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Learning Objectives

After completing this course, partici-pants will be able to:

Defi ne the concept and impli-cations of aging in placeIdentify at least three barriers to aging in placeName at least three strategies to promote aging in place

Core ContentAging Demographics

Our nation is facing substantial chang-es in its age demographics. The number of older adults in our society is on the rise, and the aging “boom” will only continue to increase in the coming de-cades.

Expand Your Aging IQ

During the 1990s, what percentage did the 85+ population increase by?

5%25%40%15%

Answer: According to the U.S. Bureau of the Census (2000), adults aged 85 and

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older showed the most rapid growth among the older adult population from 1990-2000, increasing 40%. The aver-age life expectancy continues to dra-matically increase compared to past decades, which accounts for the growth of the “oldest old” population.

Expand Your Aging IQ

By 2030, the number of people aged 65 years and older in the United States is projected to be:

15 million30 million50 million70 million

Answer: According to projections from the U.S. Census Bureau (2000), the number of older adults aged 65 and old-er will double from 35 million in 2000 to over 70 million in the year 2030.

In addition to people living longer, we also are awaiting a vast growth in the older adult population due to the aging baby-boomer generation (people born between the years 1946-1964). Baby-boomers will begin to reach retirement ages in 2011, and by 2030 it is estimat-

YOU ARE HOLDING 1.5 CEs IN YOUR HAND!NASW is pleased to offer this FOCUS Homestudy Course.

How it works: Read all the articles on these pages, complete the post-test on page 17 and mail it to the Chapteroffice with your check. Score 80% or better and NASW will mail you a certificate for 1.5 CEs. It’s that easy!

With this format and our HomEd audio programs, the Chapter continues its goal of ensuring that social workers, including those withmobility or other impairments, are able to meet their continuing education requirements. This course of 15,000 words meets the current Massachusetts Board of Registration’s requirements for 1.5 CEs and is appropriate for social workers at all licensure levels. If you have

comments, concerns or other questions please e-mail chapter@naswma.org or call 617-227-9635 x17.

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Aging in PlaceBy Stacey Skala, MSW, Curriculum Coordinator, Institute for Geriatric Social Work (IGSW,

Boston University School of Social Work with Kathy Kuhn, LICSW, Director, Education & Training,Institute for Geriatric Social Work (IGSW) Boston University School of Social Work

Course OverviewThe majority of older adults and aging baby-boomers report that they want to stay in their homes and communities as they grow older. In spite of this, one out of every fi ve older adults faces spending part of or their remaining lives in a nursing home.

With the onset of chronic conditions, illness and physical/cognitive limitations, older adults are more likely to require assistance with their personal care and household activities as they age. Despite the prevalence of assistive devic-es, home modifi cation products, community- and home-based services, many barriers ex-ist for older adults who want to remain in their homes.

The concept of aging in place refers to growing older without having to move to an institution in order to receive supportive services. Aging in place spares older adults from the negative ef-fects of relocation, transition and abandoning their established social networks. In addition to benefi ting the individual older adult, aging in place also has considerable economic benefi ts.

Compared to the costs of nursing home care, customized community-based care at home can be a cost-effective aging model. In addition, communities with older adult residents benefi t from their role as consumers, investors and do-nors of their volunteer services.

Social workers have a vital role in enabling old-er adults to stay in their home and remain in-dependent for as long as possible through their role as clinicians, case managers, educators, administrators and advocates. This course will give an overview of the emerging issue of ag-ing in place, a theme that is likely to require fur-ther attention as our baby-boomers begin retir-ing and aging at staggering rates.

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ed that people aged 65 and older will account for 20% of the pop-ulation (Federal Interagency Forum on Aging Related Statistics, 2004).

Figure 1. is a visual representation of the upcoming aging boom. As you can see, the number (in millions) of older adults in the 65+ and 85+ categories are expected to increase signifi cantly by the year 2050.

Expand Your Aging IQ

Which state experienced the highest percentage of growth in its el-derly population from 1990-2000?

FloridaNew MexicoNevadaAlaska

Answer: According to the U.S. Bureau of the Census (2001), Nevada experienced a 72 percent increase in its elderly population between 1990-2000, followed by Alaska (60 percent), Arizona (39 percent) and New Mexico (30 percent).

Despite the common belief that older adults head for sunnier cli-mates during their retirement years, studies show that the majority of older adult homeowners prefer to remain in their homes as they age. If they do change residences, it tends to be in nearby commu-nities and often in the same county (Golant, 2002).

Additional data from the U.S. Census Bureau illustrates the follow-ing demographics:

Almost four out of fi ve older Americans own theirown homesPersons between 65-85 are the least likely age groupto moveMore than 1.5 million older adults (disproportionately female and over age 85) live in nursing homes or other residential care facilities

Web ResourcesFor additional information about aging and housingdemographics, please visit:Administration on Aging:http://www.aoa.gov/prof/Statistics/statistics.aspFederal Interagency Forum on Aging Related Statistics:http://www.agingstats.gov/U.S. Bureau of the Census Age Datahttp://www.census.gov/population www/socdemo/age.html

Benefits of Aging in Place

Imagine yourself at 80 years old. Where do you see yourself living? In your own house or apartment? With your children? In a nursing home? Not surprisingly, most of us probably do not see ourselves living in a nursing home because we want to remain independent as we get older and grow older in our own homes or apartments.

A 1996 report from the American Association of Retired Persons (AARP) found that the majority of surveyed older adults (83%) re-ported that they want to stay in their homes as they get older, yet it is probable that nearly 20% of older adults will reside in a long term care facility for at least part of or the rest of their lives (Ron, 2004).

There appear to be many benefi ts to older adults staying in their communities. A recent study compared the mental health of old-er adults living in the community versus those living in nursing homes (Ron, 2004). Findings from this study suggest that residents of nursing homes are considerably more likely to experience high-er levels of depression and suicidal ideation than their counterparts living in the community.

From an economic standpoint, the costs of institutionalized care are higher than the costs of living independently (Wodarski and Williams-Hayes, 2002). In addition, older adults have a great deal to offer their communities. Not only do older adults act as consum-ers and investors in their communities, they also donate a consid-

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•Institute for Geriatric Social Work The rapid aging of our society, and the related increase in the need of older adults for services and care, is one of the major challenges of the 21st century. The profession of social work is at the forefront of those facing this challenge and is also in a unique position to respond - both to meet immediate needs and also to establish a higher standard of care for the future. The Institute for Geriatric Social Work (IGSW) is dedicated to advancing social work practice with older adults and their families. Led by Scott Miyake Geron, Ph.D. and a team of social workers, IGSW is located at Boston University School of Social Work and continues to build upon the School’s historical commitment to the aging field and current strength in gerontological teaching, research and training.

IGSW is committed to becoming a national leader in developing the workforce of social workers to meet the challenges of a growing and changing population of older Americans. Through innovative and wide-ranging education and training efforts, IGSW will provide practicing B.S.W. and M.S.W. social workers — the large majority of whom have received little or no geriatric training — with the core knowledge, skills and tools they require to meet the needs of older adults and their family members.

IGSW is also committed to expanding practice and reimbursement options for geriatric social workers. IGSW has initiated and is conducting research to demonstrate the effectiveness of social work interventions designed to improve the lives of older people, and will support innovative model programs in geriatric social work practice. IGSW will also inform and seek to influence policy-makers through the dissemination of pragmatic, timely information that documents the efficacy, benefits and outcomes of empirically-based geriatric social work practice.

For more information about IGSW and a listing of web-based CEU courses, please visit http://www.bu.edu/igsw

The American Society on AgingIn order to achieve our primary goal of providing training to B.S.W. and M.S.W. social workers across the country, IGSW has formed a partnership with the American Society on Aging (ASA). ASA is the largest professional organization in the field of aging, with over 7,000 members and subscribers to its publications and 3,000-4,000 professionals attending its annual conferences. Selected articles from ASA’s Generations journal appear in this course. For more information about ASA, please visit http://www.asaging.org.

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erable amount of their time and expertise through volunteer pro-grams. The economic value of the time and expertise donated by older adults 65 and over is estimated to be worth $22.7 billion (National Association of Regional Councils, 2004).

According to Experience Corps (2004):Nearly half of Americans 55 and over volunteered in the past year43% of those 75 and older volunteered in the past yearOlder adults volunteer over 7.5 billion hours per year

Barriers to Aging in Place

Older adults require long-term care when a chronic condition, ill-ness or physical/cognitive limitations interfere with their ability to perform personal care and household activities (Family Caregiver Alliance, 2004).

While many older adults are able to maximize their independence and remain in their homes by receiving assistance in their house, apartment or assisted living community, others are unable to age in place due to a range of barriers, such as:

Economic and structural barriersAccess to servicesNavigating resourcesTransportation issuesDeterioration of homesHome safetyHealth care needsEconomic and Structural Barriers

It is important to emphasize that the socioeconomic status of old-er adults greatly impacts their ability to age in place. Older adults with high incomes are more likely to afford costly home-based ser-vices, home modifi cations and the option of living in Continuing-Care Residential Communities that enable older adults to age in place.

On the other hand, older adults with limited fi nancial resources, the majority of whom are ethnic minorities and women, are likely to face structural and economic barriers to aging in place.

In order to age in place, older adults need to have their housing and health needs met. Unfortunately these sectors function as two separate divisions with confl icting guidelines, allocation methods and eligibility criteria. As a result, many older adults may be eligi-ble for some but not all of the services needed to help them stay in their homes. In addition, many older adults who are unable other-wise to afford home-based services fall just above eligibility crite-ria and do not qualify for government assistance.

In summary, the following structural and economic barriers to ag-ing in place exist for low income older adults (Lawler, 2001):

The eligibility guidelines for housing programs oftenconfl ict with the eligibility criteria of health programsMedicare does not cover enough servicesOnly the sickest and poorest older adults are eligiblefor MedicaidHousing programs and subsidies usually support renters

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and not homeowners (the majority of older adults own their own homes)Health and housing resources are allocated differently

Strategies for Aging in Place

In response to the range of barriers to aging in place, social work-ers play an important role in enabling older adults to stay in their homes.

The following are strategies to help older adults age in place:Increasing access to servicesCare managementHome safetyHome modifi cationsAssistive devicesTransportationCommunity and home-based servicesInformal networks of support

Increasing Access to Services

Differences in income, health and social networks have a great impact on aging in place. Several comparative analyses of older African Americans, Hispanic Americans, American Indians and Asian American/Pacifi c Islanders found that as a whole, these older ethnic groups face an increased risk of shorter life expectancy, poor health, poverty, malnutrition and poor housing quality (Hooyman and Kiyak, 1999). As a result, these are the populations most in need of services to help them age in place.

Social workers benefi t by understanding the structural, economic and cultural barriers to service utilization and how we can structure programs and services that are accessible to ethnic older adults to help them age in place.

