Since the American Society on Aging 2012 Aging in America conference my mind has been occupied by the sessions I attended, the preparation I did to give three presentations, the Aging in Place Institute Action Salon and MANY less formal conversations. A new view of Aging in Place as disruption and innovation follows.
I was pushed to think for two of my presentations. Richard Adler asked me to take my ideas into the future for a panel of the National Forum on the Future of Aging. Similarly Patrick Roden got me thinking about trends…leading me to get familiar with some that are atypical, more out of the box, than the trends we can all just rattle off the top of our heads.
And from the Boomer Business Summit, the young, new to the field, and excited business folks who are looking for disruption and innovation, I started to view what I learned from my presentations and sessions through that lens.
We know the
1. Demographics (more older people, older older people, fewer payers)
2. Consumer preference (~85+% want to remain at home)
3. Rising medical costs & limited resources (eg. too few caregivers)
Point to Aging in Place, the shift of care from centralized locations hospitals, nursing homes, and assisted living (along with CCRCs- all models of service enriched housing) to decentralized locations- homes, shared housing, co-housing, etc that result in more control, choice dignity and respect and reduced costs and more efficient use of all resources.
BUT we are bogged down because we see Aging in Place’s essential disruption as one of PLACE and look to devices to fill gaps because care workers are not present in the home.
1. That makes Universal Design, delivered through home modifications and the home remodeling industry the primary innovation. AARP and others have been pushing this route for years with practically zero market penetration.
2. On the other hand the most active sector seeking the Aging in Place market are the myriad point solutions represented by high tech monitoring and medication compliance management, etc. Despite huge investments and lots of PR, also near zero market penetration. This is innovation chasing its own tail.
3. Home health is the only bright spot economically showing incredible growth in the number of agencies, the number of franchisers, the number of clients and the number of employees.
SO, if Aging in Place is not primarily about place and devices, to what other disruptions should we pay attention? What innovations are needed to fill out the business model driving Aging in Place to move from demographic excitement to market reality? Luckily, most do not require invention as much as thoughtful repurposing and integration. Examples include:
A. Distribution: Until recently all our power was generated in huge centralized plants – hydro, coal, nuclear -distributed in one direction to homes and commercial locations over a grid. 
Now power is generated in small, medium and large solar and wind ‘plants’ virtually everywhere. The same grid distributes the power but not in one direction. It is in every direction and changes as the wind blows and the sun shines. Capacity and demand are monitored and matched constantly. This is a lot like the dynamic need for care and services. Eric Dishman refers to moving from ‘the mainframe to the PC’. Remember the power grid does not just work. It is carefully monitored, tuned and managed. We have lots to learn from from distributed generation.
B. Inventory: Nursing homes and assisted living are about all resources available all the time. This is similar to old style parts warehousing in manufacturing. Manufacturing has moved to ‘Just in Time‘ and other demand flow approaches to meeting client needs resulting in much greater efficiency and flow of resources. There is so much written about and software developed to manage inventory.
Modern inventory control is a tight relationship among suppliers and customers. Everyone participates to make it work. We can compare it to self direction and chronic care self management. Inventory control for aging in place is enlightened, close attention to individual client abilities, needs and desires so needed services flow smoothly just as needed. We need to see Aging in Place services as supply and demand and manage it with the best possible techniques.
C. Chronic care models. Everyone knows we must shift from acute healthcare approaches to chronic approaches. Aging is not about being sick, as much as it is about multiple chronic co-morbidities which flair episodically. Managing these multiple chronic conditions and reducing acute incidents results in less misery AND lower medical costs. The Veterans Administration has evidence that chronic care is best delivered in homes by teams. Lets learn and do it.
There is ample evidence that engaging the client in chronic care self management through training, coaching, tech and other prompting and monitoring is the most effective and cost effective way to lower costs. People respond to autonomy, self reliance, personal responsibility and purpose when helped with the right tools. What is the holdup on more widespread implementation?
D. Customized: Embrace Aging! Embrace the Complexity! Use Technology.
Whether we look at spreadsheets used to get new home and condo owners the right finish on their cabinets, the right stone on their countertops, paint on their walls and tile on their floors or restaurant software that gets the right appetizer, main course and desert to each diner or the right almost everything from Amazon to every address in the developed world the technology to deliver custom services is not mysterious. We need to wake up and deliver customized services to people in our communities. It does not need to be national. Locally operated, person responsive systems are in order. Technology is not the barrier.
The use of technology is not about reducing the human warmth of caregiving. The technology is an underlying organizational tool that frees clients and caregivers to stop worrying about schedules, eligibility and payment so they can concentrate on care and relationships that flow smoothly from everyone’s perspective. Like every tool, the management technology should make life easier, not colder.
D. Transportation: Para-transit and senior connection services are some of the most disrespectful and dysfunctional parts of the home and community services mishmash. People wait far too long and ride far too long.  Most services are barely reconfigured school or municipal van/bus approaches with no client centric considerations. The effect is managed inconvenience. Two anomalies are Independent Transport Network and Silver Ride. We have a long way to go. But there are models to iterate. Lets do it!
E. Entry to the home: I don’t have innovative examples for this critical disruption. That means the field is wide open! Providers of all types need earlier access to Aging in Place clients. Currently only the rare wake up call, but much more typically a health crisis- often with irreversible consequences – gets those who want to age in place connected to those who want to provide aging in place services. The results are often failure- a forced move in an health crisis that does not have to be a surprise.
