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The meanings of frailty and aging-in-place for Florida's HUD managers and their elderly tenants

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 Title Page
 Dedication
 Acknowledgement
 Table of Contents
 List of Tables
 List of Figures
 Abstract
 1. Introduction
 2. Conceptual framework and...
 3. Management and frail elder tenants...
 4. Constructing frailty: How frailty...
 5. Constructing aging-in-place
 6. Supportive service economies...
 7. Concluding remarks and the road...
 Appendix A. A brief history of...
 Appendix B. Housing types
 References
 Biographical sketch
 
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Title:
The meanings of frailty and aging-in-place for Florida's HUD managers and their elderly tenants
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xiii, 239 leaves : ; 29 cm.
Language:
English
Creator:
Wilson, Michael Phillips, 1969-
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Geography thesis, Ph. D   ( lcsh )
Dissertations, Academic -- Geography -- UF   ( lcsh )
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theses   ( marcgt )
non-fiction   ( marcgt )

Notes

Thesis:
Thesis (Ph. D.)--University of Florida, 2001.
Bibliography:
Includes bibliographical references (leaves 223-238).
Statement of Responsibility:
by Michael Phillips Wilson.
General Note:
Printout.
General Note:
Vita.

Record Information

Source Institution:
University of Florida
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
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oclc - 47721449
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MISSING IMAGE

Material Information

Title:
The meanings of frailty and aging-in-place for Florida's HUD managers and their elderly tenants
Physical Description:
xiii, 239 leaves : ; 29 cm.
Language:
English
Creator:
Wilson, Michael Phillips, 1969-
Publication Date:

Subjects

Subjects / Keywords:
Geography thesis, Ph. D   ( lcsh )
Dissertations, Academic -- Geography -- UF   ( lcsh )
Genre:
bibliography   ( marcgt )
theses   ( marcgt )
non-fiction   ( marcgt )

Notes

Thesis:
Thesis (Ph. D.)--University of Florida, 2001.
Bibliography:
Includes bibliographical references (leaves 223-238).
Statement of Responsibility:
by Michael Phillips Wilson.
General Note:
Printout.
General Note:
Vita.

Record Information

Source Institution:
University of Florida
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
aleph - 027029946
oclc - 47721449
System ID:
AA00017694:00001

Table of Contents
    Title Page
        Page i
        Page ii
    Dedication
        Page iii
    Acknowledgement
        Page iv
    Table of Contents
        Page v
        Page vi
        Page vii
        Page viii
        Page ix
    List of Tables
        Page x
    List of Figures
        Page xi
    Abstract
        Page xii
        Page xiii
    1. Introduction
        Page 1
        Page 2
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    2. Conceptual framework and methodology
        Page 20
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    3. Management and frail elder tenants in Florida's low-income, rent-subsidized housing: A literature review
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    4. Constructing frailty: How frailty is defined
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    5. Constructing aging-in-place
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    6. Supportive service economies of scope and scale in Florida's low-income, subsidized housing
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    7. Concluding remarks and the road ahead
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    Appendix A. A brief history of the United States public housing program
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    Appendix B. Housing types
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    References
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    Biographical sketch
        Page 239
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Full Text










THE MEANINGS OF FRAILTY AND AGING-IN-PLACE FOR FLORIDA'S HUD
MANAGERS AND THEIR ELDERLY TENANTS



















By

MICHAEL PHILLIPS WILSON


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA


2001






























Copyright 2001



by


Michael Phillips Wilson





















For my wife, Jody,
My past, present and future.

To the past,
Helen Miller Greenawalt, Nancy F. Wilson, Samuel P. Wilson, and Lillian Wilson

To the present,
Robert P. Wilson, Elizabeth A. Wilson, Cheryl L. Ellis, and Clare E. Greenawalt.

To the future,
Ashley Kathryn Ellis.

Here's to a Booming Future.















ACKNOWLEDGMENTS

It is with deep appreciation that I recognized those people whose help has proven

invaluable in the conceptualization and production of this research. My committee

chairperson, Dr. Stephen M. Golant, not only provided continual insight into my project,

but also a generous supply of support and understanding throughout my doctoral work

and the dissertation-writing process. I am most grateful for his ongoing support. It is

with equal respect and admiration that I recognize the other members of my committee,

Drs. Malecki, Caviedes, Thrall, and Gubrium. Their wisdom and guidance made the

entire doctoral process a much smoother pathway. For these reasons and many, many

more I am thankful to have worked and studied with such a fine group of talented and

learned scholars.