Barriers to Service Utilization Among Ethnic Older Adults: (Hooyman and Kiyak, 1999)

Lack of knowledge about servicesCultural isolation/language differencesPerceived stigma of using servicesConfusion/anger/fear of health care providers & hospitalsLack of trust of professionals and Western systemLocation of servicesLack of transportationLack of services and staff that are oriented towards respec-tive minority groups

Increasing Access to Services by Ethnic Older Adults (Hooyman and Kiyak, 1999)

Service locations in ethnic communitiesBilingual/bicultural staffCulture and language appropriate forms andassessment toolsCulture appropriate foods and activitiesPersonalized organizational climateInvolve ethnic minorities in program planning andservice deliveryUtilizing existing minority-targeted media and community groups (such as civic clubs or churches) to promote and link to sources of help

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Care Management

As the number of older adults has increased, so has the number of services to help older adults remain in their homes and commu-nities. For-profi t entities, community-based organizations and lo-cal, state and federal governments offer a wide variety of services to help seniors age in place. Adult day care, home delivered meals, home care, transportation and housing services are some of the var-ious programs offered. However, without a central point of entry, the result can be a complicated maze of services that can be diffi -cult for the average older adult to navigate (Yagoda, 2004).

In response to this challenge, many programs support care manage-ment (also known as geriatric care management for social work-ers who have a specialization in geriatrics) as a core component of their services. Care management is an individualized approach that aims to plan, seek and monitor services from various agencies on behalf of clients in order to maximize their functioning (Wodarski and Williams-Hayes, 2002).

Web ResourcesFor more information about geriatric care and case management, please visit:National Association of Professional GeriatricCare Managers:www.caremanager.orgNASW Standards for Social Work Case Management:www.naswdc.org/practice/standards/sw_case_mgmt.asp

Home Safety

Home safety is a critical aspect of allowing older adults to stay in their homes. Social workers often play a part in assessing the safe-ty of their older clients’ homes. The following article, published by the American Society on Aging, analyzes some of the assessment tools used to measure home safety.

Home Modifications

Once homes have been assessed for safety considerations, it may be necessary to make modifi cations to the home. Some of the ben-efi ts to home modifi cations include (Pynoos, 2001):

Promoting independence by making it easier to perform tasksFacilitating caregivingReducing accidentsEnabling older adults to engage in major life activitiesReducing health care costsDelaying institutionalization

Examples of home modifi cations that older adults may requireinclude (AARP, 2004):

No-step entryRamps or elevatorsOne-story living (bathroom and bedroom are located on the fi rst fl oor)Wide doorwaysWide hallwaysHandrails and grab barsNon-slip surfacesGood lightingLever door/faucet handles

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Examples of barriers to home modifi cations include (Pynoos, 2001):

Costs and affordability of modifi cationsConsumer confusion about funding sources and providers of modifi cationsLack of awareness about the problems in the physical environmentLack of awareness about the benefi ts of homemodifi cations

One example of a statewide strategy to address the barriers to home modifi cations included a state-wide partnership between local uni-versities, community-based agencies and retail Lowe’s hardware stores to offer education about home modifi cation options to help seniors age in place (Price, Zavotka and Teaford, 2004). This study found that there was a lack of knowledge among consumers and professionals on strategies for aging in place, including how old-er adults can modify their homes to adapt to their changing needs. The result of this collaboration, which included community work-shops, professional trainings and in-home assessments, was an in-creased interest and awareness about home modifi cations to help older adults age in place.

Another strategy to home modifi cation barriers includes increas-ing the use of home-modifi cation specialists. Home modifi cation specialists are able to assess the homes of older adults and pro-vide cost-effective strategies based on the assessment and consum-er input.

To find a home-modification specialist in your area, please visit: National Association of Home Builders, Database of Certified Aging-in-Place Specialists:http://www.nahb.org/generic.aspx?sectionID=126&genericContentID=8484

The ability to afford home modifi cations may act as a barrier to aging in place for some seniors, as they can be expensive and not always seen as a priority. Financial programs and other resourc-es may be available to help older adults with low incomes. Social workers who are knowledgeable about resources for home modifi -cations in their communities can help educate their older adult and family member clients.

To find out about home modification resources in your area, please visit:National Resource Center on Supportive Housing and Home Modification, National Directory of Home Modification Resourceshttp://www.homemods.org/national_directory_homemods/For more information about home modifications, please visit the following websites:AARP Home Design:http://www.aarp.org/life/homedesignNational Home Modification Action Coalition:www.homemods.org

Assistive Devices

Assistive devices are products which are used to increase, maintain or improve functional capabilities of individuals with disabilities.

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To put it simply, an assistive device, wheth-er hi or low tech, is a tool that is used to ac-complish a task.

Examples of assistive devices include (Bodine and Beems, 2002):

WalkersWheelchairsGrab barsReachersIdentifi cation braceletsPhoto-dial telephonesLarge print clocks and calendarsLaminated checklistsAutomatic pill-dispensing devicesListening systemsPicture cookbooksWander alert systemsSignaling devices

Assistive devices are another solution to helping older adults age in place and re-main independent. Each state has a desig-nated assistive technology program that of-fers a wealth of information and resources about assistive devices and how to obtain them.

Transportation

Having reliable, accessible and affordable transportation is a key factor in allowing older adults to age in place.

Despite the preference to remain indepen-dent and able to drive their own vehicle, nearly 7 million older adults aged 65 and older are not able to drive (AARP, 2002). Physical, fi nancial and community barri-ers to alternative forms of transportation put many older adults at risk for institution-alization, as they become isolated and im-mobile. Older adults without transporta-tion suffer by losing reliable access to their health care appointments, social activities and other means of feeling independent.

The article on page 11, published by the American Society on Aging, further dis-cusses the transportation issues faced by older adults.

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Web Resources For more information about transportation, please visit the following websites:AAA Foundation for Traffic Safety Quizzeshttp://www.aaafoundation.org/quizzes/index.cfm AARP Driver Safety Programhttp://www.aarp.org/driveTransit Services for Seniorswww.apta.com/research/info/briefings/briefing_3.cfm

Community and Home-Based Services

Depending on the community, there are most likely a number of community and home-based services that enable older adults to stay in their home. As mentioned before, care management helps to connect their older adult clients with resources and coordinate services in the community to help them age in place.

Below is a brief list of community-based resources as well as links to websites for further information.

Adult Day Services

Places in the community where older adults can go during the day for socializing, ac-tivities, meals and assistance with personal care and personal safety.

Friendly Visitors and TelephoneReassurance

Volunteer-based programs that provide reg-ular personal or telephone contact for older persons who are homebound or live alone.

Home Care Services

In-home assistance with health care, house-hold tasks, emergency response systems, personal care and respite for caregivers.

Nutritional Programs

Home-delivered meals or congregate nu-trition sites in the community that provide low-cost, nutritious meals for seniors.

Transportation Services

Services such as van transportation, taxi vouchers and discounts for public transpor-tation.

For more information about community re-sources for older adults in your area, please visit the Eldercare Locator website atwww.eldercare.gov.

Additional Web ResourcesFor more information about community-based services, please visit the following websites:Meals on Wheels Associationof America:www.mowaa.orgNational Adult Day Services Association:www.nadsa.orgNational Association for HomeCare and Hospice:www.nahc.org

Informal Networks of Support

In addition to formal services that can help older adults age in place, informal net-works of support also play a role in the pro-cess. Informal networks can include family, friends and neighbors who can help older adults with home maintenance, shopping, transportation, meals and socialization. Community groups such as churches, youth groups and service clubs may also be pro-viders of help to assist older adults in the community (Himes, Oettinger and Kenny, 2004).

Role of the Social Worker

Social workers are likely to face the issue of aging in place in a variety of settings when working with older adults, caregivers and family members of all ethnicities and ages. Social workers may face this issue in a va-riety of roles; as care managers, clinicians, support group leaders, program planners, educators or advocates.

Although the specifi c skills and duties may vary from role to role, social workers who work directly with older adults or their fam-ily members may utilize the following skills (Yagoda, 2004):

EngagementOutreach and identifi cation of clientsRelationship formationAssessmentNeeds assessmentFunctional assessmentBiopsychosocial assessmentStrengths assessment (individual and community)Comprehensive intakeResource/fi nancial assessmentHome safety assessment PlanningInterventionTreatmentCare

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RehabilitationStrategicSupportCrisis interventionImplementation/CoordinationService brokeringMonitoring service deliveryImplementationClient supportAdvocacySystems improvementClient well-being and functioningLiaisonMediationReassessment/EvaluationMonitoringEffi cacyEffi ciencyData collectionData analysisDisengagement Discharge planningTransferTermination

Social workers who work directly with old-er adults are encouraged to use a strengths-based perspective, which incorporates the strengths of the older adult client, fami-ly, friends and the community to help the client live independently and age in place (Wodarski and Williams-Hayes, 2002).

In addition to the diagnosis, problems and functional status surrounding the activities of daily living (ADLs) and instrumental ac-tivities of daily living (IADLs) of clients, social workers will demonstrate their con-fi dence in the abilities and independence of their clients by also including their strengths as part of the assessment process.

Examples of a strengths inventory include (Fast and Chapin, 2002):

Information on personal & environ-mental strengthsPriorities identifi ed by the clientInterests, wants and needsSocial supportsReligion and spiritualityLeisure and recreational interests

For social workers who are new to the issue of aging in place, a good place to start is to explore your values about the issue and how you may face it in your work, personal life and community. You can start by ask-ing yourself the following questions:

How will I feel about aging in

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place as an older adult? When I am 65 years old? When I am 85 years old?How can I keep my own attitudes and preferences from coloring the way I work with others?How can I help older adults cope with losing their ability to function independently?When might aging in place no lon-ger be an option for older adults?How have I faced this issue in my personal life? How has my community dealt with this issue?

Another helpful way for social workers to learn more about the issue of aging in place is to learn about local resources for aging in place by asking the following questions:

How can I assist my clients with as-sessing the home for safety issues? Which checklists are available to me?Where can I refer clients to for home modifi cations? What are the various options and costs? Is there any fi nancial assistance available?Where can I locate a home modifi -cation specialist in my area? How much does this cost? What are the options for using a home modifi ca-tion specialist?What kinds of assistive devices are available for older adults? What are the easiest and most affordable ways for my clients to order them?How can I help my clients assess the driving ability of themselves or their older family members? What are the transportation options for older adults who are not able to drive? What community-based organiza-tions are available to meet the nutri-tional needs of older adults?What adult day centers and home care agencies are in my area? What are the options and costs? Are there fi nancial assistance programs?

Case Study

Let’s further explore some of these issues in the following case study. Please read the following example and the discussion ques-tions that follow.

Mary is 55 and the only daughter of her 82 year-old mother, Mrs. J. Mary lives in the

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next city over from Mrs. J, who lives alone in an apartment in the same city she has re-sided in for over fi fty years. After seeking out assistance from a fi nancial advisor, they sold the house Mrs. J and her husband lived in after he passed away. Rather than mov-ing in with Mary, Mrs. J insisted on living in her own apartment in the same area she has been living in for many years.

Mary reports that Mrs. J has always been a strong and independent woman and has made it very clear that she never wants to be dependent on Mary or live in a nursing home. Mary helped Mrs. J choose an apart-ment that was close to a bus stop, market and local senior center. Mrs. J used to walk to the market and senior center, but in re-cent years suffered from a fractured hip and infection after falling in her bathroom.

