INT’L. J. AGING AND HUMAN DEVELOPMENT, Vol. 6(3),1975

PROVISION OF ON-SITE SERVICES IN RETIREMENT HOUSING*

SUSAN R. SHERMAN, PH.D. New York State Department of Mental Hygiene Albany, New York

ABSTRACT

The present paper addresses the question of on-site supportive services in retirement housing facilities for the wellelderly. Six hundred residents were interviewed, 100 at each of six widely varied sites in California: retirement hotel, urban highrise apartments, lifecare home, and three retirement villages. Data were also collected on 600 matched controls in age-integrated housing. Questions were asked pertaining to caring for health needs, desire for counseling services, and expected support in crises. Results showed for the most part a good match between personal needs and environmental provisions. However, at one site considerable insecurity was expressed with regard to medical provisions and support in crises, and a desire was expressed for counseling services. There was no evidence of an erosion of independence at the sites where services are provided.

It has been suggested [ 1-41 that a major advantage of group housing facilities for the elderly is the possibility of efficiently providing centralized services within the housing setting itself. In the case of special retirement housing facilities, since there is congregated a population with relatively high need, perhaps the services may be brought to the consumer rather than requiring the consumer to go out to seek the services. Such services could range from

*

The data reported in this paper are from a five-year research project conducted at the School of Public Health, University of California, Los Angeles. The research was supported in whole by PHS Research Grant MH-01358 from NIMH. Project directors were Daniel M. Wilner and Rosabelle Rice Walkley. Members of the study staff, in addition to the author, were Wiley P. Mangum, Jr., Suzanne Dodds, and Thomas C. F’inkerton. The author is grateful to Dr. Pinkerton for contributions to the descriptions of on-site health provisions. Reparation of this paper was supported by Public Health Service Research Grant MH-20959 from NIMH to the author.

229 0 1975. Baywood Publishing Co.

doi: 10.2190/XGQB-W0PC-EQV2-VKND http://baywood.com

230 I SUSAN R.SHERMAN

maintenance, housekeeping and meal preparation to counseling and full medical care. In an earlier paper [5] data were presented indicating that a common pattern of motivations propelling persons towards retirement housing was a declining energy level, possibly coupled with various health problems, influencing the person to choose a site in which maintenance of the dwelling unit was provided or relatively easy, and at which meals or personal care might be available. The question of providing services within the housing facility is not, however, uncontroversial, and involves questions of philosophy and values, as well as economics. As Lawton [6] has described the controversy, “Governmental policy makers, housing sponsors, and gerontologists have been divided on the question as to whether housing for the elderly should properly provide housing alone or whether means for serving other basic needs should also be provided under the umbrella of housing.” At the conclusion of their survey report of retirement housing in California, Walkley et. al. [7] suggested factors which might inhibit the development of supportive services at the retirement housing site: “(a) on the part of management . . . an imprecise assessment of, inexperience with, and distrust of social work methodology broadly conceived, and timidity regarding receptivity of residents to such programming; (b) on the part of [middle class] residents, a lack of experience with such helping ventures, and general suspicions regarding ‘welfarism’; (c) on the part of professionals who might provide the programming, a lack of familiarity with non-indigent populations in need of promotive service. . . .” Neither the federal public housing program for the low income elderly nor the federal 202 housing program for lower-middle income elderly has promoted services as part of the housing package [6]. For the most part, only space was set aside for services, but the services had to be provided through other auspices. However, local resources are often too limited to provide the range of services that will increase the span of independent living [8]. Additionally, there are those (both consumers and providers) who fear that the provision within congregate housing of too many services will generate an institutional, even a hospital atmosphere [5]. Perhaps even more crucial, the critics fear that if too much is provided too early, over-dependency might be encouraged, leading to further loss of function, negative change in selfconcept, lowered morale, negative affect, and maladaptive behavior [ 6 , 8-10]. “Others take the point of view that ill health, as age progresses, is an undeniable fact, and that the assembly of older persons in a site provides an extraordinary opportunity to make available comprehensive medical care to a population at special risk [ l l , p. 2551 .” Many have stressed not only the desirability but the necessity of providing easily accessible services to such an aggregate [12-151. In Carp’s [16] study of residents before and after they

