Aging in PlaceMany people wish to grow older in their own homes rather than in an institutional setting. To accomplish this, it is important to have the means to maintain a home, perform activities of daily living, and feel comfortable in their communities.
Many people wish to grow older in their own homes rather than in an institutional setting. To accomplish this, it is important for older adults to have the means to maintain a home, perform activities of daily living, and feel comfortable in their communities. This section of the report discusses aging in place in both homes and communities. Key findings include:
- Many older adults report difficulty maintaining their homes, both inside and out.
- Only one quarter of older adults say information is available about services to assist them with remaining in their homes and communities as they age.
- Most older adults in Central Indiana believe their communities are a good place to live, but 16% do not. Older adults feel positively about ease of driving and travel, moderately about ease of walking and access to food, and negatively about built environment issues, such as housing costs, availability, and accessibility, transit, public spaces, and their access to mixed-use neighborhoods.
AGING IN PLACE AT HOME
The majority (77%) of older adults in the United States wish to stay in their current residence for as long as possible as they age, which is known as “aging in place.” To accomplish this goal, home modifications and assistance with performing routine daily activities are necessary to address limitations imposed by chronic disease and disability.1
While financial assistance through grants or home equity products can pay for home modifications for some low-income homeowners, renters are unlikely to have these opportunities. Without government incentives or mandates, property owners of existing rental housing are unlikely to make these changes.2 People of color are more likely to be affected by challenges related to aging in place, as they are less likely to own their own homes than White households.3
Long-term services and supports (LTSS) are a broad range of supportive services provided formally by professionals or informally by unpaid family and friends. LTSS can be provided in a person’s home, or in community-based or institutional settings, if necessary. Such services and support are funded through the Older Americans Act, the Program of All-Inclusive Care for the Elderly (PACE), the Medicaid Home and Community Based Services (HCBS) Waiver, and Home Options to Institutional Care for the Elderly and Disabled (CHOICE) programs. See the Healthcare chapter of this report for more details about these programs.
The Indiana Family and Social Services Administration (FSSA) is implementing reforms to the administration of long-term care under Medicaid with a goal to lower costs per person and deliver more care and services at home. Twenty-five other states have implemented similar reforms, called managed long-term services and supports (mLTSS) programs.4
The case for reform is driven by demand for HCBS and growing costs. An FSSA presentation outlining the LTSS reforms states that most people prefer home-based care but few receive it, and costs for institutional care are disproportionately high. LTSS spending acounts for a quarter of Medicaid costs in Indiana, and most of that cost is institutional care.5
Advocates for mLTSS hope the reforms will reduce cost and incentivize quality care and outcomes rather than expensive procedures. In addition, researchers have found positive benefits for aging in place among established mLTSS programs. When older adults in mLTSS programs receive more at-home care, they are less likely to be admitted into a long-term nursing facility.6 (See the Health Care and Caregiving chapters for more details on these proposed reforms.)
FSSA anticipates the mLTSS program will launch in 2024 and will serve over 120,000 Hoosiers in the initial years of its implementation. By 2029, FSSA expects it will serve 165,000 Hoosiers. A proposed bill passed by the Indiana Senate in February 2022 would have limited these reforms to a 10-county pilot area.7 It was strongly opposed by FSSA leadership. The bill did not receive a vote in the Indiana House.8
AVAILABILITY OF SUPPORT SYSTEMS
While the American Association of Retired Persons (AARP) ranks Indiana 44th in the nation for its LTSS system, survey data related to the ability of older adults in Central Indiana to age in place is more positive.9 10 The Community Assessment Survey for Older Adults (CASOA™) identifies the strengths and needs of older adults in Indiana, including the Central Indiana region.11 Compared to the state as a whole, Central Indiana performs similarly with respect to indicators related to the ability of the age 60 and older population to age in place. Nearly half of older adults in Central Indiana report that maintaining their homes (57%) or yards (45%) is at least a minor problem. Nearly two-thirds (65%) report that doing heavy or intense housework is at least a minor problem.
These challenges can result in injury–34% of older adults surveyed in Central Indiana report falling or injuring themselves in their homes during the past year. This is a statistically significant increase from 2017. See the Health Outcomes chapter for the older adult death rate due to falls.