Mary has noticed that her mother’s apart-ment is becoming cluttered and messy. Mrs. J does not leave her apartment and asks her daughter to do a weekly shopping trip for her. Mary reports that she is concerned because Mrs. J’s ability to use a walker is declining and there isn’t a ramp in her apartment building. She is also concerned because Mrs. J is unable to leave the house or cook for herself. Additionally, she is wor-ried because on many occasions, Mary has been unable to reach her mother by phone because Mrs. J isn’t able to get up and walk to it in time. Mary is worried about what might happen in an emergency situation.

Mary thinks that perhaps moving Mrs. J to an assisted living community might solve her problems. She would be safe, have her meals cooked for her and would be able to socialize with other residents. Mary re-ports that Mrs. J insists she wants to stay in her home. Mrs. J admits to feeling “a bit blue” over the past year but points out that her “mind is still in order” so she can make her own decisions. Mrs. J says that she will only “go downhill fast” if her daughter moves her into “one of those homes.” Mary contacts a social worker referred by her lo-cal area agency on aging for assistance.

Case Study Discussion Questions

Imagine that you are the social worker and Mary is your client seeking out help with her situation. Please read and think about the following discussion questions.Question: When working with Mary, she asks you whether or not you agree with her

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idea to move Mrs. J into an assisted living facility.

Take a minute to think about how you feel about this situation given the information presented.

How do you respond to Mary?Tell Mary that you think she is right, her mother would benefi t the most from liv-ing in an assisted living communityTell Mary that you think she is wrong, her mother would benefi t the most from living in her own apartmentTell Mary that you think her mother should move in with herNone of the above

Discussion: None of the above. The role of the social worker is not to tell Mary wheth-er or not you think her mother should live in an assisted living community, despite how you may feel personally about the situation. The role of the social worker in this case is to build a relationship with both Mary and Mrs. J, to collect information and assess which interventions to take.

Question: After the initial meeting with Mary, what might be the next step when working with Mary and Mrs. J?

Assess Mrs. J’s apartment for safetyAssess Mrs. J’s functional abilitiesAsk Mrs. J about her desires and strengthsAll of the above

Discussion: All of the above. Mrs. J and Mary can both provide valuable informa-tion during the assessment process that will help the social worker formulate a plan. Since Mrs. J has suffered from a fall be-fore, the apartment needs to be assessed for safety and possible home modifi cations. The social worker may need to include the landlord in this process. In order to decide which services Mrs. J can benefi t from, the social worker needs to assess her function-al status and ability to live independently. Finally, asking Mrs. J about her desires and taking a strengths inventory will demon-strate your confi dence in her abilities.

Question: What community resources might help Mrs. J stay in her home?

Home delivered mealsHome care services (homemaking)

Home modifi cationsAll of the above

Discussion: All of the above. There are many resources that may assist Mrs. J to live independently. For example, a home-making service could help with the clutter and mess as well as the shopping and regu-lar chores. Since Mrs. J is no longer able to cook, she is a good candidate for home de-livered meals. Home modifi cations, such as a ramp, grab bars, non slip surfaces, emer-gency alert systems, cordless phones and good lighting are examples of options to make the apartment safer for Mary’s moth-er. Mrs. J may also need to work with her doctor about whether or not she should be using a wheelchair if she is having trou-ble with her walker. In addition, the social worker can address the isolation of Mrs. J by suggesting ways of socialization, such as adult day services, friendly visitor pro-grams, or transportation alternatives to the senior center she used to attend. Question: As the social worker in this situ-ation, you have come across many clients who are facing aging in place issues. Unlike Mary and Mrs. J, many are unable to afford home modifi cations and often do not qual-ify for assistance programs. You think that your community needs to make aging in place a priority by improving transportation for older adults, educating families and pro-fessionals about aging in place options and fi nding ways to make home modifi cations and other services more affordable. How might you take action?

Start a local coalition or task force with other professionals and community membersRaise awareness through editorials, pol-icy briefs and other publicationsAsk clients, family members and other social workers to write letters or call lo-cal decision makers as well as testify at public hearingsAll of the above

Discussion: All of the above. Social work-ers can fi nd many ways to involve them-selves with advocacy efforts on issues that impact their clients and the community. Starting a coalition or task force, raising awareness, using the voice from the com-munity (clients and family members) and informing decision makers are all examples of advocacy efforts that social workers can participate in.

Ethnicity & Multicultural Considerations

The older adult population, whose current majority is of European decent, is becom-ing increasingly diverse. Record high im-migration rates indicate that the trend of a diverse older adult population will only continue in the coming decades (Capitman, 2003).

Culture is defi ned as “the way a group lives, the ethnic background, the race, the values and norms of behavior, and ways of think-ing that are passed down through genera-tions and make the person an identifi able group in a society” (Leigh, 1998). Since culture shapes the life experiences of each individual, social workers can benefi t by understanding the cultural composition of their older ethnic clients and how it impacts communication, attitudes, values and the presenting problems of clients.

When working with older ethnic adults, social workers benefi t by having a gener-al knowledge of the cultural characteris-tics of various ethnic groups they may be working with. At the same time, it is im-portant to remember that each client comes from a unique experience that may not fi t into a predetermined cultural blueprint and may be dissimilar from the generalizations about his/her ethnic group.

To learn more about how the culture of the individual older ethnic adult affects the is-sue of aging in place, social workers can ask guiding questions about the client’s cul-tural perspective on matters such as aging, housing, illness and family systems.

Case Study

Joon is a divorced 40 year-old Korean American woman. She has no children and is a lawyer in Los Angeles. Her parents and two older brothers moved to the United States from Korea before she was born. Joon’s father passed away a few months ago and her brothers agreed that their 72 year-old mother should move out of their house in Koreatown and live in Joon’s two bed-room condo in a different part of town. Joon is feeling guilty because she doesn’t want her mother to move in with her. Although she feels obligated to take care of her, Joon is very independent, career-oriented and worries that her mother will be very lone-ly and isolated living with her. According to Joon, her mother has mentioned that she doesn’t like the idea of leaving Koreatown.

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As opposed to the area Joon lives in, her mother can communicate in her native language in Koreatown and has many friends that she socializes with. Joon’s brothers feel very strongly that their mother should not live alone. They both have children still living at home, do not have an extra room in their house and do not understand why Joon would put her career before their mother. Their mother doesn’t like to argue and says her sons probably know what is best. Joon has decided to seek help from a social worker but hasn’t told her family. Joon provided some information to the social work-er over the phone prior to making an appointment for the follow-ing week.

Case Study Discussion Questions

Question: Before the social worker meets with Joon, he or she would benefi t from:

Contacting Joon’s brothers to gather some additional informa-tionContacting Joon’s mother to gather some additional informa-tionLearn more about the general characteristics of Joon’s cultureAll of the above

Discussion: Learn more about the general characteristics of Joon’s culture. Prior to meeting with Joon, the social worker in this case will benefi t from having a general understanding about Joon’s cul-tural background and how the characteristics of Korean culture might be affecting this situation. Some issues to learn more about might include immigration patterns, differences in generations, at-titudes toward utilization of social services, aging, illness, death, mental health, divorce, family systems and gender roles. Once the social worker has a general knowledge of Joon’s cultural group, he or she can then learn about Joon’s personal experience as a Korean American woman and compare this against group generalizations to individualize Joon’s culture and how it impacts the issue she is facing.

Question: What are some skills the social worker can use during the fi rst meeting in order to gain Joon’s trust?

Follow agency assessment protocol by asking preset questionsStart where the client (Joon) is atAsk Joon to bring her family members and act as a mediatorAll of the above

Discussion: Start where the client (Joon) is at. Although agency as-sessment questions are useful and necessary tools for social work-ers, it may be inappropriate to begin right away with this approach. In order to have a successful helping relationship, the social worker needs to establish and build a relationship by starting where Joon is at and learning more about Joon’s cultural perspective. When meet-ing for the fi rst time, it may be helpful to get a sense as to how Joon feels about her present situation and coming to speak with a social worker. It may also be helpful for the social worker to explain the role that each of them play during the helping relationship. In addi-tion, the social worker may be more effective by allowing Joon to guide the social worker in his or her understanding of Joon’s cul-ture and how it impacts her presenting situation.

Question: As the social worker in this situation, how would you ap-proach Joon’s feelings of guilt?

Ask Joon about what a Korean daughter might be expected to do in this situationTell Joon that she has nothing to feel guilty aboutTell Joon about senior living options in her areaNone of the above

Discussion: Ask Joon about what a Korean daughter might be ex-pected to do in this situation. By doing this, the social worker will learn more about cultural norms and get more insight about Joon’s feelings of guilt. Having this knowledge will help guide the social worker’s interventions. Telling Joon not to feel guilty or suggest-ing senior housing options for her mother might be inappropriate in this situation and could potentially offend Joon. The social worker can build trust in Joon by asking her to explain her feelings of guilt and empathizing with the client.

Ethical & Legal Considerations

Social workers may encounter diffi cult ethical dilemmas when try-ing to help their older clients age in place.

Examples of dilemmas may include: The older adult wishes to remain independent in his or her home but the condition of the home is unsafeThe older adult is no longer able to keep up adeteriorating houseThe older adult does not qualify for resources to help him/her age in place but is unable to afford necessary services and home modifi cations The older adult requires a level of assistance that requires around-the-clock careThe family thinks the older adult will be safer and bet-ter off in an institution but the older adult has expressed strong feelings to stay in his/her homeOlder adults with cognitive impairment without local family members who begin to require constant care and supervision

The following article, published by the American Society on Aging, further explores some of the ethical dilemmas that social work-ers might face when working with older adults and their families around aging in place.

Policy Considerations

In order to make aging in place a reality for many older adults and the increasing number of older adults to come, efforts need to be made on a national, state and local level.

The Joint Center for Housing Studies at Harvard University main-tains that an overhaul of our national, state and local systems needs to include rethinking the health and housing sectors as two sepa-rate divisions and to see them instead as two integral parts of one unifi ed service-delivery system (Lawler, 2001). Their recommen-dations include:

Creating a pooling agency to combine health and housing resources at the state and/or local levelEliminating regulatory barriers that prevent the overlap of health and housing sectorsInclude housing in each state’s Olmstead planning process

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Recognize the assets of community-based organizations in coordinating health and housing services at the local level

Consumer-Directed Care

Another policy consideration concerns consumer-directed care. The ability to age in place often relies on the use of home- and community-based programs. As the movement to help older adults and disabled populations remain independent in their homes has mounted, so has the concept of consumer-directed care. Consumer-directed care, usually in reference to the use of home- and com-munity-based services, emphasizes the ability of older and dis-abled consumers to assess their own needs, make decisions based on choices and options, and monitor the quality of their services (National Council on Disability, 2004).

