Improving Quality of Life for People Aging in Community

Without proper support and treatment, people’s quality of life often declines as they age. Health conditions and disabilities increase. For example, 90% of Rhode Islanders over age 65 have a chronic disease and 35% have a disability.¹ Physical and cognitive health challenges make it harder for people to manage their daily routines and to perform activities of daily living (ADLs) such as eating, bathing, dressing, using the bathroom, standing, and walking. As they age, people may also become socially isolated and unable to participate in the activities and relationships they once enjoyed.

These challenges can make it difficult for older people to continue living on their own and therefore make them more likely to end up in institutional care.^(a) Rhode Island ranks below many other states in the rate at which older people with disabilities are able to continue living in the community.³ In 2013, almost 96% of the state’s Medicaid spending on long-term care for seniors with disabilities went to nursing homes, even though in-home care is often cheaper and is preferred by nine out of ten older and disabled adults.⁴ 

Promoting older people’s well-being and ability to live independently benefits them as well as their families, communities, and the state. Caring for the elderly has financial and emotional costs: Nearly 134,000 Rhode Islanders are providing unpaid care to seniors worth an estimated $1.8 billion. More than two-thirds of these caregivers are themselves over age 55.¹

Quality of Life Among Older Adults

Health-related quality of life is a broad understanding of the factors that contribute to someone’s physical and mental well-being, including their health conditions, social supports, socioeconomic status, mobility, and functional status (i.e. ability to perform ADLs). Being able to care for oneself or receive necessary care from others is essential to quality of life. Studies show that older people who have unmet needs related to self-care and home management have more hospitalizations and are more likely to have a range of health problems, including weight loss, hunger, and dehydration. Their caregivers also have higher rates of caregiver burden and depression.⁵ 

An older person’s quality of life affects their ability to continue living independently in the community without the support of adult day care, assisted living, or a nursing home. Researchers have concluded that no single factor determines independence, but instead a combination of impairments in mobility, self-care, and social isolation typically influence a person’s decision to move into institutional care.⁶

The Importance of Home and Community Based Services

Across the country, there is an increasing interest in keeping seniors out of institutional care whenever possible by providing them with services and supports in their homes and communities. People aging in the community need a variety of services, from transportation and technology to assistance with ADLs and access to social opportunities.

The use of HCBS can reduce nursing home admissions, particularly for older people who lack family caregiver support.⁹ One study found that states that spent more of their Medicaid funds on well-developed, comprehensive HCBS systems saved money in the long run compared to states with fewer non-institutional services.¹⁰

Model Programs for Helping People Age in Community

There are several successful models for HCBS that can help people age in place and prevent them from requiring institutional care. For instance, the Centers for Medicare and Medicaid Services funded a program called Community Aging in Place, Advancing Better Living for Elders, or CAPABLE. This program focuses on how removing barriers and hazards in the home environments of low-income seniors with disabilities can impact their health and improve their quality of life.

CAPABLE combines the services of an occupational therapist, a nurse, and a handyman. Participants receive as many as ten nursing or occupational therapy visits over the course of five months, as well as up to $1300 of minor home repairs and upgrades like grab bars in the bathroom, stair railings, and improved lighting and flooring. Researchers found that after finishing the program, participants were less depressed and more able to complete the tasks needed for independent living, like shopping or managing their medications.¹²

Some programs go beyond prevention and focus on helping older people return from institutional care to community living. In 2009, Minnesota launched an initiative called Return to Community that targeted nursing home residents who expressed an interest in returning to their homes. Helping these individuals exit institutional care would be beneficial for them as well as the state: while they had been paying for their own nursing home care, if their funds ran out they would depend on state Medicaid funding to cover the costs.

The Return to Community initiative is a partnership among state agencies, nursing homes, hospitals, and other health care providers. Community Living Specialists assist participants in their transition from nursing homes back to the community by teaching them skills for daily living and connecting them to community resources and caregiver services. Follow-up continues for years after the transition.

