Neighborhoods Age Together

by Marlene Piturro, PhD, MBA

There comes a time when Mrs. Taylor sometimes forgets to turn the oven off, Mrs. Padilla's bathtub periodically floods her downstairs' neighbor's apartment, and Mr. Zaret aimlessly wanders the halls, leaving his apartment a target for burglars.

Before long, the property manager, worrying about his elderly tenants' well being, his own potential liability, and damage to the building, calls the tenants' son or daughter, who often lives thousands of miles away. With an increasingly frail parent, perhaps a recent hospitalization, and trying to manage a string of caregivers long distance, a family member may reluctantly place the parent in a nursing home--unless that parent is in a NORC (Naturally Occurring Retirement Community) with supportive services enabling him or her to "age in place" at a cost that the family and society can afford.

NORCs are housing developments, apartment buildings, or neighborhoods where at least 50% of the residents are age 60 or older. According to the Administration on Aging, 27% of Americans over 55 live in NORCs, and 80% of NORC residents are widowed women living alone.

Michael Hunt, PhD, a Professor of Architecture at the University of Wisconsin-Madison, coined the term "NORC" in the 1980s when he observed concentrations of older people in certain apartment complexes and neighborhoods. Recognizing that building managers could not handle the needs of the frail elderly and that "people shouldn't be paying for care they don't need in places they don't want to live," Mr. Hunt reasoned that providing services such as health care, transportation, and meals to NORCs would enable seniors to remain at home.

To succeed, NORCs need supportive services organized by and with people who provide resources to facilitate care for the frail elderly at home. In the beginning, though, there were few available funding sources for those services. Hunt suggested that NORC organizers seek foundation and local economic development money to get started, a formula that organizers accepted eagerly.

Models that Work

Each NORC is unique--a geographic entity shaped by its buildings, residents, community, and local service providers. This uniqueness has led to a number of creative approaches to service delivery. Palm Beach County, FL, with the highest concentration of individuals over age 60 (28%) in the state, has many NORCs. By the late 1990s, its health care and social services agencies were hard-pressed to respond to the needs of frail elderly in the face of upward spiraling costs.

Buoyed by data from the National Center on Health Statistics that said it is possible to manage community-based care for extended periods of time for most chronic illnesses associated with aging, Palm Beach and Orange County decided to try.

In early 1997, Florida's Department of Elder Affairs reported that 87.2% of nursing home placements originated from hospitals. Recognizing that most seniors wished to return home, the department formed a unit to assess patients in the hospital to discover what it would take for a home return versus a nursing home admission.

Armed with data, in 1998, department staff turned to Harriet Goldstein, a retired social worker. Ms. Goldstein came out of retirement to start Just Checking!--a collaboration between the Department of Elder Affairs and Barry University's School of Social Work in Miami Shores, with funds from the Quantum and Picower Foundations. Servicing large NORCs such as Century Village and Kings Point, Ms. Goldstein found many patients suffering from diabetes, congestive heart failure, hypertension, and COPD. "One-third also have mental health problems, are battling depression and anxiety, and are grieving the loss of loved ones."

Using long-term case management, the program has kept 98.8% of its patients in their NORCs--94.3% without an acute hospitalization. As with other NORC residents, most in need of service are not eligible for Medicaid, and unable to finance private home health care, buy expensive medications, or take advantage of other services. Through intensive case management, Just Checking's task checklist offers a blueprint of NORC services:

• Contact medical providers--including the primary care physician, nurse case manager, and insurance case manager--to get accurate health status, diagnoses, and medical/medication regimes.
• If indicated, arrange testing for cognitive status, and mental health or substance abuse needs.
• Develop and monitor a network of formal and informal helpers--for shopping, cooking, paying bills, home-delivered meals, and recreation.
• Reduce risk of household falls--get emergency response system and necessary equipment (walker, wheelchair).
• Link to all benefits and entitlements through Social Security, VA, and Medicaid.
• Investigate and advocate for additional therapies such as physical therapy, eye exams, and transportation to medical appointments.
• Assess the need for contracted services--transportation, psychiatric nurse, caregiver respite.
• Build relationships with volunteers for friendly visits and social outings.
• Work with patients, family members, and caregivers on self care for diet and medication.