Survey respondents indicate they need more information about the services and resources available to help older adults. Two thirds (67%) of older adults say not knowing about available services in their community is a problem. Only 30% believe that the availability of daytime care options for older adults in their communities is excellent or good, and 45% believe the availability of long-term care options is excellent or good. Forty-three percent of those surveyed report that the services provided to older adults in their communities are excellent or good, which is an 11 point decrease from 2017.
Key informants, including direct service providers, believe many older adults do not receive needed assistance because they are unaware of its availability.12 Even when they are aware that services exist, distrust or pride on the part of an older adult or their caregiver can act as a barrier to receiving these services. Fear is another factor identified by key informants as an element that keeps older adults from seeking services or help. Key informants describe many reasons for their fear, but often involve fear of being removed from their home if seen as being incapable of living alone, fear of being a victim of a burglary or other type of crime or fear of the current world at large, including pandemic fears. See the Safety and Abuse chapter for related discussion.
Key informants suggested that a solution to this problem could include provision of information and outreach through faith communities, senior centers, group meal sites, meal delivery providers, senior housing units, Rotary Clubs, family caregivers, health care providers and case managers. Establishing a “clearinghouse” of information for community resources was mentioned, demonstrating that some older adults may not be aware that CICOA Aging & In-Home Solutions (CICOA) exists to connect older adults in Central Indiana to community resources, including through the Solutions Guide.
It was noted that when an individual is eligible for and enrolled in either Medicaid HCBS Waiver or CHOICE, the assistance provided under these programs is especially helpful. Concern was voiced about the aging population and if resources would be available to meet the growing need for LTSS as Baby Boomers continue to age. Information about services offered through CICOA are available in the appendix of the Caregiving chapter of this report.
“Just because you can
[do something], doesn’t mean you should.”
Focus group participant
Older adult focus group participants who still live in their communities view maintaining their independence as important to their happiness. Some can depend on a spouse, other family members, or neighbors when they need assistance with day-to-day living. Common issues of concern are challenges maintaining a household (e.g., keeping sidewalks and driveways clear of snow), obtaining home modifications (e.g., grab bars in the bathroom) and accessing transportation. One participant commented that it is important to know when to ask for help with activities such as cleaning the gutters. Some participants expressed a desire for information about eligibility for supportive services.
Some participants expressed a desire for information about eligibility for supportive services.
WHAT IS BEING DONE?
A No Wrong Door (NWD) System is being developed in Indiana, through which older Hoosiers will be empowered to make informed decisions, exercise control over their LTSS needs, and achieve their personal goals and preferences.13 A NWD System is a person-centered, one-stop coordinated system that seamlessly connects individuals to the full range of LTSS options, expanding access to services and supports in an unbiased manner.
The backbone of the Indiana No Wrong Door System are Aging and Disability Resource Centers. CICOA is the center for older adults in Central Indiana. The organization provides counseling, information and referral services, and functional and eligibility assessments for LTSS. CICOA also functions as the intake mechanism for older adults in Central Indiana accessing services through Medicaid and the Older Americans Act.
Other organizations that assist older adults in Indiana communities to stay in their homes include the Fair Housing Center for Central Indiana, which advocates for universal design requirements to facilitate aging in place, and accessABILITY, formerly known as the Indianapolis Resource Center for Independent Living (IRCIL).
Central Indiana is making progress toward facilitating aging in place through opportunities like managed LTSS reforms. Opportunities exist to expand information and outreach activities resulting in increased awareness and access to services for those who need and desire support.
AGING IN PLACE IN COMMUNITIES: SENSE OF PLACE
“Sense of place” is a multidisciplinary concept that can include elements such as a person’s physical and emotional connection to the environment around them.14 When older adults live in a neighborhood that is familiar to them, it increases their satisfaction with that area, because it improves their ability to navigate their surroundings in those environments and reduces the anxiety related to activities within them.15 In unfamiliar environments, older adults can feel more connected and comfortable when aesthetics are appealing and when usability and accessibility are sufficient to facilitate independence. Thus, how they experience “place” becomes very important. 16 Changes to the physical environment can lead to a sense of loss for older adults. 17 Indeed, place attachment is related to social well-being. A change in place can lead to a reduction in social well-being among older adults. 18 This is particularly true for lower-income households that live in areas of gentrification, where sense of place can be lost as the surrounding physical environment changes.19
See the Social Well-being section of this report for further discussion of the factors that impact the social well-being of older adults.
