woensdag 1 augustus 2007

Americans are aging. Seniors make up 12 percent of the U.S. population today; by 2050, that figure will rise to 20 percent. To sustain an aging population requires changes within cities, especially in housing, transportation, and care. In the same time frame, the European Union’s (EU’s) senior population is projected to go from around 17 percent today to 30 percent by 2050—which means that seniors will constitute almost a third of the populace.

Common challenges bridge the many differences in social and medical financing and delivery of services that exist between the United States and Europe. There are many paths toward common goals—creating livable communities in which the elderly can lead normal lives, with a real choice of levels of independence and support.  

A key issue is whether increasing choice results in increased cost. In many Western countries, including the United States, the elderly make up a growing percentage of the population not only because people are living longer nowadays, but also because birthrates are declining. As the Organization for Economic Co-operation and Development (OECD) succinctly put it, “Increasing numbers of dependent persons, mainly elderly, will depend on a decreasing number of working age.”  Shrinking workforces mean shrinking funds, so keeping seniors healthy, reforming pensions, and postponing retirement until a few years further down the road is one strategy. Once Americans retire, keeping the costs associated with aging manageable is an equally important strategy.

Even the wealthiest of countries or those most inclined to offer social programs cannot afford to provide support for this large population cohort, particularly in institutional settings. The concept of aging is changing from a vale of infirmities and disengagement from society to the realization that the elderly still have much to offer.

“Americans can learn much from a synthesis of housing, care, and help delivery that constitutes a new frontier for the aging in northern Europe.”

A more limber active life and continuing contribution to society is not only the way this generation of seniors view themselves, but it is also an economic necessity.

“European Union policy, which was originally assumed to be about economic interchange, is increasingly involved in social policy because of demographic changes. Now it is the issue in economic policy,” explains Ben Slijkhuis, director of the Netherlands Platform for Older People and Europe (NPOE), an organization that informs national organizations on EU demographic change policies and consults with businesses on aging matters. “More than 50 percent of our rules and regulations are coming from the EU,” he adds. In January, a new Dutch “communal support” law kicked in which states that local authorities must see that seniors get enough help to participate in society. “Participate, not care, is the ruling word,” he points out.

In northern Europe, with its implicit cradle-to-grave social contract, the whole notion of what it means to provide welfare for the elderly has undergone, and continues to undergo, profound changes. In the Netherlands, for example, the philosophy of placing the elderly in large impersonal nursing or residential facilities—the norm up until the 1970s and 1980s—was regarded as part of a well developed welfare system. That philosophy has turned around. 

Remaining independent and in one’s home has become the rallying point of policies that address elderly citizens. Assistance and longterm care are, more and more, not occurring in a special building, but at home. “There’s a major shift from thinking of the appropriate facility providing a certain level of care to thinking of the care, disconnected from the place where it is being supplied, and to offer it in a variety of different contexts, particularly at home,” explains Theo van der Voordt, on the faculty of architecture in the real estate and housing department at the Delft University of Technology in the Netherlands. He explains that this kind of made-to-measure care is better from a cost-control standpoint and supports the “use it or lose it” philosophy—you get what you need and no more. “However, the success of the system requires a high number of skilled people, particularly in a graying society.”  

Elderly Swedes benefit from generous state supported services. As they age or recover from illness or injury, they only have to make a call to the local authority to take advantage of a variety of services, ranging from transportation to a handyman. In Sweden, almost 18 percent of the population is aged 65 or older, with an average life expectancy of several more decades—over 85 for Swedish women and 82 years for men. Residents may be eligible for hemhjälp (home help) for cleaning, cooking, washing, supervised walks, nursing care, and also meals on wheels after a municipal assessment is made in the home.