I must also thank my parents, Robert and Elizabeth, and my sister, Cheri, for their

support and encouragement throughout my life. Without their early "conversations," I

would not have achieved the success I am enjoying now.

Lastly, but most importantly, I must thank my wife, Jody, for tolerating my long

hours of work. Without her encouragement, patience, and understanding, this

dissertation would not have materialized.















TABLE OF CONTENTS

page

ACKNOWLEDGMENTS ........................................................................................... iv

LIST O F TA B LES........................................................................................................ x

LIST O F FIG U RES ..................................................................................................... xi

A B STR A C T ...................................................................................................................... xii

CHAPTERS

1 IN TRO D U CTION ......................................................................................................

O overview ....... .................................................................................................................. 1
Older Poor People and Poverty ................................................................................. 4
Elders in Government-Subsidized Housing in the United States and Florida............ 6
M measuring Frailty.................................................................................................. 9
Frail Elders: A Desperate Need for Services...................................... ............. 11
A Strategy to Deal With Frailty and Service Need................................... .......... .. 12
Alternative Service Models and the Role of Economies of Scope and Scale.............. 14
Research O bjectives................................................................................................ 16
Im pact of the Project............................................................................................... 18
D issertation O outline ................................................................................................ 18

2 CONCEPTUAL FRAMEWORK AND METHODOLOGY.......................................20

Conceptual Framework ........................................................................................... 20
Social and Behavioral Science Models........................................................... 20
Environmental Congruence: "Constructing" Low-Income Housing Environments. 21
Transactionalism: A Way to Understand the World.............................................. 23
Understanding Frailty from the Transactionalist Perspective................................. 26
Understanding Aging-in-Place from the Transactionalist Perspective................. 26
Theories of Competence in Environmental Impact ............................................... 27
Difficulties Assessing Supportive and Unsupportive Environments.................... 28
The Larger Environmental Context: Frailty and Aging-in-Place........................ 30
Preliminary Findings: The Florida Village Case Study........................................ 33
Research Methodology ............................................................................................ 37
Target Population and Site Selection............................................................. 37
Site Selection Criteria............................................................................................ 38









Major Constructs and Data................................................................................... 41
Prim ary D ata.................................................................................... ................... 41
A ging-in-Place .................................................................................................... 41
Frailty ........................................................................................................................ 42
Qualitative Data Analysis................................................................................. 42

3 MANAGEMENT AND FRAIL ELDER TENANTS IN FLORIDA'S LOW-INCOME,
RENT-SUBSIDIZED HOUSING: A LITERATURE REVIEW.................................44

Rent-Subsidized Housing and the Frail Elder........................................ ........... .... 45
Shifts in Housing for Frail Elders......................................................................... 46
The Elderly in Florida's Rent-Subsidized Housing................................. ........... ... 48
The Presence of Elders at HUD Sites ................................................ ............. 49
Elder Concentrations at HUD Sites .................................................................. 49
County Locations of Elders in HUD Sites.......................................... ............ 50
CASERA Project: An Impetus for this Research ................................. ........... 50
The Need for Services in Florida's Subsidized Housing........................... ............ 51
D efinitions of Frailty............................................................................ .................... 52
Definitions of Aging-in-Place........................................................................ ............ 54
Frail Elderly: A Dilemma for HUD Managers....................................... ........... .. 55
Linking Housing With Services to Encourage Aging-in-Place.................................. 58
The Need Will Only Increase ............................................................................... 58
Economies of Scope and Scale: Home Health and Home-based
Supportive Services .......................................................................................... 60
Approaches to Providing Services........................................................................ 62
Service Coordinator Approach ......................................................................... 66
Congregate Housing Services Program (CHSP).................................. .......... ... 71
Section 202 Housing........................................................................................... 73
CASERA Project Findings: Successful Service Delivery Programs..................... 73
Building Upon Past Research ............................................................................... 75

