PHILADELPHIA REFLECTIONS
Musings of a Philadelphia Physician who has served the community for six decades

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Old Age, Re-designed
A grumpy analysis of future trends from a member of the Grumpy Generation.

Making the Whole Town into a CCRC

{Center-city continuing care retirement communities}
Center-city continuing care retirement communities

Probably because of cheaper land and construction costs, retirement villages are generally found in suburban or semi-rural regions. In Philadelphia for example, forty or so retirement communities dot the outermost edges of the city while the urban center contains only two or three of them. As was true during the migration of the national frontier Westward throughout American history, cheap land costs seem generally to overcome the attractiveness of urban habits and culture. Or at least that now seems a more universal theory of migration patterns than the attraction of suburban schools for the parents of teenagers. It has generally been argued in the past that the automobile made it possible for families to escape the turmoils of inner-city schools by fleeing to the suburbs. But now we see families without children continuing to flee from the center of town. Center-city continuing care retirement communities have certainly been built in the center of town, right next to libraries, museums, clubs, and department stores, but real estate salesmen know very well that it is a safer bet to locate one of them in cheap farmland, well beyond the ring of much-praised suburban school systems. When random inhabitants of such villages are asked what attracted them, most of them say it was the medical system, but that can't be precisely right since they all have Medicare. More likely, they want to locate near the suburban doctors, hospitals and pharmacies they grew accustomed to during their compulsory residence near the high school. And the circle of friends they made there; although the aging process makes that into a dwindling band.

The point here is that automobile commuting and much-praised high schools probably created suburbs, but are no longer the strongly attractive issues which induce empty-nesters to settle nearby for the rest of their lives. The CCRC is like a ship at sea, pretty much entirely self-contained because of the progressive locomotion difficulties of the residents. At first, the residents can feel free to go on living as they "always had", but habit and convenience rather quickly narrow their horizons and circle of friends. They may have been community leaders a year or two earlier, but soon after making their monastic choice they begin to withdraw into the more limited community of their new chosen monastery. Limiting perhaps, but not confining.

That's unfortunate in one way, since a theme of this book is that the young older group needs to find ways to continue productive lives. The country can't afford to have them remain unproductive, and they themselves need to have more useful things to do. An entirely recreational life simply cannot continue to get longer and longer as a sole justification for all the expensive health care we seem capable of providing for them. Therefore, one promising experiment which needs to be tried, is to organize the whole suburb into a half-way house, amicably intertwined with neighboring houses full of teenagers. With people living in their own homes a few years longer than they originally planned after the kids are out of the house.

The town where I live is now surrounded by miles of other suburbs, but I think of it as on the edge of farmland because that was the way I found it sixty years ago. The borough itself has seven thousand houses, probably somewhat too few to suit urban planners, but presenting no convincing argument for us to consolidate with neighboring suburbs except the nagging of those sociology professors. The town has plenty of doctors, most of whom practice somewhere else, and plenty of dentists. No hospitals, no nursing homes, no rehabilitation centers. But several drugstores, two ambulatory x-ray units, and two specimen-collecting laboratories for nearby hospitals. We have a busy volunteer ambulance corps, run out of the fire house, and frequently seen racing and honking its siren around the town. The composition of these independent medical facilities has varied over the decades, but is not greatly different from what can be found in a dozen near-by suburbs. The one thing we don't have is a CCRC, and there seems to be enough demand for one, even enough empty land to hold it. Just about every retiring family in the town has been heard to express a wish that a retirement village could be made available, so they wouldn't have to pull up their social roots in addition to all of the other disruptions of retiring. Having spent most of their adult lives envying people with larger, more luxurious houses, they are now at the point where they are sick and tired of fussing with the big house they do have. They want less cumber but smaller houses, especially apartments, just don't exist in the town. So they are forced to consider moving away.

Especially after one of the two elderly marriage partners dies, there is the worry of living alone. Twice in my own experience, an elderly widow living alone in a big house has broken her hip bone with no one in the house to call the police. One of these ladies was lucky; she lay on the floor for two days without food or sanitary support, until the mailman came by and noticed the mail piling up. The other lady was not so lucky; she had bought a big dog which apparently ate her when she was helpless on the floor. Old folks living alone tend to think they can cope with anything. Until suddenly they can't.

Very likely, the mobile cell phone has reduced the number of such tragedies, just as it has apparently reduced armed robberies almost by half. The mobile phone gets progressively more clever with the invention of 500,000 applications, or apps. We can probably expect to see visual surveillance systems and the like, very soon and very inexpensively. Handbars in the bathroom and other safety devices are regularly more ingenious; there are even companies which will outfit a whole house with such improvements and suggestions for use. It's a great pity that installing a home elevator is comparatively cheap when the house is being built, and almost prohibitively expensive after the builders go away; nobody over the age of 60 should really buy a house without an elevator, except for the fact that so few houses have them. They seem expensive until you realize that moving your home once or twice is going to cost $100,000, mostly because of universal tendency to buy the biggest house you can afford rather than the biggest one you need. But even so, my little town needs one more thing before it can be said to have coped with its retirement needs.

What's missing in all this is management. Relatives who live close by will often suffice, depending on their other commitments. With a competent manager, what's needed is a part-time employment agency, to supply the nurses aides, physiotherapists, and babysitters of various skill -- and to cope with the mountain of redundant government paperwork. Regulatory paperwork can rather easily be coped with by someone who has a programmed home computer, so the right equipment and program must be located, or commissioned. Since the Obama administration was recently willing to spend $29 billion dollars to equip every doctor with a computer system, what's probably most needed is a loud angry lobbying group to get the necessary money, and to cope with the passive aggressive resistance which any competitive environment is filled with. We're talking here about reducing the number of people who need to enter a CCRC, so nursing homes and other CCRSs can be expected to express hurt feelings and discover a myriad of ways it is totally unsafe to provide a competitive alternative to their business model. Getting a sympathetic congressman will help about half the time; the other half of the time you should consider the advantages of replacing him.

There are advantages to starting one of these retirement villages without walls in a rural area, with lots of experience with volunteers pitching in and helping out. The community officials are sympathetic in such areas, and costs are generally lower. In a suburban neighborhood, the environment is more sympathetic to the approach of applying for a government grant, or if there is no available program, asking for the creation of a demonstration program. That's an egg that will generally take five years to hatch, and prove to have higher costs. The rural environment needs enthusiasm, the urban one needs tenacity, and will generally find it is an advantage to have a congressman who is chairman of a committee. But everyone who wants to see a local retirement village without walls, also needs a slogan, so here it is. "Anything a retirement village can do, can be done at home. Only cheaper."

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