As the number of older and disabled adults who utilize consumer-directed home- and community-based programs increases, policy considerations arise for both consumers and the government. One policy consideration includes the quality of services, as the quality of consumer-directed programs is not regulated by the government. Another policy consideration is the experiences of the workers and consumers in consumer-directed programs. Traditional home- and community-based services maintain control of the salaries, poli-cies and supervision of their employees. In consumer-directed care however, the consumer has complete control over and directly su-pervises the worker.

A comparison of consumer-directed care programs in fi ve coun-tries by Tiller, Wiener and Cuellar (2000) revealed the following lessons learned:

Research indicates that older people are less likely to want consumer direction than younger people, although a signifi cant minority prefers control over their services. Therefore, programs should be fl exible to accommodate varying preferences.Cognitive impairment raises concerns about the capacity of older consumers to manage their own care. However, persons with cognitive impairment can participate in con-sumer-directed programs with the assistance of a surrogate decision maker (caregiver or family members).The most controversial issue in consumer-directed care is the quality of consumer-directed care and how services should be monitored.

Independent workers in consumer-directed care are more satisfi ed than their counterparts in agency-based service environments, al-though do not get compensated as well. However, many indepen-dent workers in consumer-directed care are family members.

Conclusion

This course has aimed to provide an overview of the issue of ag-ing in place in various social contexts with a specifi c focus on the role of the social worker. As older adults face increasing health and cognitive changes, they may require increasing assistance with their daily activities and decision making. Social workers are of-ten at the forefront of helping older adults and families deal with this issue and face the challenge of fi nding the balance between the wishes, safety and independence of older adults. Often we must look inward to understand what “home” means and how this may

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differ from person to person in the context of one’s culture, socio-economic status and family system. This course has offered strat-egies to promote aging in place as well as an introduction to the larger social and policy issues surrounding meeting the housing and health needs of older adults.

ReferencesExperience Corps. “Fact Sheet on Aging in America.” Retrieved

on 12/1/04 from www.experiencecorps.org. Washington, DC: Experience Corps.

Family Caregiver Alliance. Fact Sheet: Selected Long Term Care Statistics. Retrieved on 11/23/04 from http://www.caregiver.org. San Francisco, CA: Family Caregiver Alliance.

Fast, B. & Chapin, R. (2000). Strengths-Based Care Management for Older Adults. Baltimore, MD: Health Professions Press.

Golant, S. (2002). “Deciding Where to Live: The Emerging Residential Settlement Patterns of Retired Americans.” Generations. Vol XXVI (2):66-73. San Francisco, CA: American Society on Aging.

Hetzel, L. & Smith, A. (2001). “The 65 Years and Over Population: 2000.” Census 2000 Brief. Retrieved on 11/29/04 from http://www.census.gov. Washington, DC: U.S. Census Bureau.

Hooyman, N. & Kiyak, H. (1999) Social Gerontology. 5th Edition. Needham Heights, MA: Allyn & Bacon.

Kercher, B. & Rubenstein, L. (2002). “Home-Safety Checklists for Elders in Print and on the Internet.” Generations. Vol XXVI (4):69-74. San Francisco, CA: American Society on Aging.

Lawler, K. (2001). “Aging in Place, Coordinating and Health Care Provision for America’s Growing Elderly Population.” Joint Center for Housing Studies of Harvard University. Retrieved on 12/10/04 from http://www.jchs.harvard.edu. Cambridge, MA: Harvard University.

Leigh, J. (1998). Communicating for Cultural Competence. Needham Heights, MA: Allyn & Bacon.

National Council on Disability. “Consumer Directed Health Care: How Well Does it Work?” Retrieved on 12/10/04 from http://www.ncd.gov. Washington, DC: National Council on Disability.

Partners for Livable Communities. Aging in Place. The Issue: Defi ning the Problem. Retrieved on 11/22/04 from http://www.livable.com/aging/issue.

Price, C., Zavotka, S & Teaford, M.(2004). “Implementing a University-Community-Retail Partnership Model to Facilitate Community Education on Universal Design.” The Gerontologist. Vol 44 (5):697-702. Washington, DC: Gerontological Society of America.

Pynoos, J. (2001). Meeting the Needs of Older Persons to Age in Place: Findings and Recommendations for Action. The National Resource Center for Supportive Housing and Home Modifi cation. Retrieved on 11/29/04 from http://www.usc.edu/dept/gero/nrcshhm/research Los Angeles, CA: Andrus Gerontology Center, University of Southern California.

Ron, P. (2004). “Depression, Homelessness and Suicidal Ideation Among the Elderly: A Comparison Between Men and Women Living in Nursing Homes and in the Community.” Journal of Gerontological Social Work. Vol 43 (2/3): 97-116. Binghampton, NY: Haworth Press, Inc.

Continued on page 17

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The word mobility refers to the quality of “being mobile, movable, or moving readily.” For older people, personal physical mobility is infl uenced to a considerable extent by age-related changes that in combination affect muscle strength, posture, balance, and joints (Wagner and Kauffman, 2001; Whitbourne, 2002). Thus, for older people mobility in the community, and the performance of mobile activities like walking, often depends on environmental modifi ca-tions such as curb cuts, ramps, and signs that help people with mo-tor and sensory defi cits get around (Christiansen and Hammecker, 2001).

This article considers later-life mobility in the broader context of transportation (Schaie and Pietrucha, 2000). The private automo-bile continues to be the main source of transportation in our soci-ety—the primary way people gain access to services and maintain social relationships. Continuing to drive is a major factor in avoid-ing social isolation and maintaining full participation in commu-nity life. With age, changes in abilities and skills related to driv-ing may require the individual to modify driving behavior or cease driving (Sterns, Barrett, and Alexander, 1985). At age 80-plus, the proportion of older adults whose usual means of transportation is their own car falls below 50 percent. Yet, the changes in an indi-vidual’s physical mobility often make it more diffi cult to use mass transportation systems unless the system makes special modifi ca-tions. Changes in mobility can result in the loss of quality of life for older people (Schaie, 2000).

The issue of mobility and quality of life for older adults is not new. In 1976, Golant emphasized that transportation diffi culties may be the fi rst sign that a person is “becoming old” and may no longer be able to carry on his or her life in the same way as in the past. Studies of older adults’ transportation needs and modes have been available for more than twenty-fi ve years. However, the dramatic increase in the number of older adults seen now and predicted in the future demands increased attention.

Carp (1979, p. 127) stated that “unless old people can meet all their needs within the confi nes of their own homes, their satisfaction de-pends upon their mobility into the wider community, and this, in turn, is contingent upon the transportation facilities available.”

In 1971, approximately 46 percent of heads of household age 65 and older had no car. Today, people are keeping their cars and con-tinuing to drive much longer. Even frail older adults are driving more and more, and they are thus more apt to be involved in a fatal accident. With more people living longer, more people are outliv-ing their driving skills (Sterns et al., 2001). A major concern now is how to enable people to drive as late in life as possible, as long as they can do so safely, and to get them to stop driving when it is no longer safe. The challenge is to facilitate the transition from driv-ing to the next phase, driving and using transportation services, to the next phase, not driving but using transportation services.

Clearly, then, any consideration of transportation for older people must go beyond issues about driving. However, the primacy of the personal automobile in the United States is one of the greatest bar-riers to development, or even discussion, of a workable system, and this situation shows few signs of changing. While many peo-ple who are older adults now did use public transportation when they were young and may view the use of public transportation more positively, many younger adults have no experience with the use of public transportation. What is required is that people of all ages be made aware of the importance of developing and support-ing a range of transportation services in our communities, and they must be made aware of the range of service options that can be available.

Licensing agencies, safety forces, physicians, service providers, and families all play a role in a complex process. A modern geron-tologist needs to not only understand individual differences in abil-ity, but to offer interventions and solutions that give older adults choices that maintain their mobility in the community. The devel-opment of new professional roles and testing approaches helps us to better understand evaluations of normal and abnormal aging-re-lated changes in older drivers. Information from evaluations will give older adults the information they need to change their driving and to cease driving as appropriate.

Another major set of issues relates to how older adults who have stopped driving can continue leading full lives by using transpor-tation choices as well as mobility support by family. Communities that want to be “elder-friendly” need to develop appropriate plan-ning and coordination of services.Self-Management and Choices

Sterns and Gray (1999) emphasize the challenges faced by midlife and older adults as they seek to make informed choices about their transportation needs, saying that “the individual needs to be in charge, in control, and able to select adaptive options.”

An important continuing area of research will focus on the abil-ity of older people to plan and manage their own retirement. An important aspect of such planning for later life is consideration of mobility: How will I get around when I am older and my capabil-ities have changed? Successful planning for later life means mak-ing choices that will allow the person to live in the style that he or she chooses. For many people, maintaining driving skills is clearly important. But even more important is making sure that if they can no longer drive, they live in a location that provides transportation services. Retirees often choose to live in an isolated area, but such a choice may not serve them well in their later years. Part of taking responsibility for one’s own later life means making choices that facilitate mobility in a range of possible conditions. (See adaptive strategies listed on page 7).

Moving Along the Mobility Continuum:Past, Present, and Future

By Harvey L. Sterns, guest editor, Jon E. Burkhardt, and John W. Eberhard

11

Mobility and Safety

Sterns, Barrett, and Alexander (1985) have emphasized that old-er adults need to continue to live and work as they always have. Unless there is compelling evidence to the contrary, people should be encouraged to maintain their lifestyle and activities as they age. It should be remembered, however, that age-related changes and declines in health caused by disease may alter the performance level of critical skills, making older adults less able to meet task demands and thus subject to an increased risk of injury.

The term safety may be defi ned as the state of being free from danger or injury, or the use of various methods and devices to re-duce, control, or prevent accidents (U.S. Offi ce of Technology Assessment, 1978). In discussing safety and risk, W. T. Singleton (1979) points out that we are often better able to specify the degree of hazard or risk than to specify the degree of “safety.” Our de-scriptions of danger presented by an environment are likely to be more precise than our descriptions of the lack of danger.

In carrying out their daily activities, individuals are exposed to a number of risks. Their level of skills, their exercise of these skills, and the resulting level of safety are variables in a complex cost-benefi t equation. People make judgments regarding activities to determine whether the risk of injury is suffi cient to be a deterrent. Since some older adults may not be aware of their changing levels of skill, they may be unrealistic in their judgments.

Experience provides the opportunity to develop and maintain skills, and in many situations, it may be the only way to acquire and maintain the needed knowledge and performance capabili-ty. Assessment and training can provide the needed feedback and training. If necessary, the individual may need to be counseled to stop an activity, such as driving.

Maintaining Personal Mobility

Public transportation options for older adults have been recent-ly addressed by the Transportation Cooperative Research Program Report 82 (Burkhardt et al., 2003) “Improving Transit Options for Older Persons.” Looking to the future, it is clear that trips out of the home by older adults are increasing dramatically. Most trips by older people are now made in private autos. Today’s older adults use public transit for about 3 percent of their trips—fewer than 12 percent of all older adults have used public transit in the past twelve months. It should be noted that 34.3 percent of older adults have no public system available.

Many older adults now live in communities that are highly auto-oriented, and many more will do so in the future. Most people now in the generations of future older adults now living will have been confi rmed auto users all of their lives and are “high mobility con-sumers.” It is apparent that demands for all kinds of transportation services will increase.