4 CONSTRUCTING FRAILTY: HOW FRAILTY IS DEFINED.................................. 77

What is Frailty?....................................................................................................... 77
The Literature of Frailty...................................................................................... 79
Medical Model of Frailty ........................................................................................ 81
Service Model of Frailty ................................................................................... 87
Individual Model of Frailty.............. .................................................................... 89
Manager Model of Frailty ....................................................................................... 92
Summary of Frailty Models.............................................................................. 97
Frailty: C ase Studies............................................ ................................................. 99
Case Study 1: Service Model of Frailty................................................................. 101
D discussion ................................................ . ........................................................ 106
Case Study 2: Individual Model of Frailty .......................................................... 106
D iscussion.................................................. ...................................................... 110
Case Study 3: Service Model of Frailty......................................................... 111
D discussion ..................... ............................... ........................................................... 113









Case Study 4: Manager Model of Frailty.............................................................. 114
D discussion .......................................................................................................... 116
Case Study 5: Individual Model of Frailty ........................................ .............. 117
Discussion .................. ......... ...................................................... 119
Summary ..................................................................... ...................... 120
Solutions in Lived Experiences ..................................................... ......... 121

5 CONSTRUCTING AGING-IN-PLACE ................................................................ 124

What is Aging-in-Place? ........................ .................................. .......... 124
Residential and Managerial Responses to Aging-in-Place .................................... 126
Residents' Views on Aging-in-Place........ ................... ................................... 127
Residents Hide Problems from Managers............... .......................................... 130
Residents Secure Services for Independence......................... 130
Residents Relocate to Another Housing Environment ................ .................. 131
Managers' Views on Aging-in-Place ..................................................... ................. 131
Examining Issues of Aging-in-Place ...................................................................... 134
Facility Types............................................................................... ........ 134
Access to Services......................... .................................. ......................... 138
Conceptualizations of Frailty............................................................. ..... 139
Sum m ary .......................................................... ................................................ 139
Approaches to Aging-in-Place: Management's Perspective................................ 140
Inactive Approach.................................. .. ..... 140
Reactive Approach................................ 141
Proactive A pproach......................................... ................................................. 142
Sum m ary ................................................................................................................. 142
Aging-in-Place: Case Studies ............................................. ................................. 143
Case Study 1: Inactive Approach........................................................................... 145
Discussion.................................. ................................... ........... .......... 146
Case Study 2: Inactive Approach..................................................................... 148
D discussion ..................................... .................................................... ...... ..... 149
Case Study 3: Reactive Approach...................................... 150
D iscussion.................................. ............................................................... ..... .. 152
Case Study 4: Reactive Approach.............................................. ...................... 153
Discussion............. ............................. .. .... ..................................... 155
Case Study 5: Proactive Approach ................................................ .................. 156
D iscussion................................................................................................. 158
Case Study 6: Proactive Approach ............................................. ..................... 159
D discussion .. ................................................................................................. ............ 162
Sum m ary ............................................................................................. .............. 163
Solutions in Lived Experiences ...................... ..... ..... .............. ...... 164








vii









6 SUPPORTIVE SERVICE ECONOMIES OF SCOPE AND SCALE IN FLORIDA'S
LO W -IN COM E, SUBSIDIZED H OU SIN G .......................................................... 165

What Are Economies of Scale and Scope? Why Are They Important?...................... 165
Econom ies of Scale........................................................................................... 167
Econom ies of Scope........................................................................................... 169
The Cost of Providing Care ...................................................................................... 170
The Function of Economies of Scope and Scale in Florida's Government-Subsidized
Housing: Four Service Delivery M odels................................................................. 172
Service Inactivity .................................................................................................... 173
Com m unity-Based Service Activity ..................................................................... 175
On-Site Service Activity ................................................................................... 177
On-Site and Com m unity-Based Service Activity................................................. 179
Econom ies of Scope and Scale: Case Studies............................................................ 181
Case Study 1: Service Inactivity............................................................................ 182
D iscussion......................................................................................................... 183
Case Study 2: Community-Based Service Activity............................................. 184
D iscussion..................................... ......... ............ ............................................. 186
Case Study 3: On-Site Service A ctivity................................................................. 187
Discussion......................................................................................................... 189
Case Study 4: On-Site and Community service Activity..................................... 189
D iscussion......................................................................................................... 191
Sum m ary........................................................................................................... 191