ON-SITE SERVICES I N RETIREMENT HOUSING I 231

moved to senior citizen’s housing, it was found that after the move, fewer residents mentioned needing medical services, whereas their controls, who had not moved into such housing, showed a significant increase in the need for medical services. Lawton [6] found that “medical services were valued above all others, n o matter whether one was a tenant, a prospective tenant, or a nonapplicant, or whether one was associated with public housing or lower-middle income housing.” The need for medical services increased slightly one year after occupancy. Lawton’s data showed that people tended to match their own capabilities with the resources of the environment, i.e. “the offering of services [appeared] to attract older, sicker and less active people.” Outside the retirement housing setting, Shanas et al. [17] on the basis of a cross-national survey reported that “services do not undermine self-help, because they are concentrated overwhelmingly among those who have neither the capacities nor the resources to undertake the relevant functions alone.” A further possibility is that retirement housing can serve a dual function by offering services not only to residents but to other members of the community, who are able to and choose to remain in age-integrated housing [8, 15, 181. By providing intermediate services close at hand, and instituting an outreach service where necessary, more elderly can be housed independently, for a longer period of time than if services were not accessible. Such facilities could serve those on waiting lists for the housing and ease some of the problems for those who cannot get in [4]. Finally, it might be asserted that with the emphasis of the last ten or fifteen years on leisure in housing for the elderly, too much attention has been focused on recreation facilities and not enough on service deliveryparticularly for the younger elderly living in retirement villages [ 131 . A survey of housing facilities for the well-elderly in California [7] found that less than 1 0 per cent of facilities in the categories of retirement villages, retirement hotels, high-rise apartment buildings, and mobile home parks had some sort of medical provision at the site; about half the homes for the aged had some type of medical arrangement. If “we know very little about how to organize and deliver concerted, coordinated and a comprehensive range of services for the aging [ 19, p. 591 ” perhaps we know even less about integrating these services within retirement housing. The present paper reports a study of the provision of, and satisfaction with, services at six widely varying retirement housing sites, based on interviews with 600 residents. Comparative data are presented for matched controls living dispersed in age-integrated communities. Residents were interviewed after having lived at the housing sites an average of one to two years. All available respondents (952) were re-interviewed two years later, 815 at the same address as previously. The questions on services to be reported cover

232 1 SUSAN R. SHERMAN

both medical provisions and counselling services as well as expected support in crises.

Test Sites An earlier phase of the present study [7] comprised a survey of all retirement housing in California. From the census thus obtained, six sites were selected, representing the most typical kinds of such housing (of above a minimal size), and covering nearly the entire spectrum of available retirement housing. All but the Retirement Hotel had been built in the 1960’s. Although nearly every site had a doctor on call, and an emergency call system, other medical services vaned widely from site to site [20]. The Retirement Hotel (No. of residents = 156) and Apartment Tower (No. of residents = 228), both located in the central city, had no on-site medical services although a doctor was on call 24-hours a day.’ Two doctors and a dentist had offices at the Purchase Village (No. of residents = 5000).* By the second interview two more doctors and an ambulance service were located across the highway. The doctors’ offices were not open on weekends, although a doctor was on call. Many residents had their doctors in nearby towns if only because in the early days of the project there was no other alternative. A group insurance plan was available. At the suburban Rental Village (No. of residents = 688) there was a clinic which met three days a week with a nurse in attendance; a physician was in attendance on one of the days. The suburban Manor Village (No. of residents = 2384) offered an outpatient medical clinic with a staff of over 50 (physicians, nurses, technicians, pharmacists, and allied personnel). Nurses were on duty at the clinic at all times, and there was a visiting nurse service as well. Group health insurance was available. Medical services at the Life-care Home (No. of residents = 362)3 included an outpatient clinic and a convalescent hospital. A physician visited two days a week and nurses, physical therapists and others were in attendance the remainder of the time. Monthly payments covered medical care and hospitalization, extending to an outside hospital for severe illnesses. Test Residents and Matched Controls: Background Characteristics One hundred residents were selected at each site through systematic probability sampling. Table 1 presents selected background characteristics of site residents. The church-sponsored Apartment Tower was built under the Federal direct-loan

’

The Purchase Village is located in a mountain desert area, 75 miles from both Los An eles and San Diego. Both the Life-care Home and the Retirement Hotel provide meals. The Life-care Home is licensed by the State Department of Social Welfare to give personal care and protective service.