CENTRAL INDIANA COMMUNITIES ARE GOOD PLACES TO LIVE
Data from the Community Assessment Survey for Older Adults (CASOA) reveal that the majority of older adults in Central Indiana have reasonably high satisfaction with their communities as places to live and retire. Eighty-four percent of respondents rate their communities as excellent or good places to live, and more than three out of four (78%) report they are very or somewhat likely to recommend living in their communities to other older adults.
Although a large majority indicate they are very or somewhat likely to remain in their communities throughout retirement (84%), a smaller majority (68%) rate their communities as excellent or good places to retire. The difference between these responses suggests that some older adults may prefer to retire elsewhere but do not think they have the option to do so.
Of concern are the one in three (32%) older adults who rate their communities as only fair or poor places to retire. Multiple factors influence whether older adults consider their community a good place to live and retire. As discussed in other sections of this report, physical factors such as safety, transportation, access to high quality food, housing, health, and social services influence the perceptions of older adults about their communities.
When asked to rate specific characteristics of their community, respondents tended to be more critical: Only four characteristics received mostly positive ratings. Ease of travel by car was viewed positively, as was the related issue of getting to places. A slight majority of respondents view ease of walking and access to affordable quality food positively. On the other hand, only four out of ten older adults viewed the cost of living or the availability of affordable, quality housing favorably.
The way homes and communities are built can facilitate or discourage aging in place. Mixed-use neighborhoods with multiple transportation options make it easier for people to navigate life’s needs without driving. (While most older adults said it was easy for them to travel by car, 20% ease of travel by car as fair or poor.) Accessible homes allow people to remain in their house longer and without costly renovations. Unfortunately, these characteristics are rated poorly by most Central Indiana older adults.
For related discussions, see the Financial Stability, Food Insecurity, Housing, Safety, Health Care, Transportation, and Social Well-being sections of this report.
According to service providers and other key informants, location-related aspects limit opportunities for older adults to interact within their communities. For instance, distance between senior centers and community events prevents some from visiting. Additionally, a decline in neighborhood safety limits entertainment opportunities in some areas – older adults may not sit outside as frequently as in the past, especially if they perceive it is not safe to do so. This could be because their surroundings have changed and they are not as familiar with their neighbors as they once were.
Focus groups of older adults discussed changes they see in their neighborhoods. Several participants in both Hamilton and Marion counties discussed the impact of gentrification on their neighborhoods. One noted that developers want to raze her home and build expensive homes in its place. Another enjoyed living in her neighborhood when it was more racially diverse; however, as home values increased, diversity diminished and many older adults in the area fear being displaced because they cannot afford increased property taxes. This participant mentioned that she misses the way her neighborhood was, particularly her neighbors, who have since left. To learn more about the challenges residents of color, particularly Black older adults, face when aging in place, please see ‘Highlighting Equity’ on the following page.
In another focus group, participants believe their neighborhoods are in decline, with a decrease in homeowners and an increase in renters and abandoned homes resulting in disinvestment in the area by its residents. One person noted that an increase in traffic by her home resulted in property damage and trash, and she is searching for programs to assist with repairs. A sense of place from their neighborhood is impactful to older adults in Central Indiana, who rely on this to maintain a good quality of life and to remain in their communities for as long as they wish.
VETERANS AGING IN PLACE
Veterans face special challenges with aging in place. Those living at home are more likely to fall or have memory loss, and disability rates are higher among this population.20 In response to these increased needs and a growing older veteran population, the U.S. Department of Veterans Affiars announced an expansion of home-based care services in January 2022.21
In Central Indiana there are 64,000 older adults who are veterans, 13% of that age group (age 55 and older). The majority of these are middle-old, although the oldest-old are the most likely to be veterans compared to other age groups. While most older veterans are White, Latinx and Black residents have higher rates of veteran status. In some domains, veterans have fewer vulnerabilities. For example, older veterans in Central Indiana are less likely to experience poverty than non-veterans (6% vs 9%; ACS 2016-2020 five-year estimates), and veterans over age 75 have lower rates of suicide than civilians in the same age group.22
On the other hand, veterans have higher rates of disability than non-veterans (38% vs 27%). Veteran status does not eliminate the poverty gap between Blacks and Whites – Black older veterans are twice as likely to experience poverty than other veterans of color, and almost three times as likely to experience poverty compared to White older veterans.
