Intentional Elder Neighborhoods
By Alex Mawhinney

Editor's note: Alex Mawhinney has an MS in Healthcare Administration and spent most of the past 25 years developing and managing conventional “retirement communities,” including independent, assisted living, dementia care, skilled nursing, and continuing care retirement communities. A few years ago, he realized that a retirement community, no matter how beautiful or well managed, is still an institution and so began working with Dr. Bill Thomas and others in the “new paradigm elder community” movement. Currently he is a consultant nationwide to developers interested in building “elder neighborhoods” in “human scale” — including cluster cottages, atrium houses, and the Green House. He can be reached by e-mail at jamlll@charter.net.

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As we argued in my article, "Not My Father’s Retirement Lifestyle!", published in the previous issue, the new paradigm for elder living is based on the following essentials:

  • human scaled,

  • relationship based,

  • resident managed/centered, with an overlay of lifelong learning, later-life spirituality, and

  • "giving back" to your own and the greater community.

Research has shown many times, that a sense of "community" is an essential ingredient in quality of life and significantly improves health status.1 But the word "community" covers a multitude of sins, as the survey that follows shows.

Institutional Elder Care

As a baseline, let's look first at the model which we have inherited -- the conventional institutional elder care facility -- where a true sense of community is rarely found. The facility usually includes a large dining room and central kitchen to provide for congregate meals. (Or should we say "mass feedings"?) Large common living rooms, libraries, studies, and craft rooms take the place of intimate living rooms, and other spaces that would have been cozy in a personal home.

The institutional management structure promotes a resident’s sense of helplessness by mandating times for meals, structure and staff for personal bathing and hygiene, an activity director to fill empty time, nurses to dispense medications. The staff are mostly strangers to the resident, and they report to management, not to the resident.

The temptation would be, of course, simply to abandon these institutional dinosaurs. But the buildings themselves have a useful life expectancy of 40 years or more and will be around for the foreseeable future. Perhaps the better approach, then, is to challenge the management companies and facility personnel to collaborate to find new ways to empower residents by including them in decision-making and redirecting staff from their focus on healthcare to enhancing the quality of life of the residents.


Generating Real Community

While a sense of "community" may be developed in some existing "big box" institutional elder care buildings, where there is management willingness and commitment, it may be easier to start with a clean slate. The "clean slate" includes some old and new models, some you have seen before, and some that are newly minted. Here are some possibilities to consider:

Cottage Community (including retirement trailer parks)

A common model consists of clusters of freestanding, attached or semi-attached cottages, built with "aging-in-place" design elements. These are arranged in groups of 20-40 living units with a common building for gatherings. Most are built around a street grid, with relatively little green space.

Following the pattern of the cohousing cottage community, parking and driveways are located behind the cottages to enable the focus to remain on the shared lifestyle, walking between home and common space, enhancing opportunities to socialize.

Co-housing Communities

"Cohousing is a type of collaborative housing in which residents actively participate in the design and operation of their own neighborhoods. Cohousing residents are consciously committed to living as a community.

 
   

"The physical design encourages both social contact and individual space. Private homes contain all the features of conventional homes, but residents also have access to extensive common facilities such as open green areas, courtyards, a playground and a common house."2

An important aspect is that these communities are not "vehicle-oriented." The relatively small homes or cottages face a common "green" with a walkway leading from each home to a "common house" which has a large kitchen, dining/gathering area, and community guest suites, as well as other amenities specified by the residents.

Homes typically are owned individually or rented, and residents determine their shared activities, such as maintaining the common areas, projects, exercise, celebrations, meals, caring for each other, etc. Taking turns preparing and sharing meals a couple of times a week is a common and effective community relationship builder.

Individual needs can be addressed by residents helping one another, and concierge services can be obtained as needed. For longer-term care, a part-time caregiver can be hired by one or several residents, or a full-time caregiver can live in a community guest suite to serve several people as agreed. Of course, there is the option of purely private home health caregivers, or variations as determined by the community.

An example of a flourishing elder cohousing cottage/apartment community is seen at Elderspirit Community in Abingdon, VA. Members have impressively clear agreements on how they plan to live and die in place, and how to support that process.

Elder-Friendly Apartments, Cooperatives, or Condominiums

These models have been utilized for decades and are especially conspicuous in areas where retirees concentrate, like Florida and Arizona. Many cities and towns offer apartments for lower-income elders.

 
   

Because developers have not thought of it or have discounted the value, the elder apartments have not usually been built with elder-friendly design elements. With forethought, such design elements are included to support residents to "aging in place."

Some of the universal design elements include: special lighting; placement of switches and outlets; kitchen and bathroom design; wider door and passageways; user-friendly door handles, locks, and latches, etc. Units can be pre-wired for monitoring by other residents and/or staff.

The governance of such a residence is essential to the "community" nature of the assembled residents. Often the means of decision-making has been through consensus and has proven to be problematic. Once again, we urge consideration of the "Dynamic Governance" system referred to earlier.

SOTEL Community™ (Service Oriented Technically Enhanced Living)

This is a variation of the retirement apartment that offers interesting program aspects. Inspired by projects in the Netherlands, this is a hotel-like building with multiple floors of apartments surrounding an open, climate-conditioned atrium (think Embassy Suites with apartments instead of rooms).

The apartments are designed to afford an outward private orientation, each with a back patio or covered porch, and an inward community orientation. When residents walk out their front door, they are in the common house – the beautiful atrium.

Each apartment has a planter box outside the front door on the railing of the atrium, which encourages residents to grow their own herbs, tomatoes, and flowers year round (organic gardening).