ON-SITE SERVICES IN RETIREMENT HOUSING /

233

Table 1. Characteristics of Retirement Housing Samples

Mean Age % Female Marital Status (%I Married Div., Sep., Wid. Never Married Median Education

Retirement Hotel

Apartment Tower

Purchase Village

Rental Village

Manor Village

Lifecare Home

75.7 54

73.5 78

67.8 41

75.8 69

67.8 51

77.8 83

32 66 2 7th-8th grade

82 21 16 51 2 28 High College School Graduate Graduate

1

80 19 9th-11th grade

Median Occupation Codea

4

21 71

8 High School Graduate

3

92 7 1 High School Graduate

3

5

2

2

Note: N = 100 for each site. a Hollingshead Scale: 2 = Business Managers, Proprietors of Medium Sized Businesses, and Lesser Professionals 3 = Administrative Personnel, Small Independent Businesses, and Minor Professionals 4 = Clerical and Sales Workers, Technicians, and Owners of Little Businesses 5 = Skilled Manual Employees

At four sites residents averaged about 75 years of age, and widows and other singles (primarily women) predominated. The other two sites were occupied primarily by married couples with an average age of about 68 years. Most respondents were retired at the time of the interview (with retirement status based on husband’s status if respondent was a married woman), although at the Manor Village, approximately 20 per cent were still working. Nearly 90 per cent of all residents were born in the United States, and the median number of years lived in California ranged from 20 at the Apartment Tower and Purchase Village to 46 at the Manor Village. About three-quarters of all site residents were Protestant and 12 per cent were Catholic? A control group was assembled from a pool of names provided by a market research study, supplemented by screening interviews conducted to obtain scarce groups. Tests and controls were matched on sex, working status, marital status, age, income, education, occupation, housing tenure, household composition, and number of children.

Health Self-Rating and Health Problems At both interviewing waves, respondents were asked to give a self-rating on health and to respond to a checklist of health problems. The self-rating With regard to accessibility to services, i t should be mentioned that virtually all residents of the Purchase and Manor Villages h a d automobiles, only half had autos at the Lifecare Home, one-quarter of the residents at the Rental VilIage had automobiles, and even fewer did a t the other t w o sites.

234 / SUSAN R.SHERMAN

question asked: Compared to most people your age, would you rate your health: (5) excellent, (4) good, (3) fair, (2) poor, or (1) very poor? Wave I responses appear in Table 2. In general, about one-quarter of the site respondents rated their health as “excellent,” one-half as “good,” and onefifth as “fair.” Residents of the Apartment Tower on the average rated their health as better than did their controls. There were no other significant testcontrol differences, except that Total Site was slightly greater than Total Control. Two site groups (Apartment Tower and Purchase Village), three control groups (Retirement Hotel and Purchase and Manor Villages), and Total Site and Total Control reported a statistically significant decrement in health self-rating between Wave I and Wave 11. At Wave I1 only the Total Site-Total Control comparison was statistically significant. It would seem that as far as self-rated health is concerned, the tests and controls were about equally matched, and most experienced a small decrement from Wave I to Wave 11. Turning to number of health problems,’ a similar pattern emerges. Distributions on number of health problems at Wave I are shown in Table 2. Among site residents, 8 per cent listed no health problems, and one, two, or three health problems were listed by about one-fifth of the respondents, with another fifth listing four or five. The overall site mean was 2.7 and the control mean was 3.0. On this question, as on the preceding question, the only test-control difference was at the Apartment Tower, where site residents had significantly fewer health problems than did the controls. The results on the question regarding number of health problems closely follow the question on health self-rating, indicating that people do tend to appraise their health condition fairly accurately. There was very little change from Wave I to Wave I1 in number of health problems checked. The mean for all site residents interviewed at both waves increased from 2.53 to 2.72 ( p < .02), and the mean for Rental Village controls decreased from 3.76 to 3.35. At Wave 11, residents of the Apartment Tower continued to have significantly fewer health problems (mean = 2.6) than did their controls (mean = 3.4), p < .02. Having sketched this background of the health status of the study residents, one can inquire as to the perceived needs at each retirement housing site in the present study and in the community. As reported previously, 40 per cent of the respondents had moved into the sites in order to have health and personal needs cared for. How well were these needs met? The checklist included the following, and the figures in parentheses indicate the percentages of all site residents having the particular complaint: trouble with eyes (32%), hearing (33%), teeth (12%), nervousness (42%), arthritis or rheumatism (43%), kidney or bladder trouble (14%), varicose veins (14%), high blood pressure (20%), heart trouble (22%), other problems or injuries (e.g., broken bones, spine trouble, respiratory, diabetes) (31%).