Barriers to successful aging in place by Black and other older adults of color
Black and other older adults of color face challenges with aging in place due to a variety of individual, interpersonal and community factors:
Individual factors: High prevalence of disabilities
Research has shown that one of the barriers to successfully aging in place is poor health. Because of lower socioeconomic status, people of color experience more barriers to services and have a higher prevalence of disability, meaning they may be less likely to continue living on their own as they age.23
Interpersonal factors: Black older adults are more likely to live with extended family members
One study found that Black older adults are less likely to live with a spouse and more likely to live with extended family members such as children, grandchildren, or other relatives when compared to other older adult households. These multigenerational households may not have the ability to pay for age-friendly home modifications for their elderly family member, as there can be other competing demands for financial resources, such as saving for a child’s education. 24
Community factors: Housing Challenges
Black older adults face several housing-related challenges to aging in place. First, Black Americans are less likely to own their homes than White adults.25 One analysis found that nearly one in three Black older adults lived in apartments between 2011 and 2015, meaning they were most likely to be renters. This presents challenges for older adults who may need home modifications, as landlords are only required to make modifications to comply with the Americans with Disability Act, and are often unlikely to voluntarily make other modifications due to the costs involved.
Black older adults who own their home also face barriers to successful aging in place. This population was more likely than all other older adults to live in houses built before 1970, which can present health and safety risks such as exposure to lead-based paint, mold, and structural deficiencies which can be costly to repair.26 Gentrification can also be a major problem for homeowners of color, as rising property taxes and cost of living increases can force these older adults to move out of their homes and neighborhoods.27
- Davis, M. (2021). “Despite Pandemic, Percentage of Older Adults Who Want to Age in Place Stays Steady” Washington, DC: AARP Research Center. https://www.aarp.org/home-family/your-home/info-2021/home-and-community-preferences-survey.html.
- Johnson, Jr., J.H., Appold, S.J. (2017). “U.S. Older Adults: Demographics, Living Arrangements, and Barriers to Aging in Place,” Chapel Hill, NC: Kenan Institute of Private Enterprise. https://www.kenaninstitute.unc.edu/wp-content/uploads/2017/06/AgingInPlace_06092017.pdf
- Bucknell, A. (2019). “Aging in Place: For America’s older adults, access to housing is a question of race and class,” Harvard Joint Center for Housing Studies, October 24. https://www.gsd.har- vard.edu/2019/10/aging-in-place-for-americas-older-adults-access-to-housing-is-a-question-of- race-and-class/.
- Indiana Family and Social Service Administration. Managed Long-Term Services and Supports. Accessed May 13, 2022, https://www.in.gov/fssa/long-term-services-and-supports-reform/managed-long-term-services-and-supports/
- Indiana Family and Social Service Administration. Managed Long-Term Services and Supports Stakeholder Update. November 3, 2021. Accessed May 13, 2022, https://www.in.gov/fssa/long-term-services-and-supports-reform/files/mLTSS-Design-Book-Presentation-11.3.21.pdf)
- Neumann, L., & Documet, P. I. (2019). MLTSS and Aging in Place: How Personal Care Services Help Avoid Nursing Facility Admissions of Older Adults. Innovation in Aging, 3(Suppl 1), S737–S738. https://doi.org/10.1093/geroni/igz038.2703
- Benson, Darian. (2022). FSSA says a proposed bill could hinder its effort to reform long-term care. WFYI News. https://www.wfyi.org/news/articles/fssa-medicaid-managed-care-legislation
- Indiana General Assembly. http://iga.in.gov/legislative/2022/bills/senate/407#document-93f28f5e
- Indiana is 51st in the nation, a number that includes Washington D.C.
- Reinhard, S., Accius, J., Houser, A., Ujvari, K., Alexis, J., Fox-Grage, W. (2017). “Picking Up the Pace of Change, 2017: A State Scorecard on Long-Term Services and Supports for Older Adults, People with Physical Disabilities, and Family Caregivers,” Washington, DC: American Association of Retired Persons Foundation, The Commonwealth Fund, and The SCAN Foundation, 2017. http://www.longtermscorecard.org/2017-scorecard.
- Community Assessment Survey for Older AdultsTM. (2021). National Research Center Inc. https://cicoa.org/news-events/research/.
