Report: ASHRA conference in Halifax, Nova Scotia

I am so glad I was honored with an invitation to speak at the Atlantic Seniors Housing Research Alliance conference in Halifax, Nova Scotia, Canada last month. This conference was the culmination of a five years study of the situation and conditions of senior hosuing and services in this part of Canada. Don Shiner, a marketing professor at Mount Saint Vincent University in Halifax chaired the alliance study, applying businesslike techniques to retrieving and organzing information.

The conference was a mix of academics, senior network folks, health care professionals and government officials, builders/developers and housing officials as well as citizen advocates. The Atlantic provinces - Nova Scotia, Prince Edward Island, New Brunswick and New Foundland are largely rural, have high percentage senior populations and feel like closely knit communities. The Canadian health care system is not so private as ours but clearly not so centralized as some European or the Japanese model.

Four speakers set the stage the first day.
1. Andrew McIntosh represents Tunstall, a UK company providing alert and monitoring systems in the UK planning to expand to North American markets. Talking with Andrew at breakfast was worth the trip as we discussed how the differences in private/government pay impacts innovation.

Andy's presentation was eye opening. The UK is full bore into telecare, developing clear data about hospital cost savings. Their monitoring systems are robust and community based. The rapid investment in cost saving Aging in Place technologies reflects public responsibility for health expenses. Just one of the terms these folks use, 'health and social care partnerships', gives a hint to the difference in approach between the UK system and that here in the States.

2. The second speaker, Victor Regnier, is professor of gerontology and architecture at the University of Southern California. Victor has been the visionary behind many design and program innovations at Sunrise Senior Living and many other housing providers. He has written many books. Victor has visited lots of Northern European communities to study innovations and attitudes about seniors, housing and health care. His presentation showed a wide range of conceptual variations - opening our minds well beyond the familiar.

3. I spoke about technology for Aging in Place. I reviewed process and some examples of home mods (failures, too!) and assistive tech including ceiling lifts. I skipped alerts and telehealth (after Andrew's excellent intro). I spoke briefly about how smart house techniques can increase choices. My focus was the Comprehensive, Integrated and DYNAMIC Monitoring and Management SYSTEM I dream about. I described the air traffic control-like community based monitoring center that will dispatch resources to make best use of the right service/provider/technology- saving money and preserving dignity.

4. Jen Boger who does research at University of Toronto and Toronto Rehab fascinated us with their approach to automated assists for folks Aging in Place. They focus on using intelligent technologies to solve commonplace and significant problems. Jen's organization is a partner of the University of Buffalo School of Architecture based IDEA Center, a Rehabilitation Engineering Research Center (RERC) on whose advisory board I serve.

The next day and a half continued with presentations, breakouts and the design competition award. One breakout I attended captured the special nature of the whole. People got excited speaking about volunteer efforts, community efforts, best practices ...and how they can go to the next level. These people want to be responsible. The Canadian approach to private action and government partnership makes good ideas seem possible.

The differences we see on the continuum of social and health responsibility from the UK, in Canada and here gives real insight to some of the problems we have implementing new ideas. We have some lessons to learn. I am really glad I had the chance to go to this great conference and immerse myself to kick start my education.

Aging in Place Remodeling #3 - Entries

Of course you need an entry that works to get in and out. But, like a cigar, the entry is never just an entry. You need to know that you can get in and out, that you are not a prisoner or shut in, that you don't have to ask favors or hire people to get to and return from an appointment...or even more important.... an event you want to attend. The entry is both your practical and symbolic connection to the rest of the world.

No step entries are recommended. I did not use the word ramp which has an unattractive, add-on, possibly jury-rigged and/or temporary appearance and connotation. I prefer no step entries that employ berms and paths - disappearing into the landscape. That is not so hard once you conceive of it AND learn the design criteria.

No step entries (and ramps) should have a maximum slope of 1:12. That is one unit of rise per one unit of run. It doesn't matter whether it is inches or feet, the slope should be no more than 1:12. Steeper slopes can be climbed by strong users or helpers and some electric chairs and scooters but going down a steeper slope is often pretty scary and some riders have pitched forward falling out.

Turning platforms should by 5' x 5' or longer if the turn is 180 degrees. The top area must be wide enough to handle a doorswing AND the entrant. There should be 2' clearance on the latch (non-hinge) side of the door. 5' x 5' might not be enough.

Sloped entryways should have grippable handrails if they are more than thirty inches off the ground, or if the user uses a rail to pull, stabilize or slow down. All sloped entries do not NEED rails.