(1) (41 2.4 3.4d

12 16 11 24 19 15 16 20 30 16 11 5

29 14 52 41 16 31 3 9 0 5b

Note: In each test and each control group N = 100. a One additional case did not respond to this question p < .001 (chi-square) p < .05 (chi-square) p < .005(t-test) p < .02 (t-test)

3.5 3.4

Mean number of problems

14 35 16 10 13 11

(0) (1)

13 33 22 20 11 1

17 30 33 32 34 26 9 9 7 2a

Site Control

Site Control

No answer or refused

Number of Health Problems 6-10 4-5 8 3 c " 2 1 0

Health Self-Rating Excellent Good Fair Poor Very Poor

Apartment tower

Retirement hotel

7 18 17 22 28 8

32 45 20 2 1

2.4

2.5

(0) (0)

6 13 26 19 25 11

23 55 19 3 0

Site Control

Purchase village

Table 2. Health

27 18 18 15 10 10

18 37 29 12 4

3.2

3.7

(0) (2)

8 33 22 20 12 5

23 36 31 6 3a

Site Control

Rental village

2.1

2.8

2.6

10 19 22 21 18 8

38 32 28 2 0

2.0

21 5

26

4 21 23

32 46 17 5 0

(0) (2)

4 15 14 30 18 17

34 46 15 4 1

Site Control

Life-care home

(0) (2)

5 11 15 23 30 16

37 52 8 2 Oa

Site Control

Manor village

13 21 17 20 17 10

28 39 25 6 2c

2.7

3.0e

(0) (2)

8 20 21 21 22 8

27 45 21 5 2

Site Control

Total

236 1 SUSAN R. SHERMAN

Health Services At both waves of interviewing, specific attention was drawn to medical services. All respondents were asked: “Are your health and medical needs as easy to take care of here as you would like them to be?” Results appear in Table 3. The most marked test-control difference was at the Purchase Village. Less than half the residents at the Purchase Village felt their health needs were easy enough to take care of whereas about 90 per cent of their controls and 90 per cent of all other site residents felt these needs easy enough to take care of. These differences were highly significant, and were upheld in the second wave as well. At the time of the first interview, residents of the Purchase Village complained primarily about the lack of a hospital and the lack of sufficient doctors [21]. Not adequate. No hospital. No facilities for a complete examination. The doctors are too busy, can’t give enough time to a patient . . . only two doctors here and one of them is only halftime . . . the fees are too high, both dental and medical. Two years later, the residents were still waiting for the promised hospital to be built. We have to go to -to get cared for. The good doctors and hospital are in -. There is no public transportation. You have to get someone to drive you if you can’t drive yourself. We do have am’bulance service but it’s costly. We were promised a hospital when we bought our home. It’s supposed to start any day now. We had to fight for that. The county planning commission was against having one so close to -but finally they approved it. ~

I don’t think the doctors here are as good as the doctors in the big cities. The doctors here are rushed-have too many patients and can’t be as thorough. We have no hospital here-so the doctors are limited and we are limited.

Some residents, however, had become adjusted to the medical stiuation during the two years. (Wave I): Have to go too far for my doctor but the advantages of being here are so much greater that probably that’s a wrong answer. (Wave 11): We have a’ fine doctor here and we are close to a clinic here. We have an ambulance service and if you need them they will come and take you to the hospital and it is a very good service. (Wave I): No hospital, no bone specialist here. There’s only two doctors and this bothers me. (Wave 11): We have a wonderful doctor here and there’s a hospital close and that’s about all you could ask for.

2

N

21 (4)

10

(6)

Not Easy Enough (No Answer)

(1)

12

87

Note: In each test and each control group N = 100. a p < .001 (chi-square) p < .01 (chi-square)

75

84

(4)

16

80

Site Control

Site Control

Easy Enough

Apartment tower

Retirement hotel

(1)

51

48

(3)

ga

88

Site Control

Purchase village

(2)

10

88

(5)

19

76

Site Control

Rental village

(4)

0

96

(1)

10

lo6 (6)

89

(6)

7

87

Site Control

L ife-care home

84

Site Control

Manor village

Table 3. Health and Medical Needs Easy Enough to Care For

(2)

