36,000 most important (28 percent for part of the project.91 to help families pay for in-home products and services, 25 percent Affordability challenges find other care, assisted living, or a nursing for workforce development, and approaches. In Chicago, Evergreen home. The same year, SEIU 775, 22 percent for job creation). Real Estate combines a first-floor, which represents 45,000 long-term technology-focused public library care workers in Washington and Each of these economic and media center below three floors Montana, negotiated a home care development categories contains of affordable and subsidized rentals worker retirement benefit, the first opportunities to address the for low-income older adults.92 of its kind in the nation. financial inequality afflicting older To motivate developers, government populations. Underinvestment RECOMMENDATION #6 tax credits and incentives can be in neighborhoods where urban important tools. Developers can take expenses tip more people to the advantage of the Opportunity Zone financial edge—especially those on tax break, a federal program that fixed incomes—feeds a trajectory uses deferred capital gains taxes as of decline. Reversing this spiral calls Strengthen workforce an incentive to invest in low-income for broad policy reforms, from job development pipelines to meet communities. To direct projects creation to investment incentives. the demand for more health and for older-adult housing and other long-term services and supports community needs to specific areas, workers. urban officials can offer flexibility with zoning and permit processes, and reduce or eliminate fees.93, 94

HOW WE GROW 13 AGE-FORWARD CITIES FOR 2030 Collaborating with Main Street Challenge, a crowdsourcing Conclusion and Competing on Innovation competition for college students, to encourage innovations that assist The opportunity presented by Age-Forward cities enjoy supportive older adults and their caregivers with population aging heralds great relationships with their business daily living activities. economic promise for urban communities and help companies, communities that are proactive both large and small, flourish. RECOMMENDATION #7 and alert to the aspirations, Municipal pursuit of business best abilities, and needs of older adults practices can enable economic in the 21st century. oppor tunit y, given the financial power of older adults, while supporting and “Age-forward economic valuing all age groups. Create a national cities development must keep up on the changing needs of aging Using the city hall bully pulpit to competition for aging populations,” said Dionne Beaux of celebrate forward-acting companies innovation that includes Main Street America. Her sentiment as civic examples is one way to key economic development is echoed from abroad. In the city motivate participation. Many cities stakeholders including of Kilkenny, Ireland, Chamber promote guidelines from the World chambers of commerce, of Commerce President Marion Health Organization’s and AARP’s regional employers, offices Acreman reminded her city that age-friendly community networks— becoming an Age-Forward local encouraging Main Street to prepare of economic development, economy “isn’t just the right thing for population aging and consider the technology companies, to do—it’s also good for business.97 environmental, economic, and social and startups. factors that influence older adults’ well-being. Others, like London Mayor Sadiq Khan, foster virtuous competition to raise awareness and seek solutions. Khan challenged startups and medium-sized businesses to come up with innovative solutions to big issues like inequality, elder health, and isolation. Finalists were promised London Economic Action Partnership business support, with grants for further development going to three winners.95 Miami’s public-private Age-Friendly Initiative went to the Little Havana neighborhood to foster business practices attuned to the large population of older adults. The Age- Friendly Business District initiative, in a walkable half-mile around the Vista Alegre Retirement Home, provides education, resources, and tools to help companies recognize and serve older patrons and retain older employees.96 New York’s State Department of Health sponsors the Aging Innovation

HOW WE GROW 14 AGE-FORWARD CITIES FOR 2030

25% 23% 23% 23% 32% 32% 39% 22% 33% 40% RATE SELF-EMPLOYMENT SELF-EMPLOYMENT 100 14,935 45,177 24,495 16,797 16,385 16,368 15,538 25,433 44,095 23,880 TOTAL 50+ TOTAL WORKFORCE 99 2016 7,748 4,174 7,779 3,515 3,739 3,658 3,386 17,094 14,621 10,258 SELF-EMPLOYED, SELF-EMPLOYED, BUILDING A SPACE FOR OLDER OLDER FOR SPACE A BUILDING ENTREPRENEURS #5 AND #2 RECOMMENDATIONS AGE-FORWARD CITIES FOR 2030 CITIES FOR AGE-FORWARD 15

TABLE 2 50+ Age Adults Self-Employed of Rate the Highest with Neighborhoods 10 NYC ROCKAWAYS (QUEENS)ROCKAWAYS (MANHATTAN) HARLEM CENTRAL BROOKLYN HEIGHTS / FORT GREENE (BROOKLYN) BOROUGH PARK (BROOKLYN) MORNINGSIDE HEIGHTS HEIGHTS MORNINGSIDE / HAMILTON HEIGHTS (MANHATTAN) STUYVESANT TOWN / TURTLE BAY BAY TURTLESTUYVESANT / TOWN (MANHATTAN) CHELSEA / CLINTON / MIDTOWN (MANHATTAN) UPPER EAST SIDE (MANHATTAN) NEIGHBORHOOD FINANCIAL / VILLAGE GREENWICH (MANHATTAN) DISTRICT UPPER WEST SIDE (MANHATTAN) Source: Center for an Urban Future analysis of self-employment data from the US Census,AmericanCommunityUS Survey,theself-employment fromanalysis of data FutureUrban an forSource: Center 2005 and Tabulated 2016. using IPUMS. Entrepreneurship is growing among older New Yorkers, including in the in the including Yorkers, New older among is growing Entrepreneurship are residents 210,000 self-employed Nearly population. immigrant large city’s workforce the 50+ borough, every 2005. In since up 19 percent 50 and older, of evidence with Along than the 50+ population. pace a faster at is increasing and moderate- lower- among activity in entrepreneurial increase a significant finds Future an Urban for Center The from an analysis adults, older income the city’s of residents older high among are rates self-employment that communities. immigrant predominantly The table below features 10 NYC neighborhoods with the highest rates of of with the highest rates neighborhoods 10 NYC features table below The and local planners for tool a helpful 50 and older, adults ages self-employed ecosystem. entrepreneurial integrated within an channel local talent to employers However, older entrepreneursHowever, face particular hurdles, including accessto capital, technology barriers, and lack contact of with like-minded aspirants. While the city has numerous initiatives to supportentrepreneurship, scant help targets the needs mature of entrepreneurs, such as getting to up speed on social media and tech tools. The issue being is raised the by city’s own who underscoresStringer, Scott comptroller, that city agencies not “have clearly articulated how they planto respond to the changing demographics … put to chance a has now CityThe neighborhood-by-neighborhood… a basis on forward a comprehensive blueprint that investsin seniors as a way of building stronger neighborhoods and a healthier city overall.” HOW WE GROW

OLDER WORKERS AND SUSTAINABLE DEVELOPMENT SUSTAINABLE AND WORKERS OLDER 98 DEMOGRAPHY City York New of 2040, the number By will be 1.86 million, 60 age over residents 2018 Age-Friendly Action Plan priority areas include the creationof an Age- Friendly Professions Working group encouraging private-sector organizations to “address the needs and preferences of customers withpatients, clients, and older primarypharmacycare,on focus current a banking.” and Mayor’s Pledge Signatory 2000, from increase a 48.5 percent in five than one more comprising Yorkers. New BEST CITIES FOR SUCCESSFUL RANKINGS AGING HighOverall Marks: (#11), Employment Housing (#26); (#1), and Transportation (#6), ECONOMIC PROFILE ECONOMIC Knowledge-based economy Brimming with action and Brimming Broadway from flavor multicultural has Apple the Big Street, Wall to close one to in five However, lives below 65+ age New Yorkers the federal poverty line, and the OfficeMayor’s Economic for Opportunity classifies a of third this group age as poor or near- Povertypoor. among this group has increased as it even slipped among statewide. residents older an image that may read young. young. read may that an image transportation a robust But 1 in our No. network—ranked Aging” Successful for Cities “Best work of with plenty index—along adults and older for opportunities make medical offerings world-class for aging: this a fitting locale an over- is home to City York New been growing that’s 65 population its of than triple the rate more at population. younger CITY: NEW YORK

CASE STUDY care where Medicaid isnot provided: transportation, andmental healthprograms andservices suchashomehealth Population Growth,” buildsonitsstorehouse of age-friendly employment, New York City’s forward-looking “Plan 2025: Aging Services inanEra of Rapid ƒ ƒ ƒ

initiatives for long-term care staff, particularly direct care workers.” Organizations provide a range of recruitment, retraining, and retention Eleven workforce training centers designated as Workforce Investment care system through atwo-year Workforce Investment Program. workforce the to meet theneedsof anevolving long-term prepare to training $245funds which Program, million Innovation Workforce a launched of Health York New 2018,In the Department State and ReServist programs.” to expand upon the successful DFTA-funded Senior Employment Services opportunities for older people,the results of which“willinform efforts forums with labor experts to discuss ways to increase employment The Department for the Aging (DFTA) isdeveloping plansto provide services. transportation as such assistance and groups to support 2017, in issues caregiver on referrals in inquiries resulting many 10,000 nearly fielded city the expanding; are caregivers for services Respite

Recruitment of Long-Term Workers Recruitment Care Innovative and Workers Older Training for Enhanced SUSTAINABLE FOR PLANNING 2025: RECOMMENDATIONS #4 AND #6 101 HOW WE GROW WE HOW 16 AGE-FORWARD CITIES FOR 2030

102

CASE STUDY

SEEDING A ROBUST AGING AGING ROBUST SEEDING A ECOSYSTEM INNOVATION #5 RECOMMENDATION AGE-FORWARD CITIES FOR 2030 CITIES FOR AGE-FORWARD 17

Increasing home maintenance resources help to older adults remain in their homes communication intergenerational Fostering public employeesTraining in age-friendly practices and exercise more for organizations community and volunteers Engaging health programs (such as healthy food resources and opioid education)

ƒ ƒ ƒ ƒ Louisville’s nursing home, assisted living, and home health community a is the to catering and companies research with Along producer. revenue strong in a Fischer, Greg Mayor what underpins this industry aging demographic, and the city the for growth economic of area key calls “a 2012 commentary, and care lifelong in growth” “exceptional predicts The mayor nationat large.” Louisville’s aging solutions in innovative businesses and prioritizes wellness plan aims development economic Forward Louisville The portfolio. economic jobs for strategy a in estate real and design, workforce, business, integrate to in the aging support companies to team a includes place—and of quality and sphere. and care Louisville’s anchor institutions have helped seed growth for withthe sector, more than 40 health-services firms traced directlyto the Humana and Kindred taproots. rejuvenated in this living options highlights Aging” Successful for Cities “Best companies Among and health amenities. housing low-cost with relatively city has expanded Homes Masonic housing preferences, older-adult to responding with communities continuing-care operate homes to its nursing beyond Nazareth living, and skilled nursing. living, assisted independent for options in a historic care person-centered feature complexes Louisville two Home’s neighborhood setting. smoking, like wellness indicators Cities” on “Best well do as does not Louisville the above are Pedestrian deaths quality. and air activity, physical obesity, age-friendly aging finds for plan strategic and the city’s average, national and sidewalks. parks accessible safe, as such insufficient spaces Louisville’s age-friendly strategy prioritizes improved walkability; expanded pedestrian, and bike, transit networks; and exercise and social activities. Among other Age-Forward goals: LouisvilleIn a public-private endeavor, established the country’s first accelerator for innovation in aging care and lifelongwellness, $5 millionwith supportto early-stage growth. Support entrepreneurial of activity for the aging andwellness sector includes projects the like nonprofit which has featuredThriveof Center, dozens aging and wellness-focused startups seeking corporate partnerships and connections, and the Innovators Alliance formedby nonprofit senior-living HOW WE GROW

103 AN AGING-CARE HUB AGING-CARE AN 2018 Age-Friendly Action Plan emphasizes the importance “21,000 of professionals who actively support healthy aging in our community, home to the nation’s largest collection of headquarters in rehabilitation, assisted living, [and] nursing home and home administration.” health 40 percent 2050. by DEMOGRAPHY Fifteen percentof residents areover age as much as by figure expected rise a to 60, BEST CITIES FOR SUCCESSFUL RANKINGS AGING Overall High Marks: (#79), Health (#29) and Living Arrangements (#30) ECONOMIC PROFILE ECONOMIC Service-based “Rejuvenated economy, region” A crossroads Midwestern of and Southern influences with of a tinge Rust Belt, Louisville has morphed from a tobacco and smokestack stronghold on the Ohio River into a hub medical, of research, and service employers—UPS foremost among them. Attracting residents for more than its prized bourbon and Kentucky Louisville Derby, has a thriving health-care industry and proudly advertises its laser focus on aging and wellness. It boasts more headquarters, company aging-care including Humana and Kindred, than US city. any LOUISVILLE:

CASE STUDY companies on emerging solutions. young with partner to organizations education, and other services. other and education, estate, real agriculture, including sectors several spans workforce older the of concentration The shows. analysis economic an percent, to 4.6 percent 2.4 from 1995 2013, between and doubled nearly workforce of the share Their region’s of the economy.segment agrowing fuel power spending and numbers residents’ Older city’s growth. accounting for more thanhalf of the 500,000, or oneinfive city residents, is expected to doubleto nearly the population age 65andolder city. Between 2010and2030, any age group inthis Missouri River City isgrowing more rapidly than cross-state metropolis of Kansas The older adultpopulation inthe CITY:KANSAS RECOGNIZING OLDER ADULTS AHUMAN AS CAPITAL RESOURCE double. the older adult workforce will nearly 233,000 between 2010and2030, area isexpected to double,growing by Older adultpopulation ingreater Kansas DEMOGRAPHY Engagement (#24),andHousing (#26) (#12), Employment (#22),Community Overall (#26),High Marks: Health AGING RANKINGS SUCCESSFUL FOR CITIES BEST region” economy, “Rejuvenated Service-based ECONOMIC PROFILE volunteer opportunities.” of city affairs and of employment and involved andkeep allresidents informed opportunities for all residents to be adults, highlighting the goal of “providing participation andemployment of older In Aging. The planemphasizes civic and inpartnership with Grantmakers supported by thePfizer Foundation Mid-America Regional Council, is anage-friendly collaborative of the 2015 KC Communities for All Ages Plan 104 105 106

HOW WE GROW WE HOW of hospitals with geriatric and rehab services. rehab and geriatric with of hospitals andavailability affordability relative its notes which index, Successful Aging” for Cities “Best the in marks health-care strong receives City Kansas the modelingprojected. and population would boostannualincomes by nearly $500million, health-care, retail, andconstruction sectors. The resulting increase injobs age 65andolder for adecade would produce 2,600more area jobsinthe The council’s analysis found that retaining anadditional600adults Council, amulti-jurisdictional organization. health-service options, according to areport age-friendly homesandpublicspaces, andimproved transportation and development if they were persuaded to stay through offerings like Those outward-bound residents could benefit thecity’s economic losing many younger baby boomers andthosenearingretirement age. Despite thefact that older adultsmove into Kansas City, thearea is local businesses.” makers, government, education, economic development councils and ecosystems filled withpartnerships amongcivicleaders, municipaldecision- economies: “We provide resources to entrepreneurs by buildingbusiness and learningopportunities withanemphasisondiverse, multigenerational The consulting company Encorps45 provides professional development and professional growth. business development center to make connections andstimulate personal to grow businessesandserve theneedsof independent workers, provides a The nonprofit iWerx business center, with offices and co-working spaces