A study of the Return to Community program found that it improved participants’ quality of life and reduced the costs of their care.¹³ Since the program began, over 2,300 people have been served and about three-quarters of them stay in their homes each year. The program was projected to save Minnesota $20 million over five years, plus additional private savings to the participants.¹⁴

Building Programs Within Existing Communities

Other initiatives focus on supporting seniors in naturally occurring retirement communities, which are geographic areas that happen to have high concentrations of older adults but were not necessarily planned or designed to meet their needs. Supportive Services Programs (SSPs) are run by community agencies to address the gap between what is already available to seniors in a community and what they need to successfully age in place. SSPs offer activities and social events and coordinate the use of existing social services from government and non-profit organizations. They promote volunteerism and the idea of seniors helping one another, for example by providing rides to doctors’ appointments.

Federally funded SSP projects have resulted in improvements in quality of life indicators such as social engagement, access to services, volunteer participation, and confidence in health and ability to age in place. One study in an Atlanta suburb found that SSPs increased mobility, social activity, and engagement, and reduced hospitalizations, emergency room visits, and falls.¹⁶

“Villages” are similar to SSPs but are organized and run by seniors themselves. Residents of a naturally occurring retirement community pay a fee to become members of the Village organization and are encouraged to volunteer their time to help other members with tasks like transportation, snow removal, or gardening. The idea is that the “younger old,” those ages 65 to 74, are more able to help others who can no longer do everything they used to around their homes.¹⁶ The Village organization also vets local businesses that provide services older people need, from cleaners to electricians to dog walkers.

The Village concept was first developed in Boston’s Beacon Hill neighborhood in 2002 and the idea has since spread to more than a hundred locations in the United States and beyond. Villages now exist in communities with varied economic resources and researchers are studying the model. In Rhode Island, the Providence Village serves Providence’s East Side and the East Avenue neighborhood of Pawtucket.¹⁷

The Role of Mobility in Quality of Life

Programs with a single focus can also have an impact on older people’s quality of life and ability to remain in their homes. One relatively simple way to prevent age-related disability is through physical activity.¹⁸ Even small increases in activity, such as taking a walk or doing housework, can create substantial improvements in health outcomes.¹⁹ In fact, seniors with the lowest levels of physical functioning may have the greatest potential to improve their mobility through physical activity.²⁰ Physical inactivity is associated with an increased risk of falls, which have the potential to cause major injuries and long-term disability.

There are a number of programs designed to improve seniors’ quality of life through exercise. Enhance Fitness is a group exercise program for older people that has over 25,000 participants across 32 states. It is designed to increase fitness and strength, promote independence, and prevent functional decline. The program offers one-hour classes conducted by certified exercise instructors in a variety of settings such as the YMCA, community centers, senior centers, and retirement communities. Studies show that Enhance Fitness participants improve their functional health and have reduced health care costs.²¹

Other programs specifically target falling, which can lead to serious injuries and long-term disabilities. Exercise programs that focus on improving balance have been shown to reduce falls.²² A Matter of Balance is a nationally recognized program designed to encourage physical activity and reduce the fear of falling. This program consists of eight two-hour sessions focused on increasing activity, providing strategies for preventing falls, and changing attitudes to reduce the fear of falling.

While even seniors with limited mobility can benefit from physical activity, they also need programs that are realistic about accommodating their limitations. For example, home meal delivery services like Meals on Wheels can be a lifeline for those with limited mobility. People who use Meals on Wheels are more likely than other seniors to have recently fallen, to limit what they do out of fear of falling, and to have tripping hazards in their homes and yards.²³ Research shows that the Meals on Wheels program results in fewer falls, hospitalizations, emergency room visits, and nursing home admissions – outcomes that improve seniors’ health and save the state money.²³ One study estimated that, in 2009, Rhode Island could have seen $500,000 to $1,000,000 in annual Medicaid savings by increasing the proportion of older people receiving meals by 1%.²⁴

Supporting People Aging in the Community

Given to its aging population, Rhode Island faces a significant increase in spending on services for older adults in the coming years. From 2014 to 2030, people over age 65 are expected to grow from around one-sixth to nearly one-fourth of the state’s population.¹ Enabling some of these older adults to age in the community rather than in institutional care can improve their quality of life and save the state money. As part of the Reinventing Medicaid Initiative, Rhode Island is developing infrastructure to serve older adults in the community and provide preventative care to keep aging residents from entering nursing homes.