16

82

(41

14

82

Site Control

Total

238 I SUSAN R.SHERMAN

(Wave I): I’m new here and I don’t know who’s good and who isn’t. I’m so used to knowing my doctors back East. That’s half my trouble here. I worry about not having a good doctor. (Wave 11): I think it was a year ago I went for a checkup and I haven’t had a doctor since. I imagine you’d call one if you needed one. By Wave 11, many residents were encouraged by the plan to build the hospital. We have four good doctors here, and we just have to go I5 to 25 miles to get to the hospital which is fine for any minor illnesses. If it’s a more serious illness we have a very good efficient ambulance service. Soon we’ll be getting our own hospital. We don’t have smog-so we have fewer health problems. In contrast to the Purchase Village, at the Manor Village at Wave I, more test residents felt their health needs easy enough to take care of than did their controls. In particular, residents of the Manor Village were “quite pleased with the clinic: the proximity, the service, and the cost” [21]. They mentioned house calls by the nurse and the physical examination. When I need help we get it in a hurry. The nurse comes, the doctor is right behind her. As far as medical help is concerned this place is hard to beat. We have wonderful doctors here. You can’t get it on the outside. Twenty-four hours a day there is someone on duty all the time. That is why we moved here. If you feel you can’t get to the clinic, a nurse will come. They give you the most marvelous physical. They’re very kind and conscientious and good here. I still have the coverage that was included with the payment on the home. It’s the convenience and the closeness. You just feel secure knowing that someone is near when you need them.

They’re marvelous. My big event of the week is going to the doctor here. It is apparent that there are large differences among sites regarding adequacy of health services (a difference which cannot be accounted for by number of health problems), with the Purchase Village standing in contrast to the other five. What is the impact at the Purchase Village of not being able easily to care for one’s health needs? HEALTH WORRIES

A not surprising relationship was found at the Purchase Village between ease of caring for health needs and worrying about health. Among those who did not find their health needs easy enough to care for, 67 per cent said they worried about their health a lot or a little, whereas among those who

ON-SITE SERVICES IN RETIREMENT HOUSING I 239

did find their health needs easy enough to care for, only 42 per cent worried about their health. The same relationship holds between ease of caring for health needs and worrying about health even when controlling for health self-rating. MORALE

A relationship was found at the Purchase Village between perceived ease of caring for health needs and morale (using a morale scale composed of selected items from Cavan et al.’s [22] Attitude Inventory; Kutner, Fanshel, Togo, and Langer’s [23] Morale Scale; and Neugarten, Havighurst, and Tobin’s [24] Life Satisfaction Index. Among those who said their health needs were easy enough to care for, 54 per cent were in the highest morale category, whereas among those who said their health needs were not easy enough to care for, only 29 per cent were in the highest morale category (X2 significant at p < .05, 1 d.f.). ADJECTIVE CHECKLIST

A similar relationship was found at the Purchase Village between ease of caring for health needs and scores on an adjective checklist. The checklist included nine adjectives such as ambitious, confident, fearful, and helpless; high scores indicate the more positive response. Among those who said their health needs were easy enough to care for, 62 per cent were in the highest category on the adjective checklist, whereas among those who said their health needs were not easy enough to care for, only 31 per cent were in the highest adjective category. Although these are only correlational relationships and as such cannot be definitive as to direction of causality, if it is not certain that worries and lower morale are results of insufficient health services, they are at least concomitants. Desire for Counseling Service

At the second wave in the present study, respondents were asked: “Do you think (name of site) could use an advisory service on the premises that would provide legal, financial, psychological, and other counseling to the residents?” Results are shown in Table 4.Once again a disparity is found between the Purchase Village and the other five sites. At each of the other five sites, about 40 per cent of all respondents answered that the site could use such a service, whereas at the Purchase Village the perceived need was much more widespread, with nearly 70 per cent responding affirmatively. In particular, residents at the Purchase Village mentioned the distance from the city where

240

I

SUSAN R. SHERMAN

Table 4. Perceived Need for Counseling Service (Per cent) ~~

Retirement hotel

Apartment tower

IN)

138)

Yes: site could use and does not have sew.

~~

~~

Rental village

Manor village

Life-care home

Total site

(631

Purchase village (80)

I641

(78)

(79)

1402)

37

41

69

47

40

43

47

No: site already has service

3

5

10

22

17

30

16

No: needs taken care of by in-

21

16

8

11

20

11

14

3

6

7

2

4

3

4

24

16

0

9

11

4

9

12

16

6

9

8

9

10

dividual advisers el sewhere

No: never need counseling

No: disapprove of such a service at site Combination of above, or no answer

these services are more widely available. Many residents could not or did not wish to drive the necessary distance to reach these services, and there was no public transportation available. They also mentioned the high cost of such help as was presently available. There are many people here who need this kind of thing and they have to go elsewhere when they need this kind of information. So many people here are too old to drive and there isn’t any public transportation to take them out of [Purchase Village]. There are so many problems we have-people don’t know where to go for advice. They need to go to professional people instead of their neighbors. There should be some sort of counseling so that the people here in moderate circumstances can afford to pay a small fee for it. Maybe it could be a free service by the county or state because lots of people here are living on just social security with a very small income on the side. We have the same problems as any other community. Wherever you find people you will find problems that involve finances and emotions so I think it is a good idea to have a service like this available to the people in [Purchase Villagel.