107 18 AGE-FORWARD CITIES FOR 2030 RECOMMENDATION #2 OF OLDER ADULTS THE CONTRIBUTIONSMEASURING RECOMMENDATIONS #4 AND #5 ECONOMIC DEVELOPMENT SUPPORT FOR MULTIGENERATIONAL by theMid-America Regional

CASE STUDY CHAPTER 2. Age-Inclusive 21st Century Design: How We Build

FORECASTING 2030 Understanding the Socioeconomic Drivers of OPPORTUNITY: Longevity Disparities There is an urgent need for affordable, accessible, and innovative housing: Cities can design environments that narrow longevity gaps while improving life for all residents. Neighborhood design, while not a panacea for all ills, » The number of middle-income adults age 75 and older will double holds power to support sustainability and resilience. Block by block, cities can by 2029, and 60 percent will have transform lives by fostering new routes to well-being. mobility limitations. More than half will lack sufficient financial resources to pay for senior housing and care, such as assisted Designing for older adults is designing for the canary in the living and independent living coal mine. They experience the stresses of the environment 108 communities. more acutely than many other groups.” » The number of renters over —LINDA FRIED age 65 will double between Dean of the Columbia Mailman School of Public Health113 2010 and 2030.109 » Between 2010 and 2030, 74 percent of new housing demand is The structure and design of neighborhoods themselves, as many urban projected to be for small homes on planners are recognizing, hold solutions for improved community well-being. smaller lots than were the norm in Older adults’ wellness and function, as described by the Healthy Aging 110 the previous two decades. Research Network of the Centers for Disease Control and Prevention, CHALLENGE: flourish in physical environments that support “attitudes and behaviors known to promote health and well-being, and by the effective use of health The mobility landscape is changing rapidly: services and community programs to prevent or minimize the impact of acute and chronic disease on function.” » By 2035, the number of households where someone age For cities to take the lead is a natural fit. Cities are home to what urban planners 65 or older has a mobility disability call NORCs, or naturally occurring retirement communities: neighborhoods will reach nearly 17.1 million.111 whose longtime residents have aged along with the infrastructure around them. » Regulatory approvals of driverless Additionally, more than half a billion people over age 65 live in cities around the vehicles in the decade ahead could world, and by the middle of this century, the number will be over 1 billion.114 make possible on-demand, autonomous electric-car driving The demographics are more nuanced in US metro areas. The number of 65-and- for the vast majority of US older residents in dense urban neighborhoods grew by nearly 800,000 between passenger miles.112 2000 and 2016. But the share of all older adults living in those neighborhoods GOAL: actually fell, Harvard researchers found, while less dense metropolitan areas Livable cities for all ages that are (city suburbs) saw their share of older residents rising. That trend is cause for designed for walkability, safety, concern because services and supports tend to be more sparse in less dense and accessibility, and a diversity of neighborhoods. In 95 of the nation’s 100 largest metropolitan regions, the share affordable transportation and housing of older residents declined over this 16-year period.115 options to meet all mobility and multigenerational needs. Population aging will be among the most significant social transformations of the 21st century, and cities will need to be nimble in addressing an older population that is vast, not just in number but also in age range, and diverse in all the ways that younger adults are—in interests, needs, motivations, and physical and cognitive abilities. Simply stated, aging is a universal human process, but it is not individually uniform.

HOW WE BUILD 19 AGE-FORWARD CITIES FOR 2030 Understanding the is high on both baby boomers’ and ensuring that these renovations Socioeconomic Imprint millennials’ list of priorities for account for diverse lifestyles, metro areas, a 2014 survey by the cultural norms, and abilities. Socioeconomics—a critically American Planning Association important determinant for successful An Age-Forward Design found.119 In addition, neighborhood aging—are knit into neighborhood Roadmap disadvantage may promote social features that are strongly linked to disorder, find Beard and Petitot, How can design foster, not deter, physical and cognitive health. Older which can thwart the development of neighborhood well-being and adults are particularly affected the social networks that help buffer safety? What innovations can cities by neighborhood stressors, which 120 employ to support positive aging and 116 the impact of daily stressors. are cumulative over a lifetime. wellness in an urban environment? Urban design can address these Gentrifying urban areas—where stressors, in part, by targeting social affordability has slipped dramatically— Specific steps are part of a livability determinants that create inequity in contributes to these issues; older profile that is beginning to emerge outcomes. residents often are priced out of in many cities. Measures are neighborhoods, and an uptick in connected in a strategic web of Social determinants are the need for support services follows. urban age-friendliness: policies for “conditions in the environments New York residents displaced mixed-use development and diversity in which people are born, live, by gentrification, for instance, of housing; public transit; access to learn, work, play, worship, and age were in the emergency room health, commercial, and recreational that affect a wide range of health, and hospitalized more often for facilities; safe, walkable streets with functioning, and quality of life mental health issues than those well-regulated traffic; good lighting outcomes and risks.”117 Examples who were able to remain in their and signage; and accessibility include safe and affordable housing, neighborhoods, one study found.121 features. This holistic approach to public safety, and the availability of neighborhood design aligns with Gentrification and renovation healthy foods. principles of the New Urbanism can also spur positive impacts for Neighborhood improvements movement, as well as the Complete residents who manage to remain can be pivotal to improvements Streets and Vision Zero agendas in place while new investment in health. Longitudinal research that are gaining traction in policy improves conditions around them. confirms that fears of crime, traffic, discussions nationwide as mayors When remodeling infrastructure, and neighborhood decay have and their cities look for 21st century city leaders must be deliberate in negative effects on human health. livability solutions. Older residents of chronically disadvantaged neighborhoods are far less healthy than occupants on the wealthier side of town, including in mental health, a review by researchers John Beard (former head of the WHO’s Healthy Aging initiative) and Charles Petitot found.118 Even a lack of greenery (i.e., trees, landscaping, and parks) can undermine a sense of well-being. Crime- and traffic-plagued streets are less likely to invite healthy outdoor pursuits at any age, and concern for neighborhood safety

HOW WE BUILD 20 AGE-FORWARD CITIES FOR 2030 FROM THE EXPERTS years with insufficient savings. insufficient with years retirement entering are people most and widening, is time whenthegulf between thehaves andthehave-nots That thesefeatures come to thefore isunsurprisingat a flexibility to allow varied housingoptions. pro-social connectivity andsafety, as well as zoning underscored theneedfor homefeatures that enable affordability asthemostimportant issue. They also concerns abouthousing,four in10of theexperts cited in supportingthehealth of older adults. Regarding of theexperts namingitthemostsignificant goal Again, housing was overwhelmingly cited, with 79percent their relative impactonthehealth of agingpopulations. Nations sustainabledevelopment goals according to We alsoasked our experts to rank specific United address. to leaders local for priority aging-related top the is affordable and safe is that Housing unambiguous: was response one number the question, this answered experts policy 150 of network of Aging Future the for Center our When prepare for the future of aging?” leaders shouldprioritize between now and2030 to better “What are the mostcritical policy interventions thatcity Affordable Housing Sustainable Development andthePrimacy of Source: Milken Institute, 2019. Institute, Milken Source: same age. same the of renters of that times 60 of $292,000—nearly worth anet had 64 to 50 aged homeowner median the US adults have no retirement savings. retirement have no adults US 124 9% Access and Safety and Access Universal Design Affordability 18%

14% Environmental Priorities Housing and Built 122 Almost a quarter of aquarter Almost 22% 37% HOW WE BUILD WE HOW 123 Multigenerational Flexible Zoning In 2016, In

21 heightened economic stress. economic heightened into slipping from them to preventing is fundamental cohort. at more than eight times the rate of thelow-income size, in to 14.4 double by 2029, million to nearly growing pressing inthecoming years. This population ispoised with incomes of $24,450to $90,320, will beespecially with incomes of $25,001to $75,025,or those85or older boomers, defined by onestudy as75- to 84-year-olds Demand for housingto accommodate middle-income baby in 80percent of USmarkets. inequality deepeningashomeprices risefaster than wages urbanites struggling to make endsmeet, with economic Homeownership hasbecome unattainable for countless in shortsupply. accessible rental unitsandcondominiums—housing that is make endsmeet. They are amarket for affordable and neighborhoods face highprices with fewer options to over thesameperiod.Renters andthoseindisadvantaged in medicalcare costs, which saw a2.3percent increase country, rose 3.5percent. That increase surpassestherise housing costs, basedonaverage rent prices across the urban housingcosts are aparticular challenge. In 2018, inequality along with thepopulation at large. Rising In addition,older adultsare experiencing economic complex policy challenge. complex policy deeper, a more remain forces market and affordability although mix, the facilitate can cities regulations, and policies zoning Through desires. varied their to meet apt more be can arrangements living shared and homes, communities, along withapartments, single-family for everyone. A mixof more traditional retirement segregates residents from other age groups, isnot generally which community, retirement self-contained manicured, The situations. living uniform want not do people older adults, Like younger of needs. assortment an with and levels income at all residents for room making of challenge the face cities environment, this In TOOL indicate. income goes to rent, USCensus data from 2010-2012 residents—meaning that more than30percent of their quarters of UScitiesthat have more than100,000 households, meanwhile, are “rent-burdened” inthree- Joint Housing Studies Housing Joint for Center Harvard Metros, US in Age with Rising Interactive Map AGE-FORWARD CITIES FOR 2030 127 126 Meeting the housing needs of the middle class class middle the of needs housing the Meeting on Cost Burdened Households Households Burdened Cost on 125 A majority of rental

To encourage construction and ƒ Student matches, a way for multiple generations in one household, operation of housing for this market, older homeowners to rent according to the Pew Research regulators should develop innovative spare rooms to students, Center. The trend has grown, with financial solutions and deploy pension especially through companies nearly 10 percent of children in the US funds, which manage the retirement that screen both parties. living with parents and grandparents savings of many in the middle class Apps and databases ranging in 2016, compared with less than and are one of the largest sources of from Boston-based Nesterly’s132 6 percent a decade earlier.137 middle-market capital.128 to city programs in Toronto133 Asian and Hispanic populations, and the Portuguese university Accommodating growing more rapidly than the town of Porto,134 help match Multigenerational and white populace, are more likely house-hunting students with Nontraditional Living to live in multigenerational family older residents. In Brussels, the Environments households.138 Multigenerational popularity of intergenerational households tend to prefer public Many older adults face barriers, sharing arrangements has transportation options and living both financial and discriminatory, spurred public housing policies close to shops and restaurants.139 to affordable rental housing. to support the creation of 350 A study from the Equal Rights new intergenerational homes.135 Yet many cities curtail multifamily Center revealed that 48 percent structures with setback rules and ƒ Home sharing, for older adults of LGBTQ older adults “have faced controls on accessory dwelling looking to save money and at least one form of rental housing units, or ADUs, so-called granny share household duties. In discrimination.”129 Those concerns units or in-law suites. Economic Los Angeles, the nonprofit have led some cities, including repercussions of such regulatory Affordable Living for the Aging’s New York, Chicago, Philadelphia, constraints are costly: In high- program connects older adults Los Angeles, and San Francisco, to productivity cities, they cost with compatible housemates build affordable housing complexes the United States an expanded who can pay rent and/or help targeted to LGBTQ residents, workforce that would increase US with chores and upkeep. New facilitated by a combination GDP by 9.5 percent, University of York Foundation for Senior of nonprofits, developers, and California, Berkeley and University Citizens has a Home Sharing government subsidies to provide of Chicago researchers calculated.140 Program with a database to an accepting and supportive The appeal of multifamily housing match people over 60 with environment as residents age.130 is especially relevant where urban housemates or student renters.136 In the face of shrinking availability housing stock sags under the pressure and rising cost, alternative housing Shared housing meets overlapping of bustling job markets that draw new models for unrelated adults are urban needs and social concerns. house hunters, driving up prices. emerging both organically and It addresses housing affordability, Some cities and states have responded by design, their benefits felt both helps reduce traffic by enabling more by easing rules that limit ADUs. financially and socially: residents to live near schools and jobs, In California, where the massive ƒ Cohousing, in which people and offers opportunities for social housing crunch is projected to leave own their homes and an connection and mitigating loneliness. the nation’s most populous state interest in common areas such Meeting Multigenerational short more than 3.5 million units by as outdoor, kitchen, living, Housing Demand: Recognizing 2025, the McKinsey Global Institute and dining space where they Growing Ethnic Diversity estimates that as many as 790,000 can share meals and social Twin trends—the urban affordability of these units could be created by interaction. Nationwide, crunch and growing numbers of easing ADU restrictions.141 168 established cohousing ethnic minority families—point to communities exist—14 of them In 2018, the mayor of notoriously the relevance of multigenerational focused on older adults— pricey, housing-strapped housing and the need for reformation according to the Cohousing San Francisco ordered accelerated of city policies. In 2016, a record Association of the US.131 processing for ADU permits to clear 20 percent of the US lived with a backlog of 900 applications that

HOW WE BUILD 22 AGE-FORWARD CITIES FOR 2030 languished in a bureaucratic tangle. CityHealth, a joint initiative of the de Beaumont Foundation and Within six months, the city said it Kaiser Permanente, “offers the 2018 updated assessment of how our TOOL had permitted more ADUs—most of nation’s 40 largest cities fare when it comes to policies that can make them rent-controlled—than in the real, lasting impacts in people’s everyday quality of life,” and includes 142 previous three years combined. an assessment of inclusionary zoning city laws. Minneapolis, responding to community demand, changed its FOUR MOVEMENTS FOR LIVABLE CITIES zoning in 2014 to allow ADUs citywide on properties with one- or ► Universal design: Accessibility for everyone, regardless of disability, includes two-family homes, after previously features such as no-step entry; bedroom, bathroom, and kitchen on ground level; wide doorways and hallways; variable counter heights; and lever-style handles. limiting the structures to a small portion of one community.143 The ► New urbanism: Principles that promote quality of life through features city recently eliminated exclusive including walkability; an interconnected street grid; mixed-use and diversity; single home districts as part of its sustainability; density of buildings, mixed housing, and shops; and traditional neighborhood structure. Minneapolis 2040 plan. Alaskan cities are also making major strides ► Complete streets: The entire right of way is designed to enable safety for all to incentivize ADU construction. users—pedestrians, bicyclists, motorists and transit riders—making it easy to Since 2015, the city of Juneau cross streets, walk to shops, bicycle to work, and allow buses to run on time. has handed out $6,000 grants to ► Vision Zero: This strategy seeks to eliminate all traffic fatalities and severe homeowners who want to build injuries, while increasing safe, equitable mobility through road design, speed, backyard cottages or ADUs. In behaviors, technology, and policies. Kodiak, a small island community including an expanding Coast Guard and homes geared to accessibility, base, officials created a special Designing For engagement, and mobility are zoning district in 2018 for smaller Accessibility increasingly important for the lots in hopes of encouraging In the 100 largest US metropolitan diverse range of older adults who smaller-scale development.144 areas, nearly one in four residents seek a variety of independent living arrangements. In one category alone, RECOMMENDATION #8 are over age 65 or living with a disability. Housing characteristics the number of households that are not keeping up. For US homes include a person over 80 is set to overall, just 3.5 percent include the more than double between 2016 basic access features for people with and 2037, Harvard’s Joint Center Expand incentives for limited mobility: no-step entrances, for Housing Studies reports. affordable older-adult living single-floor living, and extra-wide The traditional senior residence model is being reinvented to meet arrangements, emphasizing the doors and hallways, so-called visitability features.145 Visitability is a different preferences and needs. need for varied middle-income measure of ease of access for people housing solutions; remove Incorporating housing for older adults with functional limitations and/or in mixed-use developments can check regulatory disincentives that disabilities. The approach known as a number of boxes for aging residents, curtail cohousing arrangements universal design adds to visitability from the “live-above-the-store” for unrelated adults; and with features like lever-style door convenience of apartments, retail, accelerate permit process for handles and faucets, accessible offices, and recreation in one complex accessory dwelling units. electrical controls, varied countertop to specialty housing, like the heights, and curbless showers with mixed-income, loft-style NoHo Senior handheld, adjustable showerheads. Arts Colony in North Hollywood, CA. The way people live and age in the Residents can take free arts, dance, 21st century opens the door to and theater classes, and have access strategies for new kinds of housing to studio space and a ground-floor and mixed development. Businesses theater.