Payment for these services goes up to a set maximum, although those with low incomes are not charged. In addition, changes to the home are made free of charge, including the removal of thresholds for wheelchair access, the alteration of kitchen cabinets, and the replacement of tubs with showers. Some local authorities also offer accident-reducing services; employees come to a senior’s home to change hard-to-reach lightbulbs, hang curtains, and perform other chores to reduce the number of falls and hip fractures. These preventative measures are seen as ways to reduce a municipality’s overall medical costs.
“The number of people living in special housing for the elderly has diminished and more people have home care,” explains Per Olov Nylander, a director specializing in elderly concerns at the Swedish Association of Local Authorities and Regions (SALAR), which represents all of Sweden’s municipalities and regions. A 2006 study conducted by SALAR showed that the cost per Swedish care recipient living in regular housing was half the cost of special housing. Only 1 percent of those under 75 years of age, according to the Swedish National Board of Health and Welfare, now live in special housing.

 

In the Netherlands, users of in-home care pay a modest amount, supplemented by an insurance system funded by taxes. Private companies, for those who can afford it, also deliver home care. Only Denmark provides free in-home care without regard to income. As people age, the number of citizens needing special housing for long-term care rises dramatically; in Sweden, it is 25 percent of those aged 85 and over.

When in-home care becomes inefficient, moving into special housing, allotted after a needs assessment, may become necessary. Instead of American style nursing homes with shared rooms and hospital ambience, special housing mirrors the private home setting as much as possible; most provide one or two individual rooms (often with a small kitchen), common spaces, and activities. 

In Scandinavia, the Netherlands, and the U.K., a number of housing and care elements, including special housing, are combined near or with community centers into one neighborhood source, called a “care center.” The Leo Polak House in Osdorp, an Amsterdam borough, is an example of a woonzorgcomplex, an integrated care center. “The idea is that in combination, resources can be shared, costs reduced by substituting technology for labor, and social and community cohesion strengthened,” explains Jasper Klapwijk, spokesperson for Woonzorg Nederland, a not-for-profit housing organization that developed the Leo Polak House with care provider Antaris, part of the OsiraGroup (a recent merger of two nursing home providers with a care provider for the physically handicapped).  

In Scandinavia, the Netherlands, and the U.K., a number of housing and care elements are combined near or with community centers into one neighborhood source, called a “care center.” The Leo Polak House in Osdorp, aborough of Amsterdam, the Netherlands, is an integrated care center that includes a restaurant, a mini-mart, a beauty shop, a computer and library room, billlards, laundry facilities, physical therapy, and a gym—forboth residents and neighbors. 

What used to be a nursing home for the elderly with four to six residents to a bedroom has been transformed by Dutch architects Claus en Kaan into a red-, pink-, and yellowstriped Complex. The mix includes a tower of 72 independent senior apartments (with 20 percent using in-home care services), 126 apartments for the physically disabled with on-site care, and a dozen six-person apartments for those with Alzheimer’s on the second floor overlooking courtyards.

 

Also on site is the care hotel, which fills a gap between staying in the hospital and one’s own apartment, providing the service level of a hotel with medical supervision. A five-bed hospice center is part of this facility. On the ground floor, for both resident and neighborhood use, are a beauty shop, a mini-mart, a computer and library room, billiards, laundry facilities, physical therapy, and a gym. A restaurant located on site bills residents monthly and has a purchasable card with ten meals for community users. 

Technology helps facilitate the mix of users. For example, the Alzheimer’s units are electronically controlled by the staff. If a resident gets up at night, a light comes on. This system allows individual programming so that residents still do the tasks they are capable of doing on their own. Residents wear an oversized wristband that allows them access to three zones of the building: the door to their apartment, to the floor of the Alzheimer’s wing, and to the front door of the Leo Polak House. Doors open automatically if zoned for the patient, not requiring staff assistance, or remain shut if not in their zone of access. Should a resident find a way to wander past a door not in his or her zone profile, the staff telephone beeps loudly as a warning. 