In the future, older adults will expect to be able to make more and different types of trips that are not currently available because of various limitations. People will expect high levels of consumer choice and fl exibility. It is clear that we are not ready to meet the forecasted changes.

Focus-group research indicates that older adults are most con-cerned about the reliability of public transit. Many older people are not able to wait outside for long periods of time, especially in poor weather conditions. On-time arrivals are considered very important. Older adults want door-to-door service, and they want fl exible service that responds to the needs that they may have on a particular trip. This service could include help in carrying parcels or traveling with other people.

Older adults also indicate that they want comfortable vehicles and waiting areas. They want to be able to have access to service on less than a twenty-four-hour notice. Older travelers want to be able to travel more hours of the day and days of the week than many public transit authorities currently offer. As travel consumers, they want control, autonomy, and choice.

Our understanding of the needs of the future comes at a time when there is lack of funding, lack of interest, and reluctance to begin the process of changing our transportation approaches.

Perspectives on Transportation Modes:Independence-Dependence

At every level of capability, older adults desire to maintain inde-pendence, decision making, and choice. Sterns and Sterns (2000) have emphasized that, traditionally, transportation choices have been studied in the framework of a transit-centered continuum, which emphasizes the modes of transportation. This bipolar con-tinuum begins with drivers of a private vehicle, considered by transportation planners to be most desirable because it provides the greatest degree of independence, and ends with riding a public fi xed-route bus or train, considered by transportation planners to be the least desirable because it results in the greatest degree of de-pendence (Figure 1). By placing private and public transportation modes on the same continuum, the transit-centered approach dis-regards the fact that anyone using public modes must have certain capabilities. Further, the approach does little to recognize or sup-port those older adults who use more than one mode to travel.By emphasizing the bipolar anchors of personal independence and dependence instead of discrete points along the continuum, geron-tologists offer another way to consider decisions about using trans-portation modes.

This person-centered approach recognizes the relationship be-tween an individual’s capabilities and the environment in which those capabilities must fi t and leads to a categorical division in as-sessing degrees of personal independence in using private versus public modes. The market-centered continuum (Figure 2) focuses on the highest levels of personal independence and decision mak-ing available in the private modes, such as walking and driving a car, and in public modes, such as using fi xed-route transportation services. In the most independent mode, public or private, the indi-vidual chooses where, when, and how to travel. In both instances, the person must display high level of capability and independence in travel ability for system use.

The market-centered continuum emphasizes the individual us-er’s independence of choice and action in using various modes of transportation and the complexity involved in making choices of

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which modes to use. Research indicates that older adults, especial-ly those with limited functional capabilities, do not rely on a single transportation mode for all trips. They tend to choose among a va-riety of transportation modes for specifi c trips, depending in their capability for making a particular trip and mode availability. Older adults prefer the independence afforded by fi xed routes and de-mand-responsive public transportation to the dependence on fam-ily or friends for a ride (Burkhardt, 2000; Burkhardt et al., 2003; Nelson and Sterns, 1996).

Conclusion

The importance of mobility through transportation options is cen-tral to the concept of independence. One of the lessons of later life is to accept, when necessary, help from others, including fam-ily and friends, as part of the informal support system and, when available, the options of the formal transportation support system. The best option is to be able to draw on the formal system, but also have the informal system available. It is important to remember that 34 percent of older adults are in areas with no formal transpor-tation services. Even in those areas that have transportation servic-es, the real issue is how accessible and acceptable the services are to older adults.

Harvey L. Sterns, Ph.D. is professor of psychology and director, Institute for Life-Span Development and Gerontology, University of Akron, Akron, Ohio, Jon E. Burkhardt is senior study director, WESTAT, Rockville, Md., and John W. Eberhard, Ph.D., is a re-search psychologist and consultant on transportation and aging is-sues, Columbia, Md.

References

Burkhardt, J. E. 2000. “Limitations of Mass Transportation and Individual Vehicle Systems for Older Persons.” In K. W. Schaie and M. Pietrucha, eds., Mobility and Transportation in the Elderly. New York: Springer.

Burkhardt, J. E., et al. 2003. “Improving Public Transit Options for Older Persons,” tcrp Report 82, Cooperative Research Program, Washington, D.C.: Trans- portation Research Board.

Carp, F. M. 1979. “Improving the Functional Quality of Housing and Environments for the Elderly Through Transportation.” In T. O. Byerts, S. C. Howell, and L. A. Pastalan, eds., Environmental Context of Aging: Life-styles, Environmental Quality and Living Arrangements. New York: Garland STPM Press.

Christiansen, C. H., and Hammecker, C. L. 2001. “Self-Care.” In B. R. Bonder and M. B. Wagner, eds., Functional Performance in Older Adults Second Edition. Philadelphia: F. A. Davis Co.

Golant, S. M. 1976. “Intraurban Transportation Needs and Problems of the Elderly.” In M. P. Lawton, R. J. Newcomer, and T. O Byerts, eds., Community Planning for an Aging Society: Designing Services and Facilities. Stroudsburg, Pa.: Dowden, Hutchinson & Ross, Inc.

Schaie, K. W. 2000. “Preface.” In K. W. Schaie and M. Pietrucha, eds., Mobility and Transportation in the Elderly. New York: Springer.

Schaie, K. W., and Pietrucha, M., eds., 2000. Mobility and Transportation in the Elderly. New York: Springer.

Singleton, W. T. 1979. “Safety and Risk.” In W. T. Singleton, ed., The Study of Real Skills, Vol. 2—Compliance and Excellence. Baltimore: University Park Press.

Sterns, H. L., and Gray, J. H. 1999. “Work, Leisure, and Retirement.” In J. Cavanaugh and S. Whitbourne, eds., Gerontology. New York: Oxford University Press.

Sterns, H. L., and Sterns, R. 2000. “Commentary: Social Structures and Processes in Public and Private Transportation.” In K. W. Schaie, and M. Pietrucha, eds., Mobility and Transportation in the Elderly. New York: Springer.

Sterns, H. L., et al. 2001. “Family and Friends Concerned About an Older Driver.” NTIS Publication No. dot hs 8090307. Washington, D.C.: National Highway Traffi c Safety Administration.

Sterns, H. L., Barrett, ., and Alexander, . 1985. “Accidents and the Aging Individual.” In J. E. Birren and K. W. Schaie, eds., Handbook of Psychology of Aging. New York: Van Nostrand-Reinhold.

U.S. Offi ce of Technology Assessment. 1978. Wagner, M. B., and Kauffman, T. L. 2001. “Mobility.” In B. R.

Bonder and M. B. Wagner, eds., Functional Performance in Older Adults, 2d Edition. Philadelphia: F. A. Davis.

Whitbourne, S. K. 2002. The Aging Individual—Physical and Psychological Perspectives, 2d Edition. New York: Springer.

“Moving Along the Mobility Continuum: Past, Present, and Future,” Reprinted with permission from Generations, Summer 2003, Volume XXVII, Number 2: 8-12. Copyright 2003 American Society on Aging, San Francisco, California. www.asaging.org.

13

First, do no harm. This is a major tenet in medical ethics. It is also the fi rst statement of the ethical principle of benefi cence—do-ing good, which holds that ethical profes-sionals act so as to benefi t their clientele and, at the very least, to do no harm.

This most basic goal of doing no harm has been extended in the view of some people to mean that the care and service plans de-veloped for home- and community-based services (HCBS) for older people should be designed to maximize physical safety and protection and to minimize the likelihood of preventable negative events, such as falls, injuries, or relapses. The social work-ers, nurses, and others who hold up safety as a goal may be doing so as part of their commitment to do no harm. But such pro-fessionals may have lost perspective on the nature of their appropriate role in helping individuals plan their lives; they may be as-suming too much responsibility. They may have also lost perspective on the facts—that is, what actually constitutes safety and what actually constitutes risk. With “do no harm” as the overriding goal, protecting clients ultimately may mean declining to serve them in their own homes because the plan may be unsafe. Protecting clients ul-timately may mean reshaping assisted liv-ing settings through regulations until they mirror more restrictive settings like nursing homes. Paradoxically, the desire to do no harm and to achieve safety above all oth-er goals may actually result in harm for the consumer.

The most exquisitely diffi cult ethical dilem-mas that arise in home- and community-based services concern the proper bound-aries between promoting freedom for older people and avoiding interference with their life goals, on the one hand, and acting re-sponsibly to promote their health and safe-ty, on the other. These are anguishing situ-ations for professionals. The case fi les of ethics committees that have sprung up in HCBS are littered with examples wherein professionals wrestle consciously and con-scientiously with the problems of striking

the right balance between safety and free-dom. Often, the professional has the pain-ful sense that he or she is joining the forces pushing unwilling clients toward nursing homes, yet the push seems to be for their own good.

The problems are exacerbated by the pro-found ambivalence that so many people feel about tradeoffs between their freedom and safety. Older people—like people of all ages—want to be both free and safe. Older HCBS consumers, who often are aware of their increased risks and diminished capa-bilities, can have great diffi culty making a necessary choice between the two values. In one study of more than 800 elderly clients in these settings, about a third chose free-dom, a third chose safety, and a third vacil-lated between the two (Degenholtz, Kane, and Kivnick, 1997). Professionals express similar ambivalence. One study (Kane, 1995) showed respondents overwhelming-ly agreeing with the proposition that older HCBS clients should be free to act against advice of a professional from an agency or program regarding risk-taking without the agency or program withdrawing from the scene. When asked to elaborate the circum-stances under which such client risk-taking would be permissible, almost all responded with a variant on the phrase “when it does not jeopardize their own safety and that of others.” Professionals endorsed informed risk-taking, but apparently only when it was risk-free!

In this article, we examine the concept of consumer risk-taking and profession-al responsibility in home- and communi-ty-based services. We then turn to possible ways for professionals to negotiate these ethical minefi elds, including an exploration of the relatively new concept of managed risk contracting, or negotiated risk. We ar-gue that active steps need to be taken to preserve and promote the right of compe-tent older people to make decisions about their care in general, not just narrow deci-sions about specifi c procedures. (Currently, it is easier to refuse a recommended ampu-

tation than a recommended nursing home placement.) However, some safeguarding procedures and perhaps even some regula-tion need to be in place to govern any con-tractual mechanisms for risk-taking among older HCBS clients.

The Right to Take Risks

One ethics sourcebook defi ned a risk as “an adverse future event that is not certain but only probable” (Shöne-Seifert, 1995). People who are competent decision-mak-ers ordinarily make autonomous decisions about the risks they wish to take based on the magnitude and the likelihood of expect-ed harms and benefi ts associated with each course of action. There may, of course, be limits to a person’s right to take informed risks. Obviously, one should not implicate other parties in one’s risk-taking. For ex-ample, the emphysema patient who wish-es to risk smoking around her oxygen sup-ply improperly endangers others in a living setting. On the other hand, the insulin-de-pendent diabetic who fails to stick to a diet may be said to risk injuring only himself. Yet, some would argue that this noncom-pliant individual has no right to repeated-ly drive himself into diabetic coma, if, in so doing, he harms others by drawing re-sources away from them. Without getting into the more abstract arguments about fi -nite resources for healthcare, we could cer-tainly argue that a person who has a week-ly health crisis in an assisted living setting takes valuable and often limited staff time away from others.