HOW WE BUILD 23 AGE-FORWARD CITIES FOR 2030 “Americans are aging in traditional Exempt from the federal Americans by developers found that it homes, neighborhoods, and with Disabilities Act (ADA), most would have minimal financial communities that were designed for older housing stock fails on these repercussions on their projects yesterday’s demographic realities, measures—shortcomings that can and that homes meeting the not those of today or the future,” force people to move to assisted code sold well.151 said Henry Cisneros, the former living communities or nursing homes ƒ Sarasota, FL’s Board of US secretary of Housing and Urban prematurely. The ADA was not County Commissioners Development and former mayor of intended to apply to individually adopted a Universal Design San Antonio, TX. “We can change owned or leased housing in the and Visitability program for our communities so that people living private sector, including single- residential housing units.152 very long lives can live well.”146 family homes, condominiums, or ƒ apartments.148 The Fair Housing In Sonoma County, CA, the RECOMMENDATION #9 Act established ADA standards for wildfire rampage that destroyed most public and private multifamily thousands of homes gave housing built after 1991 but still does advocates a window to raise not cover single-family homes and awareness about visitability small apartments. A 2015 analysis in the rebuilding process. The Identify and leverage private county Board of Supervisors conducted by the US Department investments and incentives to of Housing and Urban Development listened and passed a 2018 build mixed-use, affordable (HUD) found that units occupied by resolution to encourage housing and commercial a black or Asian householder are home construction that meets voluntary visitability developments to house and less likely to be accessible than those standards.153 serve older communities. occupied by a white householder. Similarly, foreign-born householders Smaller, tactical adjustments can are less likely to occupy accessible also be meaningful to incentivize units than native-born.149 accessibility. Grantmakers In Aging From the Experts: Accessibility in Federal requirements for accessibility (GIA), in collaboration with the Housing Developments extend to public buildings and those WHO, analyzed senior housing innovation case studies from around “How likely is it that at least receiving federal funds, but not to the world with its Innovation@Home 10 percent of US rental units will single-family homes—which are fulfill all five universal design more than 70 percent of the nation’s initiative. What was surprising, requirements (no-step entry, housing stock—nor to duplexes or their teams noted, was that the single-floor living, lever-style door townhouse buildings without an selection committee chose to handles, accessible electrical controls, FROM THE EXPERTS elevator.150 Some states and cities are award projects that are more prosaic. and extra-wide doors and hallways) An example is the fee abatement by 2030?” stepping into the gap, including by helping residents shoulder the costs for older people in Marin County, Our network of experts was not of modifications like building ramps CA, who are doing small-scale home especially hopeful when asked or lowering shelves. Tax credits or repair to make their home safer as this question. They predicted a they age. “Innovation does not have 24 percent chance that one in grants, deferred loan programs, and to be flashy; many of the best ideas 10 rentals by 2030 would meet construction permit fee waivers are universal design criteria—which part of the incentive mix. are out there already but need help only one in 100 meets today— to be scaled,” said John Feather, ƒ despite the fact that 17 million In Bolingbrook, IL, city leaders chief executive officer of GIA, in an older adults have a mobility enacted a visitability ordinance interview with the Milken Institute. disability, impeding functions like in 2003, requiring no-step walking, climbing stairs, and getting entrances, wide hallways 147 in and out of bed. and doors, and ground- floor bathrooms. The local homebuilders’ association supported it after analysis

HOW WE BUILD 24 AGE-FORWARD CITIES FOR 2030 Creating Civic Spaces for The American public is not only RECOMMENDATION #10 Multiple Needs of All Ages receptive to intergenerational sites, but 89 percent also say they Public spaces are a planning feature are a good use of resources, a poll often overlooked and ripe for smart from the Eisner Foundation and design. Designing public sites and Generations United found.155 Incentivize visitability features spaces—parks, transportation hubs, in homes, set universal design public and commercial plazas, or joint Where development is dense and goals for new public buildings, locales for programs serving old and crowded with high-rises, some cities are requiring that public spaces— and expand programs to help young—serves the community by providing beautification opportunities whether on rooftop gardens, interior residents install accessibility and encouraging healthy lifestyles, courtyards, or sliver parks—be included features. and offers intergenerational meeting as a condition of new development. grounds. They can promote social connections that reduce the isolation RECOMMENDATION #11 Realizing Age Diversity and loneliness often experienced by in Public Spaces, Transit older adults. Systems, and Innovation Designing public spaces and shared Districts sites for programs serving old Expand public initiatives that City streets provide an obvious and young is “an ideal blueprint prioritize investment in the for attacking age segregation Age-Forward starting point, with civic commons to facilitate and supporting all generations multipurpose benefits. Good design intentional intergenerational promotes overall livability by in families,” states Donna Butts, interaction and engagement. encouraging people to engage in their executive director of Generations communities and social networks. United. “Connecting with younger Green spaces and parklets make generations promotes a sense of purpose, which has been shown Designing Complete Streets for healthful outdoor pursuits appealing, Walkability and Convenience as do park and street benches to increase longevity and health. and landscaping that offer resting Meanwhile, children and youth grow Cities can add street design elements spots. Building orientation that up with an older adult presence in to improve walkability, a high priority allows sunshine to reach pedestrian their lives—which leads to improved for older adults. Walkability is areas makes streets more inviting. academic performance and long-term generally defined as a system that Pedestrian-focused gathering spaces, prospects, and a stronger society integrates the density of housing non-slip pavement, wide sidewalks, for all,” Butts writes in an American and intersections and multi-use and sidewalk cafes help older people Society on Aging article with Eisner destinations. It complements the 154 engage and keep moving. Foundation CEO Trent Stamp. Complete Streets policy agenda that is generating excitement in cities grappling with crowding and safety We increasingly live in segregated ways with people who are at issues. Complete Streets planners and engineers design rights of way the same life stage. The problem is that’s a heck of a challenge to enable safe access for users of all to the development of empathy. The notion that we’re going to ages, abilities, and transportation isolate older adults diminishes the richness of community and modes.156 diminishes our ability to empathize and see ourselves as part of Short distances to affordable a community that includes who today may be strangers to us. transit to access jobs and other The power of the public space can bring us together again, but opportunities are an important we need to also think about civic spaces as longevity assets.” design consideration for older adults.

—CAROL COLETTA President and CEO, Memphis River Parks Partnership, at the 2019 Milken Institute Global Conference

HOW WE BUILD 25 AGE-FORWARD CITIES FOR 2030 When public transit is coupled keep neighborhoods affordable. RECOMMENDATION #12 with reduced incentives for cars— Forty-one states provide TOD narrowed streets and more bike and support through taxes; public-private walking pathways, for example—the partnership arrangements; state result is healthier environments grants; tax credits or exemptions; that can reduce respiratory illness, and other financial incentives, an Promote Complete Streets pollution impacts, and traffic AARP Public Policy Report found stress.157 and Vision Zero metrics that in 2017.161 harness city data to better Concerns about street safety, As for the payoff,Atlanta’s BeltLine identify vulnerable older adults, however, deter walkability and is instructive. Conceived in 1999, its healthful benefits. The New improving neighborhood safety the BeltLine has evolved into a Urbanism movement’s research for all ages. TOD network of neighborhoods finds that traffic-calming bumps linked by parks, trails, and transit and narrower streets reduce traffic along a 22-mile historic rail corridor and speed, and that short blocks Fostering Equitable Transit- circling downtown. Its economic and dense street grids encourage Oriented Development and impact is calculated at more than walking and use of alternative Comprehensive Mobility $3 billion in private development, transportation.158 Solutions which is seven times greater than the total public/private investment From Honolulu to Washington, DC, Moving beyond the mere presence of $450 million through the end cities are becoming more proactive of bus or subway systems, transit- of 2015.162 Tax revenue from the on street safety. They are cracking oriented development (TOD) is a increased property values along down on speeding and installing way to enhance livability and create the rail line secures bond funding protected bike and scooter economically vibrant neighborhoods. for more BeltLine investments.163 lanes, long sought by cyclists, The concept is to orient housing and The BeltLine demonstrates how an with buffered striping and plastic commercial development within a impactful project grew from posts as separators from traffic lanes. walkable half-mile of quality public collaborative TOD thinking to Traffic signals with audible cues transportation, reducing traffic transform how and where people live. and “walk” signals give pedestrians and pollution. TOD emphasizes a head start over same-direction connections to health services and traffic. Mayors across the country work and social opportunities—a have embraced the Complete gateway to purpose for older adults Streets design parameters for safety when options even as basic as visiting and committed their cities to end a library on a bus stop are unlocked. pedestrian traffic deaths through The Northern Virginia road design and safe-speed measures, Transportation Commission found the goal of the Vision Zero network. that increased transportation Complete Streets projects offer options in walkable, mixed-use long-term economic gain for neighborhoods boosted mobility budget-conscious cities. Data for local residents 75 and older. suggest that economic gains like They took 20 percent more trips per increased employment and higher week than their suburban Northern property values follow Complete Virginia counterparts, and more of 160 Streets projects. As for savings, those trips were on foot. Smart Growth America found The cross-pollination required that the safer conditions under for TOD involves an interplay of 37 Complete Streets projects planning, budgets, and construction, avoided $18.1 million in collision often as part of redevelopment and injury costs over one year.159 projects—all amid pressure to

HOW WE BUILD 26 AGE-FORWARD CITIES FOR 2030 to personal independence andfreedom. adults 50andolder found they perceived drivingasakey convenience or even necessity. A national survey of challenges, their lossof mobility isnot simply about health. As older peoplegive updrivingdueto physical the linkbetween mobility andphysical andemotional Its importance assumes greater significance in light of transit acrucialelement intheage-friendly toolbox. Americans age 65andolder grew by 40percent, making with older adults.Between 2001and 2009,itsuseamong Ridership data indicate that publictransit isa winner good lighting andseating alsomake adifference. for themobility impaired. Well-located transit stops with are pivotal, along with personalized van or pick-up systems needs andabilities. Reliability, frequency, andaccessibility Transit systems mustaccount for arange of passenger social outings. family, andalmostthree timeslesslikely to participate in stop drivingare three timeslesslikely to visitfriendsand they have notransportation options. Older adults who Non-drivers face isolation anddecliningquality of life if FROM THE EXPERTS Source: Milken Institute, 2019. Institute, Milken Source: transportation options before 2030. identified was to provide more affordable, integrated of 150 policy experts this question, the third-highest priority When we asked our Center for theFuture of Aging network prepare for the future of aging?” leaders shouldprioritize between now and2030 to better “What are the mostcritical policy interventions thatcity The Future of Age-Forward Mobility Accessibility and Safety Activity Social Enabling aService, as Mobility 164 17% 24% Transportation and Mobility Priorities Housing/Health/Employment with Coordination Transit Public in Investment 20% 39% HOW WE BUILD WE HOW 166 165

27 Uber ridesto localgrocery stores. $5 credits from theCOMET bussystem for peopleto take people livingin“food desert” neighborhoodsprovides they used ride sharing for their transportation needs. transportation their for sharing ride used they that reported percent 3.3 only and services, of these knowledge no reported 74 sample of the adults, percent older of 2018In a study Lyft. and Uber as such services, ride-hailing to adopt slower have been people Older aride. just with end don’t needs Yet passengers’ future. the for older prospects mobility more opens vehicles driverless of frontier new The transportation systems that include: that systems transportation age groups—through and disability, geographic, income, users—across all of needs the incorporating for calls Institute, Policy Public by AARP described as aService, as Mobility of Universal concept The Mississippi-grown fruitsand vegetables. areas of Mississippi andto promote thepurchase of low-income older adultsabove theage of 60incertain for nutrition to good access more to provide designed program is aunique partners, state other with along the Mississippi Department of Agriculture andCommerce The Senior Farmers Market Nutrition Program, led by disabilities. Dial-A-Ride services are available to passengers with and upto $3.50to transport passengers around thecity. Lyft to provide subsidized rides for aslittle50 cents the Southern California city of Monrovia partners with Taking advantage of theopportunity to personalize transit, ƒ ƒ ƒ

for a variety of transportation avariety for information traveler and systems payment Seamless driving of solo place in transit Shared principles design universal and transportation specialized of Integration AGE-FORWARD CITIES FOR 2030 168 —JANA LYNOTT disabilities.” with people and adults to older deliverand service higher quality services to modernize transportation emerging technology harness that we can allow sector hope for transportation the Major disruptionsoccurring currently in A program inColumbia, SC,designedfor Institute, in an interview with the Milken Institute Milken the with interview an in Institute, Policy Public AARP Advisor, Policy Strategic Senior 169 170 167

