August 4th, 2010

Table of Contents:

Senior Living Models Revisited (Introduction to special issue)

Creating Purpose-Driven Communities (Join the conversation!)

Senior Living Models Revisited

by American Senior Fitness Association

Following is a very interesting article by Kay Van Norman, longtime friend of the American Senior Fitness Association (SFA). While extolling the senior living industry’s movement to promote whole-person wellness among older adult residents, she asks some hard questions about today’s "conventional wisdom" on the subject.

We invite you to read Van Norman’s insightful — and controversial — essay "Creating Purpose-Driven Communities" and weigh in with your ideas and comments. You may do so here or on our Facebook page.

Kay Van Norman, MS, is a member of the National Advisory Board of the American Senior Fitness Association and is an internationally known author, speaker and leader in the field of exercise and wellness programming for adults over 50. In addition to numerous journal articles and book chapters, she authored Exercise Programming for Older Adults (1995) and its revision Exercise and Wellness for Older Adults (2010), which includes a full chapter on psychosocial aspects of health behaviors, a chapter on programming for senior living environments, and a section on strength and power training. She directed the Keiser Institute on Aging from 2000 to 2003, and currently serves on the boards of the National Council on Aging’s Health Promotion Institute and the International Council on Active Aging. Van Norman, whose business is named Brilliant Aging, can be reached at www.kayvannorman.com.

This article was originally published in the Journal on Active Aging(R) (September/October 2009), and appears here with the permission of the International Council on Active Aging(R), www.icaa.cc. All rights reserved.

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Creating Purpose-Driven Communities

by American Senior Fitness Association

The opinions expressed in this column do not necessarily represent those of the Publisher.

This active-aging expert offers an unflinching look at current senior living models and invites an industry-wide conversation about where we go from here.

by Kay Van Norman, MS

Senior living products and services have evolved steadily over the past 20 years. Medical model nursing homes are giving way to person-centered approaches and models such as the Eden Alternative. Assisted living and continuing care retirement communities (CCRCs) have beautiful spaces, lovely grounds and excellent food served restaurant style. Whole-person wellness has emerged as a gold standard for quality programming, and senior living professionals are dedicated to improving resident quality of life (Edelman & Montague, 2006). However, in spite of everything, the majority of current residents are not engaged in offerings, and many frail older adults fight with every ounce of determination not to move into senior living communities.

This article invites you to take an unflinching look at where we are and contemplate where we go from here. It’s an opportunity to evaluate if current senior living models will support or restrict continued growth and innovation; and discuss, what if.

What if we reevaluated the senior living priorities presented in marketing materials? What if we took age out of the equation and compared services offered young people with disabilities to services provided frail adults with “age-related” disabilities? What if we consciously and consistently integrated research on quality-of-life indicators into applied operations? And what if instead of creating lots of activities to support meaning and purpose, we created purpose-driven senior living communities?

Priorities disconnect

Let’s consider how senior living is commonly portrayed to community-dwelling older adults. Assisted living and CCRC marketing materials highlight what companies believe are the priorities of potential clients:

  • safety
  • security
  • closeness to healthcare
  • help with activities of daily living (ADLs)
  • home-like environment
  • activities
  • low stress
  • lack of responsibility
  • Unfortunately, they also expose underlying negative attitudes and expectations about aging.

    For instance, boasting of proximity to healthcare and hospitals exposes the expectation that residents will likely have a health crisis at any moment, so—because of age—should be close to doctors and a hospital. Another common message? Have staff take care of everything so residents have plenty of time for leisure. This message reinforces the concept of “retirement” as a time for rest, relaxation and fun activity; it also suggests that no one expects older adults to contribute to the daily business of life. In fact, a Webster’s dictionary published in 1972 defines “retire” as “to withdraw, retreat, or recede.” A large percentage of older adults, especially Baby Boomers, value something different (Edelman & Montague, 2006).

    Marketing efforts that use fear as a motivator are especially problematic. One showed a worried-looking couple in front of their house while listing all the reasons they should move:

  • They weren’t capable of maintaining the steep roof and big yard.
  • How could they get to the doctor through heavy traffic?
  • Old neighbors had moved, and none of these “young” neighbors looked out for them.
  • Wow! I know connecting emotionally is effective, but a fear-based approach reinforces negative stereotypes and gives the impression that moving to senior living is “giving up.”