It is good to consider the conditions at unloading from a vehicle. I often suggest a 'bell shaped' widening so transfers can occur on pavement instead of in the mud. There should be room for the transferee, mobility aid like a wheelchair or walker and an assistant.

Sometimes mechanical equipment is the best way to make a no step entry. The financial advantages become clear around 30" of rise (30 feet of run). The equipment can blend into the landscape or be built into porch and rail. Often a strategically placed bush helps a lift to be almost unnoticeable.



Critical: The top area must be level with the interior floor. You may laugh but I have many pictures of no step entries that get to the STOOP - 8" from the goal. That last step is not just a doozy, it renders the whole effort a total failure. Many I have seen that fail this way are solidly built by skilled and well meaning folks. They just didn't quite get it.
The entry also includes getting the mail, getting in with packages and doing it all safely. A package shelf is helpful so things do not have to be set on the ground. Safety means not falling, but it also means feeling secure from the night and other fear inducing elements. It is great if the entry is covered so weather is at bay when you look for your key and operate the door. A light...possibly motion detected- is a great idea. AND the house numbers should be large and mounted with contrast.

Everyone is not best with a sloped entry. Folks with hip replacements, for example, sometimes find sloped walkways difficult. Porches and steps should be in good condition with handrails on both sides. An additional grip from the stoop to the interior may be needed. There are also 'walker steps' large enough for a walker or other device and the user to take steps slowly. These should rise three or four inches per tread and may be 18" to 24" deep.

The entry is # 1 on most people's agenda when they start to imagine getting in and out of their house. Almost everyone wants to Age in Place. Too many of us are forced to move, losing the comforts and familiarity of our home, because we cannot get in the door. It is also important that YOUR home welcome visitors. When you are waiting to get out of rehab from an injury or illness is not the time to make your home accessible. The time to do it is NOW!

Affordable, Sustainable & Universal Design!

The Cutting Edge!

Howard County Maryland Department of Housing and Community Development released an RFQ for affordable, sustainable and Universal Design homes on a small parcel. I believe this is the first time these three factors have been combined in one place. The county required a Universal Design consultant on each team. This is a bold move that makes complete sense.

What can be more important to those with limited incomes than assurance their home will last them a long time with minimized energy and use costs and will continue meeting their needs throughout their lifespans? Everyone who buys a home want to Age in Place. Everyone wants costs held down. This county is making a stand.

I am especially excited about the project because I am on the winning team!!! I had impact on the proposal. I will carry though the whole project. One home site may be retained by the county as a learning tool. I will be weighing in on that as well. The project, called the Glens at Guilford, is a dream come true opportunity. Other team members include Baltimore Green Construction, Marks-Thomas Architects, Poole Design, Min Engineers and Stavrou Associates.

Howard County Maryland is a very progressive community. The Rouse Company built the planned community of Columbia, Md. there opening in 1967. Howard County has been a leader on livable communities, visitability and Universal Design with the Howard County Homes for Life Coalition I helped launch a few years back under the legendary Phyllis Madachy's leadership.

This is some of the harvest from seeds planted long ago. A good lesson for advocates. I will keep you posted here as this crop grows.

Paula Span on Caregiving in the Washington Post

Paula Span wrote an excellent article on caregiving issues in yesterday's Washington Post Health Section. I wrote about another article of hers in the Post just last month. I guess this is a firm endorsement. Paula gets it!

Though she does not specifically speak to Aging in Place the implication and recommendation are clear. Have the conversations. Do some planning. Don't get caught out of touch and out of ideas in a crisis. The odds are you or the loved ones you care for are going to need some help.

Aging in Place Remodeling #2

Since Aging in Place remodeling is pro-active - planning for an unknown future - the goals are not triggered by immediate needs like other remodeling projects. How do you decide when your project will do what you need it to do?

Performance Standard #1. Of course you want it to be attractive.

Performance Standard #2. It is should follow the Principles of Universal Design. Some people think that means attractive but Universal Design is about performance not beauty. Universal Design means functionality is not tied to specific abilities or health issues. Universal Design has been used to inform us that it does not have to be unattractive and institutional looking to be smart design.

Here are a couple of Universal Design definitions:
a. Design of products and buildings so they are useful to the largest number of people without special adaptation.
b. The process of embedding Choice for all people into the things we design.