The Leo Polak House is a consolidated example of what can also be smaller-scale care centers with supportive housing for the elderly located nearby. The Dutch have broadened this concept into a woonzorgzone (service zone) for an urban neighborhood of 10,000 residents. “The idea is that the housing isn’t specially dedicated to seniors, but built so that anyone can stay there even as [they] age or have mobility problems,” explains Danielle Harkes, executive manager at the Expertise Centre on Housing and Care. 

From conception, the new urban district of IJburg, being built on seven artificial islands in IJ Lake in Amsterdam, was planned to be a service zone. Moerwijk in the Hague, a renewal area, has become a service zone as well. Walking through these communities, there is not much to see, and that is the point. Making all housing accessible, having a care center connected by alarms to some houses, and locating activity centers and assisted living units within the area should not make this community look any different than a normal neighborhood, except that it is networked to be much more user friendly and secure for everyone, not just seniors. 

Another approach is provided by Humanitas, a Dutch member-based organization for social services and community development. Its housing for the elderly features levensloopbestendige woning, an “apartment for life.” These apartments adapt to a variety of care and aging needs, including intensive nursing home care. The philosophy behind these 753.5-square-foot (70-sq-m) units is that residents can stay put for the rest of their lives; and social networks among neighbors and community connections remain intact.  

The red-, pink-, and yellow-striped complex combines a variety of options for seniors’ housing—a tower of 72 independent senior apartments with optional in-home care services, 126 apartments for the physically disabled with on-site care, 12 six-person apartments for those with Alzheimer’s on the second floor overlooking courtyards, a five bed hospice center, and a care hotel for thoseneeding temporary medical supervision. 

Care is tailored to each individual by a permanent “care manager” who helps residents fill out a care contract. The resident can determine the type, amount, and time of care from several care suppliers. “Self-management by the client remains the number-one priority,” explains Inge Odigk, health manager at Humanitas.

Humanitas has found that although care is organized differently, it is not more costly than traditional approaches as the apartments are not more expensive than nursing home space; and daily costs are cheaper than those that would be incurred while living in an institution, given the help of family and volunteers. Made-to-order care, self-management, and stretching the idea of community and home to cover tasks of specialized institutions now dominate northern European experiments in seniors’ housing.

While the EU is not involved directly in the building programs of its member countries, it works diligently to facilitate an exchange of information, spur research, and provide policy papers. “Mobilizing and facilitating the independence, initiative, and talents of people to create a meaningful existence for themselves is one of the cornerstones of the transformation of the welfare states in Europe,” explains P.P.J. Houben, who has researched new seniors’ housing at the Delft University of Technology. These efforts show a kind of best practice for combining housing and care.

The United States has its own brand of alternatives, including the in-home menu of services provided by Beacon Hill Village of Boston (www.beaconhillvillage.org), the social network of Mather’s More than a Café (www.matherlifeways.com), the volunteerism of senior friendship centers (www.seniorfriendship.com), and high-end seniors’ housing affiliated with universities and performing arts centers. Reducing reliance on nursing homes and introducing more people-centered solutions is also starting, with examples such as the Eden Alternative (www.edenalt.org), an organization working to deinstitutionalize the culture of these long-term facilities.  

What were once a few standard solutions for the elderly have now evolved into a multitude of experiments and ideas, with many individual permutations as the marketplace responds to seniors’ demands. For senior Americans, though, there is a dearth of coordination among housing, care, technical, and social organizations.

Options abound, but many hinge on a certain level of wealth, health, and consumer savviness, and show a marked tendency to herd seniors into closed-off and private worlds. What is most admirable about northern European examples are their efforts at delivering and coordinating an array of options with the intent of creating strong, and equitable,communities. 

Bron | DORIT FROMM, Urban Land, Augustus 2007

Dorit Fromm, author of Collaborative Communities: Cohousing, Central Living and Other New Forms of Housing, is now researching senior planning and housing in the United States.

Bekijk hier de projectpagina van Leo Polak op deze website.