Let us assume a consumer’s desired risk-taking is likely to cause no harm to others. Let us further assume that the consumer has decided, after much consideration, that the benefi ts of following the risky course of action outweigh the potential harms to herself. She may still not be free to follow her preferences. Care providers might still argue that they cannot allow people under their care to assume certain risks because they, themselves, would then be negligent in their duties. For this reason, homec-are agencies or case managers sometimes

Who’s Safe? Who’s Sorry?The Duty to Protect the Safety of Clients in

Home and Community Based CareBy Rosalie A. Kane and Carrie A. Levin

14

choose to terminate a case rather than pro-vide a lower level of service than they think proper (Kane and Caplan, 1993). For cer-tain technical procedures, like administra-tion of intravenous fl uid or treatment of wounds, the consumer has no privilege to waive technical standards. The provider is not off the hook for negligence because the consumer has consented to, say, reuse of a needle. But what about the quadriplegic client who cannot take his own medicine and prefers to have his housekeeper admin-ister the medications rather than eat up the resources for his HCBS plan by expensive visits from a licensed nurse, which regu-lations require? Such issues may become hotly debated by providers struggling to defi ne where appropriate deference to the client’s informed risk-taking ends and pro-fessional negligence begins. Or, the ethi-cal tension may be at least temporarily re-solved at a policy level by rules that require certain training to perform certain tasks. To take another example, regardless of a resi-dent’s informed choice, staff of an assisted living program often obsess over whether they would be negligent to retain someone in their setting whose needs seem to exceed the service capability in the setting. Such a problem typically involves a risk, not a certainty. The resident might fall, and if he were to fall at night, the staff would be in-suffi cient to transfer him back to bed. The resident might wander out because of in-suffi cient staff supervision and, if so, might sustain an injury, which might be serious. However, in jurisdictions where assisted living programs are legally required to eject anyone who reaches a certain level of need, the consumer’s prerogative to take certain risks has been preempted. The great variety of prohibitions and permissions that gov-ern licensed HCBS entities suggests con-fusion about how much protection should be required.

Thus, the right of a consumer to take in-formed risks is modifi ed by the moral, le-gal, and regulatory responsibilities of health professionals and care organiza-tions. However, the moral foundation for the legal and regulatory constraints on con-sumer risk-taking needs constant examina-tion. Professional orthodoxy, aversion to risk, and motivations to protect the guild may all in effect serve to reduce the free-dom of the consumers to take chances in the interests of their own goals.

Deconstructing Consumer Risk-Taking

Whether a client is “better safe than sorry” is a complicated question, and at present, no common language is available to dis-cuss risks and risk taking. The following elements should be considered in any ap-praisal of potential risk to an HCBS con-sumer.

Type of risk. Risks may be physical, psy-chological, or social, including fi nancial. For the most part, physical risks are the ones that care providers bring to the atten-tion of consumers, while tending to dis-count psychological and social risks. But even physical risks, to health and well-be-ing, should be evaluated based on specif-ic characteristics—some risks are certainly more potentially grave than others.

Risks in the psychological or social sphere are not usually taken as seriously, but they are often far from trivial. For example, some care plans may be accompanied by a high risk of painful depression. Usually, howev-er, care providers are only in the business of identifying risks to physical health and safety. Rarely would they review social or psychological risks and advise people, for example, to avoid a nursing home because they seem at high risk for human misery.

What about the risk of death, to some the ultimate harm? Viewing death as the result to be avoided at all times belies the fact that many people receiving home- and commu-nity-based services are very old and have shortened life expectancies.

Severity of consequences. The potential consequences of some risks are even life-threatening, whereas others are relatively trivial. Surely, the nature of potential con-sequences of the risk must be taken into ac-count.

Likelihood of consequences. Some poten-tial negative consequences of behavior or actions deemed risky may actually be quite unlikely. Often, professionals and family members of the older person with the dis-ability concentrate on the severity of conse-quences, say, if an older person with some dementia is alone in the home and becomes prey to a dangerous criminal, rather than concentrating on the likelihood of such an event actually occurring.

Diffculty of predicting risk. Risks associat-ed with home- and community-based ser-

vices are notoriously diffi cult to quantify. In contrast, the risks of medical procedures are almost easy to measure and describe. Although science is far from exact, it is of-ten plausible to provide the potential con-sumer with information about death and complication rates associated with a sur-gical procedure or a drug intervention and even to elaborate on the circumstances that exacerbate or minimize the likelihood that the particular person will experience a bad outcome. Similarly, it is often possible to provide information about the likely course of action if the surgery is rejected or the medicine not taken.

In contrast, long-term care typically deals with many small consecutive or repeated decisions rather than one big decision. For example, the likelihood of falling, diffi cult to predict at best, is related to each decision involving independent ambulation or trans-fer in a variety of circumstances. The con-sumer who is advised to curtail activities to prevent falls may adopt a partial strate-gy, perhaps with more risk than providers would prefer but with more caution than the consumer would normally adopt. The likely consequences of such highly individ-ualized strategies to avoid risks are almost impossible to calculate with any precision.

Negative effects of avoiding the risk. These potential effects are also not a certainty, but merely a prediction. They too can be clas-sifi ed in terms of type of effect—for exam-ple, physical, psychological, social, fi nan-cial. They too can be examined in terms of their likelihood and their potential negative consequences.

Role of providers. Homecare providers, care coordinators, or assisted living provid-ers are often present on an almost daily ba-sis with much more intensity and intima-cy of involvement than is usually the case between patient and physician. Homecare providers may fi nd themselves still active in a case after their advice has been ignored and may feel compelled to renew the sub-ject of their concerns regularly.

Ingredients of Informed Risk-Taking

Informed risk-taking of course requires a source of trustworthy information. The consumer may also require time to digest that information and consider the implica-tions. At issue is whether and under what circumstances care providers are a good

15

source of information about the riskiness of various courses of action. And, if not the care provider, who should be the source of such information? Should it be provided in writing? With a witness? Will all those trappings create an aura of dread and fear that will unduly infl uence the deliberations of the consumer? Yet, without such a pro-cess, how is it clear that the consumer has been informed, and how do professionals and care organizations protect themselves from legal liability?

Informed risk-taking also requires a com-petent individual who is capable of un-derstanding the tradeoffs and making the choices. Many long-term-care consumers suffer from some degree of impaired mem-ory or judgment that may render them inca-pable of making a decision to take chanc-es in the name of autonomy. It still may be feasible to develop a process by which an agent weighs the benefi ts and harms of var-ious courses of action on behalf of the in-dividual with impairment, but the rationale for such a process is based on a different set of assumptions.

Managed Risk Contracting

Managed risk contracting is a concept that has come into vogue in the 1990s as many state HCBS programs have given explicit recognition to such notions as “dignity of risk” in their supporting legislation or pro-gram rules. In the state of Oregon, managed risk contracting has had the most wide-spread application. As developed there, it is an orderly process for examining and re-solving issues that arise when providers be-come concerned about the risks that their clientele are assuming (Kapp and Wilson, 1995). Managed risk contracting as it has evolved in Oregon has several steps:1. Defi ning risks and provider concerns.2.Defi ning probable consequences of the consumer’s behavior or condition.3.Identifying the preferences of everyone involved, which could include the at-risk consumer, one or more care providers, and one or more family members.4. Identifying possible solutions.5. Choosing a solution.

Ultimately, the person incurring the risk is perceived as the ultimate decision-mak-er (assuming competency and no inordi-nate risks to others), but the search is al-ways for compromise solutions. The plan is documented in writing and signed by the

consumer and other parties relevant to the agreement.

Managed risk agreements in Oregon have evolved in the assisted living setting, which, by law, is a congregate care set-ting that is expected to maximize privacy, dignity, choice, independence, and normal lifestyles. The setting is structured so as to encourage people with nursing-home lev-els of disability to live in their own self-contained small apartments with features and amenities that encourage independence but have elements of danger—for example, roll-in showers, refrigerators, and cooking appliances, lockable doors. Assisted liv-ing programs in Oregon charge less than do nursing homes and receive less in pub-lic payment. They are not staffed for con-stant attention even if the environments are conducive to such surveillance, which is seldom the case. As individual residents are perceived to be at some risk because of their own behavior—not waiting for bath-room assistance, violating special diets, go-ing out on their own, imperfectly managing a self-medication regimen—formal man-aged risk contracting is sometimes consid-ered. At times, the managed risk contract is put into effect because the consumer’s pref-erence counters that of the provider. For ex-ample, the provider might prefer to admin-ister all medications, whereas the consumer prefers to take them independently, either to keep independent or to avoid extra costs associated with accepting more help. At other times, the managed risk contract clar-ifi es what kind of assistance can and cannot be expected in the setting. For instance, the consumer might be content to be accompa-nied on all walks, but the provider may not have the staff to provide this service.

In an ongoing study, we asked about six-ty assisted living providers to comment on their views of managed risk contracting as a mechanism for clarifying and perhaps re-solving some of the ethical confl icts arising over safety-freedom tradeoffs. Few people say they believe that a managed risk agree-ment is a legally binding document, and, indeed, we have not identifi ed any case law that is directly on point to clarify the top-ic. Proponents of managed risk contracting say that the very act of identifying the is-sues is salutary and may in fact lead to cre-ative compromise solutions. Some oppo-nents contend that managed risk contracts are meaningless documents, while others say they see formal managed risk contracts

as a failure in care planning. We also iden-tifi ed a small subset of providers who were using the mechanism to clarify the risks providers were willing to take. For exam-ple, the managed risk agreement might read that the consumer would be permitted to smoke in a defi ned area of the building but, if he dropped the cigarette, he would thereafter be required to smoke outside. Certainly, the establishment of the progres-sive steps in a provider’s willingness to tol-erate the risky behavior and the ultimatum approach (three strikes and you’re out!) distorts the original consumer-empowering intent of managed risk contracting.

When Things Go Wrong

All concerned can congratulate themselves on being sensitive to consumer preferenc-es as long as no untoward events occur. But when things go wrong, especially in publicly funded programs, there is a nat-ural tendency to seek someone to blame (Kapp, 1997). The true test of an approach whereby consumers can make decisions to take chances comes after a negative event. After a fall occurs, does the consumer get a chance to fall again? And in the worst pos-sible scenario, when the consumer dies as a result of the course of action pursued, will providers be held culpable? Even if they are not blamed, will they feel re-sponsible in a way that detracts from theireffectiveness?

The more long-term care mirrors nor-mal life, the more things can go wrong. Depressed people will have more access to weapons with which they could harm themselves, for example. Die-hard smok-ers on oxygen will have the opportuni-ty to become human torches (an event that is more likely to kill them than injure oth-ers nearby). People may leave their homes or assisted living settings, suffer a fall or a stroke, and die unattended. Should care providers be held responsible for such neg-ative events? Should it make any difference that an event was unlikely or that the possi-bility had been discussed with the consum-er?

