While the Baby Boomers were growing up, the needs of young families were a high priority in community development, with particular concern for family-friendly housing, parks, and schools. In 2011, these children will start turning 65 in large numbers. Many predict that if communities want to be successful in caring for their aging population, they will have to make significant, yet certainly feasible, changes in housing, health care, and human services.
In preparing for the needs of large numbers of elderly, it is crucial to think of the challenge as a community issue. If the care of the elderly begins and ends with entry into a formalized system that takes over when a person is almost unable to function day to day, society will face large service costs and will miss opportunities to help the elderly function as productive, independent citizens for larger portions of their elderly years. A community's social and economic systems need to become attuned to arranging services to meet the needs of an aging society in natural, informal ways.
Most Baby Boomers would like to stay in their own homes, or at least in their own communities, as they age. Nearly three-quarters of all respondents in a recent AARP survey felt strongly that they want to stay in their current residence as long as possible (Bayer and Harper 2000
). The image that most elders will move to a retirement village away from their communities is the exception rather than the rule. Most people will not have the resources or the inclination to move to Florida or its equivalents; communities cannot rely on “exporting” to meet the needs of an aging population.
In thinking about community capacity, three stages of community aging can guide planning: the healthy-active phase, the slowing-down phase where the risk of becoming frail or socially isolated increases, and the service-needy phase when an elder can no longer continue to live in the community without some active service in and around the home.
Perhaps the most important challenge of the healthy active phase of aging is for a community to learn how to tap the human resources that elders represent in the community. This is a phase where elders can be key volunteers to improve the life of many segments of a community. Healthy elders can be considered a potential component of the paid workforce if jobs can be structured to meet their changing preferences and capabilities.
The second phase of aging, when elders begin to slow down and may face some challenges in doing the every day activities required of community living, represents a subtle challenge for communities. Elders in this phase often need assistance with transportation to remain independent, and communities need to take the lead to develop affordable transportation systems (U. S. Department of Transportation 1997
). Safe and affordable housing options also are a priority for community capacity efforts. At this phase of aging, many elders want to move into smaller housing units that are more aging-friendly but still are affordable and integrated in the community. It is important to begin developing such options on a large scale in the coming 10 to 20 years. In a community with five thousand projected elders, for example, a project with 30 units will not meaningfully attack the problem.
Voluntarism is an important community need for elders who are mostly independent but slowing down (Butler 1997
). Volunteers can provide services in a manner that makes elders continue to feel connected to a community and not dependent on a formal care system. And, volunteers often can act as preventive medicine, keeping away the effects of social isolation and keeping elders as active and engaged as possible. Volunteer capacity does not emerge without effort, however. Communities need to recruit, train, and support volunteers.
The most prevalent form of “voluntarism,” of course, is the care provided informally by families and friends. These caregivers also need support through training programs and respite programs. Many believe that additional financial assistance for family caregivers is needed as well (Stone and Keigher 1994
). Such efforts to support family care-giving also represent an important aspect of community capacity to support elders.
While communities need to make day-to-day aspects of community life more aging friendly and while volunteers and family caregivers represent crucial “capacity” to meet the needs of elders, a well organized, affordable formal long-term care system still is essential for every community. It is unclear whether such local care systems can emerge naturally through market forces or whether market failures will emerge to block the evolution of care systems that reflect the wants and needs of elders. Clearly, the large financing roles of Medicare and Medicaid give the public sector an interest in ensuring that adequate systems of care emerge.
How many people will require formal services in 2030? As discussed earlier in the paper, this is an unanswerable question in the year 2002. If efforts at healthy aging are successful and if informal caregivers and volunteers can help to meet the needs of elders, the total number of frail who need formal services in a community in 2030 could be quite similar to the number in 2000, even though the number of elders will more than double. Keeping the number of frail constant at 2000 levels must be the goal of every community to keep costs affordable.
However, even if the aggregate number of frail elders stays the same or grows slowly, formal care capacity must be better structured at the community level. Importantly, most communities rely too much on nursing homes as the source of formal care, at least for Tweeners and the Medicaid Bound populations. Sixty-seven cents of every public dollar supporting long-term care for the elderly is spent on institutional care (Congressional Budget Office 1999
), despite the clear preferences of frail elders for services in the community.
Why does this mismatch of dollars versus preferences happen? In part, nursing homes are seen as the long-term care “safety net” and most public dollars are invested using a safety-net mentality: only pay for services when it would be socially unconscionable not to do so. We have not developed social consensus about when and for whom community-based services should be supported with public dollars; therefore few public dollars are allocated to community-based services.
This overreliance on nursing homes—what some people call an “unbalanced” long-term care system (Kane, Kane, and Ladd 1998
)—may be changing with help from the federal court system. Recent court rulings support the idea that the disabled have a right to receive services in community settings (Pear 2000
). Such rulings are putting pressure on public programs to rethink the balance between nursing home services and community-based services.
The challenge over the next 10 to 30 years is to develop new approaches to delivering community-based care. Home care, using a range of unskilled to highly skilled workers, represents the dominant type of community-based care. But, this service type, relying on a one-on-one model, is expensive and creates challenges for providers to assure quality. New models, such as adult day services and housing-based services that can use one caregiver to assist more than one elder at a time, need to become more prevalent (Feldman 1990
). In addition, emerging technologies might increase the ability of one caregiver to meet the needs of two or three elders through enhanced ability to communicate and monitor a person's needs (Gottleib and Caro 1999
One other key challenge in assuring community capacity is to recruit the required numbers of caregivers working in formal settings. With changing demographics and a strong overall labor market, it is becoming increasingly difficult for home care agencies and other providers to find and retain qualified caregivers. New incentives and organizational structures will be required to maintain a stable workforce in long-term care settings.
Finally, every community needs to think about what types of institutional long-term care should be available. Even if community-based services expand, the most frail among the elderly will sometimes require the high level of care that traditionally has been provided by nursing homes. It is possible, however, to think about restructuring nursing homes to make their living environments and caring style more attractive to elders and their families (Allen and Mor 1998
). Assisted living is emerging as a significant option for many elderly—both disabled and nondisabled. The idea of institutional care should not be considered as a static model that cannot evolve, improve, and become more responsive to the preferences of elders.
Expansions in community capacity to care for elders need to be paid for in some way. In the case of formal services, the financing options discussed previously are the source of expanded resources. In the case of community-based changes beyond formal services, the give and take of the political process will shape how high a priority health-promoting community programs become among the range of local priorities. And, the willingness of seniors and their families to allocate private resources to long term care and related services will determine the scope of “caring features” in twenty-first century communities.