    Regardless of marketing strategies, we need to examine if the priorities we present in marketing are the same priorities potential clients hold dear. We have to be willing to ask the hard questions. For example:

  • If these are the real priorities of our potential customers, why do so many people resist moving into senior living?
  • Why don’t more current residents regularly engage in offerings?
  • Would older adults embrace completely new senior living options if they existed?
  • Smith and Mullen (2007) compared awareness of and attitudes towards independent living, assisted living, CCRC and active adult communities between 1998 and 2007. Results showed a significant increase in the awareness and usage of all types of age-qualified properties, while thedesirability of these properties as a place to live remained the same or decreased. Most declines in the appeal of senior housing occurred in households 70-plus years of age. The appeal of independent living communities went from 64% to 55% among households aged 70–74, and from 65% to 55% among households aged 75-plus. The appeal of assisted living also decreased, from 60% to 50% for ages 70–74 and from 61% to 52% for ages 75-plus.

    If senior living priorities matched consumers’ priorities, shouldn’t senior living—with all its innovations—be more, rather than less, appealing? Smith and Mullen concluded that mature consumers may still think of these properties as a place where they might “need to move,” instead of “want to move.” To improve the desirability of senior housing, the researchers continued, advertising and word of mouth should be used to elicit attitudinal changes. Perhaps a better strategy is to consider changing the product to more closely match potential clients’ needs and priorities.

    Consider different priorities

    Age demographics will drive growth in senior living, but there is an opportunity for so much more. What would it take for potential clients to want to move in, rather than wait until they “have to”? What makes living in their own home, even if they’re having difficulties, preferable to living in a CCRC or assisted living community? What are they afraid of losing if they move from their home?

    I don’t know the answers yet, but believe the right questions are being asked in behavioral and quality-of-life research. Unfortunately, little of this research is disseminated to senior living practitioners and even less is integrated into daily operations. We know how to meet basic needs for shelter, food, safety and personal care. Understanding how to meet other basic human needs is less obvious—the need to love and be loved, give as well as receive, be of value to others, and have feelings of competence and control.

    Clues are embedded in research exploring resiliency, self-efficacy, self-esteem, self-responsibility and optimism. These personal assets help people overcome obstacles and find life satisfaction, regardless of circumstances. Senior living professionals can use behavioral and quality-of-life research to develop strategies and policies that consciously and consistently support these assets. (See below for a listing of resources and references.)

    Asking more hard questions

    We also have to start asking ourselves uncomfortable questions about the opportunities we provide residents. Why, even in program-rich environments, do only 20–30% of residents regularly participate in offerings? Are we providing what we can—what is logical based on expectations—or what potential residents really need and want? Do we unintentionally limit opportunities based on what we think residents are capable of?

    For example, compare differences between independent living and assisted living programming. Before you identify things that residents with significant physical and cognitive limitations simply cannot do, however, I want you to contemplate something: Thirty years ago people with profound disabilities were housed in facilities where they were sheltered, fed, clothed, and provided personal care; there were no expectations, few opportunities, and no hope for anything different. The disability movement dramatically changed attitudes, expectations and environments. Gradually people with even profound disabilities began accomplishing amazing things, revealing the tragic waste of human potential imposed by low expectations.They demonstrated how individuals could overcome seemingly insurmountable barriers when immersed in an environment of encouragement, positive expectations, adaptive strategies, support, and most of all hope. (For a snapshot of what is possible, read “Kyle Maynard: rising to the occasion.”)

    Senior living has worked hard to provide opportunities. But, back to the uncomfortable questions, how do our attitudes, expectations and environments impact resident interest and engagement? What role do they play in outcomes? Which aspects of the physical and emotional environments of senior living communities support feelings of value, competence and control? Which ones don’t? What specific operational strategies are consciously and consistently applied to build the personal assets of self-efficacy, resiliency, self-esteem, self-responsibility and optimism?

    Learning from the disability movement

    It’s interesting to compare the level of opportunities and services offered to youth with disabilities versus older adults. For example, a major goal of disability policy is to ensure the inclusion of people with disabilities in the mainstream of society. Another is for people with disabilities to be treated as first-class citizens (Batavia & Schriner, 2001). However, most disability legislation has an age cutoff of 65. The inability to perform ADLs or IADLs (instrumental activities of daily living) poses certain challenges no matter the person’s age, yet someone who becomes disabled after age 65 will not receive the same services as another with the exact same disabilities who becomes disabled before that age (Jonosn & Larsson, 2009).