ƒ Fixed-route and demand- term financial and political gain while Unlike conventions relegating responsive public transportation, overlooking the longer-term benefits older adults to the sidelines, the taxis, commercial ride-share, of forward-thinking approaches to BoomTown model emphasizes carpooling, bike-sharing, and zoning, services, transportation, well-connected spaces that foster volunteer transportation.171 environment, and street design. intergenerational relationships. Its Neighborhoods cannot thrive with planning integrates senior living into Deloitte 2019 City Mobility systems and design methods created neighborhoods and, through mixed- Index “takes a holistic view for earlier eras that no longer suit use design, mobile technology, TOOL of the city’s entire mobility the populations of the 21st century. and walkable amenities, it seeks landscape, and it is informed to reinforce shared interests. Short-sighted decisions that deepen by our clear image of how the BoomTown principles include: inequity and leave residents without future of mobility could unfold shelter, mobility, or purpose are ƒ Communities located close in urban areas.” neither healthy nor sustainable for to commercial, medical, and the future of cities. The factors that recreational facilities, with RECOMMENDATION #13 make a city livable are not driven by multiple-use spaces, and design near-term gratification. They are the features for safe, comfortable building blocks of sustainability, homes for all residents the tools for creating cities that will ƒ Use of mobile devices for support and enrich residents through Revise local transit-oriented on-demand services, the ages. development guidelines to including assistive services and telemedicine include special attention to the Age-Forward Cities mobility needs of older adults Making a Difference ƒ An intersection between physical and social space, with and people with disabilities; Age-Forward BoomTowns opportunities for informal additionally, expand regional interaction, and communities The Gensler Research Institute, transit planning to reduce oriented around commonalities the research arm of one of the systemic inefficiencies and that transcend generations, world’s largest architecture firms, is promote Universal Mobility. allowing older adults to pursuing ways that architects and be proactive about their developers can work together to health and find inclusion and create age-friendly urban livability. ownership in the community 172 Conclusion Gensler experts have developed a model called BoomTown as The Gensler Research team From street safety to housing options an alternative to self-contained has created visualizations of to intergenerational engagement, retirement communities, which, neighborhoods that are undergoing neighborhood design has the power although sometimes incorporating age-friendly transitions across the to enrich individual well-being and desirable amenities, typically leave nation. The visualizations for two community resilience. Across the residents segregated from other neighborhoods in Washington, DC US and the world, this message is age groups. and Los Angeles, included in this catching on as cities incorporate report, depict the powerful changes Based on evidence that emotional livability concerns into their that can occur through livability wellness suffers and costs are borne planning and join the World Health design frameworks, providing a by family members and society at Organization’s Global Network for dramatic look at how design can large when older people are isolated, Age-Friendly Cities and Communities. improve lives. the Gensler Research Institute Nevertheless, the momentum—like set out to reset the default that most efforts to upend convention— prevents older adults from living is far from universal. Inertia finds fully engaged lives. many cities still distracted by development that promises short-

HOW WE BUILD 28 AGE-FORWARD CITIES FOR 2030

9 10 11 Devote ample public space for for ample public space Devote with programming community for equipment exercise outdoor all ages. Provide affordable residential options that embrace inclusivity and diversity. Integrate residential housing with retail shops, services, and venues. entertainment AGE-FORWARD CITIES FOR 2030 CITIES FOR AGE-FORWARD 29

7 8 5 6 Expand and revitalize the historic Crummel School foster to civic and engagement. social Create commercial space for co-working, maker spaces,and learning. continued Strengthen local transportation networks for greateraccess to hospitals, universities, and local recreation. Provide a centralized, easily- center wellness and healthaccessible promoteto healthy living. HOW WE BUILD

4 3 2 1 Credit: The Gensler Research Institute Build a rooftopcommunity garden createto spaces for shared affinities across generations. Revitalize existing residential areas with green pocket parks. Soften and buffer major adjacent andhighways railyard with green space. municipal facilities to create hubs to create municipal facilities work creative (b) health care, (a) for public centralized (c) environments, and residential, mixed-use (d) space, education. (e) Consolidate industrial and Consolidate DESIGNING INTERGENERATIONAL COMMUNITIES DESIGNING INTERGENERATIONAL foster age-inclusive development inTo Ivy City, Washington, DC, the Institute Milken Center for the Aging Futureof and Gensler teams reimagined spaces and programs better to meet residential, health-care, and educational needs.

CASE STUDY and older live alone. but more thanhalf of adultsage 65 and well represented inthe workforce, Older residents are avid volunteers walk of apark. residents are within a10-minute officials boastthat virtually all numerous livability amenities,and related sectors. The city incorporates federal government anditsmany hub of jobopportunity, ledby the diverse andcosmopolitan mix,isa The nation’s capital,hometoa pioneered inBoston’s Beacon Hill any state, following theconcept “villages” per square milethan age-friendly leader, ithostsmore World Health Organization asan friendly sphere. Named by the Washington isbusy intheage- Against thesechallenges, WASHINGTON, DC: have retirement income. half of residents age 65andolder Excluding Social Security, fewer than compared to 9.2percent nationally. age 65-plusadultslive inpoverty, and wellness, 13.4percent of DC’s city ishighly rated for transportation the nation.” to make DC“themostsustainablecity in Sustainable DC,thecity’s planningeffort items, bolstered by thedevelopment of Environment as itsfirst pillar of action lists improvements to theBuilt 2018 Age-Friendly DCStrategic Plan 117,223.173 to 15,000 by nearly grew of 60 age the over Washingtonians of2018, before the number In the decade DEMOGRAPHY (#19) Wellness (#8), and Convenience and (#1), Transportation (#19),Overall High Marks for Employment AGING RANKINGS SUCCESSFUL FOR CITIES BEST economy service-based Diverse ECONOMIC PROFILE 174 175 While the 176 IVY CITY CLIMBING CITY IVY

HOW WE BUILD WE HOW on community amenities. Development prioritiesincludelandscaping, walkable streets, andemphasis in aninterview with theMilken Institute. good for other people,” saidGail Kohn, Washington’s age-friendly coordinator, Villages thrive on “feelings of purpose and the goodwill that’s created by doing approved contractors. or bookkeeping provided by volunteer andpaidresidents, organizations, and typically pay anannualfee for access to services like transportation, yard work, neighborhood. Villages are service andsupportnetworks in which residents provided jobs. including for industrialsites that hadstabilized nearby affordability and Washington core. New development, however, pushesuphousingcosts, Ivy City isrevitalizing as demandfor affordable housingspillsout from the high level of poverty. moved to thesuburbs. Today, thearea’s population of morea than24,000has reached aheyday inthe1950sbutfaded asmany large-scale enterprises thriving industrialhub,Ivy City boasted warehouses andmanufacturing that corridor, amajor entry route to thecapital,alongsideahistoric rail yard. A once Washington’s Ivy City neighborhoodsitsastridethebusy New York Avenue Blossoms City Ivy include: initiatives Washington’s age-friendly and improving environmental stewardship andconnectivity options. businesses while bolstering existing companies, providing well-paid jobs, Washington new planners are working to diversifycreate theeconomy and other uses,andmany need modernization to accommodate new industries. ƒ ƒ ƒ ƒ ƒ ƒ

in thetransit-centric Mount Vernon neighborhood older residents, includingunitsreserved for thoseraising grandchildren Construction of more than500units of below-market-rate housing for residential zones Zoning revisions that allow ADUs, or granny units,inlow-density and handrails for qualifying older adultsandthoseliving disabilities with The Safe-at-Home program grants for homeadaptations such as ramps women Allocation of $28million for 50new supportive housingunits for older have disabilities who residents for service taxi Program’s curb-to-curb DC Transport The nutrition and health of $11.4 holistic on siteCommitment focused senior anew for million

178 180

Industrial buildings are under market pressure to convert to 30 179 RECOMMENDATIONS #8 AND #11 AND #8 RECOMMENDATIONS ENGAGEMENT NEIGHBORHOODS AND INTERGENERATIONAL INVESTING IN AFFORDABLE MIXED-USE

AGE-FORWARD CITIES FOR 2030 177 181

CASE STUDY

182

ECONOMIC PROFILE ECONOMIC Diverse service-based economy BEST CITIES FOR SUCCESSFUL RANKINGS AGING Overall High Marks (#56), for General Livability Transportation (#7), and Convenience and Wellness (#13), (#21) DEMOGRAPHY Population65 overis projected to nearly double percent, to 18 from million 1.1 to 2.1 million2.1 between and 2030 2010 Plan Action Age-Friendly 2018 include identifying recommendations “expand to strategies cross-agency adult population older the inclusion of City’s and County the as part of including through Initiatives, Homeless the ordinance of implementation Units Dwelling Accessory authorizing and innovative new (examining) and by housing, such as co-op strategies multi-generational other or co-housing, housing help reduce to living arrangements social isolation.” and mitigate costs, AGE-FORWARD CITIES FOR 2030 CITIES FOR AGE-FORWARD 31

5 4 6 Establish a sense place of through design elements that celebrate the history and culture the of existing neighborhood. Provide ample space for the programming community-conscious eventsof and festivalsto minimize connections. social foster and isolation Leverage existing transportation infrastructure access to services and area amenities. HOW WE BUILD

3 2 1 Credit: The Gensler Research Institute Support existing localvendors through designated structures and lightingto forcreate a haven engagement. intergenerational networks for people of all ages all ages people of for networks throughout their lifetime. Integrate and coordinate surrounding surrounding and coordinate Integrate business, and health-care residential, Encourage safe and calm traffic and calm traffic safe Encourage clear and signals audible using patterns pedestrians. for transitions pavement In Los Angeles, the teams created a proposal completely to reform how MacarthurPark serves its community.By re-allocating space—creating space for a playground, outdoor classroom, andother fitnesscommunity-focused center, amenities—theteams proposed a hub that leverages mostthe area’s valuable assets—the reasons people why come Macarthur to Park begin to with. DESIGNING INTERGENERATIONAL COMMUNITIES DESIGNING INTERGENERATIONAL

CASE STUDY friendly planacross arange of domains,suchas: Purposeful Aging Los Angeles Initiative created an age- Taking aregional perspective, the city and county’s and transit shortcomings suchaslongbus waits. crime, broken sidewalks, unclean streets, lackof benches, impediments to walking includetraffic safety concerns, Despite thedensity of retail andservice amenities, older shot up22percent. slightly in2018,homelessness amongresidents 62and While homelessnessamongthegeneral population dipped California’s highestpercentage of low-income families. and tourism, Los Angeles isanexpensive place to live, with A city of great healthand wealth disparities,jobcreation, with 90languages spoken. account for 57percent of thetotal older population, wellness. Its substantial ethnic minority populations now economic vitality, transportation and convenience, and business andimmigration isknown for its overall livability, entertainment industry profile, thishub of international that will doubleby 2030.Far more complex thanits friendly initiatives in anticipation of an over-65 population The nation’s second-most populouscity ispursuing age- ANGELES: LOS ƒ ƒ ƒ ƒ ƒ ƒ

pursue to track on city the put has Garcetti Mayor Eric improve emergency preparedness outreach. live to adults of older clusters where neighborhoods reviewing are officials management Emergency transit. public of outs and ins the with people older help County Angeles Los throughout Clubs Move Riders the On considering older-adult taxisubsidiesfor longer trips. Rides program more affordable andaccessible and Transportation officials are working to make theCity and wellness programs. programs. wellness and recreation in participation adults’ older encourage and of community asense to build is underway amenities and accessibility to improve park Planning projects. age-friendly to inform services wellness and employment, of housing, need in residents older of locations is mapping city The sidewalks. improving and transit, public

Vision Zero Vision MACARTHUR PARK ON THE MOVE RECOMMENDATIONS #9 AND #12 AND #9 RECOMMENDATIONS AGE-FORWARD HOUSING AFFORDABLE TO SAFETY STREET FROM goals of safe streets, revitalizing revitalizing streets, of goals safe

HOW WE BUILD WE HOW

32 house mature adults. new housingstock andretrofitting of tiredbuildings that Saborio, who listed other areas ripefor investment as which posesaproblem for many older residents, said The area haslittle affordable, high-speed internet access, to MacArthur Park to improve accessibility. buildings andrepaired buckledsidewalks andentry points residents. They have negotiated rents insenior apartment and nutritionaspriorities for MacArthur Park’s older City officials cite rental costs, walkability, medicalservices, Milken Institute. the with interview an in said home,” Saborio back them to get transportation about worried they’re of course, then, and dark, after out being at ease feel don’t “Seniors shortages. parking and streets, trash-burdened by crime, stressed are people older insecurity, housing from Aside nonprofits for programs andservices for older residents. The area relies heavily onSt. Barnabas andother said Rigo Saborio, CEO of St. Barnabas Senior Services. under pressure for updates andcommercial conversions, The area has26senior livingsites. Affordability haseroded of long-time lives residents. the and character neighborhood of future the about questions come has gentrification With crime. on acrackdown and concerts, outdoor children’s playgrounds, and fields sports new in have resulted decade last over the projects Renewal downtown’s skyscrapers afew milesaway. apartment tower that will riseto meet thegaze of a hotel andperforming artscenter with a41-story Latino populace. The emerging changes have attracted professionals and Asian residents amidthelongtime lofts and restaurants, andnewcomers including young Los Angeles, atransitioning community withstylish 118,000-population Westlake neighborhood of Boulevard, MacArthur Park isaslice of the With itssignature lake bisected by storied Wilshire through neglect,decline,andgangdrugaffliction. it hasahistory of demographic shiftsandhascycled An early 20thcentury neighborhood of elegant homes, immigrant andincreasingly older resident populations. MacArthur Park ishometo oneof thecity’s largest Park MacArthur AGE-FORWARD CITIES FOR 2030 183

CASE STUDY 185 184 ECONOMIC PROFILE ECONOMIC Service-based economy BEST CITIES FOR SUCCESSFUL RANKINGS AGING for Marks (#48), High Overall (#6) Convenience and Transportation (#37) Care and Health DEMOGRAPHY 10.3 percent Chicagoans of are or 65 Illinois’ and 65 over. older population is projected percent to grow 18 2030 by 2015 Age-Friendly Planprioritizes safety improvements for lower-income older adults aging in high-rise buildings creatingby an innovative Vertical Independent Collaborative (VIC) pilot program, now with 21 operational sites. AGE-FORWARD CITIES FOR 2030 CITIES FOR AGE-FORWARD 33 HOW WE BUILD REINVENTING THE WEST LOOP WEST THE REINVENTING CHICAGO:

CASE STUDY a number of priorities and steps: and of priorities a number lists 2015 in and plan age-friendly its developed Chicago recommended American Geriatrics Society’s ratio. the geriatricians,half with statewideunder numbers well diabetes andchronic illness,itsuffers asevere shortage of most medically underserved areas, with elevated rates of poverty istwice thenational average. Among thenation’s older adults,particularly onthe South Side where elder Chicago, however, struggles with strikingpoverty among as oneof thenation’s most walkable cities. skyline with more than3,000high-rises,italsoisknown for its workaday transit system. Beneath itsimpressive important cities—alively, service-based economy known Chicago hasevolved to become oneof thenation’s most powerhouse, thenhometo globalfinancial exchanges, From itsbirthasafur-trading outpostandlater asteel ƒ ƒ ƒ ƒ ƒ

of planning. a larger mixed-use redevelopment planafter years assisted-living housing, was constructed aspartof Belmont Village Lincoln Park, much-needed at Chicago. of Illinois University the and city by the developed to training access have staff and managers building apartments; their in age sufferers dementia helping streets, Chicago tower above that buildings apartment of the some in established are Villages Interdependent Vertical service needsfor older residents. interaction andidentify homeand community concept—uses senior volunteers to provide social Collaboratives—a fee-free version of the Village Age-Friendly Village Interdependent 2038. by disabilities with living people to accessible percent be are to 100 stations rail Chicago all Authority Transit directive, mayoral By oflevels disability. all address to requirements Act Disabilities with Americans beyond going facilities, new for design universal uses Commission Building Public The

