Elderly

The Continuum of Housing

The vast majority of persons enter old age living in homes or apartments that were chosen for their appropriateness in midlife when they were healthy and independent. However, as persons age, they may find that these settings no longer fit their needs or preferences. A variety of housing types have arisen over the last several decades that provide a range of lifestyle, environment, and service options. The concept of a continuum in housing recognizes that as people age and become less independent, they may require increased services and more physically supportive environments. Figure 1 illustrates how different housing types, such as single-family homes, conventional apartments, congregate housing (multi-unit living arrangements that generally provide group meals), assisted living (residential settings that provide individualized health and personal care services), and nursing homes, generally meet the needs of older persons who can be categorized as independent, semi-dependent, and dependent. The semi-dependent and dependent categories may include persons with physical and cognitive impairments. Although semi-dependent and even dependent older persons can be found throughout the housing continuum, supported by caregivers and the formal service system, independent older persons are unlikely to reside in housing types such as assisted living. A major exception are the approximately 1,800 continuing care retirement communities (CCRCs), which each house 400 to 600 older persons in settings that include [Page 150]independent living, assisted living, and nursing care. The number of older Americans living in CCRCs was shown to nearly double over a single decade, from 350,000 in 1997 to 745,000 in 2007.

Figure 1 The Continuum of Housing: Level of Support to Various Housing Options

Ideally, the needs and preferences of older persons would be matched to appropriate housing types. The reality is that many housing options are limited by political opposition, lack of affordability, and the bias of long-term care expenditures toward institutional care. Accessory units and shared housing often face local zoning restrictions, while congregate housing, assisted living, CCRCs, and retirement communities are typically too expensive for low-income older persons. Policies that encourage aging in place—the desire of older people to live in their own housing and communities as long as possible—through retrofitting housing with special features have generally been underfunded. Medicaid has provided incentives for housing frail older adults in institutional settings rather than offering funds for community-based services. Over the last several decades, efforts have been made to address these issues through a number of housing approaches that encourage aging in place and the development of supportive housing arrangements that are residential in nature.

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