7 CONCLUDING REMARKS AND THE ROAD AHEAD....................................... 193

Overview of Research................................................................................................. 193
Goals ................................................................................................................. 194
Poor Elders........................................................................................................ 195
HU D Facilities ........................................................................................................ 195
Qualitative Investigation......................................................................................... 196
Definitions............................................................................................................. 197
Frailty ...................................................................................................................... 197
Aging-in-Place ........................................................................................................ 199
Service Delivery Types........................................................................................... 201
M major Results........................................................................................................ 203
Frailty ...................................................................................................................... 203
Aging-in-Place ........................................................................................................ 204
Econom ies of Scope and Scale ............................................................................... 205
Significance........................................................................................................... 206
Program m atic Im pact One...................................................................................... 206
Program m atic Im pact Two ..................................................................................... 207
Program m atic Im pact Three ................................................................................... 208
Program m atic Im pact Four.................................................................................. 208
Concluding Rem arks............................................................................................... 209









APPENDIX A A BRIEF HISTORY OF THE UNITED STATES PUBLIC HOUSING
PR O G R A M ......................................................................................................................211

APPENDIX B HOUSING TYPES.............................................................................221

LIST OF REFERENCES.................................................................................. ......... 223

BIOGRAPHICAL SKETCH .........................................................................................239















LIST OF TABLES


Table Page

2.1. Transactional A xiom s ..................................................................................................... 24

2.2. Government-Subsidized Housing Types and Characteristics......... .......................... 31

2.3. Site Selection Criteria.............................................................................................. 39

4.1. Clinical Criteria to Identify Frailty in Elderly Patients.............................. ............. 82

4.2. Factors Contributing to Frailty Based on the Four Models of Frailty........................ 123

5.1. Characteristics of Managerial Approaches in Subsidized Housing............................ 140















LIST OF FIGURES



Figure Page

6.1. Graphs of Economies of Scale .................................................................................... 167

6.2. Service Inactivity Model......................................................... ................................ 174

6.3. Community-Based Activity Model........... ................................................................. 176

6.4. On-Site Service Activity Model............................................................................... 178

6.5. On-Site and Community-Based Service Activity Model............................................ 180















Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

THE MEANINGS OF FRAILTY AND AGING-IN-PLACE FOR FLORIDA'S HUD
MANAGERS AND THEIR ELDERLY TENANTS
By

Michael Phillips Wilson

May 2001

Chairman: Stephen M. Golant, Ph.D.
Major Department: Geography

Long-term care services for elders, like nursing homes and board and care

facilities, represent a substantial share of total health care spending in the United States.

This study attempts to understand the "triggering mechanisms" that low-income housing

managers use to determine elders' abilities to remain in housing projects. By

understanding how Florida's HUD managers and their elder tenants ascribe meanings to

frailty and aging-in-place, more supportive housing environments can be created and

premature institutionalization can be minimized.

Interviews were conducted with 48 housing managers and 105 residents based on

a transactionalist perspective of environmental congruence. From these interviews,

personal constructions of aging-in-place and frailty were revealed. The study participants

were questioned about supportive service access, use, and residential dynamics of the

housing project.









Findings suggest that the conceptualizations of frailty and aging-in-place by both

managers and residents are closely linked with the facility type. The housing type

determines the level of supportive services, service access, and physical design options

available to maintain elders in their homes.

The residents demonstrated four models of conceptualizing frailty--medical,

service, individual, and manager. Though few residents defined their frailty within any

single model, many had clear enough conceptualizations to make them easily

categorized.

Additionally, managers revealed three approaches to conceptualizing aging-in-

place--inactive, reactive, and proactive. Each of these models describes a level of

attention to resident's needs for supportive services.

Lastly, one of the most significant influences on the ability of rent-subsidized

housing to maintain residents is its capacity to create networks of community-based

services taking advantage of economies of scope and scale. These services are the

lifeblood to maintaining frail elders in their homes. Four major models were uncovered--

service inactivity, community-based service activity, on-site activity, and on-site and

community-based service activity.

The importance of these findings is not simply for fiscal reasons. People must

realize that bringing services to low-income seniors allows them to age-in-place with

dignity and autonomy, giving them a home until they choose to move.














CHAPTER 1
INTRODUCTION

We want to live out our days in our apartment. I hope they'll let us.
Resident 33 to Resident 32
Central Florida


Overview

According to the United States Census Bureau (2000), America's population of

age 65 or older persons grew by 74% between the period of 1970 and 1999. This overall

increase from 20 to almost 35 million people will pale in comparison to the burgeoning

population of the upcoming Baby-Boomers. In 1945--around the end of World War II--

the United States laid the potential foundations for great economic success or dismal

failure. In the stable, two-parent era of suburbia began the Baby Boom that will have a

monumental impact on the United States as those children move through the lifecourse.