RECOMMENDATIONS #10 #13RECOMMENDATIONS AND AGE-FORWARD COMMUNITY PUBLIC SPACES AND INNOVATIVE ACCESSIBLEMAXIMIZING 186 HOW WE BUILD WE HOW

34 age-friendly goals: goals: age-friendly several include West Loop for guidelines City places to live, work, and visit. character andscaleasoneof thecity’s mostdesirable center, city guidelinesaimto retain West Loop’s urban Loop asanemployment, transportation, and residential conveniently to other areas of thecity. In elevating West and anelevated “L” train stop that connects thearea more evolved to includelofts, restaurants, boutique hotels, west of thedowntown Loop. The neighborhoodhas the traditional meat-packing andindustrial center just Chicago hasspecificplanningguidelines for West Loop, West Loop and maintain connections with vulnerable older adults. older vulnerable with connections maintain and practices best share to network Village the connecting and strengthening and services, them providing and adults older isolated identifying include 2030 for priorities that survey aMilken Institute in said services, senior of Joyce Gallagher,director Chicago’s executive ƒ ƒ ƒ ƒ ƒ

installing high-quality lighting lighting high-quality installing and landscape, and gardens public encouraging bike safety, and pedestrian emphasizing impacts, environmental minimizing lots, vacant Improving spaces public and parks around outlets retail encourage and spaces, public larger create and sidewalks widen expressways, toward shadows their cast to buildings orienting while thoroughfares important improve that sites Specific streets on daylight and access solar maximized and level at street space Tall public with buildings walkability preserves and spaces public and parks, streets, for sunlight maximizes that Development and over remain intheir homes. detectors—that helplower-income adultsage 60 improvements—like ramps, grab bars, andsmoke program provides safety andaccessibility The city’s Small Accessible Repairs for Seniors AGE-FORWARD CITIES FOR 2030 187

CASE STUDY CHAPTER 3: Resilient Networks for Healthy Aging: How We Care

FORECASTING 2030 The term “resilience” may call to mind cities’ defenses against natural OPPORTUNITY: disasters, terrorism, and climate change—the realm of disaster and emergency preparedness. But it also encompasses the preparation and perseverance The potential of technology to impact needed to safeguard well-being in the routines of daily urban life. lives across diverse communities is dramatically changing the provision of “Resilient cities promote sustainable development, well-being, and inclusive care in cities. growth,”192 according to the Organization for Economic Cooperation and » The virtual care marketplace is Development. A resilient city is one in which governments and economic expected to surpass $13 billion structures foster the population’s ability to meet short- and long-term stresses, by the end of 2026, as health-care including those related to critical health and social services. Systems attuned companies increase software- to the unique needs of older adults—especially those who are isolated or who driven automation of services in pharmacies, hospitals, and other have complex needs—are central to this mission. 188 community settings. The US Departments of Homeland Security and Health and Human Services » According to McKinsey Global advocate for a Community Health Resilience agenda, which it defines as Institute projections, if cities “the ability of a community to use its assets to strengthen public health deploy smart city applications to and healthcare systems and to improve the community’s physical, behavioral, their full capacity, they have the and social health to withstand, adapt to, and recover from adversity.”193 potential to reduce disability- adjusted life years—the primary This strength-based approach can deliver more collaborative, efficient metric used by the WHO to networks—across services, sectors, and community-based interventions—to convey the global disease enable better, healthy aging. burden—by 8 to 15 percent.189 CHALLENGE: Strengthening Social Connections for Stronger

Isolation among US older adults is Communities growing. Between 2015 and 2035, Resiliency is reflected in the daily functioning of communities as well as in their the number over age 75 who live alone longer-term actions to protect against social and economic weakness. Access to will nearly double, from 6.9 million to 13.4 million, the majority of them health care, supportive services, and safe housing, bolstered by social ties and women.190 In the coming years, seven tech-enabled connectivity, all combine to enhance older adults’ resiliency in the out of 10 adults age 65+ will need face of unanticipated events. long-term services and supports, and more than half will experience a high Research has shown that a lack of social connection can lead to health level of need, defined as assistance problems and reduce resiliency. Twenty-two percent of older adults report with two or more activities of daily that they lack companionship some of the time, and 19 percent report feeling living for at least 90 days or severe isolated some of the time.194 cognitive impairment.191 Stanford Center on Longevity found that 55- to 64-year-olds are less socially GOAL: engaged than their predecessors were 20 years ago in terms of marriage, 195, 196 Resilient local communities that foster family ties, and interaction with neighbors and friends. healthy aging through the integration The implications for health are profound. Older adults who are socially isolated of health and social services and the or lonely have significantly increased risks of depression, Alzheimer’s disease, use of technology to improve quality of 197, 198 life and safety for older adults. and stroke, as well as premature death. “A resilient community requires strong connections at all levels: between neighbors, between neighborhoods and community organizations, and between local government and non-governmental groups,”199 a 2018 report by the RAND Corporation concluded.

HOW WE CARE 35 AGE-FORWARD CITIES FOR 2030 Social cohesion is paramount for Integrated Focus on Economic At the state level, performance on underserved populations. Many and Health Inequality LTSS is tracked by the AARP Long- LGBTQ older adults, for example, Term Services and Supports State Urban resiliency relies on are estranged from family and lack Scorecard. Using state data and collaboration to connect social, social supports, deficits that worry analysis, it measures and highlights health, and cultural services. New three-quarters of LGBTQ adults, state performance in this crucial payment models and a focus on according to a national AARP survey area.206 The LTSS Scorecard also social determinants of health have in 2018.200 By 2030, the LGBTQ showcases promising state and caused most hospital-based systems population over 50 is expected to community-based practices such as and health plans to offer services in reach an estimated 7 million in the mobility managers, community living the communities where people live, US, and, according to the advocacy for veterans, and strategies to reduce rather than in hospitals and doctor’s group SAGE, well over half will need the risk of long-term nursing home offices. Communities across the elder care and services. LGBTQ care after hospitalization.207 nation are forming new coalitions adults are more than twice as likely (public-private partnerships, These best practices highlight the as heterosexuals to be single and nonprofit and commercial projects, importance of forging partnerships live alone, SAGE reports, and they or coordination among universities, across different sectors in the face discrimination and disrespect cities, and the private sector) community, including through an in treatment settings as well as in to narrow economic and health initiative at the intersection of housing. More than a third worry inequality. These efforts can provide planning and public health that is they’ll have to hide their identity to all residents, including the most geared to population-level change. find suitable housing as they age.201 vulnerable, a chance to age with Rooted in the idea that the built Health-care pioneers such as purpose and health. environment impacts all aspects of CareMore, an integrated health plan and care delivery system for Medicare and Medicare patients, We are exquisitely unprepared for that [oldest] age have implemented community demographic pushing through. We need to lean in much programs to address social isolation, harder if we want to help seniors thrive at home as long as which is often a symptom of living with chronic illness. At CareMore, possible. The opportunities for person-centered care to patients determined to be at risk reduce costs and improve outcomes for people with complex for social isolation can receive medical conditions have never been greater.” home visits from social workers —BRUCE CHERNOF who encourage them to participate President and CEO, The SCAN Foundation204 in free social activities such as Zumba classes and group lunches.202 CareMore reports it has reduced Resiliency for people with long-term health, the health-equity-focused hospital admissions by 21 percent illness, disabilities, or frailty is closely Plan4Health initiative—created by after launching its “Togetherness linked to the quality of their services the American Planning Association Program.”203 Among its benefits, and supports: a broad range of day-to- and the American Public Health outreach coordinators make weekly day help, whether personal care like Association—promotes strategies phone calls to patients to encourage bathing and dressing, complex care focused on nutrition and physical preventive care, and through regular such as IVs and wound care, or help activity. It emphasizes working check-ins, seek to reduce loneliness with housekeeping, transportation, in coalitions—which may include and its negative health effects—even bill-paying, and meals, among other nonprofits, schools, recreation 205 making sure older patients are not supportive services. These long- departments, planners, health alone on holidays. term services and supports (LTSS) are professionals, and more—to ignite provided in homes, health facilities, policy and environmental changes.208 or other settings, and include support Cities aligned with the initiative for unpaid caregivers. employ health considerations

HOW WE CARE 36 AGE-FORWARD CITIES FOR 2030 across decision-making sectors. between buying food or medicine.212 Healthcare Research to investigate They are pursuing projects such as how health and safety screenings The economic benefit of locally bike- and pedestrian-friendly streets, can be integrated into meal delivery based services is well established: farm-fresh produce brought to services for homebound older neighborhoods, and school gardens.209 ƒ Ninety-two percent of home- adults. The pilots are taking place delivered meal recipients say across six cities:Cambridge, OH; Integrated Health and Long-Term the meal programs allow them San Diego, CA; Fort Worth, TX; Services and Supports to remain in their homes in Raleigh, NC; Sheboygan, WI; and The social determinants of health lieu of considering more costly Westwood, NJ. The program, called are a growing focus for insurers assisted living, according to More Than a Meal Phase 3, aims to and governments alike. Social the federal Administration for standardize reporting mechanisms 213 determinants, including health Community Living. and improve communication with behaviors and social and economic ƒ In several studies, meal health-care providers to prevent an factors, account for 80 percent of programs were found to adverse health event. The assessment health outcomes in a population, improve health and reduce will help identify health, safety, and compared with 20 percent attributed nursing home placement.214 social needs such as loneliness, to clinical care.210 depression, or fall risk. By providing ƒ Humana’s data revealed that volunteers with simple screening To address these determinants, community-level changes tools and user-friendly technology, the health-care industry has been improved older adults’ the study is designed to improve moving more services out of clinical conditions including diabetes, care coordination and prevention settings and into the communities heart disease, respiratory efforts.217 where people live. Research problems, and poor mental confirms that integrating medical health.215 Research also indicates that and social services improves health counties in which Area Agencies on Building on the idea that the benefits and lowers costs. For example, Aging (AAAs) partnered with a range of nutritious foods save on health- community-based organizations of organizations in health care and care costs, especially in emergency and social workers can identify other sectors saw significantly lower room utilization, Meals on Wheels and address risk factors such as hospital readmission rates than America has sought to integrate its poor self-care skills, environmental counties where AAAs partnered services with traditional health-care hazards, mental-health challenges, with fewer types of organizations.218 delivery and reach more homebound or difficulty with medication residents. To explore a new funding Other community-based programs management before a doctor has to mechanism using a Pay for Success concentrate on providing preventive intervene. outcomes-based financing model, services in places that are Health insurer Humana is targeting the organization partnered with convenient or frequently visited. social determinants with its Quantified Ventures and Johns One model based at the University Bold Goal Initiative, focused Hopkins Bayview Medical Center in of Maryland offers preventive on food insecurity, loneliness, Baltimore, to offer home-delivered services at barbershops and beauty and social isolation “because of meals in conjunction with its other salons. Instead of having to deal their direct impact on healthy supportive services for enrollees.216 with the health-care system, days and clinical outcomes,” the neighborhood residents can get Meal delivery volunteers are often company states.211 Among its many their blood pressure or glucose the only people that older adults initiatives—including a predictive levels checked while getting their may see on any day, and as such, model allowing care managers and hair cut. can report changes in health status clinicians to identify patients at risk to health-care providers. Meals on Drug and grocery stores are also of loneliness and isolation—Humana Wheels America is collaborating on setting up mini-clinics so consumers has partnered with Feeding America a nationwide project with the Gary can get a flu shot or a blood test while on a physicians’ food insecurity tool and Mary West Health Institute and shopping. For example, Humana kit in view of older adults’ unique researchers from Brown University’s and Walgreens have joined forces challenges such as having to choose Center for Gerontology and to create “care centers” oriented to

HOW WE CARE 37 AGE-FORWARD CITIES FOR 2030 older adults and offer primary-care evidence-based practices known as bolster resilient aging: collaboration services and representatives to the 4Ms Framework: between public health departments 219 answer Medicare questions. ƒ What Matters: Care aligned and the AARP Network of Age- Friendly States and Communities. The new company model created with each older adult’s health Public health agencies in communities by the merger of CVS Health and goals and care preferences throughout the US are responsible Aetna is poised to make such ƒ Medication: Use of age-friendly “for protecting, assessing, and conveniences commonplace, using medications that do not interfere assuring individual, community, and the drug stores that dot US cities with goals and preferences, environmental health.”223 The public for a major delivery disruption. mobility, or mentation health system focuses on prevention With stores located in virtually ƒ Mentation: Prevention, through population-based health every neighborhood in the US, CVS treatment, and management promotion—public services and Health President and CEO Larry of dementia, depression, and interventions that protect entire Merlo predicted the combined delirium populations from illness, disease, effort would “transform the and injury. The AARP Network consumer health experience and ƒ Mobility: Ensuring that older of Age-Friendly States and build healthier communities through adults move safely every day Communities, the US affiliate of a new innovative health care model to maintain function and do the World Health Organization’s that is local, easier to use, less what matters expensive, and puts consumers at the center of their care.”220 The Age-Friendly Health Systems initiative has become a RECOMMENDATION #14 movement to transform care for all of us as we age.”