The main floor has the atrium with edible landscaping and features common spaces for dining, gathering, exercise, and socializing.

This building is designed to be user- and elder-friendly in every aspect, from height-adjustable bath and kitchen cabinets, to specialty lighting and fixtures with motion detectors, to nanny-cam capabilities, to modular wall systems, to customized apartments for various uses, and computer controlled environmental systems, etc.

A comprehensive concierge service can provide an array of services from dog-walking, shopping, dining, and personal care. Licensed home health care can be added, as needed. A "concierge" can coordinate and assure delivery of services to residents, who only pay for services received.

This community model can be resident-managed (cohousing-style), managed by an outside company, or a hybrid model of resident management and professionally managed concierge service.3

A new variation has been recently approved for HUD financing, which substitutes an unconditioned, but covered atrium, and smaller apartments. These units can be subsidized or market rate, but incorporate the essential elements of the SOTEL concept.

Green House Project

The Green House Project was conceived by Dr William Thomas, a physician who declares that "people do not belong in institutions – they belong at home." A Green House is a 10-bedroom home, conceptualized as a small intentional community.

The project replaces institutional nursing homes with clustered neighborhoods of Green Houses.

They are designed so each resident has a private room with private bath, and their room opens onto the shared living/dining room area. Life is centered around a hearth; meals are shared at a single table by residents and caregivers together.

Care is provided by a "Shahbaz" (Persian word for "Royal Falcon") who protects, sustains, and nurtures the residents. The same team of Shahbazim serves the same house every day (turnover in this setting is almost nil) which allows for relationships to be built among residents and caregivers.

Residents and Shahbazim plan the menu, order the food, and store it in the pantry together. When meals are being prepared, residents can watch, gossip, offer advice, and smell the meal to come…as in any normal home.

Residents determine how they will spend their day, whether gardening, individual or group volunteer projects, studying, playing with visiting children, or petting the housedog or cat. They plan together for special events such as barbecues, trips, and sightseeing.

Health care professionals (nurses, therapists, and doctors) are welcomed to the house as "honored guests" where they conduct services and leave. Health care is not the focus of life. In the Green House, residents receive the care they need and still are an integral part of life in the house and neighborhood.

More than 50 Green House Projects have opened since 2002, and many more are under development. Each can be licensed for assisted living, dementia care, or skilled nursing care.4


Other Possibilities

A subset of housing types can be free-standing or incorporated into the cluster cottage neighborhood and/or the SOTEL neighborhood, or any urban setting. Perhaps the most popular is the "collaborative household."

Collaborative Household

This is a home in which two or more unrelated individuals live, usually for social and economic benefit. Life in a collaborative household has been popularized by the TV series, The Golden Girls (currently in re-runs), and featured in The Ladies of Covington book series, by Joan Medlicott.

Each resident has his or her own bedroom and may have a private bath. Some houses or apartment units are designed accordingly and have several master suites and a shared living room, kitchen, dining area, and other common spaces.

Residents can live in the home by owning it collectively as a cooperative (a legal structure) or as a tenants-in-common arrangement, or they can be renters. By combining resources, several residents can share a far more elaborate house than if each bought a single residence alone.

The residents need to organize their arrangements with written expectations and agreements.5 

Intentional Elder Village

While any of the aforementioned elder-housing types can be created as a free-standing, contained community, combining the options into an integrated neighborhood creates a continuum of choice to meet any need or desire a mature person might have. Add proximity or ready access to urban commercial areas and you have a well-rounded and well-functioning village.

Such a village has all the elements of a continuing care retirement community without the insurance aspect-- entry fees and legal contractual issues. A resident can buy into or rent a unit in this village and be assured access to any service they may require for the rest of their life.

Incorporating an Intentional Elder Village into the context of a town or village or into a new urban-design community seems very promising. The human-scale, relationship-based, resident-centered elder community is created as a vital, participating, contributing asset to the greater, multi-generational community.


Organizational Types

Most of the "old paradigm" institutional elder communities are licensed and for some services, such as high acuity skilled care, this is appropriate. But with licensure comes restriction of choice and structuring or institutionalization of a resident’s life.

The intent of the intentional elder neighborhood is to create an organization in which the resident is in charge of selecting the caregivers who assist. This is a marked difference from the old paradigm in which staffing is selected by management and turnover is rampant, leaving residents to be cared for by strangers.

Some neighborhoods may opt to have a caregiver occupy a guest suite or living unit, becoming an employee, selected and paid by the resident group. Others may choose to contract services to a comprehensive concierge/home healthcare service. In either case, the residents have the ability to change service providers if the services rendered do not meet their expectations.

An intentional elder neighborhood can be structurally organized in a variety of ways. Some of the more usual are:

Homeowner Association – more loosely organized community with community decisions made by elected board or, more consciously, using Dynamic Governance.

Managed community – owned or rented living units managed by a professional management company, which is attuned to resident input and decisions. This model is rare at present, as resident choice is diluted.

Other variations on the theme -- limited only by our imagination.

The choice to imagine a future as self-directed and institution-free is ours to make. The manifestation of our dream for the second half of life is limited only by our individuality, our desire to live consciously, and the people we include to plan and live the rest of this lifetime. GO FOR IT!
 

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Notes

         1        See "The Rosato Effect" at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1695733/.

         2        See www.cohousing.org for more information.

         3        For additional information, see www.sotelliving.com

         4        For additional information, read the fascinating book, What Are Old People For? by Dr William H. Thomas. See http://www.ncbcapitalimpact.org/default.aspx?id=146.

         5        An excellent example of such an agreement can be found at www.stateofgracedocument.com.