From 1946 to 1964--the entire period now called the Baby Boom--a total of 77 million

babies were born. Within the ranks of this group, America will face its greatest

challenges to address the needs of an aging population as this group approaches and

moves beyond their mid-sixties.

Since the mid-1850s, life expectancy has consistently increased over the last 150

years. Many researchers believe the Baby Boomers will have an average life expectancy

of 78 years for males and 83 years for females. This factor, combined with other age-

related challenges, will force the United States government to face some major demands

when coping with this group of the population. According to historians and









demographers, recent U. S. history contains three separate and unprecedented

demographic phenomena that are converging to produce what Dychtwald & Flower

(1989) calls the age wave. These are:


1. The Senior Boom. Americans are living longer than ever before, and older
Americans are healthier, more active, more vigorous, and more influential than any
other older generation in history.

2. The Birth Dearth. A decade ago, fertility in the United States plummeted to its
lowest point ever. It has been hovering there ever since, and it's not likely to change.
The great population of elders is not being offset by an explosion of children being
born.

3. The Aging of the Baby Boom. The leading edge of the boomer generation has
passed forty. As the boomers approach fifty, and pass it, their numbers will combine
with the two other great demographic changes to produce a historic shift in the
concerns, structure, and style of America. (Dychtwald & Flower 1989, p. 4)


The combined effect of the first two demographic phenomena has a direct influence on

the third--the aging of the Baby Boomers. The aging of this group creates an America

that is increasingly concerned with the needs and desires of its middle-aged and older

citizens (Thurow 1996, Dychtwald & Flower 1989).

The concerns for an aging population are great--dealing with the sheer numbers of

aging Boomers and the current aging population is enough to create financial and

emotional strains at the personal, local, state, and national levels. In a country like the

United States that has achieved only moderate success in dealing with the spectrum of its

aging population, failure to address the needs of members of this group could prove

catastrophic. Unquestionably, one of the most needy sub-groups of this population will

be those not making enough money to satisfy their daily needs. These elders will face a

variety of obstacles in their later years, including fragmented access to services,









continued occupancy of their home, and generally limited opportunities to successful

long-term care.

Long-term care services for elders, like home-based care, nursing homes, and

board and care facilities, represent a substantial share of total health care spending in the

United States. For this reason alone, many policy makers have made long-term care an

important issue on state agendas. Nursing home and home health care accounted for 12%

of personal health expenditures in 1995, and 14% of all state local health care spending

(Weiner & Stevenson 1998, see also Polivka et al. 1996). In the state of Florida the

potential need for long-term care is enormous. With the largest proportion of elder

population in the country, Florida has great pressure from many sides to develop a low

cost system of long-term care. In 1996, 19% of Florida's estimated 2.7 million people

were over age 65 (Weiner & Stevenson 1998). Dunlop et al. (1996) and Lipson et al.

(1997) both document the need and cost projections for long-term care of this population.

Based on current and expected future disability rates and service costs, projections of

need and cost through 2010 were made. Over the next ten years Florida--and the nation--

will be faced with extreme demands from certain segments of the senior population for

long-term care and housing that can accommodate frail seniors.

Currently, however, a gap exists between the needs of frail seniors and the

services available. In terms of the compatibility between services and needs, the state

creates a burdensome eligibility and service structure to obtain long-term care assistance.

These systems do not exist in sufficient quantities to meet either present or future needs

of Florida's elder citizenry. With respect to housing alternatives few types of affordable

options at any income level are available for Florida's elders who do not need or want to









occupy a nursing home (Dunlop et al. 1996). Florida's low-income elders must confront

a variety of obstacles--reduced quality of life, extreme cost expenditures for needed

services, loss of autonomy and control in premature institutionalization.

This group faces tremendous disadvantages because they will not have the

financial assets to address their long-term and supportive service needs as they age.

Some researchers' suggestion that low-income elders face problems similar to those of

other groups of poor in the country is an oversimplification. For this group there is not

one but multiple complicating events and obstacles that permeate their lives. These

events affect older persons differently depending on their finances, physical and mental

capabilities, and lifestyle.


