Health & Human Services

Seniors and the City

More than two decades ago, Michael Hunt noticed something interesting about Hilldale, a well-established neighborhood in Madison, Wisconsin. Elderly people were moving into its apartment...
by | May 31, 2009
 

More than two decades ago, Michael Hunt noticed something interesting about Hilldale, a well-established neighborhood in Madison, Wisconsin. Elderly people were moving into its apartment houses in large numbers at the same time that builders and developers were struggling--and failing--to attract seniors to assisted-living communities designed for their needs. What struck Hunt, an architect and professor of urban planning at the University of Wisconsin, was that Hilldale, with apartments set close to a local library and small shopping center, was senior-friendly but not senior- segregated. Even more to the point, it was warm and welcoming to the many widowed women who moved in there. The apartment buildings were almost like dorms, with hallways that were, he says, "socially alive." Hunt had spotted something that seemed novel--what he called "a naturally occurring retirement community," or NORC.

Although the phrase was new, the phenomenon Hunt saw wasn't. Virtually every community in the country has a NORC. In some instances, it's the apartment complex people move to after their spouse dies. In others, it's a neighborhood where the children have left and residents are aging in place. According to the American Association of Retired People, more than a quarter of seniors already reside in NORCs. As the baby boom generation approaches retirement, demographers expect the growth of NORCs will accelerate dramatically.

"We need to be designing communities in which people can age in place," Hunt is convinced. "There is no way to have enough age-specific housing to take care of the elderly."

Around the same time that Hunt was noticing aging patterns in Hilldale, Fredda Vladeck was a social worker at St. Vincent's Hospital in Manhattan. Vladeck had noticed that an increasing number of older New Yorkers were showing up in the St. Vincent's emergency room with fractures or injuries suffered in falls. One housing development in particular stood out: a 2,820-unit co-op called Penn South. Established by the International Ladies Garment Workers Union in 1963, Penn South was home to a large concentration of former union members, many of them single women. But as Penn South's residents aged, their health began to deteriorate. Now, they were appearing at the hospital in disproportionately large numbers.

When Vladeck called the building's managers, they acknowledged the problem and asked if St. Vincent's could help by placing a geriatric nurse and a social worker on site. But Vladeck felt the issue was more about psychology than services. She knew that most older adults resist connecting with services until an acute crisis forces them to. And the residents of Penn South were no exception. What was needed, she felt, was a conversation changer where it's acknowledged by all that this is an aging-in-place community, and there are things we can do in the community to make aging as normal as possible."

Vladeck had heard the term NORC. Now, she set out to turn a demographic description into a service model--one that could combine the outreach aspects of community organizing with traditional social services, such as support for home health aides. Backed by the United Jewish Communities, an umbrella group for hundreds of Jewish philanthropies, she created a model that has emerged as one of the most promising ideas for meeting the coming surge of retiring baby boomers.

In some ways, supporting NORCs is a no-brainer for state and local government officials. Demographers estimate that 90 percent of baby boomers will age in place. Making sure NORCs have amenities such as curb cuts, mass transit, libraries and other clusters of services is common-sense urban planning. The other alternatives--assisted-living facilities or nursing homes--are both associated with huge expenses, most of which are borne by state Medicaid programs, and a jarring decline in senior well-being.

But the push to expand government support for NORCs raises broader and more nettlesome issues. Up to this point, NORC services have been funded primarily by foundations and through modest fees paid by their beneficiaries. In making the argument that it's time for government to step forward, philanthropies are pursuing an old and familiar path: The nonprofit develops and pilots innovative programs, then government takes over. But given the current fiscal crisis (and the approaching retirement of millions of baby boomers), can government afford to help NORCs? Or, frankly, can it afford not to? It's a debate not just about how government should promote aging in place but about the role of government itself.

Vladeck's work at Penn South is a case in point. Soon after her efforts got underway, her program caught the attention of the United Jewish Association Federation of New York. The reason was demographically driven. About 25 percent of the Jewish population is 65 and over, roughly twice the national average. "The Jewish community's older adult population, as a percent of community, is where rest of the country will be in 20 years," says Rob Goldberg, senior director for legislative affairs at the United Jewish Communities. "So we are already dealing with the challenges of long-term care."

The UJA Federation set out to replicate Vladeck's NORC model in other high-rise apartment complexes where half or more of the residents were seniors. In 1999, the city of New York funded an effort to extend the model to the Deepdale Gardens apartment complex in the borough of Queens. Vladeck and the UJA decided to take the concept even further. They created a prototype "horizontal" NORC in next-door Floral Park, a neighborhood of modest single-family homes, many of them occupied by older residents.

The effort was challenging. A typical "vertical" NORC in the city was funded in part by a $1-per-month fee that was added to participating residents' rents. There was no automatic way to levy a similar fee on residents of Floral Park. Instead, UJA turned to community organizers to canvas the neighborhood, surveying residents about their priorities, organizing residents into a group that could define its own priorities and helping them connect with services. Local politicians, block associations, local businesses--everyone was brought in.