Here are a couple of Universal Design examples:
1. closed captioning on TV is useful for everyone but was conceived for those with hearing difficulties
2. no step entries and curb cuts are useful for bicycles, strollers and suitcases but were conceived for those using wheeled mobility devices
3. the grabber advertised for easy reaching on late night TV is useful for everyone but was conceived as a reacher for those with reach range and balance problems

A bathroom that has no steps, curbs or bumps and a place where you can sit to use the sink, reduces risk of falling, provides for ergonomic and safe caregiving AND is attractive has unlimited uses for everyone. A wheelchair can be used in the room but the room provides great value even if a wheelchair never enters the room.

Performance Standard #3. You should be able to get out to an early doctor appointment on a bad day when you have the flu. Think of the day after you have come home from knee surgery. Or think an older, frailer, arthritic YOU.

If you have that possibility covered in attractive, life affirming, comforting space you have done a great job. The chance of you being forced from your home in a health crisis is severely minimized. Congratulations!!

Aging in Place Remodeling #1

Good friends visiting over the weekend told me excitedly that they are making Aging in Place modifications to their home. I told them what I always say in these cases. Please let me glance at the plans and make suggestions so I am not disappointed. I explained, gently, that many well meaning contractors don't have the experience to get this stuff right.

I went by the next day. Their goals were in line. Whether one of their moms ends up living with them or they need it themselves they want a full bath they can reach without steps. Their main goals were more standard remodeling improvements...the Aging in Place stuff is just thoughtfulness. This is exactly what I think people should do.

They planned to:
1. Redo the kitchen
2. Create the mudroom they never had
3. Get his dump space off the kitchen counter by creating a desk on the main floor where he can see the TV, sit in the sunlight, be in the center of things.
4. Add a shower somewhere to supplement the half bath.

When I walked in I avoided reviewing the plans sitting on the kitchen table. I wanted to hear what they had in mind. I encouraged them to speak in terms of problems to be solved rather than solutions. This allows me to help find the solutions, which I consider the true benefit of working in this specialty for over twenty years.

They were already a little uncomfortable with the way the bathrooms cut into the rarely used living room. Even if they don't use it they don't want it to be an uncomfortable hallway of a room. When I pointed out that neither bath design choice would be workable for Aging in Place I was relieved that I insisted on taking a look. Neither bath had sufficient maneuvering space to help someone onto and off the toilet or into or with the shower. These two caregiving activities, along with reducing the risk of falls are the goals of an Aging in Place bathroom. As designed, these baths would not reach my friends' goals.

So here starts a series on the basics of Aging in Place remodeling. The issues are:
1. Getting in and out.
2. Moving around with in the house
3. Safely getting into and out of bed and getting to clothing storage
4. Safe use of the bathroom including ergonomic caregiving
5. Preparing and taking meals
6. Home office function
7. Entertainment- TV, music, reading, guests
8. Enjoying the outdoors

All these issues are not priorities for every client, household or house. It is always important to spend our resources wisely....making sure the problem we set out to solve is taken care of by the work we have done.

Individual and Collective action

I was part of a recent discussion led by Matt Wald, energy and environment correspondent for the New York Times. Matt pointed out that individual and collective action are both parts of the solution for global warming and sustainability. We can conserve energy in our homes, and make purchases to lower our impact. We can change the grid, our sources of fuel and the related subsidies.

Aging in Place has similar opportunities for individuals and the collective. Individuals can modify our homes, increase our exercise and watch our diet and prepare our financial picture. The country can change the way healthcare and in home assistance are provided and paid for.

Both levels have impact, both require commitment. Once we own up to the problems and agree to work toward a solution we will want to work on both levels. We see it now with sustainability, energy, etc. We have finally acknowledged the problem. Now, collectively and individually, we want to do something about it.

When will we see it with housing and care? What will tip us over from a noodling, inkling but quiet worry to outright concern and then stepping up to the plate?

Do We Need a Crisis to Reach Aging in Place?

Writing on the opinion page of today's Washington Post, Robert Samuelson says we need a crisis forcing Congress and the President to face the "political stinkbomb of an aging society" I hope he is wrong.

We all know Medicare and Social Security face insolvency. Recent updates from the monitoring trust funds move the dates closer, but Samuelson thinks they are not close enough to force action. Samuelson makes the point that reorganizing the medical system to improve care and restrain costs can be effective. I think Aging in Place is the central organizing principle that will solve the problem. Can we make it happen before the crisis?

We are paying attention to environmental issues like never before. Is it the crisis or the impact of communication? What tipped the issue from those who have cared for a long time to a general willingness to act? Was it "An Inconvenient Truth", spokesperson Al Gore, the rise in gasoline prices, the economical meltdown, the election cycle or am I kidding myself that we are really committed to change?