- Thirty-five key informant interviews with caregivers and service providers and nine focus groups with older adults were conducted during 2019 and 2020 to collect input on issues facing the older adult population in Central Indiana. Public and not-for-profit sector leaders and service providers who are knowledgeable about service systems and issues pertaining to older adults in Central Indiana were identified and interviewed as key informants during report preparation. Focus groups composed of older adults were assembled with the identification and recruitment assistance of community service providers. These focus groups were conducted by researchers, in person prior to the COVID-19 pandemic, and by Zoom after the pandemic began. The questions asked of the focus group participants were discussed and agreed upon by research faculty and staff.
- Indiana Family and Social Services Administration – Division of Aging, Indiana State Plan on Aging, Federal Fiscal Years 2019-2022, June 2018, Indianapolis, IN. https://www.in.gov/fssa/ files/2019-2022%20Indiana%20State%20Plan%20with%20Attachments%20A-D.pdf.
- Jorgensen, B. S., and Stedman, R. C. (2001). “Sense of Place as an Attitude: Lakeshore Owners’ Attitudes Toward Their Properties,” Journal of Environmental Psychology 21, (2001): 233-248. https://doi.org/10.1006/jevp.2001.0226.
- Fornara, F.,Lai, A.E., Bonaiuto, M., Pazzaglia, F. (2019). “Residential Place Attachment as an Adaptive Strategy for Coping With the Reduction of Spatial Abilities in Old Age,” Frontiers in Psychology 10, article 856, April 24 . https://doi.org/10.3389/fpsyg.2019.00856
- Phillips, J., Walford, N., and Hockey, A. (2011) . “How do unfamiliar environments convey meaning to older people? Urban dimensions of placelessness and attachment,” International Journal of Aging and Later Life, no. 2: 73-102. https://doi.org/10.3384/ijal.1652-8670.116273.
- Cook, C.C., Martin, P., Yearns, M., Damhorst, M.L. (2009) . “Attachment to “Place” and Coping with Losses in Changed Communities: A Paradox for Aging Adults,” Family and Consumer Sciences Research Journal 35, no. 3: 201-214. https://doi.org/10.1177/1077727X06296794.
- Afshar, P.F., Foroughan, M., Vedadhir, A., and Tabatabaei, M.G. (2016) . “The effects of place attachment on social well-being in older adults,” Educational Gerontology 43, no. 1: 45-51. https://doi.org/10.1080/03601277.2016.1260910.
- Shaw, K.S. and Hagemans, I.W. (2015). “’Gentrification without Displacement’ and the Consequent Loss of Place: The Effects of Class Transition on Low-income Residents of Secure Housing in Gentrifying Areas,” International Journal of Urban and Regional Research 39, no. 2: 323-341. https://doi.org/10.1111/1468-2427.12164.
- Speechley, M., Belfry, S., Borrie, M., Jenkyn, K., Crilly, R., Gill, D. (2005). Risk Factors for Falling among Community-Dwelling Veterans and Their Caregivers. Canadian Journal on Aging / La Revue Canadienne Du Vieillissement, 24(3), 261-274. doi:10.1353/cja.2005.0083
- U.S. Department of Veterans Affairs. (2022). VA amplifies access to home, community-based services for eligible Veterans. https://www.va.gov/opa/pressrel/pressrelease.cfm?id=5757
- Karel, M, Wray, L, Adler, G, Hannum, A, Luci, K, Brady, L, McGuire, M. (2020). Mental health needs of aging veterans. Clinical Gerontologist, online preprint https://doi.org/10.1080/07317115.2020.1716910
- Office of Policy Development and Research. (2013). Aging in Place: Facilitating Choice and Independence https://www.huduser.gov/portal/periodicals/em/fall13/highlight1.html
- James HF, Jr., Lian, H. (2018). “Vulnerable African American Seniors: The Challenges of Aging in Place.” Journal of Housing For the Elderly 32: 135–59. https://doi.org/10.1080/02763893.2018.1431581.
- Parker, A. (2020). “Wealth Gap: Examining the Root Causes of Poverty among African Americans.” Post and Courier. Accessed January 21, 2021. https://www.postandcourier.com/news/local_state_news/wealth-gap-examining-the-root-causes-of-poverty-among-african-americans/article_89406f92-e7b0-11ea-894e-73687a88cf63.html.
- James & Lian (2018) https://doi.org/10.1080/02763893.2018.1431581
- Epps, Gretchen, & Luster (2018) https://doi.org/10.1016/j.gerinurse.2018.04.018.