    Why are young people with disabilities given encouragement, resources and opportunities to overcome and live fully in spite of disabilities, while older people are primarily given strategies to cope? There is a profound difference between outcomes derived from a mindset of coping with disabilities verses a determination to live fully regardless of disabilities.

    In Sweden, for instance, traveling for a weekend outing is considered a “normal” activity for a young person, so disabled young people are afforded a personal attendant to allow them to travel just like anyone else. Frail older adults, often with similar disabilities, are not afforded that opportunity, according to Jonosn and Larsson (2009). Disability legislation discounts age-related disabilities as “normal aging,” and literature suggests that the “situation is justified by healthcare and service personnel who refer to older people as being content with staying in nursing homes,” the researchers add. Ouch! This is a concrete example of how negative attitudes and expectations of aging shape behaviors, interactions and outcomes.

    Excelling–regardless

    The disability movement strives to provide individuals with what they need to help them contribute to the community and be self-sufficient and self-responsible to the greatest extent possible.Why then should older adults with functional limitations be placed in environments where they are no longer expected to contribute to the greater community?

    I know the frustrations; many residents resist doing anything. But how much does ageism impact personal expectations, expectations of others, and the created environments? One thing I know for sure is that without feelings of value, competence and mastery, without meaning and purpose, what is wrong becomes bigger than what is right and what a person cannot do becomes bigger than what a person can. (See “Nora Belle” for a personal account about the power of purpose.)

    What would senior living be like if we shifted our mindset from “taking care” of residents to creating the optimal environment for continued growth and contribution, regardless of age or functional restrictions? What if, from the first moment of project conception, discussions about the look of the project were secondary to deciding how to develop the property to support residents’ needs to give as well as receive, be of value to others, stay connected and engaged, and feel competent and in control of their own lives? How would the building and site be designed, operations developed, and marketing created if we prioritized support for self-efficacy, self-responsibility, self-esteem, optimism and resiliency? What if we created purpose-driven communities? (For some “what ifs” to consider about purpose-driven communities, see the sidebar below.)

    Purpose-driven communities: some ‘what ifs’ to consider

    Creating purpose-driven communities would require us to rethink the optimal locations for senior living. Instead of boasting about closeness to hospitals and doctors, we could look for locations that offer opportunities to contribute to the greater community.

  • What if communities were built next to an animal shelter, recycling center, elementary school, boys and girls club, or food bank? Residents would realize from their first contact with the senior living community that they were viewed as important assets to the greater community. They could envision how each individual’s contribution could be vital to the success of community programs.
  • What if instead of perfectly manicured lawns, the grounds boasted organic gardens, where residents and staff grew organic vegetables for the local schools, day care centers, food banks and hospitals (plus their own meals)?
  • What if a community was designed around residents developing and maintained a living history farm, demonstrating techniques used by homesteaders to make a living and raise a family? What a terrific educational asset to community schools!
  • What if residents maintained a working organic farm with cows, chickens and gardens to provide the community with organic products, as well as to demonstrate "green" concepts in action?
  • Existing senior living communities can also create strategic partnerships with the greater community.
  • What if the senior living "café" was known in the community for the best lunches in town and also encouraged local artists to hang artwork and local talent to perform?
  • What if residents and staff identified a cause to support with their effort, expertise and time–the environment, education, political causes, children’s causes, animal causes, world hunger?
  • Every school has fundraisers to support sports, academic or special interest programs. What if a senior living community "adopted" a school program or programs and helped them with fundraisers?
  • Compelling reasons to change

    The senior living industry has been steadily changing. Now it’s time for a major revolution. We’ve created nice models and a wide range of excellent activities to entice resident participation, but it’s important to acknowledge that being occupied is not the same as being engaged. Clearly, something is missing when a large percentage of our customers don’t consider our product desirable.

    We need to support our residents’ ability to give as well as receive, be of value to others, and feel competent and in control of their lives. It’s also time to observe and learn how the disability movement helps individuals live fully, even with profound disabilities. We need to evaluate which of our approaches and policies support and which ones diminish the personal assets necessary for people to live well in spite of challenges.