ON-SITE SERVICES IN RETIREMENT HOUSING / 241

It turned out in a follow-up probe, that, regarding the need for a counseling service, persons answered n o for several somewhat distinct reasons. One-third of the residents at the Life-care Home and one-fifth at the Rental Village perceived the site already t o be providing such services-either formally or informally. Life-care Home: You get a lot of advice from the people in the office. They can help you with problems and I see no need to have such a service. The management takes care of these things. Whatever the problem they will see that you get the help to solve it. I think here they attempt to provide everything we need. The administrator is an attorney and we get help that we need. If we have psychological troubles it’s taken care of in the Medical Unit. I just feel we can get help for anything we need. Rental Village: You can get any counseling you want at the Village office. In particular, at the Manor Village, respondents thought other residents could provide such services. You can always get advice free from people here at Manor Village. We’re surrounded by lawyers, investment brokers, and the like that we can get advice from. Another group of residents did not desire such a service because whatever needs they had were being handled on an individual basis (elsewhere). At the Retirement Hotel and Apartment Tower, some residents did not conceive of the site as more than “housing.” (Retirement Hotel): Most people move here and know that all they get is their apartment and utilities and they don’t expect it. Our city offers counseling to the needy and those who aren’t needy can hire it. Everyone is an individual here and they have their own way of doing things. After all, it’s just an apartment house. (Purchase Village): People that are getting on in years already have these kinds of contacts. So I do not see a need for a service of this kind. If people need anything like that it is available within 20 miles of the community. (Rental Village): If the people would belong to the Senior Citizens League they could get all the help they need. (Manor Village): Every kind of service is available just outside of the gates. I mean lawyers, bankers, stock brokers, in town. We have free bus service t o shopping center advisors.

242 / SUSAN R. SHERMAN

(Life-care Home): . . . We already have any kind of service we want available in the community. Another small group said they did not think the site should offer such a service because they never had problems for which they needed to consult an advisor, i.e., there was no perceived need whatsoever. Finally, 9 per cent of all site respondents expressed disapproval of such a service at the site either because people “wouldn’t listen,”6 there would be a loss of privacy, people should be independent, residents would exploit the service, or the service would be too expensive. It would seem, in sum, that although the need varies widely from site to site, at least a plurality of residents at each site would approve of such a counseling service on the premises. The fears of those who disapprove of such a service as encouraging premature dependency, for example, seem more than offset by a strongly felt need on the part of others. At the sites which are perceived as already providing services, little evidence was found of dissatisfaction with the services; rather it seemed to enhance feelings of security. Even at the -sites where many residents considered their needs adequately cared for on an individual basis one might surmise that there is probably room for improvement were the service to be instituted at and under the auspices of the site. Perhaps a relatively simple educational effort could be employed to maximize utilization of the counseling service such as assurances of confidentiality, low (or no) cost, etc.

Expected Community Support Finally, as a more direct measure of expected community support and perhaps providing an integration of the two preceding questions concerning health and counseling, site residents were asked whether it would be easier to cope with four serious personal crises (major financial problem, trouble with family, serious illness or physical disability, death of a loved one) at the site or where they were living formerly. Results appear in Table 5, in the order in which residents perceived the site as providing relatively more support. There were large differences from site to site. For the most part, the sites fall into three groups: the most relative (and probably absolute) support was felt at the Life-care Home, the Rental Village, and the Manor Village. The least (relative) support was expected at the Purchase Villagecertainly congruent with responses to the earlier questions on need for medical and counseling services. In fact, on each item only about half of the respondents at the Purchase Village expected the site to be more supportive. These are similar to responses above about needs handled on an individual basis but the responses here seem to be expressed with more vehemence and rejection of any intrusiveness implied by such a service being on the premises.

ON-SITE SERVICES I N RETIREMENT HOUSING

I 243

Table 5. Perceived Community Support (Per cent) Retirement Apartment Purchase Rental Manor Life-care Total Total hotel tower village village village home site controlsa 138) 163) (801 (64) 178/ 179) 14021 (4131

IN) Easier at site if:

b

\

Illness or d i s ability

63

66

46

81

88

100

76

22

Death of loved one

66

54

50

72

82

83

69

8

Major financial problem

55

60

51

76

58

79

64

15

Trouble with family

57

52

49

67

63

62

59

9

a Percentages are given for Total Controls only, as there was little variance across control groups. As compared to “former residence,” (present residence for controls) or to “no difference between two residences.”