Older Poor People and Poverty

The condition of poverty is complex and should not be conceived of as a single

problem with a single solution. Instead, race, gender, familial status, age, and place of

residence all come together to influence the risk of living in poverty. For the elderly,

these risks become even more influential in predicting poverty and the duration of an at-

risk life event.

These diverse factors of complicating circumstances have converged to put some

of the elderly at risk for poverty in old age. Currently 10% of the nation's elderly--

roughly 3 million people--have annual incomes below the official government-defined

poverty line. The income at the official U. S. annual poverty line for 1997 is $8,183 for a

person living alone and $10,473 for a family of two adults (Everding 1999, p. 1).

Also, less education and increasing age have been shown to contribute to the risk

of being poor or near poor and having catastrophic health problems. Health and poverty






5


have an inter-related effect: "At the time that low-income elders are experiencing greater

declines in their health they also have fewer financial resources with which to cope with

this poorer health" (Coward 1997, p. 1). Currently poor elders likely had low incomes

throughout most of their adult lives, contributing to a lifetime of debilitating

consequences that culminates in few resources, poor housing, significant health

problems, and dependence in old age.

Rank & Hirschl (1999) cite a major public policy success over the last forty years

for the reduction of poverty within the elderly population, mirroring the successes seen in

other population sub-groups. They highlight the following:

In 1959 the poverty rate for those aged 65 and over stood at 35.2%, representing
the age group with the highest level of impoverishment. By 1997 the poverty rate
for elderly adults had fallen to 10.5%. This was lower than the 13.3% rate for the
overall population, and substantially lower than the 19.9% rate for the children
under age of 18. (Rank & Hirschl 1999, p. S 184)

While researchers cite many causes for this reduction, including Social Security increases

and the Medicare program, Rank & Hirschl (1999) and other studies at state (Golant

1999, Nachison 1985) and local levels find that the likelihood of experiencing poverty

varies dramatically by race, education, and marital status. In a variety of contexts, being

black, having less than 12 years of education, and not being married increase the

likelihood of poverty during the elderly years (Rank & Hirschl 1999, Golant 1999).

Additionally, Rank & Hirschl (1999) state the following:

In combination, these variables radically reduce or increase the cumulative
chances of experiencing poverty. For example, 88.1% of not married black
females with less than 12 years of education fell below the poverty line at some
point during the ages of 60 to 85, whereas only 13% of married white females
with 12 or more years of education were touched by poverty. (p. S191)

Implications of these findings suggest that despite the decrease in the percentage of elders

in poverty, it would be a mistake to consider this issue inconsequential. The assumption









that programs like Social Security and Medicare have "solved" these problems is also

incorrect.


Elders in Government-Subsidized Housing in the United States and Florida

Nationally, a small though significant portion of this subgroup of poor elders

resides in government subsidized rental housing. However, most facilities were built and

designed for relatively healthy elderly tenants. These buildings satisfy this group's need

for housing, but few offer the types of supportive services and design features necessary

to prevent premature institutionalization and to ensure aging-in-place. Additionally, few

facilities have the staff needed to handle the needs of an aging, low-income population.

This type of housing addresses the most serious accommodation problems among

elders' low-income accommodations. By 1997, 1.6 million elders lived in federally

subsidized housing (HUD 1999). These programs have proven overwhelmingly

beneficial to this subgroup, despite unfavorable opinions about entering a government

housing project, and have drawn disproportionate numbers of elders into government

subsidized housing.

Compared with other low-income populations, elders are disproportionately more

likely to occupy government rental subsidized housing. According to Golant (1992) and

Redfoot & Gaberlavage (1991), there are three key reasons that older people have

received more than their share of subsidized housing units: "(1) older renters are poorer

than other renters, (2) long-time residents have aged-in-place, and (3) several federal

housing programs have targeted assistance to older people" (p. 117). Ultimately,

however, the greatest inducement for moving into government-subsidized housing is the

need for financial relief (Golant 1992, p. 147). Beyond the immediate need for housing,









these residential environments have proven to offer elders incentives for relocating; and

once moved into these accommodations, they will tend to remain unless they experience

physical or mental impairments that limit their ability to live independently (Golant 1992,

p. 118).