    It’s difficult to change an entire mindset and the momentum of established approaches, but the reasons for evolving are compelling. Shame and regret accompany our look back on the journey of disabled people in our society. We now possess the insight to prevent such negative attitudes and expectations from confining frail older adults. In addition, a tremendous opportunity for innovation exists right now. Baby Boomers cut their teeth on the concept of supporting “causes.” They’ve marched against injustice, invested in socially responsible companies, purchased “green” products, and advocated for civic responsibility. These consumers will be drawn to senior living communities that value residents as assets to the greater community. Purpose-driven goals will merge with whole-person wellness programs to ensure residents have choices between activity/engagement for personal growth and entertainment, and activity/engagement for a greater purpose.

    So I invite you to open your minds and consider the possibilities. Read behavior and life satisfaction research and realign priorities. Look into programs for young people with mental and physical disabilities to learn how they facilitate living fully with disabilities. Seek opportunities to really partner with programs in the greater community. Envision innovations as a developer, executive director, marketing director or programs coordinator, and consider what this new paradigm would mean for designs and development, operations, employee training and marketing.

    Real change will require a fundamental shift in organizational missions, goals and strategies. But we need to start with a sincere and open-minded industry-wide conversation. Is your organization up to the challenge?

    References

    Batavia, A., & Schriner, K. (2001). The Americans with Disabilities Act as Engine of Social Change: Models of Disability and the Potential of a Civil Rights Approach. Policy Studies Journal, 29(4), 690.

    Chappell, Jr, J. A: (1994). The whole is greater than the sum of its parts. American Rehabilitation, 20(1), 23.

    Edelman, P., & Montague, J. (2006). Whole-Person Wellness Outcomes in Senior Living Communities: The Resident Whole-Person Wellness Survey. Senior Housing and Care Journal, 14(1), 21–33.

    Guillory, M. D., & Moschis, G. (2008). Marketing Apartments, Townhouses, and Condominiums to Seniors. Seniors Housing and Care Journal, 16(1), 39–51.

    Jonosn, H., & Larsson, A. (2009). The exclusion of older people in disability activism and policies: A case of inadvertent ageism? Journal of Aging Studies, 23(1), 69–77.

    Shapiro, A., & Taylor, M. (2002). Effects of a community-based early intervention program on the subjective well-being, institutionalization, and mortality of low-income elders. Gerontologist, 42(3), 334.

    Smith, E. R., & Mullen, A. J. (2007). Trends in Awareness, Attitudes, and Usage of Retirement and Age-Qualified Properties: Findings from a National Survey of Households 60 Years of Age and Older. Seniors Housing and Care Journal, 15(1), 19–29.

    Ten research resources for suggested reading

    1. Bandura, A. (1997). Self efficacy: The exercise and control. New York NY: Freeman.
    2. Benjamin, K., Edwards, N. C., & Bharti, V. K. (2005). Attitudinal, perceptual and normative beliefs influencing the exercise decisions of community-dwelling physically frail seniors. Journal of Aging and Physical Activity, 13, 276–293.
    3. Bradley, D. E., & Longino, C. F. (2001). How older people think about images of aging in advertising and the media. Generations, Journal of the American Society on Aging, 3, 17–21.
    4. Coalman, M. (2007). Positive psychology: a new way to support wellness in older adults? Journal on Active Aging, 6(4), 51–55.
    5. Cohen, G. D. (2005). The mature mind. The positive power of the aging brain. New York NY: Basic Books.
    6. Edelman, P., & Montague, J. (2006). Whole-Person Wellness Outcomes in Senior Living Communities: The Resident Whole-Person Wellness Survey. Senior Housing and Care Journal, 14(1), 21–33.
    7. Maynard, K. (2005). No excuses. The true story of a congenital amputee who became a champion in wrestling and in life. Washington DC: Regnery Publishing.
    8. Ray, O. (2004). How the mind hurts and heals the body. American Psychologist, 59(1), 29–40.
    9. Semerjian, T., & Stephens, D. (2007). Comparison style, physical self-perceptions, and fitness among older women. Journal of Aging and Physical Activity, 15, 219–235.
    10. Wise, J. B., & Trunnell, E. P. (2001). The influence of sources of self-efficacy upon efficacy strength. Journal of Sport and Exercise Psychology, 23, 268–280.
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