—TERRY FULMER President, The John A. Hartford Foundation, in an interview with the Milken Institute Bolster the capacity of trusted, At least 325 teams from 126 health Age-Friendly Cities and Communities, community-based organizations systems in 37 states are testing “helps cities prepare for rapid through economic and human this Age-Friendly Health Systems population aging and the parallel resources so they can effectively framework in hospital and ambulatory trend of urbanization.”224 settings and sharing data.222 partner with the health systems While public health has a proud and plans seeking to engage in While cities and counties have history of helping to extend human their communities. traditionally not been the primary longevity, it has not been a prominent driver in health-care financing participant in healthy aging and delivery, several factors collaborations. “Landmark programs Age-Friendly Health (e.g., polarization at the federal including Medicare, Medicaid, and Systems for Age-Forward level and more emphasis on the Older Americans Act, did not public health) have led to the explicitly call for a role for public Cities rediscovery of the importance of health organizations,” the John A. 225, 226 A growing movement involves local governments in health care. Hartford Foundation states. Whether the issue is Medicaid, health systems that participate Age-friendly cities and communities hazardous wastes, homelessness, in an age-friendly agenda aimed bring together local leaders with or lead paint poisoning, more at optimizing value for patients, community-based organizations such attention is focusing on what state families, caregivers, health-care as Area Agencies on Aging to promote and local governments can do to providers, and the overall system. planning for livable communities for promote health. An initiative of the John A. all ages—“communities that are good Hartford Foundation and partner This increased attention has places to grow up and good places organizations,221 it calls for the care spurred connections that could grow old.”227 of every older adult to be guided by

HOW WE CARE 38 AGE-FORWARD CITIES FOR 2030 Bringing these two influential the American Hospital Association. less than non-Lyft curb-to-curb community partners together to According to the Transit Cooperative rides.231 address fundamental health issues Research Center, the market Many older adults have begun to use for older citizens could provide a opportunity created as a result of on-delivery, app-directed services. powerful combination to affect this lapse in access is estimated to be An MIT AgeLab Study found that change. The National Prevention worth over $3 billion. for aging adults wishing to remain Council makes the case for Both ride-hailing companies in their own homes, using these collaboration in preventive services have seized this opportunity by app-directed services for help with like screenings, behavioral health, developing pilots with cities to activities of daily living such as and counseling.228 Public health has provide subsidized rides to low- household errands, transportation, been a key partner, for example, with income older adults to remove and meal delivery cost less than the Vote & Vax, providing Election-Day barriers to health-care access. Lyft’s average monthly cost of assisted flu vaccines at US polling places—a Grocery Access Program began with living, even as the need for services notable service since up to nine in a successful pilot in Washington, increases with diminishing physical 10 flu-related deaths occur among DC, last year, providing thousands of capability.233 people age 65 or older.229, 230 A pilot affordable rides to grocery stores for program in Tampa, FL, creates a Housing for Health: Insurers on low-income families and older adults testing ground for efforts to scale the the Ground Floor living in food deserts, and has since partnership of public health agencies expanded to Atlanta with plans to Housing, which is crucial to well- and age-friendly communities on a launch in more than a dozen US being and resiliency, is one of the national level. cities this year. best-researched social determinants of health.234 Selected housing RECOMMENDATION #15 A 2016 JAMA study showed that interventions for low-income and as a result of Lyft’s partnership with underserved older adults have proved Anthem subsidiary CareMore, the successful in improving outcomes and health plan reduced transportation lowering health-care costs. costs by about 30 percent per ride, Scale and pilot more Age- or $10 per patient per ride, while Building on these findings, health- Friendly Health Systems increasing patient satisfaction by care payers have begun to improve in cities across the US and 80 percent. As a result of the pilot housing stability for at-risk groups. create meaningful alignment in Southern California, CareMore For example, UnitedHealthcare has invested in dozens of affordable- between local public health embarked upon a larger scale pilot throughout all of its Medicare housing communities nationwide, departments, local Age-Friendly Advantage markets serving committing more than $400 million Coordinators, Area Agencies 75,000 members in California, through local partners from 2011 on Aging, and other community- Nevada, Arizona, and Virginia. to 2019. The investment produced based organizations serving The result? Within three months, more than 4,500 new homes for older adults. on-time performance and patient individuals and families in need, satisfaction improved, wait times the company says, furthering its decreased, and it cost 39 percent stated goal to improve health in Ride-Hailing for Health: underserved communities.235 On-Demand Transportation as a Means to Better Health As studies reveal that senior loneliness can increase Ride-hailing giants Uber and Lyft a person’s risk of mortality—more than air pollution, have recently found themselves front obesity, and excessive alcohol use—it is more important and center in the business of healthy than ever that we come together to exchange ideas and aging. Transportation is the third- most frequently identified reason discuss solutions.” for missed doctor’s appointments —SACHIN JAIN among older adults, according to President and CEO, CareMore & Aspire Health232

HOW WE CARE 39 AGE-FORWARD CITIES FOR 2030 UnitedHealthcare cites data showing with Bay Area Community Services Digital Networks, dramatic drops in emergency room (BACS), Kaiser Permanente Connectivity, and admissions where homeless people announced in 2019 a first-of-its- entered stable housing. “Access to kind community partnership that Resiliency for All safe and affordable housing is one will house 515 adults ages 50 and Preparing for the Worst: of the greatest obstacles to better older in Oakland who were identified Disaster Planning health, making it a social determinant by BACS as being “particularly Although older adults suffer that affects people’s well-being and vulnerable,” chronically homeless disproportionately when disaster quality of life,” UnitedHealthcare and living with at least one chronic hits, public health leaders cite CEO Steve Nelson stated.236 condition. “In turn, BACS will provide emergency preparedness gaps in comprehensive outreach, housing In East Oakland, CA, tenants faced national policy and legal frameworks coordination, landlord development, the prospect of steep rent hikes as that are supposed to protect them. housing locator, and tenancy- their building was listed for sale in sustaining services over the long the housing-shortage-plagued San Experts’ Insights: On Disaster term.”240 Francisco Bay Area. The integrated Planning health system Kaiser Permanente RECOMMENDATION #16 “In a survey of adults 50 and older, put up the money to help a nonprofit one-third of respondents (34.3 percent) purchase the building and keep it reported that they participated in affordable.237, 238 The organization an educational disaster preparation program in their community. How likely says affordable housing is a lynchpin is it that at least 65 percent will do so FROM THE EXPERTS in its impact investment efforts Pilot test and evaluate by 2030?” to “advance economic, social, innovative financing models and environmental conditions for The fierce storms and wildfires that to improve the coordination are becoming more problematic health.”239 In addition to supporting of housing stability and with global warming have put a housing development, Kaiser sharper focus on preparedness health services for high-risk Permanente is looking to scale measures to keep the population efforts to address homelessness older adults. safe.242 However, our experts did not through a new partnership with hold high hopes for comprehensive Community Solutions aimed at disaster education programs. Overall, the experts said there is a 45 percent accelerating efforts to end chronic likelihood that two-thirds of the age homelessness in 15 communities. 50+ population will participate in As part of Kaiser Permanente’s any such program by 2030. broader strategy, and in collaboration Three-quarters of those who lost their lives during Hurricane Katrina in 2005 were older than 60. The Housing and health are totally connected … What we majority of fatalities during Northern California’s 2017 wildfires were know from the data is people who are homeless have a life adults over 65.243, 244 Older people expectancy that’s 27 years less than those who are housed. are more likely to be vulnerable to As a health organization, we have to be looking at housing and unexpected events and catastrophes homelessness as a key indicator for health.” due to mobility and transportation challenges, age-related issues like —BECHARA CHOUCAIR Senior Vice President and Chief Community Health Officer, hearing and vision impairment, and Kaiser Foundation Health Plan, Inc. and Hospitals241 isolation that hinders their awareness of threats. Research has found after disasters that older people have a greater risk of health problems and emergency room visits and that communities need to dedicate more

HOW WE CARE 40 AGE-FORWARD CITIES FOR 2030 resources and planning to ensure A 2012 survey found that 15 percent cities and states are investing in they have access to medical facilities, of US adults age 50 or older would water, energy, and transportation medications, and safe housing in be unable to evacuate their homes infrastructure that is more post-disaster situations.245 without assistance, underscoring resilient. Carmel, IN, initiated a the need for preparedness and monthly household fee to bolster Most policies guiding US disaster cross-sector planning to protect the stormwater system against preparedness, response, and them.248 Ensuring that residents have more frequent heavy downpours. recovery do not address older communication tools is essential. Scottsdale, AZ, hosted a cool roof adults specifically.246 Cities’ roles workshop series in 2015, promoting then become even more crucial in City inventories of residents who rely roofs that improve energy efficiency building awareness and employing on electricity-dependent medical and reflect away sunlight and heat life-saving technology to ensure equipment can be important tools that cause heat islands. New York that older people are not left behind for assigning early-evacuation or City also included cool roofs in its when floods, wildfires, earthquakes, back-up electricity priorities during $106 million Cool Neighborhoods hurricanes, or human-caused power outages. Following Hurricane NYC program, launched in 2017 emergencies cause havoc. Katrina, the US Department of with measures from tree plantings Health and Human Services created There is work to be done to to climate risk training for home the emPOWER map, “enabling transform city networks, as revealed health aides. hospitals, first responders, electric in the 2018 RAND Corporation companies, and community members survey of public health department Adaptation Clearinghouse, to identify Medicare beneficiaries officials, coordinators of age- developed by Georgetown with electricity-dependent TOOL friendly communities (government- University’s Climate Center, equipment.”249 Hurricane Katrina community group partnerships), is an interactive website that also accelerated efforts to digitize all and executive directors of senior provides a series of maps health records when it batteredNew villages.247 Their assessments include: depicting the vulnerability to Orleans with floods that ruined paper heat of each county in the US ƒ Most age-friendly communities medical records. as a result of climate change. and villages do not place a high Climate change affects everyone, Vulnerability is measured priority on promoting disaster and compelling research shows the across four domains—heat preparedness. Public health heightened risk to older people— and humidity, social agencies typically have disaster especially those 85 and older and vulnerability, medical access, preparedness and resilience in physical decline due to mobility and physical environment. activities but not necessarily challenges and restricted access to tailored to older adults. resources such as transportation RECOMMENDATION #17 ƒ Determining where the ultimate and air conditioning in extreme responsibility lies can leave weather events. According to the older adults without a clear Environmental Protection Agency, sense of who they can depend 20 percent of older adults live in an on in emergencies. Agencies area hit by a hurricane or tropical Engage older adults in often take the view that another storm within the last 10 years. emergency preparedness and agency is the lead for older Adapting cities to the impacts of adult–focused services and it is climate change involves focusing on deploy tech-based solutions to not part of their own mission. the most vulnerable residents as reduce loss of life. ƒ Where cities keep registries of well as protecting infrastructure and residents who have functional ecosystems. Adaptation measures disabilities, stakeholders cite vary depending on geography. Local difficulties in getting people governments in southern Louisiana signed up and maintaining are pooling hazard reduction funds them in a way that would be to address increased flooding useful during an emergency. from heavy rainfall. Northeastern

HOW WE CARE 41 AGE-FORWARD CITIES FOR 2030 generally express optimistic views an emergency. Still, older adults communication difficultiesin most likely to encounter solutions inthedemographic calls for collaborative resiliency and older. to 42percent, amongthose80 that figure drops by nearly half, ages 65to 69report internet use, drops. While 82percent of those the likelihood of internet use survey respondent increases, As theage of thePew Research less. or education school ahigh with those as broadband have likely to as home times three nearly are graduates college adult Older- Institute. Pew Research to the according $30,000, under incomes with of27 those percent with compared at home, internet have87 to high-speed access percent more, or of $75,000 incomes over age 65 with those Among income. and by education driven divide digital awidening with but years— recent in adults older among rise sharp a Techseen has adoption FROM THE EXPERTS by 2030. speed computing intheir homes adults would beliving with high- quarters of theselow-income older 57 percent chance that three- Overall, theexperts projected a in 21stcentury communication. critical role of digital connectivity among older adults,given the the state of technology adoption this question for a reality checkon surveyed nearly 150experts with The Center for theFuture of Aging speed internet athomeby 2030?” at least75percent will have high- internet athome.How likely isit that below $30,000have high-speed 65 andolder with householdincomes “Twenty-seven percent of USadults Divide On Resiliency andtheDigital 251 This digitaldivide 250

HOW WE CARE WE HOW their loneliness. to decrease networks family and encourage building interactivefriend to designed app communication a with connections, internet and to tablets access residents older giving with experimented has city the interaction, human meaningful days without their spending report and live alone adults of older Barcelona, In divide. digital the to bridge cities across the world are working of solutionsis far from robust, but a resilient population. The uptake literacy are partof theformula for digital and access Technology with regularity. And 67percent say they go online at homeisessential or important. that access to high-speedinternet society, while the vast majority say had amostly positive impacton adults feel that technology has use. Fifty-eight percent of older enhancing benefits of technology when itcomes to thepotential life- first three months, thecity said. participated intheprogram inits More than100 older adults senior centers, andother locales. mobile tech labanduseslibraries, tech support. The program hasa and socialmediausage, andfree workshops, lessonsonsmartphone technology, includinginternet safety program helpsolder residents with Washington, DC’s new Senior Tech quality of life for allresidents. solutions that are ready for publicinvestment andpoised to deliver improved The era of thesmartcity isbeginningto take shapethrough data management and smartphonesholdsolutions for urbanchallenges and everyday convenience. century life—enhance cities’ Age-Forward activities? Applications, databases, How cantechnology—which isintegrated into virtually every of part 21st where about a quarter aquarter about where 252, 253 252, 42 SMART CITIES FORSMART ALL AGE-FORWARD CITIES FOR 2030 254

service budgets. on zoning, infrastructure, andsocial with implications for city decisions at any time over thenext 20 years, living in50-square-meter locations number of peopleage 65and older geospatial mappingpredicts the block by block,to older adults. The planning andtargeting of services, offers theprospect of long-term developed in Austria, for example, algorithmic method called Age Spot informs urbanpreparedness. An and other data-intensive techniques Harnessing data through mapping in both English andSpanish. technology classesof varying levels Humana Foundation grant, teaching 2018 with thehelpof amillion-dollar a center inSan Antonio inOctober Most recently, theprogram added in five states andsixlocations. Adults Technology Services, operates by New York-based nonprofit Older The free program Senior Planet , run platforms.” networks, andcloud-based intelligence, bigdata transportation use, suchasintegrating artificial around optimizing collective environment butbroader questions out not justour immediate living adults, andcaninform how we build that are at risk,particularly older processes canidentify people Cities Summit panel.“ for Global Futures at a2018SXSW James Canton from theInstitute planning themnow,” stated futurist new tools, but we needto start “Smart-city technologies will deliver 255, 256 Sensemaking places to do business.” to do places productive more become also they When cities function more efficiently,and waste, reduce even help boost social time, connectedness. save can They burden. disease the reduce and crime, prevent save lives, can tools “These Future,” asserts. Livable aMore for report, “Smart Cities:Digital Solutions 2018 Institute’s Global McKinsey years,” many in the kit tool to that powerful and cost-effective additions most the are solutions digital great, acity making for kit tool full of the part one only are “Although they FROM THE EXPERTS 75 percent of respondents. and at leastatop-two priority by half of allexperts (58percent) as thetop priority by more than the middle. physical infrastructure, landingin rankings, andsafety, as well as governance at thebottom of the measures, with energy and care andmobility over theother The experts prioritized health environmental sensors.” efficiency, includingsmartgridand apps; andenergy andresource services platforms and mobile reporting governance, includingconsolidated street lighting andsmartbuildings; infrastructure, includingsmart emergency response systems; physical real-time response procedures and systems; safety andsecurity, including parking andintelligent transportation and transportation, includingsmart remote patient monitoring; mobility health care, including telehealth and their importance in serving older adults: Please rank the domainsaccording to highlights sixdomainsof smartcities. “The USConference of Mayors smart cities: surveyed nearly 150experts about The Center for theFuture of Aging for an Aging Population Experts’ Insights –Smart Cities Health care was cited HOW WE CARE WE HOW communities. their in included more to be adults older and disabilities with people help would accessibility technology and information improve that initiatives cities smart that agree strongly or agree of experts McKinsey. by 20to 35percent, according to speed upemergency response fatalities by 8 to 10percent and cities already useapps to reduce The implications are enticing: benefits, by smart-city underserved most the are groups demographic poorer and older Though networks. social online through isolation reduce and emergencies, other and outages, floods, fires, about alerts remotely, vital access relatives and friends homebound on up check diet, and exercise as such activities health track residents help apps level, street At the to address the needs of older adults: of older needs the to address city technologies have been deployed Here are several ways in which smart solutions. mobility and care health to related those are adults older for applications city relevant smart most two the experts, to our According assessment tool. Model Maturity Inclusion Digital City Smart called Microsoft of support the with project pilot inclusion digital a for city first Chicago named recently World Enabled, and G3ict between All,” for partnership a Cities “Smart initiative, global the start, emissions by 10to 15percent. 15 percent, andcutgreenhouse gas the diseaseburden by asmuch as commute by 15to 20percent, lower the potential to reduce the average deploy smartcity applications have 259 257 more than 90 percent percent 90 than more By 2025,citiesthat 260 As a promising apromising As 43 as the the as , an , an AGE-FORWARD CITIES FOR 2030 258 Smart Mobility Smart Connected Healthcare ƒ ƒ ƒ ƒ