F. A new manager role: If Aging in Place 2.0 means dynamic management of resources delivering respect and dignity to clients in the home of their choice, what is AiP1.0? AiP 1.0 is the current mishmash of home and community based services that defies efficiency, management and satisfying results. Professional geriatric care managers know this frustration as do many others who dearly want to serve older folks in their homes as well as the families trying to navigate the morass. A new manager role will emerge to distribute the supply of resources, Just in Time, using technology to best advantage for all. The new hub care manager will still be a warm, passionate, professional. The difference is they will be empowered to dispatch the right intervention, service or product or just when it is needed. This is going to be a great job people will love.
G. Mindset: We don’t think this way. We need a wholly new system for aging, care and services. Even many advocates only see aging in place as a stop gap to an inevitable move. We need to go all the way and commit to aging in place a s fully viable integrated system. Incremental adjustments to the current cobbled together Home and Community Based Services (AiP1.0) is not going to cut it.
A paradigm shift of this magnitude requires sharp minds and commitment. Change will be influenced by many factors- health reform/accountable care organizations and reduced home values making senior housing entry fees difficult are two on the immediate horizon. These are big issues requiring bigger ideas and bold leadership. That is The Aging in Place Institute‘s role. (see my previous blog also)
In a conversation with Jason Popko of Bosch Health Care he suggested the best Aging in Place location may be camping in a corner of Walmart. Everything you need is right there there: The greeters are your social network, discount prescriptions are available, scooters, small devices and food are on sale. (you can use a camping stove to cook) There is a coffee shop/lunch counter on site.
What could be better? Aging in Place 2.0 will be much better than camping at Walmart. We have to work on that!
Louis Tenenbaum, one of the nation's leading authorities on aging in place, is the founder of HomesRenewed, a coalition of business, consumers and nonprofits, driving policy and investment to increase the number of age-friendly homes.
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Our society is horrified at the thought of aging. People who have aged to the point where they’ve lost some of their capabilities fear being stigmatized as “being less of a man,” “becoming a burden on their already-burdened adult children,” or being just plain embarrassed by the fact that they can no longer do some of the things that everyone else does with ease. Their own home then becomes a place of retreat and withdrawal. To many, “aging in place” gradually becomes “aging in private,” withdrawing from the world piece-by-piece as the aging process relentlessly continues.
To overcome this negativity, someone who is aging must honestly believe that a particular element of aging in place (the one that applies to their situation) is a means of empowerment. (This/these “tools” give me the ability to continue doing nearly all of the things I want to do and/or to experience less pain/frustration than I would otherwise have.) Thus, when viewed as enabling solutions, universal design (cost notwithstanding), technology and/or care management can and will become much more widely accepted.
HOWEVER, no element of aging-in-place will be accepted by most people until they actually begin to experience some of the pain and frustration of the aging process. Regardless of what we’d like to believe, most people don’t plan ahead, especially for the eventuality of losing some of their cognitive or physical capabilities. “It not going to happen to me.”
Now the question becomes: “How do we reach our real market?” For the most part, they are not going to come to us. And, it’s of little good if their adult children come to us. Their elderly parents will most likely rebuff their recommendations, or seemingly accept their recommendations just to close off any further discussion of the issues.
So, we must go out and find our market. But, where are they? They’re not in a nursing home. They’re not in an assisted living facility. Home health care agencies will probably be of little use. And, most doctors would discourage hanging out in their office until a likely aging prospect wanders into our sight.
The answer to “Where?” is probably SENIOR CENTERS, or similar places where elderly people congregate (church groups?).
The next question becomes “Who?” Who has the credibility to talk about the empowerment of aging-in-place, whether that means universal design, low-tech solutions (canes) or high-tech solutions? That certainly leaves out most people under 65, except perhaps former family caregivers.
Our best representatives would be people who already have or have had some of the limitations experienced by our market.
How do we “make the sale?” Price is not the first issue. First, a prospect must be thoroughly convinced that we have THE SOLUTION that best answers their own personal WIIFM question (What’s In It For Me?) RIGHT NOW! (“Avoid being sent to a nursing home in the future” will not make the sale.) Then, their attitude will more likely change from “can’t afford it” to “can’t afford not do it!”
Design schools are required to incorporate Universal Design into their curriculum, so the next generation of designers are (hopefully) going to incorporate UD as an integral and seamless part of the design. It is our job, as designers, to create aesthetic and functional spaces – for everyone. Builders should be educating their clients to put things into place so features can be added later – when needed (such as blocking in the walls to add handrails and grab bars). UD allows people to age in place – it’s smart design. Wider doorways and hallways help everyone – mothers and fathers with strollers and packages, moving or adding furniture. At least one level entry into the house is a no-brainer in my mind.
As a CAPS certified interior designer, with a depth of marketing research and new product development experience, it is my opinion that the AIP marketing initiatives are misdirected. I have consistently run into the same objections in speaking with elderly, potential clients. They express they either don’t have funds or don’t see the return on investment, or are adverse to major changes and disruption required to truly address their needs.
When I speak to Boomers like myself about aging-in-place, they are immediately put off with visions of grab bars and walk in bath tubs. Clearly, those who are marketing this concept need to conduct focus groups in several demographics in order to retool and reposition the message.
In my opinion, these products and services should be targeted and conveyed in the same manner as retirement financial planners. Target 50+ who are still working and periodically renovating their homes. Marketing our services as “Planning for your future Home for Life” to this demographic makes much more sense. Acting as consultants to those contemplating home remodeling to ensure they install long term solutions, hence best value for dollars spent, that will accommodate unforeseen events such as a health crisis or bringing an aging parent into their home.
This is not to debunk the ideas presented above in terms of community planning. They are all valid. Interestingly, they make sense across all demographics, not just for aging. The concepts would seem to strengthen communities of all ages and actually would encourage multi-generational living, which historically, and in many cultures now is the norm.
Very thought provoking! I KNOW no want thinks they are aging! Aging is not a word I can use when addressing baby boomers.. Managers of this sort are a great idea!
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