Group of older adults having breakfast
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In an earlier post, we explored retirees’ freedom to choose where to live and what kind of home to occupy, along with the many options they enjoy. As retirees get older, or any time their need for household support and medical care increases, the availability of care becomes a dominant factor in the housing equation. Many people move twice in retirement, first to fit their lifestyle and later to receive needed support and care. Retirees still have many options, as we’ll see. But the COVID-19 pandemic, especially the infection rates in nursing homes, is leading older Americans to take a closer and more urgent look at where and how they want to live.
Aging in Place
Americans’ traditional preference is to continue to “age in place” in one’s own home. Over 70% of those age 65+ say they prefer to stay at home even after they need extended care. Most of that care is provided by family members – and can be an enormous burden on them – because most older individuals and their families can’t afford extensive reliance on professional caregivers. But a common arrangement is to have paid care supplement family-provided care.
In the U.S., 4.5 million people use home care services, or three times as many as reside in nursing homes. The home care market is projected to reach $187 billion in 2027, nearly doubling in a decade. But it faces a workforce crisis, with about 8 million job openings in that same time frame. Caregiver responsibilities are expanding, with more call for a mix of personal and nursing aide services, and more need to interact with care recipients with dementia. Especially during the pandemic, it’s in everyone’s interests – care recipient, recipient’s family, caregiver, caregiver’s employer – to take all precautions and deliver care safely and efficiently.
Successfully aging in place usually requires renovations to make the home more “aging friendly” – lever handles on doors and faucets, grab bars in bathrooms, higher chairs, lower counters, better lighting. As mobility declines and elders use walkers or wheelchairs, they need ramps, lifts, and wider doorways. Almost every aging-in-place home needs such renovations, because only 2% of America’s total housing stock is aging friendly today.
There’s another option for those who need help and want to stay at home – take in a roommate. It’s most commonly a friend or relative, but there are other creative arrangements. Affordable Living for the Aging’s (ALA) Shared Housing Program finds people who can provide household services such as cooking and cleaning in exchange for paying low or no rent. Programs in Germany, Netherlands, and Portugal match university students in need of affordable housing with older residents in need of company and household support. And the roommates household need not be limited to two. One of our favorite examples is of four retired women who purchased and renovated (with aging-friendly features) a six-bedroom farmhouse – the “Golden Girls” model.
Moving in with Family
As mentioned in our last post, multigenerational households, those with more than one generation of adults, were on the rise long before COVID-19. The number rose steadily from 27 million in 1980 to 64 million in 2016, with an extra bump up after the 2009 recession, and one in five households is now mutigenerational. Generations live together for reasons of economy, convenience, and cultural or family tradition.
Part of the recent growth has been driven by record numbers of adult children who “boomerang” home, not only twenty-somethings trying to get started after college, but also young families with financial difficulties or following a divorce. And part of it has been driven by older parents who move in to receive care. Either way, we see this as a reflection of increasing interdependence and commitment across generations.
Moving close to family can still involve separate quarters. New kinds of duplex home designs offer living spaces and privacy for all. The NextGen home from Lennar is two houses in one, built for extended families who want both proximity and privacy, each with its driveway, entrance, kitchen, and living spaces. NextGens are available in a dozen states, including the most popular retirement destinations.
Another option is Accessory Dwelling Units (ADU), small-scale apartments that can be built or modularly assembled in a homeowner’s yard or a neighboring lot. The idea is to enable those who need regular assistance to preserve as much independence as possible. Over 30% of adult Americans say they would consider an ADU for a loved one who needs some care.
Communal Living
What about older people without children, without households to join? Twelve million Americans age 65 and older live alone, and 46% of women over 75 live alone. Those who are “aging solo” without active networks of friends are subject to isolation, loneliness, and associated declines in their health. The antidote can be more communal living.
Several arrangements can work well for older retirees, though not restricted to them.