’

The intermediate group includes the Apartment Tower and the Retirement Hotel. Responses for the Apartment Tower and Retirement Hotel are congruent with perceptions reported elsewhere [25] that the site is “just housing.” Different patterns are apparent in each of the crisis areas. As far as coping with serious illness or physical disability, which would be related to definite physical and programmatic elements of the site, there is a strong contrast between the Life-care Home, Manor Village, and Rental Village, and the other three sites. Nearly as many chose “former residence” as chose Purchase Village. On the question of major financial problem, some support seemed to be expected at the Life-care Home and Rental Village as distinct from the other four sites, which all clustered together. The other two questions would seem to require primarily emotional support more than any other kind: with regard to death of a loved one, one might expect the response at the Life-care Home, but the contrast between the Manor Village and Purchase Village is striking and would seem to suggest a sense of anomie at the Purchase Village and a sense of community at the Manor Village. Finally, with respect to trouble with family, there was much less spread from site to site, and more than a quarter of all site residents said there would be no difference. Control residents were asked whether it would be easier to cope with the four problems at their present residence or easier if they were living in special housing for retired people. Obviously, the two forms of the question are not parallel since the control residents are being asked to imagine a totally new

244 / SUSAN R. SHERMAN

situation, specifically, one where all the people would be new. It was difficult in the first place for many, regardless of place of residence, to imagine coping with the four problems, but at least the site residents could have the two specific housing circumstances in mind, whereas the dispersed residents had additionally to conjure up a picture of special retirement housing which was unfamiliar to them. For this reason, and because there was very little variance among control groups, data are shown only for Total Control Group, not for each control group separately. Test-control differences were large, as expected. Only a small minority of control residents can envision retirement housing as being more supportive. Approximately three-quarters of the control respondents thought it would be easier to cope with each crisis where they were presently living; they found it easiest to imagine site support with regard to illness. They thought very little in terms of emotional support in retirement housing.

Summary and Conclusions While it has been suggested that a major advantage of group housing facilities for the elderly is the possibility of efficiently providing centralized services within the housing setting itself, such provision is not entirely uncontroversial. There has been some fear that the provision within congregate housing will generate a hospital atmosphere and that over-dependency will be encouraged. Others have taken the view that the need for services is undeniable, and that the congregation of an elderly population presents a good opportunity for service provision and delivery-for those residing at the site, and in the community as well. In order to gain some insight into the provision of on-site supportive services in the retirement housing setting, residents of six varied facilities for the wellelderly were interviewed with respect to medical and counseling services, as well as expected support in crises. Comparative data were presented for matched controls living dispersed in age-integrated communities. Results showed a remarkable contrast between the Purchase Village-located in a mountain desert area-and the other five sites. At the Purchase Village only half the residents perceived their medical needs as easy enough to care for, and those who did not tended to worry more about their health and have lower morale. Seventy per cent of the residents at the Purchase Village expressed a desire for an on-site counseling service. Residents of the two center-city sites tended to perceive the site as “just housing” and did not expect auxiliary services. With respect to a number of possible crisis areas, the most relative support was expected at the Life-care Home, the Rental Village and the Manor Village and the least expected at the Purchase Village. For the most part persons have self-selected themselves appropriately. That

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is, at the urban Retirement Hotel and Apartment Tower which offer little in the way of services, residents do not seem to m i s s such services. On the other hand, at two sites which offer a great deal in the way of services-the Manor Village and Life-care Home-residents seem to welcome these services and to report a desire for and utilization of the very good package that is provided. There is n o evidence of an erosion of independence at these sites; if anything, the service provision enables the residents to enjoy independence by maintaining themselves at optimal levels. Applying Lawton and Nahemow’s [ 101 ecological model of adaptive behavior and aging it would appear that the level of environmental press is near adaptation level for people of this degree of competence. There is n o evidence as yet discovered that these residents are experiencing negative affect or exhibiting maladaptive behavior due t o environmental press being weaker than needed for their level of competence, or even that these individuals have accepted a situation in which maximal behavioral potential is not realized. However, a most glaring lack with respect to services is apparent at the Purchase Village-particularly as it stands in contrast to the other sites. On every indicator of satisfaction with services residents of this site report discomfort with the level provided and a wish for much more. Since the environmental press are greater than optimal for this level of competence, again applying Lawton and Nahemow’s [ 101 model, it would seem that either applying engineering to the environment (more services) or to the person (raising level of competence through necessary service provision), services would be indicated. This site serves perhaps as a case study of the very great need to provide considerably more in the way of services than recreation facilities, particularly in non-urban areas. REFERENCES 1. M. B. Hamovitch, Social and psychological factors in adjustment in a retirement village. In F. M. Carp (Ed.), The retirement process: Report of a conference, December 1966. PHS Publication No. 1778, USGPO, Washington, 1968.