How can we who care about the future of housing and care for the growing population of older Americans AND have some great ideas for the solution get the coverage and credibility to begin solving the problem before the funds are bankrupt? How can we best bring the policy changes to help Aging in Place reach it's promise?

Keynote in Canada....and more

I am looking forward to giving a keynote presentation at the Atlantic Seniors Housing Alliance conference in Halifax, Nova Scotia next week. My topic is "Technology for Aging in Place". Yes, I will speak to low tech solutions like Home Modifications and Assistive Technology as well as high tech solutions like PERS, telehealth, environmental controls and the dynamic and comprehensive management system.

I am also excited to attend the whole conference and learn more about the canadian apporach. We know Canadian health care is different. We know their approach to social programming is different, yet in so many ways we think of our countries as similar. I expect to come home with some new ideas - for Aging in Place - as well as this blog.

Dear Governor O'Malley (President Obama, Secretary Sebelius, etc.)

I sent a letter to my Governor, Martin O'Malley of Maryland last week. The subject - good ways to use the stimulus money - has been on my mind. I sent notes to Obama web sites during the transition. I am not sure who to reach and how. The essence is copied below.

"I hope you will add grab bar installation and a home safety check to the home energy saving activities planned in our state. Workers can be cross trained or specially trained to make these inexpensive but very cost effective installations. The populations to be served overlap significantly."

If you have ideas how we to move this ball forward, rephrasing, redirecting - whatever, please let me know.

Great Caregiver Article- and some irony?

Paula Span wrote a great article about caregivers in this Sunday's Washington Post magazine. Marilyn Daniel's Reward combines the facts and the emotions of clients and caregivers quite deftly. Caregivers are already a critical resource that will grow more critical as the boomers need assistance. The story is clear: Caregivers are working really hard for a reward that is not money. The second story is how determined clients are to stay in their homes. She has a book When The Time Comes: Families with Aging Parents Share Their Struggles and Solutions coming out soon.

The article centers on one caregiver, Marilyn Daniels. Span describes the energy Daniel lavishes on her own home on her days off. Span points out: the work on her home nets lasting improvement while her care clients are all declining. I see another lesson. We all love our homes. I bet Daniel will want to Age in Place as much as her clients.

The irony I saw when I opened my Sunday paper this week is not apparent reading the article on line. In the print edition an eight page special advertising section called Retirement Horizons is embedded after the the first pages of the article. The beautiful and happy people pictured in the ads paint a much different story than those we see in the article and pictures. The contrast speaks pretty clearly. "Move here and you will smile like these happy folks."

Is this product placement like we see in the movies? Is this different than resort ads in the quarterly travel issue? Or an education or camp story in those seasons? Google ads on the Washington Post page are related, but I have come to expect (and ignore?) that. Regardless, there could not have been a better juxtaposition to make me think about the place our homes have in our hearts.

A Great Presentation

I went to the local senior provider monthly networking meeting operated by GROWS this morning. I attended these meetings regularly for about ten years. I dropped back as my focus shifted from local home modification consulting and contracting to writing, speaking and consulting on Aging in Place and Universal Design on a larger scale. It was great to see so many friends and colleagues (Do you sense is a life theme here?) I went because my stream of local Independent Living Strategy design consulting and project management work has slowed but more importantly because my good friend Steve Gurney was the presenter.

Steve is the publisher of an outstanding quarterly resource guide and website Guide to Retirement Living. I remember when it was a xerox handsheet. Now it is a very full slick magazine and robust website.

It was a fantastic presentation based on Steve's move into a retirement community this winter. He calls it 43 Year Old Man Moves into a Retirement Community. He chronicled the entire experience on his blog, Everyone is Aging. You might think this was a publicity stunt. I didn't think that because I know, like and respect Steve. The presentation made very clear that it was nothing like that. Steve's intention was to walk the walk, to better understand the experience he has dedicated his life to facilitating- moving out of your own home into a retirement community.

I encourage you to read through the blog. Steve spent time planning to give up his car, blackberry, work and family for a week. He recognized his move was not permanent like his fellow residents' experience. That's why he was even more struck by the intensity of his emotional reactions. Everything Steve said rang true.

Also interesting was that Steve's remarks about segregation, walkable neighborhoods, wisdom, grasping the purpose of life and learned helplessness are almost word for word matches to the conclusions of the Atlanta Regional Commission's Lifelong Communities Design Charrette this winter.

I will be writing more about the design charrette shortly. I promise it will be worth your time reviewing Steve's blog. Let me know what you think!