· The “Village Movement” began in Boston in 2002, is the most “virtual” approach. Members of an existing community form an organization to share information, arrange social events and cultural and learning experiences, and contract for services such as health and wellness programs. The Village to Village Network promotes the movement internationally, to the tune of over 350 villages to date.
· “Cohousing” originated in Denmark in the 1960s. Community members have individually owned homes plus a common house and community center. They organize activities, share meals on designated days, and support and care for each other.
· Naturally Occurring Retirement Communities, or NORCs, have residents of all ages but have evolved to have higher proportions of older individuals. Again, residents organize group dinners, classes, excursions, and other activities. Shared facilities typically start with health centers and gardens.
In such communities, residents have their own dwellings and thus can maintain distance as needed. They’re also motivated to be part of the community, and to watch out for one another in respectful ways. In a pandemic, we’d expect them to take mutual precautions and behave conservatively.
Housing plus Care
Skilled nursing facilities, aka, nursing homes, were declining in popularity well before COVID-19 exposed tragic flaws in their layouts and operations. The number of facilities has been shrinking as alternatives have arisen, but there are still about 16,000 facilities in the United States, home to about 1.5 million Americans in need of continuous long-term care. Alternative designs have been in the works, such as the Green House Project, founded by innovator and anti-ageism advocate Dr. Bill Thomas. The nonprofit organization facilitates development and operation of facilities with small, home-like environments and more stimulating staff and social interaction. There are close to 250 Green House Project locations across 32 states, and only a small fraction have reported positive cases of COVID-19.
The high rates of contagion and death in nursing homes presents a challenge to other types of facilities that incorporate care – assisted living and continuing care retirement communities (CCRC). The 36,000 licensed assisted living facilities in the United States are home to about a million residents. They receive personal and household support, and medical help is typically nearby. They have private living spaces, most meals are communal, and residents are encouraged to join in social and fitness activities. Because assisted living facilities tend to be have smaller populations and more private space than nursing homes, keeping residents distanced when necessary is easier.
In CCRCs, also called “life plan communities,” residents live independently in houses, duplexes or apartments. When the need for care arises, they move into assisted living and some eventually into continuous care, including memory care. There are about 2,000 CCRCs in the United States, 80% of them operated as nonprofits. The typical community has 300 or so units for individuals or couples, with 70% of residents living independently, 10% in assisted living, and 20% in skilled nursing. CCRCs are largely self-contained communities, with facilities including restaurants, shops, recreation and fitness, workshops for hobbyists, and auditoriums for entertainment events and meetings of resident organizations. For those who can afford the buy-in price and monthly fees, the reward is security in both housing and availability of care.
The COVID-19 Effect
How might the pandemic reshape the options and preferences of older retirees? Where will they want to be if and when another wave of pandemic arises?
More of them (and their families) will do all they can to avoid moving into traditional close-quarters nursing homes. But will interest in assisted living facilities and CCRCs decline as well? Those facilities that are relatively untouched by the pandemic may well become much more attractive options because of their offerings of convenience, protection, and social connections, combined with their infection prevention protocols that worked and can be trusted.
We anticipate increasing interest in the multigenerational arrangements and communal living options we’ve mentioned, as well as in nursing home alternatives like the Green House Project. And the need for renovation services will certainly grow as households add rooms for older relatives and retirees make aging-friendly modifications to their own homes.
A big question is whether aging in place becomes more attractive because seemingly safe and secure. Or can it be less practical and too isolating, especially for older retirees without nearby family, or who lack the technological aptitude to videoconference with family and friends and order services online?
One of the pandemic’s big lessons is how connected and interdependent we all are. Older retirees need living arrangements that help keep them connected and supported as well as safe and healthy.
This is the eighth in a 10-part series on “The Future of Retirement” that we are posting over the course of several months. If you are interested in better understanding what’s ahead, we invite you to check out our new book What Retirees Want: A Holistic View of Life’s Third Age.