daily Medicaid trips,andan handle approximately 11,000 has beenkey initsability to web-based brokerage model transportation services. Its manage human service transportation broker to and Human Services asa Executive Office of Health contracted with Regional Transit Authorities Transit Authority isoneof six The Montachusett Regional walkways. challenges of navigating city other data that mapthespecific construction information, and about sidewalks, curbramps, and maintaining opendata on pedestrian ways by gathering providing tripplanningsupport those with limited mobility by a trip planning tool that supports Project haslaunched AccessMap, Seattle,In theOpenSidewalks setting and the home. the and setting aclinical between gap the bridge patients and caregivers environment—helpingcare clinical the for innovating entrepreneurs for is a hub campus, Center’s Medical Texas the with partnership in Health, Connected for Houston, In safely at home. safely to age want who seniors and remote monitoring, requiring those areas, rural in patients to access to expand plans and broadband 5G next-generation use to hospital US first the become will Health for System Rush the and Center Medical Chicago, In Rush University University Rush AT&T’s Foundry 262 Massachusetts’ 261

open-data-exchange platform Conclusion allows approximately 160 registered providers to bid From the digital divide to social determinants and disaster planning, cities on non-emergency medical are just beginning to realize what’s possible in gaining the benefits of an transportation trips, review engaged older population. The landscape already holds resources—human, competing bids, and counter- organizational, and technological—that can transform models for urban bids.263 resiliency. However, lack of awareness and connectivity among agencies, organizations, and consumers, deters the flourishing of networks and RECOMMENDATION #18 outcomes. Through cross-sector efforts and integrating systems for communication, efficiency, and impact, cities can realize Age-Forward solutions that will strengthen security, independence, and well-being for current and coming generations.

Create cross-sector programs to bridge the digital literacy gap for lower-income older adults and invest in the development of open data tools to help older adults navigate tech-based challenges.

HOW WE CARE 44 AGE-FORWARD CITIES FOR 2030

266 265 267 FOSTERING CONNECTIVITY CONNECTIVITY FOSTERING SOLIDARITY SOCIAL AND #17 AND #14 RECOMMENDATIONS AGE-FORWARD CITIES FOR 2030 CITIES FOR AGE-FORWARD 45

Expand transportation options and address complaints that older adults’ ride requestsgo oftenunanswered, including through an online concierge tool find to transportation that meets riders’ needs Expand existingtech Tablet training programs, such as AgeWell’s Café and partnerships with tech companies, for increased volunteer opportunities andconnection across generations Develop a disaster preparedness plan targeting areas with large populationsof older adults and persons with disabilities

ƒ ƒ ƒ Pittsburgh’s age-friendly efforts focus onaccess and connection, including improving new options in neighborhoods and health systems for all ages, creating intergenerational spaces to combat social isolation and loneliness, and championing technology help to older people remain in their communities. The city’s age-friendly plan includes effortsto: Pittsburgh emphasizes a community-wide focus on age-inclusivity. For For focus on age-inclusivity. community-wide a emphasizes Pittsburgh adults Trust had older Cultural the Pittsburgh by a program example, theAnd center. a childcare from with children collaborate on arts projects Senior Virtual well-attended a operates Foundation Healthcare Jewish by isolation their reduce problems with mobility helping people Academy, activities. clubs, and other online classes, joining live As Laura Poskin, project manager for Age-Friendly Greater Pittsburgh, asks, asks, Pittsburgh, Greater Age-Friendly for manager project Poskin, As Laura in it? ... participate to everyone for built us not around world is our “Why issue.” a social justice That’s HOW WE CARE This bustlingThis 264 STEEL TOWN THAT’S BOUNCING BACK BACK BOUNCING THAT’S TOWN STEEL emphasizes new options 2017-2020 Age-Friendly Greater Pittsburgh Action Plan DEMOGRAPHY nearly for account 65 and older Adults Pittsburgh the greater of 18 percent population region’s BEST CITIES FOR SUCCESSFUL RANKINGS AGING Overall #44; High Marks for Community Engagement Education (15), (20), and (15) Transportation/Convenience ECONOMIC PROFILE ECONOMIC Service-based “Rejuvenated economy, region” and opportunities for all ages and relationships intergenerational abilities, to counter social isolation and loneliness, and technology and ideas enabling people to age in community. Growing from a frontier village into into village a frontier from Growing has Pittsburgh steel, of a center attract to times hard weathered a and become investment new hub. tech burgeoning PITTSBURGH: Appalachian city at the headwaters headwaters the at city Appalachian marks strong gets River the Ohio of Successful for Cities in the “Best transportation for rankings Aging” as itswell as and convenience, reversing opportunities, educational its university saw that a trend jobs for Pittsburgh exiting graduates elsewhere.

CASE STUDY older. five homeless residents isage 55or homelessness; anestimated onein has seenanincrease inolder-adult on Social Security income. Denver to half of baby boomers reliant solely need for localcosts of living, with up Fixed incomes fall shortof what they affordable housingoptions for them. age 65andolder feel there are no geography. Two-thirds of adults starting to match Denver’s mile-high doesn’t helphousingcosts that are are adultslivingalone, which However, 38percent of households occupations. service health on emphasis growing a driving is population older Its index. Aging” Successful for Cities “Best the by opportunities job for 8nationally No. is rated and culture wellness astrong has city The be ageover will 65. residents five in one nearly when mid-century by double nearly will population older its anticipates Denver vistas, dramatic and lifestyle outdoor its for known and Mountain-high Rocky DENVER: 20 percent by 2050. a number that will increase to nearly than 11percent of Denver’s population, Adults 65andolder account for more DEMOGRAPHY Employment (#8),andHealth Care (#18) Overall (#12), High Marks for Wellness (#4), AGING RANKINGS SUCCESSFUL FOR CITIES BEST hub” economy, “Innovation Knowledge-based ECONOMIC PROFILE Recommendations,” 2018 Matters in Denver: Needs, Assets and Age-Friendly Action Plan 60 years of age. four Denver residents will beover 271 270 MILE HIGH AND WIDE ENOUGH FOR ALL AGES 269 268 By 2030onein : “Age HOW WE CARE WE HOW Denver’s numerous age-friendly goals include: include: goals age-friendly numerous Denver’s Broomfield counties. Medicaid beneficiaries in Denver, Arapahoe, Adams, Douglas, Jefferson, and health outcomes anddecrease costs. The AHC will work with Medicare and by integrating clinicaland community service providers asa way to improve in 2017to implement the Accountable Health Communities (AHC)model received $4.5millionfrom theCenters for Medicare andMedicaid Services long-term services andsupports. The Denver Regional Council of Governments efforts to enhance itslivability for allages—which includes coordinating Denver hasaplanto optimize the vitality of itsolder residents—in keeping with ƒ ƒ ƒ ƒ

center called DenverConnect called center resource mobile new via a services various to adults older Connecting challenges mobility with people for options transportation on focused Guide There Getting acomprehensive developed Council Access and Mobility Regional Denver The by 2030. injuries serious and deaths traffic goals ofZero zero Vision meeting and conditions, sidewalk poor fixing transportation, public inefficient and inflexible Addressing to recognize and respond to it respond and to recognize providers and caregivers, responders, training and Targetingabuse elder adults older on to focus preparedness emergency Expanding

46 AGE-FORWARD CITIES FOR 2030 RECOMMENDATION #14 TO OPTIMIZE HEALTHY AGING DEPLOYING RESOURCES MORE EFFICIENTLY

CASE STUDY , a national service program for In Tampa alone, there In Tampa are more than 300 Senior DRIVING HOME AGENCY COORDINATION COORDINATION AGENCY HOME DRIVING SOLIDARITY SOCIAL AND #16 AND #14 RECOMMENDATIONS AGE-FORWARD CITIES FOR 2030 CITIES FOR AGE-FORWARD 273 47 274

In partnership with the Florida Department Health, of this two-year effort will lead first theto nation’s Age-Friendly Public Health System.According Universityto South of Florida gerontologist Kathy Black, the partnership has already led half the of public state’s health departments assess to aging priorities in datacollection. have included Many age across metrics such as vaccinations and data points werethat previously not known—such as percentages older of adults living alone—as isolation becomes a more prominent public health issue. adults young pairs which Papa, startup on-demand” “Grandkids Miami-based with tasks, has struck a partnership with household help adults to with older pilot a in services Papa’s testing is Humana partnership, the of part As Humana. Advantage Medicare Humana’s 150 of the pilot, Through Tampa. in program loneliness, alleviating of hopes in services Papa’s to access receive will members health outcomes. positive and achieving minimizing isolation, studyA 2018 the by Corporation for National and Community Service (CNCS) analyzed the programSenior Corps those ages and older 55 and found that, after years two of service, 22 percent fewer reported health and 78 percent improved reported volunteers of depression. of symptoms Corps volunteers at 96 locations. 96 at volunteers Corps Theircontribution has an estimated worth billion. $2.4 of HOW WE CARE Pinella County County Pinella 272 ACTIVATING AN AGE-FRIENDLY HEALTH SYSTEM HEALTH AGE-FRIENDLY AN ACTIVATING Age-Friendly Action Plan: Action Age-Friendly DEMOGRAPHY population, 65 and older Bay’s Tampa its overall of 18.5 percent currently the oldest this metro makes population, cities in the US among 53 major become has applied to Tampa) (including and is in community Age-Friendly an a from results collecting of the process survey. Assessment Community BEST CITIES FOR SUCCESSFUL RANKINGS AGING General for Marks #84; High Overall (#25) Security Financial (#20) and Livability ECONOMIC PROFILE ECONOMIC Service-based “Rejuvenated economy, region” In 2017, Trust for America’s Health Trust In 2017, held funded a summit in by Tampa, The John A. HartfordFoundation, called A Public Health Framework Supportto the Improvement the of Health and Older of Well-Being Adults. The goal was “to develop a public health framework support to the improvement the of health and well-being older of adults, focusing on areas where public health can support, complement, and enhance services.” aging TAMPA:

CASE STUDY Endnotes

1. “World Population Ageing 2015,” United Nations Department of Economic and Social Affairs: Population Division, (2015): 3, https://www.un.org/en/development/desa/population/publications/pdf/ageing/WPA2015_Report.pdf. 2. Carrie A. Werner, “The Older Population: 2010 Census Briefs,” United States Census Bureau, (November 2011): 11, https://www.census.gov/prod/cen2010/briefs/c2010br-09.pdf. 3. Centers for Disease Control and Prevention, Healthy Aging—At A Glance 2011, (2011), https://stacks.cdc.gov/view/cdc/22022. 4. L. A. Anderson et al., “Aging in the United States: Opportunities and Challenges for Public Health,”American Journal of Public Health, vol. 102, no. 3 (2012): 393. 5. John R. Beard and Charles Petitot, “Ageing and Urbanization: Can Cities be Designed to Foster Active Ageing?” Public Health Reviews, vol. 32 (2010): 427–50, https://publichealthreviews.biomedcentral.com/track/pdf/10.1007/BF03391610. 6. Laura Dwyer-Lindgren, Amelia Bertozzi-Villa, and Rebecca W. Stubbs, “Inequalities in Life Expectancy Among US Counties, 1980 to 2014: Temporal Trends and Key Drivers,” JAMA Intern Med., vol. 177, no. 7 (2017): 1003-1011, doi:10.1001/jamainternmed.2017.0918. 7. “Life Expectancy at Birth, Total (Years),” The World Bank Data, accessed August 2, 2019, https://data.worldbank.org/indicator/sp.dyn.le00.in. 8. Richard Dobbs et al., “Urban World: The Global Consumers to Watch, Executive Summary,” McKinsey Global Institute, (April 2016), https://www.mckinsey.com/global-themes/urbanization/urban-world-the-global-consumers-to-watch/~/media/57c6ad7f7f1b44a6bd2e24f0777b4cd6. ashx. 9. Teresa Ghilarducci, Michael Papadopoulous, and Anthony Webb, “Policy Note: Downward Mobility in Retirement: 8.5 Million Middle-Class Workers Will Be Poor Retirees,” The New School Schwartz Center for Economic Policy Analysis, February 18, 2019, https://www.economicpolicyresearch.org/images/docs/research/retirement_security/Downward_Mobility_in_Retirement_P_N.pdf. 10. “Fastest Growing Cities Have Higher than Average Unemployment for Older Workers,” New School Schwartz Center for Economic Policy Analysis, November 5, 2015, https://www.economicpolicyresearch.org/jobs-report/october-unemployment-report-for-workers-over-55-22. 11. Anita Yadavalli, Christiana K. McFarland, and Brooks Rainwater, “State of the Cities, 2018,” National League of Cities, (2018), https://www.nlc.org/sites/default/files/2018-05/NLC%20State%20of%20the%20Cities%202018%20FINAL%20WEB.pdf. 12. “The Longevity Economy Generating Economic Growth and New Opportunities for Business,” Oxford Economics and AARP, (2013), https://www.aarp.org/content/dam/aarp/home-and-family/personal-technology/2013-10/Longevity-Economy-Generating-New-Growth-AARP. pdf. 13. Sindhu Kubendran, Liana Soll, and Paul Irving, “Best Cities for Successful Aging 2017,” Milken Institute, (2017), https://www.milkeninstitute.org/reports/best-cities-successful-aging-2017. 14. “The Mayor’s Pledge,” Best Cities for Successful Aging, accessed August 2, 2019, http://successfulaging.milkeninstitute.org/mayors-pledge/. 15. 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ENDNOTES 48 AGE-FORWARD CITIES FOR 2030 https://www.nlc.org/sites/default/files/2018-05/NLC%20State%20of%20the%20Cities%202018%20FINAL%20WEB.pdf. 30. “The Longevity Economy: Generating Economic Growth and New Opportunities for Business,” Oxford Economics and AARP, (2013), https://www.aarp.org/content/dam/aarp/home-and-family/personal-technology/2013-10/Longevity-Economy-Generating-New-Growth-AARP.pdf. 31. Crystal N. Reisig and Bronwyn S. Fees, “Older Adults’ Perceptions of Well-Being After Intergenerational Experiences With Youth,” Journal of Intergenerational Relationships, no. 4 (2006). 32. Dawn C. Carr, Linda P. Fried, and John Rowe, “Productivity and Engagement in an Aging America: The Role of Volunteerism,” Columbia University Academic Commons, Daedalus, no. 144 (2015). 33. Kenneth Terrell, “Shaping the Future of Work to Fit All Ages,” AARP, June 7, 2019, https://www.aarp.org/work/working-at-50-plus/info-2019/future-of-work-forum.html. 34. “Investing in Place: Two Generations’ View on the Future of Communities,” American Planning Association, accessed July 10, 2019, https://www.planning.org/policy/polls/investing/. 35. Jan E. Mutchler, Yang Li, and Ping Xu, “Living Below the Line: Economic Insecurity and Older Americans Insecurity in the States 2016,” Umass Boston Center for Social and Demographic Research on Aging Publications, (September 2016), https://scholarworks.umb.edu/demographyofaging/13/. 36. Dennis Fulhane et al., “The Emerging Crisis of Aged Homelessness: Could Housing Solutions Be Funded by Avoidance of Excess Shelter, Hospital, and Nursing Home Costs?” Actionable Intelligence for Social Policy, (January 2019): 3. 37. 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ENDNOTES 49 AGE-FORWARD CITIES FOR 2030 https://www.mckinsey.com/business-functions/strategy-and-corporate-finance/our-insights/five-forces-reshaping-the-global-economy- mckinsey-global-survey-results. 61. “The Longevity Report, Business Insights in an Aging World: Managing the New Multigenerational Workforce,”Baxter Consulting Group, (2017). 62. Dimple Agarwal et al., “The Longevity Dividend: Work in an Era of 100-year Lives: 2018 Global Human Capital Trends,” Deloitte Insights, March 28, 2018, https://www2.deloitte.com/insights/us/en/focus/human-capital-trends/2018/advantages-implications-of-aging-workforce. html#endnote-20. 63. Ibid. 64. Ibid. 65. Catherine Collinson, “Perspectives on Retirement: Baby Boomers, Generation X, and Millennials, 17th Annual Transamerica Retirement Survey of Workers,” Transamerica Center for Retirement Studies, (April 2019). 66. Matthew S. 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ENDNOTES 50 AGE-FORWARD CITIES FOR 2030 89. Chuck Sudo, “4 Keys to Successful Senior Living Projects in Mixed-Use Developments,” Senior Housing News, April 5, 2019, https://seniorhousingnews.com/2019/04/05/4-keys-to-successful-senior-living-projects-in-mixed-use-developments/. 90. Tim Regan, “SHAG Strikes Innovative Partnerships to Create Affordable Senior Housing,” Senior Housing News, April 4, 2019, https://seniorhousingnews.com/2019/04/04/shag-strikes-innovative-partnerships-to-create-affordable-senior-housing/. 91. “News Release: NYC-based Interior Design Firm is Bringing a Fresh Look to Senior Living with Luxury Heartis Buckhead High-Rise,” Healthcare Real Estate Insights, May 15, 2019, http://wolfmediausa.com/2019/05/15/news-release-nyc-based-interior-design-firm-is-bringing-a-fresh-look-to-senior-living-with-luxury- heartis-buckhead-high-rise/. 92. Rachel Koning Beals, “This is How Boomers are Reinventing Retirement Living,” MarketWatch, May 22, 2019, https://www.marketwatch.com/story/boomers-are-reinventing-retirement-housing-imagine-galleries-walkability-and-multi-age- communities-2019-05-22. 93. Matt Horton, “How Federal Opportunity Zone Tax Incentive Can Help California Build an Inclusive Economy,” Cal Matters, April 9, 2019, https://calmatters.org/articles/commentary/opportunity-zone/. 94. 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ENDNOTES 52 AGE-FORWARD CITIES FOR 2030 145. Jennifer Molinsky, “Four Challenges to Aging in Place,” Joint Study for Housing Studies of Harvard University, January 25, 2017, https://www.jchs.harvard.edu/blog/four-challenges-to-aging-in-place/. 146. Cisneros, et al., “Independent for Life: Homes and Neighborhoods for an Aging America,” UT Press, 2012. 147. “America’s Rental Housing: Expanding Options for Diverse and Growing Demand,” Joint Center for Housing Studies of Harvard University, (2015), https://www.jchs.harvard.edu/sites/default/files/2015_jchs_rental_report_key_facts.pdf. 148. “Chapter 1: Using the ADA Standards,” United States Access Board, accessed August 1, 2019, https://www.access-board.gov/guidelines-and-standards/buildings-and-sites/about-the-ada-standards/guide-to-the-ada-standards/chapter-1-using-the-ada- standards. 149. Luke Bo’sher et al., “Accessibility of America’s Housing Stock: Analysis of the 2011 American Housing Survey (AHS),” US Department of Housing and Urban Development, (March 2015): 28, https://www.huduser.gov/portal/publications/mdrt/accessibility-america-housingStock.html. 150. Shannon Guzman, Janet Viveiros, and Emily Salomon, “Expanding Implementation of Universal Design and Visitability Features in the Housing Stock,” AARP Public Policy Institute, (July 2017), https://www.aarp.org/content/dam/aarp/ppi/2017/06/expanding-implementation-of-universal-design-and-visitability-features-in-the-housing-stock. pdf. 151. Ibid. 152. “Universal Design and Visitability,” Sarasota County Government, accessed August 20, 2019, https://www.scgov.net/government/sustainability/sustainability/universal-design-and-visitability. 153. Jennie Orvino, “‘Visitability’ Standards for Homes Rise Amid Sonoma County Rebuild Effort,” Northbay Business Journal, February 12, 2019, https://www.northbaybusinessjournal.com/northbay/sonomacounty/9249963-181/housing-visitability-sonoma-construction. 154. Donna Butts and Trent Stamp, “Older Adults Thrive in Intergenerational Shared Sites,” American Society on Aging, https://www.asaging.org/blog/older-adults-thrive-intergenerational-shared-sites. 155. “All In Together: Creating Places Where Young and Old Thrive,” Generations United and The Eisner Foundation, (2018), https://www.gu.org/app/uploads/2018/06/SignatureReport-Eisner-All-In-Together.pdf. 156. “What are Complete Streets?,” Smart Growth America, accessed July 11, 2019, https://smartgrowthamerica.org/program/national-complete-streets-coalition/publications/what-are-complete-streets/. 157. Ibid. 158. Hamid Iravani and Venkat Roa, “Health Benefits of New Urbanism,” Public Square: A Congress for the New Urbanism Journal, February 4, 2019, https://www.cnu.org/publicsquare/2019/02/04/health-benefits-new-urbanism. 159. “Safe Streets, Stronger Economies: Complete Streets Project Outcomes From Across the Country,” Smart Growth America and National Complete Streets Coalition, (March 2015), https://smartgrowthamerica.org/resources/evaluating-complete-streets-projects-a-guide-for- practitioners/. 160. Jana Lynott, Mariia Zimmerman, and Patricia Happ, “Communities are Embracing Development Near Transit: A Snapshot of Transit-Oriented Development Support across the United States,” AARP Public Policy Institute, (September 2017), https://www.aarp.org/content/dam/aarp/ppi/2017/09/tod-full-report.pdf. 161. Ibid. 162. “How the Atlanta BeltLine Is Funded,” The Atlanta BeltLine, accessed July 11, 2019, http://beltline.org/about/the-atlanta-beltline-project/ funding/. 163. 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ENDNOTES 53 AGE-FORWARD CITIES FOR 2030 Columbia, https://agefriendly.dc.gov/sites/default/files/dc/sites/agefriendly/page_content/attachments/Age-Friendly%20DC%202023%20Strategic%20Plan%20FINAL. PDF. 174. Ibid. 175. “2019-2022 District of Columbia State Plan on Aging,” The District of Columbia Office on Aging, https://dcoa.dc.gov/sites/default/files/dc/sites/dcoa/page_content/attachments/DCOA%20State%20Plan%20on%20Aging%202019%20 to%202022_FINAL%20DRAFT_CLEAN_%205.21.2018.pdf. 176. Ellen Squires, “A Portrait of DC’s older adults,” DC Policy Center, June 22, 2018, https://www.dcpolicycenter.org/publications/a-portrait-of-d-c-s-older-adults/. 177. “Age-Friendly DC 2023 Strategic Plan,” Age-Friendly DC, The Office of Deputy Mayor for Health & Human Services, and the Government of the District of Columbia, https://agefriendly.dc.gov/sites/default/files/dc/sites/agefriendly/page_content/attachments/Age-Friendly%20DC%202023%20Strategic%20 Plan%20FINAL.PDF. 178. Ibid. 179. 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ENDNOTES 54 AGE-FORWARD CITIES FOR 2030 202. “CareMore Health Announces New Outcomes Data from First-of-its-Kind Togetherness Program,” Business Wire, December 18, 2018, https://www.businesswire.com/news/home/20181218005059/en/CareMore-Health-Announces-New-Outcomes-Data-First-of-its-Kind. 203. “Confronting the Growing Health Impact of Loneliness,” AHIP, January 2, 2019, https://www.ahip.org/confronting-the-growing-health-impact-of-loneliness/. 204. Melanie Mason, “California’s Senior Population is Growing Faster than Any Other Age Group. How the Next Governor Responds is Crucial,” Los Angeles Times, October 7, 2018, https://www.latimes.com/projects/la-pol-ca-next-california-demographics/. 205. Matthew Hale, Sarwat Shah, and Andrew Clegg, “Frailty, Inequality, and Resilience,” Royal College of Physicians Clinical Medicine, vol. 19, no. 3 (2019): 219–223, doi: 10.7861/clinmedicine.19-3-219. 206. “Long-Term Services & Supports State Scorecard,” LongTermScorecard, accessed August 21, 2019, http://www.longtermscorecard.org/. 207. “Promising Practices,” Long-Term Services & Supports State Scorecard, LongTermScorecard, accessed August 21, 2019, http://www.longtermscorecard.org/promising-practices. 208. Ellen O’Brien and Wendy Fox-Grage, “Home and Community-Based Services beyond Medicaid,” AARP Public Policy Institute: Long-Term Services & Supports State Scorecard, February 19, 2019. http://www.longtermscorecard.org/promising-practices/home-and-community-based-services-beyond-medicaid. 209. 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ENDNOTES 55 AGE-FORWARD CITIES FOR 2030 Lowers Costs,” Health Affairs Blog, September 13, 2018, https://www.healthaffairs.org/do/10.1377/hblog20180907.685440/full/. 232. “CareMore Health Announces New Outcomes Data from First-of-its-Kind Togetherness Program,” Business Wire, December 8, 2018, https://www.businesswire.com/news/home/20181218005059/en/CareMore-Health-Announces-New-Outcomes-Data-First-of-its-Kind?rel=0. 233. Julie Miller et al., “Sharing is Caring: The Potential of the Sharing Economy to Support Aging in Place,” Gerontology & Geriatrics Education, (2018), https://doi.org/10.1080/02701960.2018.1428575. 234. 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ENDNOTES 56 AGE-FORWARD CITIES FOR 2030 ACKNOWLEDGMENTS

Our work depends on the efforts of many colleagues who share our aspirations. Special thanks to Rita Beamish for her journalist’s eye and our productive writing collaboration, Marlon Graf for his research contributions, and Cara Levy for her assistance with research and planning for this report. We also appreciate our colleagues Jill Posnick, Karen Rogers, and Emily Ball for their editing and design help. To our friends in the field—John Feather, Rodney Harrell, Sarah Thomas, Gretchen Alkema, Brian Kaskie, and Kitty Hsu Dana—thank you for your insights and feedback during our review process. To our partners—Laura Latham and colleagues from the Gensler Research Institute and Gensler’s Washington, DC and Los Angeles offices—we are grateful for your creative talents and generosity of time in designing neighborhoods that exemplify Age-Forward 2030. To our partners at The SCAN Foundation, we thank you for spotlighting Age-Forward principles with this year’s Innovation Award. Thanks, as always, to the members of our Center for the Future of Aging Business Council and Academic and Policy Advisory Board. Their support, ideas, and shared commitment to a better future motivates our work in many ways. Finally, we want to express gratitude to our Age-Forward survey participants for their predictions, insights, and

ABOUT THE AUTHORS

CAROLINE SERVAT is an associate director of the Milken Institute Center for the Future of Aging. Her work focuses on research, developing collaborative partnerships, and analyzing best practices for aging policy at the local and regional levels. Servat serves on the American Society on Aging’s Public Policy Committee. Prior to joining the Institute, she served as a program coordinator for the Goldhirsh Foundation, implementing programming and activations focused on social innovation. She also conducted research for the dean of the Sol Price School of Public Policy at the University of Southern California, specializing in economic policy and community reinvestment. She holds a master’s degree in public policy from the University of Southern California Sol Price School and bachelor degrees in politics and theater from Bates College. NORA SUPER serves as senior director of the Milken Institute Center for the Future of Aging, whose mission is to improve lives and strengthen societies by promoting healthy, productive, and purposeful aging. In this role, she oversees all programs and policy initiatives and is responsible for managing and creating data-driven research, meaningful policy initiatives, and impactful convenings in the United States and internationally. Prior to joining the Institute, Super held key leadership roles in the public and private sectors. Most recently, she served as the chief of program and services at the National Association of Area Agencies on Aging (n4a). In 2014, Super was appointed by President Barack Obama as executive director of the White House Conference on Aging, where she received wide recognition for her nationwide efforts to improve the quality of life of older Americans. In 2015, Super was recognized as one of America’s top 50 “Influencers in Aging” by PBS Next Avenue and was the Honoree for Outstanding Service to Medicare Beneficiaries by the Medicare Rights Center. She has also held leadership roles at the US Department of Health and Human Services, AARP, and Kaiser Permanente. Super serves on several advisory boards, including the Board of Directors of the Long-Term Quality Alliance, the Bipartisan Policy Center’s Advisory Committee on Improving Care Delivery for Individuals with Serious Illness, the Better Medicare Alliance Beneficiary Education Technical Advisory Council, the Brookings Institution and Kellogg School of Management Retirement Security Advisory Board, and the Editorial Board of the Gerontological Society of America’s Policy and Aging Report. A frequent speaker on health and policy issues, Super has also taught in the MBA program at Georgetown University, leading a faculty track on health care and the budget process. A native of New Orleans, Super studied political science at Tulane University and completed her masters’ work in public administration, with a concentration in health policy, at George Washington University.

ABOUT THE AUTHORS 57 AGE-FORWARD CITIES FOR 2030 SANTA MONICA | WASHINGTON | NEW YORK | LONDON | ABU DHABI | SINGAPORE