Cognitive Impairment and Surrogate Risk-Taking

The most diffi cult situations concern cog-nitive impairment, and these situations are where most risks occur. Some family mem-bers express confi dence that they know what kinds of risks their relative would pre-

16

fer to take, and some lay claim to greater freedom for their rela-tive with Alzheimer’s disease. Do family members have the right to assert that Mother would rather be at home, even if at times alone and unsafe, than in an unfamiliar institution? Do they have the right to assert that they would rather have that independent ex-perience for Mother? Do they have the right to say Dad should re-main in an assisted living setting, where he might at times wander out, and accept the consequences—for example, that the assisted living setting could check his whereabouts at intervals and call 911 if he was found missing? What if family members appear to have a confl ict of interest?

Toward Clarity

Resolving the problems that arise when perceived safety and free-dom confl ict will require new organizational and perhaps legal ve-hicles. It will be necessary to determine who has a stake in the out-come and who deserves to be part of the deliberations. It will be necessary to develop better ways of engaging consumers in gen-uine and ongoing consideration of the risks they want to take and the way they want to live. We will need to learn how to distinguish between negligent care and care that respects autonomous risk-taking, between protecting consumers and coercing them into con-forming lifestyles. Most ethical problems in HCBS revolve around the safety-protection tradeoffs, and consumers and providers alike are anguished about what to do. We have already tried making safety (in the eye of the provider) the default position without guaranteeing either safety or other sorts of well-being. A cautious effort to develop a new approach seems worth the risk.

Rosalie A. Kane, D.S.W., is professor, and Carrie A. Levin is a doctoral student and research assistant, both at the Institute for Health Services Research, School of Public Health, University of Minnesota, Minneapolis.

The work that led to this manuscript was supported by the Retirement Research Foundation.

References

Degenholtz, H. B., Kane, R. A., and Kivnick, H. Q. 1997. “Care-Related Preferences and Values of Elderly Community-Based ltc Consumers: Can Case Managers Learn What’s Important to Clients?” Gerontologist 37(6): 767–76.

Kane, R. A. 1995. Quality, Autonomy, and Safety in Home and Community-based Long-term Care: Toward Regulatory and Quality Assurance Policy. (Report of a minicon-ference for the White House Conference on Aging, Washington, D.C., February 11 and 12.) Minneapolis: National ltc Resource Center, University of Minnesota School of Public Health.

Kane, R. A., and Caplan, A. L. 1993. Ethical ConXict in the Management of Home Care: The Case Manager’s Dilemma. New York: Springer.

Kapp, M. B. 1997. “Who Is Responsible for This? Assigning Rights and Consequences in Elder Care.” Journal of Aging and Social Policy 9(2): 51–65.

Kapp, M. B., and Wilson, K. B. “Assisted Living and Negotiated Risk: Reconciling Protection and Autonomy.” Journal of Ethics, Law, and Aging 1(1): 5–13.

Shöne-Seifert, B. 1995. “Risk.” In W. T. Reich, ed., Encyclopedia of Bioethics, Vol. 4. New York: Macmillan.

“Who’s Safe? Who’s Sorry? The Duty to Protect the Safety of Clients in Home- and Community-Based Care,” reprinted with permission from Generations, Fall 1998. Copyright 1998 American Society on Aging, San Francisco, California. www.asaging.org.

Glossary

Activities of Daily Living (ADLs) - Activities usually performed for oneself in the course of a normal day including bathing, dressing, grooming, eating, walking, using the telephone, taking medications, and other personal care activities.

Adult Day Care Centers - Adult Day Care Centers offer social, recreational and health-related services to individuals in a protective setting who cannot be left alone during the day because of health care and social need, confusion or disability.

Aging in Place - The ability to grow older and have your health and housing needs met without having to move to an institution in order to receive supportive services.

Assisted Living Communities - Residential communities for older adults who need assistance on a daily basis but do not need constant nursing care. Assisted living provides help with personal care activities while maximizing independence. Assisted living facilities may stand alone or be part of a retirement community or nursing home. Accommodations range from single or double rooms to suites and apartments, depending on how much the older adult resident can afford.

Assistive Devices - Any item, piece of equipment, or product system, whether acquired commercially off the shelf, modified,

or customized, that is used to increase, maintain, or improve the functional capabilities of individuals with disabilities.

Baby-Boomer Generation - A sudden increased post-war birth rate between 1946 and 1964.

Case Management - Case managers work with family members and older adults to assess, arrange and evaluate supportive efforts of seniors and their families to remain independent.

Care Management - Geriatric Care Managers specifically trained in geriatric care management, and provide case management services on a fee-for-service basis to individual clients.

Congregate Meals - These meal programs provide older individuals with free or low cost , nutritionally sound meals served five days a week in easily accessible locations. Besides promoting better health through improved nutrition, meal programs provide daily activities and socialization for participants which help reduce the isolation of old age.

Consumer-Directed Care - Emphasizes the ability of older and disabled consumers to assess their own needs, make decisions based on choices and options, and monitor the quality of their services.

Continuing-Care Retirement Communities - Expensive residential

17

communities for older adults with different levels of housing and services across the continuum of care, from independent living, to assisted living to skilled nursing care. Residents sign a life-care contract that allows them to age in place by accommodating their changing needs and care for the rest of their life.

Culture - The way a group lives, the ethnic background, the race, the values and norms of behavior, and ways of thinking that are passed down through generations and make the person an identifiable group in a society.

Ethnicity - A group that shares common characteristics such as religion, traditions, rituals, culture, language, and tribal or national origin.

Home and Community-Based Services - A variety of supportive services delivered in community settings or in an older person’s home are designed to help older persons remain living at home and avoid institutionalization.

Home Delivered Meals - Sometimes referred to as “meals on wheels,” home delivered meals are hot and nutritious meals delivered to homebound persons who are unable to prepare their own meals and have no outside assistance.

Home Modification - Adaptation and/or renovation to the living environment intended to increase ease of use, safety, security and independence.

Informal Support Network - Non-paid persons (family, friends, neighbors) and community groups (churches, neighborhood associations, civic groups) that provide assistance to older adults in the community.

Instrumental Activities of Daily Living (IADLs) - Daily activities other than personal care or household chores such as money management, medication management and administration, meal preparation, transportation and employment.Long-term Care - A general term that describes a range of medical, nursing, custodial, social, and community services designed to help people with chronic health impairments or forms of dementia.

Managed Risk Contracting - Referring to the use of home- and community-based services, an orderly process between the agency and clients for examining and resolving issues that arise when providers become concerned about the risks that their clients are assuming.

Nursing Homes - Institutions that are licensed by the state and offer round-the-clock care for residents who are unable to live independently and care for themselves. Nursing homes provide the full range of personal and medical care.

Senior Housing - Apartments for rent that are designed specifically for older adult residents who are able to live independently. Senior apartment complexes may offer home modifications, emergency call service, assistance with chores, social activities and a range of transportation and social services.

Strengths-Based Approach - A model that operates on the premise that older adults have a tremendous capacity for continued growth and autonomy by focusing on their individual experiences, talents, interests and aspirations. The strengths approach assumes that each person is the expert in defining his/her own needs or will and what he or she needs to achieve well-being.

Straight, A. & Gregory, S. (2002). “Transportation: The Older Person’s Interest.” AARP Public Policy Institute Fact Sheet. Retrieved on 12/1/04 from http://www.research.aarp.org/ppi. Washington, DC: American Association of Retired Persons (AARP).

Tilly, J., Wiener, J. & Cuellar, A. (2000). “Consumer-Directed Home- and Community-Based Services Programs in Five Countries: Policy Issues for Older People and Government. Generations. Vol XXIV (3):74-83. San Francisco, CA: American Society on Aging.

Wodarski, J. & Williams-Hayes, M. (2002). “Utitlizing Case Management to Maintain the Elderly in the Community.” Journal of Gerontological Social Work. Vol 39 (4): 19-38. Binghampton, NY: Haworth Press, Inc.

Yagoda, L. (2004). “Case Management With Older Adults: A Social Work Perspective.” NASW Aging Practice Update. Retrieved on 11/29/04 from www.socialworkers.org. Washington, DC: National Association of Social Workers.

“Who’s Safe? Who’s Sorry? The Duty to Protect the Safety of Clients in Home- and Community-Based Care,” reprinted with permission from Generations, Fall 1998. Copyright 1998 American Society on Aging, San Francisco, California. www.asaging.org.

Continued from page 9

References from “Aging In Place”

18

While the importance of making our homes childproof to prevent injuries is well ac-cepted, an equivalent attention to home safety for our growing older population is only beginning to evolve. The Department of Health and Human Services (2001) re-ports that, in 1998, unintentional injuries accounted for the deaths of 18,538 young persons between the ages of 1 and 24 years, and for the deaths of 32,975 Americans age 65 years and older. Falls account for ap-proximately 75 percent of unintentional in-juries among community-dwelling older adults, followed by burns (8 percent) and improper dosages of prescription medica-tions and other mishaps (17 percent). Most of these injuries occur in the home environ-ment (Roberts and Irons-Georges, 2000). The majority of home environments are not “elder-friendly” to individuals with limita-tions in mobility or perceptual ability as-sociated with aging (Lanspery, Hyde, and Hendricks, 1997; Houts and Rubenstein, 2002).

A multitude of judgment-based home-safe-ty checklists, designed for use by elder-ly people in their homes, provide practi-cal tools for assisting them in making their home environments safer. The checklists vary in number and severity of risk fac-tors addressed, practicality and product cost of proposed solutions, and apparent over-all quality. Because of this wide spectrum of available lists, and their potential impor-tance in addressing this major problem, we undertook a content analysis of home-safe-ty checklists for elders available in the con-sumer literature and on the Internet. ( See Appendix.)

Methods

We conducted a systematic search of sci-entifi c and consumer literature as well as Internet sites for checklists and itemized hazard lists focused on preventing uninten-tional injuries among community-dwelling elders. This project involved an extensive electronic library search and use of sever-al Internet search engines. Our analysis of checklists began with an itemization of ex-trinsic risk factors, which we classifi ed into six broad categories: physical accessibili-

ty issues, lighting, general assistive devic-es, safety devices, emergency preparedness, and hazard containment.

Our analysis focused on content and “elder friendliness”—factors affecting the check-lists’ acceptability to older adults. Because of the visual and other physical chang-es that occur with aging, larger typefac-es, easy-to-read graphics layouts, and suc-cinctness are important characteristics. Out of respect for the older person, the tone of the guides should be one of presenting ma-terial to an informed consumer, offering re-sources and alternatives, rather than patron-izingly presenting directives. Further, we assessed the overall diffi culty and estimat-ed costs of implementing each safety rec-ommendation based on Bakker’s “Resource Guide” (1997) and our respective experi-ences as homeowners.

