Aging in place is not the way to go

MOST OF US can expect to live longer than ever before. This longevity bonus gives us more time to build the society we want, and we must start by considering how we’ll live as we grow old.

But for starters, we need to shift our thinking about what it is we really desire if we want to age affordably and live well.  We need to stop thinking about aging in place, but instead shift our thinking and planning towards aging in community.

There are two disturbing trends we need to consider:

First, most people have insufficient income and savings to meet ever-growing housing and medical costs as they get older. According to Fidelity Investments, the average baby boomer will need after-tax income of $4,800 per month starting at age 67 and will live to 92. Income from social security, pensions, and savings is projected to make up $2,700 of this amount. That leaves a monthly income gap of $2,100, a shortfall of 44 percent, with housing and health care costs key contributors to this family budget deficit. In Massachusetts, high housing costs have resulted in our ranking 49^th among the states in elder economic security.

Second, suburban development patterns combined with weather conditions that limit mobility leave many older adults who are living on their own alone for many more hours than they should be. The average baby boomer will live seven years after they are no longer able to drive. All this alone time leads to isolation, which leads to chronic loneliness. Loneliness is now widely recognized as the biggest threat to healthy aging, surpassing smoking and obesity. Loneliness has contributed to a doubling of dementia rates, climbing diagnoses of immune system suppression, and increases in heart attacks and strokes.

At 2Life Communities, we promote aging in community, which we define as living a full life of connection and purpose in a dynamic, supportive environment. And we do this with a laser-sharp focus on affordability.

At the four (soon to be five) campuses of 2Life in Massachusetts, older adults have private apartments they can afford. The median household income is just over $10,100 per year, and rent is generally limited to 30 percent of income. We make up the difference using federal subsidies and philanthropic dollars. Many of our residents are eligible for income-eligible state-sponsored services.

Residents have only to walk out the door of their own home to engage with the community and, with our extensive program offerings, there is something for everyone: lectures and classes; music, art, and dance (including a very accomplished resident dance troupe); intergenerational connections; fitness activities, including posture and balance work, chair and regular yoga, arthritis exercises (to help manage pain without drugs); and resident-led book clubs and current event discussions.

We also open our campuses for neighbors to join in the richness of community life—making our 2Life Communities into village centers. Wednesdays at Coleman House in Brighton we offer the broader community a full day of senior learning, in addition to open invitations to special lectures and fitness classes. In Framingham, we collaborate with the public library to offer specialized programs at Shillman House to all older adults in the wider community. Our Shillman House veterans are docents at the World War II museum and host the area veterans’ meetings. We want to help those without the benefit of living in our communities to have some of the opportunities that nurture critical, revitalizing connections.

We truly hope to reshape the perception of on-campus senior living from one of last resort to the obvious first choice. When neighbors join our programs, they typically put themselves on our waiting lists for housing units as soon as they see, up close and personal, the enormous jump in quality-of-life that campus living offers.

Our experience, along with study after study, demonstrates the health and longevity impacts of aging in community:

• Last year, residents at our Brighton campus pulled their emergency cords 1,101 times. With round-the-clock staff, we resolved 94 percent of these emergencies without a 911 call and the emergency department visit that would have followed. An emergency department visit with hospitalization causes tremendous stress and even health decline for those over 80, and, as underscored by findings from our state’s Health Policy Commission, results in hundreds of millions of dollars of annual health care spending—much of it potentially avoidable.
• The average age at which our residents depart to nursing homes is 88, compared to the average age of departure in all HUD-subsidized housing of 81 in Massachusetts.
• A study by Enterprise Community Partners and CORE of 145 service-enriched properties in Oregon found that Medicaid expenditures declined 16 percent, emergency room use fell 18 percent, and inpatient use fell 14 percent, while outpatient primary care use increased 19 percent for new residents in their first year.
• A LeadingAge study on the SASH program in Vermont, which provides care coordination through a housing-based coordinator with a wellness nurse, found that the annual growth in Medicare expenditures was $1,756 to $2,197 lower per person than for the non-service-receiving group.

We are collecting our own data as well. In partnership with 12 agencies including the Massachusetts Executive Office of Elder Affairs, LeadingAge, and UMass Medical School, we’re leading a study to document the impact of affordable housing communities on health care utilization and outcomes.

Despite the mounting evidence and the positive experiences of individual residents in communities like our 2Life housing, people in America are still encouraged to “age in place,” remaining in their single-family homes. Though a much-ballyhooed way to maintain independence, for most, aging in place ultimately becomes aging in isolation, with the horrendous health effects of chronic loneliness. In reality, aging in community is far more likely to maximize and prolong independence, because of the engagement and connection it offers.

The challenge is how to make service-enriched senior housing affordable to a broad range of older adults. The good news is that, as baby boomers, our numbers make our generation too big to ignore. We have a voice, and we can use it to advocate for more and better homes for our parents, our future selves, and even our children, who will someday grow old themselves.

The best government program for creating senior housing that is affordable to low- and moderate-income households, HUD 202, has been essentially frozen for six years. Although the last Congress budgeted funds to re-start the program, less than one-third of the households needing this housing support will receive it, according to Harvard University’s Joint Center for Housing Studies. Similar to health care affordability challenges, middle-income older adults, in particular, face a financing gap. This group is the largest and fastest-growing group of older adults, but the costs to build and operate engaging community housing for this group are higher than their modest incomes and retirement savings will support.

One solution would be to capture the savings that aging in community will generate to the health care system. As we move health care from fee-for-service to outcomes-driven payment, conversations have begun about how to invest wisely in the social determinants of health—housing among them. In these conversations, 2Life Communities is making our voice heard, advocating for changes in reimbursement rules that currently limit the scope of allowable investments in older adult housing by Medicaid accountable care organizations.

The real transformation of options in aging will come from partnerships of mutual interest between health care providers and payers on the one hand, and housing developers and operators on the other. At 2Life Communities, we’re ready to be active partners in creating a system in Massachusetts that provides the best old age for all.

But we think it all starts with a reframing that aging in community is where we need to refocus our thinking if our goal is to support seniors to live their lives to the fullest.

Amy Schectman is president and CEO of 2Life Communities, a nonprofit organization founded in 1965 that serves 1,500 older adults.