By 2005, the Floral Park NORC had taken root. Other New York state and local politicians quickly scrambled to get programs of their own. In 2006, the state passed legislation that created a neighborhood NORC model. New York now contributes $4.4 million to 17 horizontal or "neighborhood" NORCs and another 40 "vertical" NORCs statewide. New York Citys budget provides another $5.5 million, plus $1 million more in earmarks. As a result, some 67,000 New Yorkers live in officially supported aging-in-place communities based on the NORC model.

NORCs are going nationwide. In recent years, United Jewish Communities has helped underwrite more than 50 NORCs in communities around the country. As the idea has expanded, state and local governments are becoming increasingly important partners. In early 2003, the Atlanta Regional Commission (which coordinates regional planning and serves as the Area Agency on Aging for the 10-county greater Atlanta area) conducted a survey of 1,200 seniors. It found that respondents were less interested in traditional services such as Meals on Wheels than they were in fostering a strong sense of community. At the same time, the Fulton County Office on Aging was trying to figure out how to better utilize its Bowden senior center in East Point, a lower-middle class, African-American community that is located near Atlanta's international airport. With help from the Jewish Federation for Greater Atlanta, the ARC reached out to politicians, nonprofits and community groups in East Point. A local advocacy group spent six weeks canvassing NORC neighborhoods, assessing needs and mapping neighborhood resources. Public safety, transportation and home repair emerged as priorities.

The responses to these perceived needs were creative. Working with a neighborhood advisory council, for instance, the Atlanta Regional Commission (which served as the lead agency) organized a "fashion show" in which police, firefighters, water and electricity meter readers and even FedEx delivery drivers walked down a catwalk in the senior center in order to show seniors the types of people who might legitimately come onto their properties. A total of six NORCs are now up and running around Georgia.

An even more ambitious statewide effort is taking place in Indiana. In June 2007, Steve Smith, then the state director of aging, hired the University of Indianapolis Center for Aging and Community to develop a request for proposals for several NORC pilot programs.

The Indiana initiative was born of the recognition that as Indianans aged, a growing number needed help to stay in their homes. The state's CHOICE home health care program was underfunded and had long waiting lists. As a result, many seniors who, with appropriate support, might have been able to maintain their independence, were being forced into institutional facilities. The pyramid of services the state offered its seniors was, in effect, upside down. The state reoriented its dollars away from institutional care and toward community-based services, but that wasnt enough.

In tackling its RFP assignment, the University of Indianapolis did something unusual. It sought to develop a picture of the overall needs of state seniors by fielding the AdvantAge Initiative telephone survey, which assesses seniors' well-being by asking questions about their health status (have they had a flu shot? when was their last mammogram?) as well as their access to local services. The results of the statewide survey were eye-opening. A lot of respondents weren't sure where to go for services. The prevalence of illnesses such as diabetes were very high compared to the nation as a whole.

Ultimately, five NORC pilot programs were selected, with locations ranging from urban Gary to suburban Indianapolis to rural Linton. Each NORC chose its "banner issue" to target. In Linton, for instance, the focus has been on mobility. The NORC has modified homes to remove hazards, created a walking program and continues to provide transportation vouchers (and volunteer drivers).

Indiana's five NORCs are currently in their second year of operation. State officials are waiting for an evaluation before seeking to expand further.

Despite their rapid spread in recent years, NORCs as a program struggle with the fundamental question of sustainability. "We can't do it without government," says UJC's Goldberg of the effort to build a national NORC infrastructure. And yet not everyone agrees that the future of NORCs is as a governmental program. Madison's NORC, Supporting Active and Independent Lives, or SAIL, has taken a different approach. Although it was started with seed money from a federal demonstration grant, it has sought to organize itself as a fee-supported membership organization. The goal, says Michael Hunt, is "that over time it will become financially independent so we don't have to rely on city and state subsidies."

But it's more than philosophy that drives Hunt to his conclusion. He also stresses numerical reality. "We can't count on government to support this population," he says. "There's not enough money and too many people."

Nonetheless, SAIL's approach has been controversial in the NORC world. "If you charge by membership, you are encouraging people not to participate," warns Vladeck. Although SAIL has a lower-cost membership rate for low-income seniors, Vladeck and other program-oriented NORC supporters worry that SAIL's approach is too close to what is sometimes called a "concierge model."

The best-known example of that is Boston's Beacon Hill Village. Established in 2003, it provides a range of programs to seniors throughout central Boston--from weekly grocery shopping to house cleaning to help getting on the Internet. Although subsidized memberships are available for low-income seniors, most members pay an annual membership fee of $850 per household. That segregation of services by income worries Vladeck and other NORC advocates. They want to weave the programs and culture that support aging in place into the core of existing communities. That's a goal both Vladeck and Hunt support. They just differ on the most realistic way to get there.

"From a public policy viewpoint," Vladeck says, "it's clear we need to figure out what to do to make these communities good places to grow old."

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