Results

Our content analysis revealed many extrin-sic risk factors that were identifi ed repeat-edly on checklists—for example, grab bars in bathrooms (98 percent overall) and hand-rails and stairs in good repair (91 percent overall). Certain risk factors were more commonly found on Internet lists than on published lists (e.g., smoke detectors, 74 percent versus 31 percent), and some were more common on published lists (e.g., non-skid wax, 22 percent versus 61 percent). List recommendations varied widely in both the complexity and the expense (e.g., from arranging a buddy system with a neighbor to hiring a professional help-response sys-tem). Accompanying texts, including illus-trative examples, advice, referrals, and tes-timonials, further enhanced the value of many of these checklists and referred read-ers to additional nonprofi t resources (e.g., toll-free numbers or websites). Indeed, 65 percent of the Internet checklists offered searches within the site where the checklist was located.

Readability of the Internet checklists and their corresponding texts was quite vari-able. During the course of our search and analysis of elder home-safety checklists, we discovered signifi cant duplication; when

possible, we traced each list to its original author. At minimum, a cursory review of several checklists of either type is advised prior to using one or more of them and, in particular, prior to the provider recommend-ing them for elder use.

Discussion

This content analysis was intended to pro-vide an overview of educational check-lists for improving home safety for elders. Though intended to be as comprehensive as possible, it is inevitable that some sourc-es were missed, as new materials are being produced constantly. Therefore, this analy-sis must be considered a work in progress.

Each home-safety checklist served to identi-fy home hazards and sensitize its readers to the importance of safe home environments. The majority also offered specifi c sugges-tions for actions to correct or eliminate the home hazards identifi ed, within the content of the checklist itself or within its accompa-nying text. These suggestions ranged from relatively easy, no-expense home adapta-tions (e.g., arranging furniture to ensure un-obstructed pathways) to home modifi cations that required some skill and low-to-medium expense (e.g., installing grab bars), to ex-pensive modifi cations that required hiring professionals (e.g., replacing kitchen cabi-nets). Indirect evidence suggests that these environmental modifi cations can enhance functional ability and lower rates of disabil-ity. and, fortunately, many of the most crit-ical home modifi cations and repairs, such as improved lighting and grab bars, are rel-atively inexpensive, permanent, and pro-vide years of benefi ts (Lanspery, Hyde, and Hendricks, 1997). Many modifi cations that exceed an individual’s resources can often be completed with the help of local, state, and federal assistance programs.

The scientifi c and consumer literature, and the Internet sites, offer a continuum of home-safety checklists and corresponding text for independent elders and their health-care providers. Several checklists are avail-able in hard copy at no fee, as well as on the Internet for reference and printout. Others are published as booklets or brochures for

Home-Safety Checklists for Elders inPrint and on the Internet

By Barbara J. Kercher and Laurence Z. Rubenstein

19

Post Test and Course Evaluation on pages 20 - 21.

providers. No one home-safety checklist and text, even if published as a reference, can encompass all home environmental issues and solutions. Some are clearly better than others. The most compre-hensive ones are not necessarily the most useful ones to an individ-ual elder. Yet, any of them serve to remind their readers of the im-portance of environmental issues at home and elsewhere.

The best and the worst features of elder home-safety checklists and related text may be found on the Internet. The best-designed web-sites tend to be those with large black text on a white background, appropriate photos, menus for further specifi c information, an on-site search option, and an easy way to ask questions by e-mail. The more poorly designed websites feature monochrome text and col-or-fi lled backgrounds which tend to camoufl age the text or inappro-priate pop-up and in-your-face animated ads (which could disturb some elders). Providers would do well to review the preferences and needs of each elder before recommending a website or provid-ing a home-safety checklist to their clients or patients. As with any Internet source, some websites may contain inaccurate or mislead-ing information or copyrighted material.

None of these checklists has been tested as a specifi c intervention in a randomized controlled trial, so these recommendations are based on judgment alone.

More attention to safety in the home environment is clearly need-ed to maximize injury prevention. Programs to reduce intrinsic risk factors (e.g., exercise programs, risk-factor assessment and abate-ment programs) have proven successful, but relatively little re-search has been devoted to environmental risk reduction. Many papers suggest that elderly patients should use home-safety check-lists themselves or in conjunction with their healthcare profession-als. However, such checklists have not been standardized and vary considerably, as seen in our analysis. Nonetheless, there is a re-

markable consistency in content among the better lists. Several are clearly superior in formatting and comprehensiveness. It is hoped that these better lists will be tested for effectiveness in future con-trolled trials. Barbara J. Kercher, M.P.H., is a health educator, Los Angeles County Department of Health Services; Laurence Z. Rubenstein, M.D., M.P.H., is professor of geriatric medicine, UCLA School of Medicine, and director, Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, Sepulveda, Calif.

This project was completed as part of Barbara Kercher’s graduate work at ucla School of Public Health.

References

Bakker, R., 1997. Elder Design: Designing and Furnishing a Home for Your Later Years. New York: Penguin.

Houts, P. S., and Rubenstein, L. Z., eds. 2002. Eldercare at Home. American Geriatrics Society. www.healthinaging.org/el-dercare/index.html.

Lanspery, S., Hyde, J., and Hendricks, J., eds. 1997. Staying Put: Adapting the Places Instead of People. Amityville, N.Y.: Baywood.

Roberts, P., and Irons-Georges, T., eds. 2000. Aging, Volume 1 and 2. Pasadena, Calif.: Salem Press.

“Home-Safety Checklists for Elders in Print and the Internet,” Reprinted with permission from Generations, Winter 2002-3, Volume XXVI, Number 4:69-74. Copyright 2003 American Society on Aging, San Francisco, California. www.asaging.org.

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1. According to the U.S. Bureau of the Census (2000), adults age 85 and older increased by what percentage during 1990-2000?

25%15%50%40%

2. The concept of aging in place encompasses:Growing older in one’s own homeReceiving supportive services at homeMaintaining pre-existing social networks though the lifespanAll of the above

3. Which age group is the least likely to move or changeresidences?

45-6485+65-8525-44

4. It is probable that how many older adults will reside in a long term care facility for at least part of or the rest of their lives?

20%5%15%25%

5. Research suggests that compared to older adults living in the community, residents of nursing homes are considerably more like-ly to experience higher levels of :

DepressionSuicidal ideationSatisfactionBoth a and b

6. The economic value of the time and expertise donated by older adults 65 and over in their communities is estimated to be worth:

$22.7 billion$5.5 billion$12.8 billion$18.2 billion

7. Which of the following structural and economic barriers exist for allowing low income older adults to age in place?

Housing programs and subsidies usually support homeown-ers and not rentersHealth and housing resources are allocated differentlyMedicare only supports the very sick or the very poorMedicaid does not cover services for older adults age 65 and older

a)b)c)d)

a)b)c)d)

a)b)c)d)

a)b)c)d)

a)b)c)d)

a)b)c)d)

a)

b)c)d)

8. Several comparative analyses of older African Americans, Hispanic Americans, American Indians and Asian American/Pacifi c Islanders found that as a whole, these older ethnic groups have the same risk of shorter life expectancy, poor health, poverty, malnutri-tion and poor housing quality as older non-Hispanic whites.

TrueFalse

9. According to the Home-Safety Checklists for Elders in Print and the Internet article, approximately how many older adults died as a result of unintentional injuries in their homes in 1998?

5,59510,62532,97558,235

10. Barriers to home modifi cations include:Costs and affordabilityConsumer confusionLack of awareness about problems in the physical environ-mentAll of the above

11. True or False? Research indicates that older people are less likely to want consumer direction than younger people.

TrueFalse

12. Assistive devices are:Any product used to increase, maintain or improve function-al capabilities of individuals with disabilitiesChanges made to the home to allow persons with disabilities to live independentlyHi-tech products that are used to increase, maintain or im-prove functional capabilities of individuals with disabilitiesLo-tech products that are used to increase, maintain or im-prove functional capabilities of individuals with disabilities

13. Despite the preference to remain independent and able to drive an independent vehicle, nearly how many older adults age 65 and older are not able to drive?

1 million750,0005 million7 million

14. According to the Moving Along the Mobility Continuum: Past, Present, and Future article, approximately how many older adults do not have access to a public transportation system?

15%20%35%5%

a)b)

a)b)c)d)

a)b)c)

d)

a)b)

a)

b)

c)

d)

a)b)c)d)

a)b)c)d)

Aging in PlacePost–Test

Please circle the one correct answer for each question.

21

15. Adult day centers are places in the community where older adults can go during the day for:

Socializing with othersAssistance with personal careScreening for cognitive impairmentBoth a and b

16. Immigration rates indicate that the trend of a diverse older adult population will decrease in the coming decades.

TrueFalse

17. A strengths-based approach to working with older adults in-cludes taking an inventory of:

Functional capacities (ADLs and IADLs)Medical and mental health history of the clientLeisure and recreational interests of the clientAll of the above

18. According to Leigh (1998) the defi nition of culture is:The way a group livesThe race and ethnic background of a personThe values and norms of a person All of the above

19. According to the Who’s Safe? Who’s Sorry? The Duty to Protect the Safety of Clients in Home- and Community-Based Care article, older adults who choose to stay in their homes may encounter the following risks:

Physical risksPsychological risksSocial risks (including fi nancial)All of the above

20. The Joint Center for Housing Studies at Harvard University maintains that an overhaul of our national, state and local systems needs to include rethinking the health and housing sectors as:

Two separate divisionsOne unifi ed service-delivery systemNone of the aboveBoth a and b

a)b)c)d)

a)b)

a)b)c)d)

a)b)c)d)

a)b)c)d)

a)b)c)d)

Please indicate whether the stated learning objectives were achieved:

Participants will be able to identify the concept and implications of aging in place. Achieved in full 5 4 3 2 1 Not Achieved

Participants will be able to identify at least three barriers to ag-ing in place.Achieved in full 5 4 3 2 1 Not Achieved

Participants will be able to name at least three strategies to pro-mote aging in place.Achieved in full 5 4 3 2 1 Not Achieved

Please evaluate the course content:This course expanded my knowledge and understanding of the topic.Achieved in full 5 4 3 2 1 Not Achieved

The course material was clear and effective in its presentation.Achieved in full 5 4 3 2 1 Not Achieved

This course was relevant to my professional work/interests.Achieved in full 5 4 3 2 1 Not Achieved

As a result of this course, I learned new skills, interventions or concepts.Achieved in full 5 4 3 2 1 Not Achieved

The resources/references were comprehensive and useful.Achieved in full 5 4 3 2 1 Not Achieved

This course addressed issues of diversity and/or the social justice implications of the topic.Achieved in full 5 4 3 2 1 Not Achieved

Please provide comments on current course and suggestions for future courses._________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Complete and return Post-Test and Course Evaluation afterreading the CE course in this issue of FOCUS.

A score of 80% or better is passing and we will send acertifi cate of completion for 1.5 CEs to you.

Name ___________________________________ NASW Membership # _________________Address ______________________City _______________________ State_____Zip ________Day Phone ________________________ Email ______________________________________

Members $15 Non Members $25

Please enclose check payable to NASW(Sorry, credit cards not accepted for this offer.)

Send to: NASW, 14 Beacon Street #409, Boston, MA 02108