Choices Give New Meaning to ‘Home, Sweet Home’

AFTER Isidore Monblatt, a retired controller who had worked at Lehman Brothers, had a series of minor strokes and falls in the mid-1990s, he and his wife, Nancy, a homemaker, realized that they could no longer stay in their two-story Brooklyn house. But they were not sure of what they needed.

“Something that didn’t feel like a nursing home,” recalled Cathy Monblatt, 56, an information technology manager and one of their three children. “Something where they could feel independent, but they could get meals and some assistance.”

Another daughter found an apartment in an elderly-only building near her home in Alexandria, Va. It had a full kitchen and washer-dryer, along with dining-hall service, regular bingo games and a nursing-care floor.

Nancy Monblatt liked the setup, Cathy recalled. Nevertheless, she missed her old neighborhood up until the time she died in 2007 at age 91, five years after her husband.

Until recently, the Monblatts’ experience might have seemed typical. Today the couple would have far more options. There are group homes that try to be familylike, and “villages” of individual households. Homes can be remodeled with a special certification.

As millions of baby boomers reach retirement age (and in many cases care for elderly parents), families and the retirement industry have reworked old lifestyle formats and created hybrids.

“We used to think that a person lived in their own home, and if they got frail they moved in with a relative or to a nursing home,” said Jon Pynoos, a professor of gerontology, policy and planning at the University of Southern California. “People need more choices.”

The first choice of most people, like Nancy Monblatt, is to stay put. When AARP surveyed 2,000 Americans in late 1999, 89 percent of those age 55 and older said they would prefer not to leave their current residences.

But staying put no longer means staying with the same living arrangement.

Amy Goyer, the home and family expert at AARP, recommends that a geriatric case manager, social worker or other professional analyze the older person’s needs to find the best option. AARP and the National Association of Home Builders in 2002 developed “aging in place” certification for home modifications, to teach contractors how to adapt homes. Among typical improvements are widened doorways for wheelchair access and safety features like grab bars in bathrooms.

Still, some houses cannot be realistically remodeled. The biggest problem, said Dan Bawden, owner of Legal Eagle Contractors in Houston, who helped write the certification, is not having a full bathroom or usable bedroom space on the ground floor.

But if such drawbacks are not an issue, almost anything can be brought to an existing home. The number of health workers who make house calls has been rising steadily since 2005, and about 3,000 primary care physicians and other health practitioners now make house calls full time, typically charging about 12 percent more than for office visits, according to the American Academy of Home Care Physicians, a Maryland-based professional association. Meals on Wheels programs are widely available, with fees based on a sliding scale and averaging $6.50 for a daily meal.
At first, home health aides are usually hired for a few hours a day to provide companionship and run errands, experts say. Older people then move on to more intensive assistance, if needed, with bathing, dressing and, where it is permitted, basic nursing care.

Emma Dickison, president of Home Helpers, based in Cincinnati, said she would replace an aide if the personalities did not click, or even for something as simple as: “Does the caregiver make the toast the way the client likes it?” However, she urged clients to give their aides a couple of weeks.

Increasingly, machines can keep electronic tabs on people at home, and the elderly apparently are not bothered by the idea. A 2011 AARP study predicted that around one-fourth to almost one-half of those over age 65 “may be willing to use” electronic devices that remind them to take medicine, check blood pressure or alert caregivers if they are not following their normal routines.

“The cohorts who are moving into their 60s and 70s are used to smartphones and Skype,” said Melissa Hardy, a professor of sociology and demography at Pennsylvania State University.

In a new approach, called villages, neighbors band together to arrange support services like transportation and home repairs, often hiring a manager to coordinate things. According to Lori Simon-Rusinowitz, interim director of the University of Maryland’s Center on Aging, about 80 villages have been established nationwide since 2002 and at least 120 more are planned, “primarily in white, middle-class communities.”

Eventually, such home-based arrangements may need to be rethought. “What usually shakes up the family is a health crisis,” said Larry Minnix, chief executive of LeadingAge, an association of nonprofit providers of services to the aging, based in Washington.

Moreover, the ties that bind people to their homes weaken. “Your friends can leave, or die. Your doctor can retire,” pointed out Professor Pynoos of U.S.C.

For Sharon Goldzweig, that moment arrived five years ago, when her mother, Shirley Shulman, now 92, was found to have Alzheimer’s disease. Ms. Shulman left her Boston apartment to live with her daughter and twin granddaughters, now age 16, in New York.

“The parts I love are when we sit in front of the TV together,” said Ms. Goldzweig, 59, a benefits lawyer.

Not everyone can take parents in. But for those who worry that group housing arrangements are cold, experts say they can actually be more nurturing, “When people move into a community, they thrive,” Mr. Minnix said.

The dividing lines between types of living arrangements can be amorphous, but at the youngest end are so-called active adult communities that typically set minimum age limits of 55 or so. They may offer swimming pools, classes, excursions and meals, but little medical support. For more care, the next step is usually an assisted-living facility. Aides and nurses help with basic functions but do not provide 24-hour nursing. Residents — generally in their 80s — are mobile enough to eat in the dining hall and join activities.

Moving into a skilled nursing home usually means that constant monitoring is required. The person may be on a respirator or need to be fed.

The Green House Project, started in 2003 and now in 32 states, tries to create a “familylike” version of nursing homes. About a dozen people live in a house, with private bedrooms and bathrooms but shared meals.
Many of these choices are brought together in continuing-care retirement communities. In a single location, residents can transfer among independent living homes, assisted-living homes and nursing homes. A 2010 report by the Government Accountability Office found over 1,860 such communities.

If it seems impossible to pick among this variety, one deciding factor is usually cost. But staying at home is not cheap. Widening a door costs about $2,500, and a full bathroom renovation might run $20,000, Mr. Bawden, the contractor, said. Some federal tax breaks are available.

Some of the special villages charge annual fees of a few hundred dollars. Then an older person might pay around $2,200 a month for an aide for four hours daily, according to Genworth Financial, an insurance provider.

By contrast, Genworth reported, the average monthly cost is $3,450 for assisted living and $6,210 for skilled nursing. The continuing-care facilities studied by the G.A.O. charged entrance fees of $80,000 to $750,000 plus monthly rent starting at $1,300.

Long-term care insurance, Medicare, Medicaid and Veterans Affairs benefits cover only some of these charges.

Beyond price and their health needs, people should consider the weather, the locale, how much socialization they want, the availability of family and transportation, experts say.

Finally, Ms. Goyer of AARP said: “Be flexible. Just when you thought you’ve got it all figured out, it changes.”