What it Takes to Age in Place

Time is measured in many ways. For Jane, the big turkey and overflowing trays of Thanksgiving fixings served up on her long dining room table each year were the indication of how much her family had grown. But this year, her daughter and daughter-in-law handled the side dishes and the turkey had to be delivered, because Jane no longer drives. Still Jane – a real story, but not her real name –celebrated her holidays at home, and that says everything about how eldercare has changed.

According to research by AARP nearly 90% of seniors want to stay in their own homes as they age. That’s a lot of us who want to “age in place” –1 in 5 Americans (more than 72 million people) will be over 65 by 2030. But, as Jane’s story illustrates, this preference is not necessarily the course of action first pursued by families and doctors.

When Jane and Steve moved into their four-bedroom Westchester, N.Y. house as a young couple, it practically echoed. Through the years, two sons and two daughters filled the playroom with toys and friends and college roommates until everyone was married and on their own. One bedroom became Jane’s sewing room, and Steve took over the basement for his woodworking. Then Steve died, and the house began to echo again.

As Jane approached her 85th birthday, her doctor suggested she think about an assisted living facility. With the tough weather, Jane and her friends had a difficult time getting together, and the doctor said she needed more of a social life again.

Her doctor’s suggestion is a viable one for many – more than 735,000 people nationwide live in assisted living facilities. But Jane didn’t need help with meal preparation, and her health problems were all quite manageable. Despite her social isolation, group living held little appeal. She stayed in her home, managing her loneliness as best she could.

Then the doctor told Jane she needed to give up driving. What a stab to the heart that was. The kids were all in cahoots with the doctor. Once, just once, she had a fender bender, she argued. Had she taken her kids’ licenses away with each of the car wrecks they had as young adults? She actually had a set of keys hidden away for an “emergency,” but then they sold the car. It was complicated, but with delivery, taxi services, and some help from the kids, Jane still managed at home.

Just after her 90th birthday, Jane tripped over the cat and was hospitalized. The hospital staff insisted she go to rehab before she could go home, and even after six weeks there, they said she couldn’t live alone anymore. The kids and the doctor wanted her to stay in the nursing home connected with the rehab, which is a traditional approach to this transition, or move to an assisted living facility with a health aide to assist her. For Jane, it was a truly low moment.

Then Jane reminded everyone about Sylvia, who continued to live in her own house thanks to her kids finding her the help she needed. Jane wanted to live at home and she insisted that her kids help her “age in place.” The social worker at the rehab was reluctant, until she met Linda, the geriatric care manager that Sylvia had worked with. Linda is part of a growing profession. The National Association of Geriatric Care Managers reports their membership has grown from 250 in 1990 to well over 2,000 last year.

A geriatric care manager is trained and certified to partner with older adults and their families to assess, plan, coordinate, and monitor the services they need, like one stop shopping for aging in place. This service was essential for Jane, especially since advocacy for older adults is a primary function of the care manager, and her out-of-town kids needed a little persuading.

Linda also helped with some essential math. If Jane were to move to move to an assisted living facility in the New York area, a one-bedroom unit would cost her, on average, $6,500 per month. If she used an aide for just 12 hours a day ($20/hour) that would be another $6,720 per month. And she might want to see her geriatric care manager as often as weekly, at least until she gets acclimated ($200/hour), adding another $1,000. Assisted living would cost her $14,220 per month – and that was without the cost of moving – and figuring out what to do about her house.

If she could arrange to stay at home, her home health aide coverage for 24 hours would cost her $13,440, per month, and weekly geriatric care manager visits would add $1,000, bringing her costs to $14,440 monthly. Her mortgage was paid off and the utilities weren’t that expensive. Of course she’d have to pay for her own meals, but how much better was her own cooking, which her health aide would help her do.

Bottom line: it sure cost a lot to grow old, but it was worth a little extra money to do so in her own home.

Linda explained to Jane’s children that having a geriatric care manager would allow them to be Jane’s children, not her caregivers – and that she’d be there to manage any crisis – and prevent caregiving issues from interfering with their family relationships. A geriatric care manager is also trained to prepare a plan to address any home safety issues, so Linda went to the house with two of the kids while Jane was still in rehab. She measured the height of the toilet and suggested changing the toilet to a “handicapped”-type toilet. She examined the shower downstairs and the tub upstairs, recommending grab bars for the walls. Linda talked about removing the saddles between rooms and removed some of the throw rugs that Jane had made years ago. She suggested the washer and dryer be moved to the kitchen. She eventually convinced Jane that a bedside commode would be a help until she was stronger to walk (with a walker) to the bathroom.

It wasn’t perfect. As Linda moved furniture in the bedroom to make more room, she tossed Jane’s collection of Gourmet magazines that had taken a permanent place in the corner of the bedroom. Jane was furious at that. She’d relied on those recipes for inspiration. But soon she accepted that her cooking would be more limited, and the lack of clutter would allow her easier movement at home.

Linda pre-screened home health aides for Jane and the kids to meet – checked all their bona fides through the agency that employed them. They selected Nancy as the aide to be the daytime person. She was an excellent cook, and, she drove. When they settled into their new routine, Nancy did the shopping and took Jane her doctors’ appointments. Linda met them at the doctor’s appointments so she could report back to the kids. Soon Nancy was taking Jane to Sylvia’s house for lunch. They both loved movies, and Nancy drives them there. In the evenings, Nancy is relieved by another aide, Jenny. Jane and Jenny love watching the same late TV shows, then she helps Jane get ready for bed. All of her medications are lined up in boxes; Nancy takes care of all that.

Next month Jane will celebrate her 100th birthday. She has now managed with this help in the house for the last nine years, surrounded by her memories, able to see old friends and often visited by her family in the house that is her home. No one is sitting around watching Jane’s every breath. She manages her own schedule. She feels that this is the best “assisted living facility” in the world – the one she wanted, the one made possible through professional advocacy of a geriatric care manager.

And although it is months away, Jane is thinking about Thanksgiving. Maybe Sylvia can lend her some chairs so she can invite Nancy and Jenny and their families.


Patricia L. Mulvey, LMSW, a certified advanced social work case manager, is lead geriatric care manager at Jewish Home Lifecare in New York.






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