2. R. W. Kleemeier, Attitudes toward special settings for the aged. In R. H. Williams, C. Tibbitts, and W. Donahue (Eds.), Processes of aging, Vol. 11.

New York: Atherton Press, 1963. 3. I. Rosow, Retirement housing and social integration. In C. Tibbitts and W. Donahue (Eds.), Social and psychological aspects of aging. New York: Columbia University Press, 1962. 4. White House Conference on Aging. Toward a National Policy on Aging. Final Report, Volume 11. Washington: USGPO, 1973, 0-468-218. 5. S. R. Sherman, The choice of retirement housing among the well-elderly. Aging and Human Development, 1971, 2, 118-138. 6. M. P. Lawton, Supportive services in the context of the housing environment. The Gerontologist, 1969, 9, 15-19.

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7. R. P. Walkley, W. P. Mangum, Jr., S. R. Sherman, S. Dodds, and D. M. Wilner, Retirement housing in California. Berkeley: Diablo Press, 1966. 8. White House Conference on Aging. Housing the Elderly: Background and Issues. Washington: USGPO, 5247-0025, 1971. 9. W. Donahue, Impact of living arrangements on ego development in the elderly. In F. M. Carp (ed.), Patterns o f housing o f middle-aged and older people. Washington, D.C.: USGPO, 1966. 10. M. P. Lawton and L. Nahemow, Ecology and the aging process. In C. Eisdorfer and M. P. Lawton (Eds.), The psychology o f adult development and aging. Washington: American Psychological Association, 1973. 11. D. M. Wilner and R. P. Walkley, Some special problems and alternatives in housing for older persons. In J. C. McKinney and F. T. deVyver (Eds.), Aging and social policy. New York: Appleton-Century-Crofts, 1966. 12. R. C. Atchley (Ed.), Ohio’s older people. Prepared under contract for the Division of Administration on Aging, Department of Mental Hygiene and Correction, by the Scripps Foundation for Research in Population Problems, Miami University, Oxford, Ohio, 1972. 13. M. B. Barker, California Retirement Communities Special Report No. 2. Center for Real Estate and Urban Economics, Institute of Urban and Regional Development. Berkeley: University of California, 1966. 14. J. Kaplan, Gerontology in 21st century. Presented at meeting of hospital coordinators of geriatric services, New York State Department of Mental Hygiene, Albany, November 1972. 15. M. P. Lawton (Ed.), Housing. International research and education in social gerontology: Goals and strategies. The Gerontologist, 1972, 12, 3-10. 16. F. M. Carp, A future f o r the aged: Victoria plaza and its residents. Austin: University of Texas Press, 1966. 17. E. Shanas, P. Townsend, D. Wedderburn, H. Friis, P. Milh@jand J. Stehouwer, Old people in three industrial societies. New Y a k : Atherton Press, 1968. 18. W. M. Beattie, Jr., Responsibility of the long-term facility to the longterm patient. Hospitals, 38, 1964. 19. R. J. Havighurst (Ed.), The status of research in applied social gerontology. The Gerontologist, 1969, 9, No. 4, entire issue. 20. T. C. Pinkerton, Site visits to six retirement housing facilities. University of California, Los Angeles, School of Public Health, 1968. 21. S. R. Sherman, Satisfaction with retirement housing: Attitudes, recommendations and moves. Aging and Human Development, 3, 1972, 339-366. 22. R. S. Cavan, E. W. Burgess, R. J. Havighurst and H. Goldhamer, Personal adjustment in old age. Chicago: Science Research Associates, 1949. 23. B. Kutner, D. Fanshel, A. M. Togo and T. S. Langer, Five hundred over sixty. New York: Russell Sage Foundation, 1956. 24. B. L. Neugarten, R. J. Havighurst and S. S. Tobin, The measurement of life satisfaction. Journal of Gerontology, 1961, 16, 134-143.

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25. S. R. Sherman, Housing environment for the well-elderly: Scope and impact. Paper presented at the meeting of the American Psychological Association, August, 1973, Montreal.

Address reprint requests to: Susan R. Sherman, Ph.D. New York State Department of Mental Hygiene 44 Holland Avenue Albany, New York 12229