In another effort, UJA/Federation in New York City wrote its own service blueprint for NORCs so that residents who had lived in cooperative apartment dwellings for many years could remain at home. Anita Altman, UJA's Office of Development's Deputy Managing Director said that "there were 2,800 units of moderate income housing at Penn South [housing complex]. As people, aged problems cropped up. They forgot to pay carrying charges, wandered the halls, flooded apartments below them by leaving the bathtub running, and had piles of newspapers, making the apartment a fire hazard. The building managers couldn't cope with these things and worried about a catastrophe such as a fire."

UJA/Federation stepped in. With a $250,000 grant, it helped build new social structures by organizing clubs, classes, and outings in the complex, and recruiting volunteers whenever possible to run the activities. It charged a small membership fee to help defray costs and generate a sense of belonging. To help more severely impaired residents, the agency deployed a team consisting of a social worker, nurse practitioner, recreation worker, and volunteer coordinator for case management. "This is why grant funding was essential. Very few residents were eligible for Medicaid because they had pensions and social security," Ms. Altman explained (see box below for information on other New York City NORC initiatives).

The type of support that NORCs receive depends on how the host community operates. For example, Atlantic City uses casino taxes to retrofit seniors' bathrooms and kitchens. The city of Houston, TX, works through the University of Texas School of Nursing to provide NORCs with post-retirement financial and legal counseling, ongoing case management by geriatric nurse practitioners, and liaisons with family members outside of Houston wanting to remain active in their parents' care.

Los Angeles extends the time of red stoplights near NORCs to give seniors extra time to cross streets. Supermarkets in Minneapolis ran NORC focus groups, and found that 80% of participants said that supermarkets understand their needs, and that they request home delivery when they're ill.

UJA/Federation built on its success with Penn South with more foundation funding for two other New York City NORCs, adapting the social service and recreational components to fit the needs of each housing complex.

In 1994, the agency worked with the state legislature to establish a public/private partnership to provide funding of up to $150,000 to establish NORC health and supportive services. It's now expanding its NORC concept to suburban areas, one with single and two family homes, and the other with large concentrations of seniors in a 10-block area.

Unlike NYC NORCs, which are mainly in highly populated apartment complexes, suburban and rural NORCs require different skill sets for organizers. "Identify key players, do your community organizing, build coalitions, and find a good social service agency to spearhead the effort," says Ms. Altman.

As with many innovations, it takes time for funding to catch up with the need. To bridge that gap, David Nolan, Director of the non-profit Coming Home Program of Oakland, CA, has helped establish NORCs in 19 states. With $12 million in seed money from the Robert Wood Johnson Foundation, Mr. Nolan helps build coalitions of state housing agencies, Medicaid offices, local charities, and social service and health care agencies.

Starting with states that have Medicaid waivers for ALF--signaling "a consensus that affordable assisted living is a good way to spend Medicaid dollars"--Mr. Nolan puts together other funding sources, such as low income housing tax credits, HUD, USDA, philanthropy, sponsor equity, and revolving loan funds.

On the service side, he adds social service agencies and "chore providers," finds ways to upgrade kitchens, provides transportation, and gets the right mix of health care services (RN, LPN, medication management, nutrition) to keep people at home. "I look at it this way," said Mr. Nolan. "If the only thing standing between a frail elder and a nursing home is getting her insulin twice a day, society should figure out how to do that."

Dr. Hunt, who coined the term "NORC" two decades ago, is encouraged that there are now NORC models that we can replicate. But society has a way to go, he noted. Pointing to Sweden, with its senior congregate housing clusters complete with service centers, Dr. Hunt says communities--with local, state and federal support--need to reach out to NORCs so that aging in place is a supportive rather than an isolating experience.

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