Low-income elders in the state of Florida have sought housing alternatives that

minimize monthly expenses and, that maximize avenues for accessible supportive

services and locales to remain at home. According to Golant's CASERA Project (1999),

senior households were concentrated in two federal housing programs conventional

public housing (14,981) and Section 202 (14,504) accounting for roughly 21% of the

subsidized elder population in rental housing. Section 8 Certificates and Vouchers used

by elders (12,754) and administrated by Public Housing Agencies constitute about 13%

of the elder housing population. The next largest programs are Section 236 projects

(9,240) with 13%, other HUD programs comprise about 7%, Section 8 projects (3,566)

with 5%, and rural housing (4,822) with 7%. This research, however, focuses on the four

key low-income housing programs in the state--Section 202, Section 221, Section 236,

and Section 8. Together, these four categories of housing total about 50% of Florida's

low-income, elder population. In all, about 80,000 elders live in Florida's government

subsidized housing (Golant 1999).

While many of the elders living in these housing facilities lead independent and

active lives, a portion of them need some form of assistance with daily activities,

including bathing, dressing, toileting, housekeeping, and shopping. On the horizon, an

even greater proportion will require supportive services as the Baby Boomers age. For

these groups of low-income, service-needy elders, government subsidized housing









becomes an obstacle or an opportunity depending upon the type of responses of housing

managers and sponsors to address the needs of elders when they become frail.

In Florida the older rent-subsidized population is top heavy "with persons over the

age of 75, women, people living alone, and African Americans" (Golant 1999, p. 3). If

this group cannot maintain independent living arrangements, they become prime

candidates for nursing homes, board and care facilities, or other long-term care options at

the expense of federal and state tax dollars. If this population is able to access supportive

services and receive assistance from housing managers and sponsors, premature

institutionalization can be at least delayed, allowing for elder occupants to age-in-place.

Recent estimates suggest that between 15 and 20% of older people living in low-

income housing nationally suffer from some form of frailty (Keen 1997, p. 1; Golant

1999; Winograd et al. 1991. Approximately 14,000 residents in Florida's HUD housing

can be classified as frail--that is they are experiencing difficulties taking care of

themselves and/or their apartments (Golant 1999). Just these two problems alone,

according to housing managers, force tenants to be relocated to more supportive housing

environments, especially in those facilities that do not have staff or on-site services to

assist elders with their day-to-day lives.

The elders living in government-subsidized housing have a variety of strikes

against them. Older people in this type of housing are the poorest and most vulnerable

residents in any housing system. Neighboring residents may be disinclined or unable to

provide assistance because of their own frailty or lack of community feeling. One might

expect housing sponsors or managers to address these shortfalls and problems by helping

frail residents to age-in-place, or choose to remain and concentrate in communities and









neighborhoods over time. Indeed, service providers, residents themselves, and families

often make the assumption that senior housing includes senior services (Brice & Corey

1991, Merrill & Hunt 1990). In reality, managers and sponsors address a broad array of

concerns. Residents coping with their frailties do not always rise to the top of that list.

Historically, federal and state housing policies have held housing sponsors

accountable only for physically and fiscally sound dwelling units and have required

residents to live independently--a term, that like frailty, has great variation among

housing providers as well as state and local governments. These policies have

discouraged housing providers from involvement in social service provision and/or

access. While studies such as Golant's CASERA Project (1999) indicate that some

managers do provide support, assistance is far from universal and tends to be

unsystematic. Managers often lack the resources and expertise necessary to ensure

quality service and can be just as overwhelmed as residents in attempting to access them.


Measuring Frailty

The term frail has become a very highly charged--though imprecisely defined

word that is used to describe elders having "deficiencies" that prevent them from safely

living alone or performing everyday activities without assistance. Currently, no

consensus exists on the best way to define or measure frailty, or its effects on such

outcomes as future institutionalization. Various groups of researchers, medical

professionals, and social workers--as well as other professionals in the field--all have

varying definitions for understanding frailty. For elders in government subsidized

housing, frailty has come to mean a lack of access to needed supportive services,

particularly transportation, hot meals, housekeeping chores, and other day-to-day








activities. Often with no family to turn to for assistance, frail elders become embedded in

a cycle of un-addressed needs that will eventually force them from their affordable rental

units.

Frailty of this group is often simply determined by assessment or manifest as

ADL (activities of daily living) or IADL (instrumental activities of daily living)

deficiencies. These deficiencies are examined in the research of Golant (1999),

Winograd et al. (1991, 1988), and Bernstein (1982) as being contributors to the need for

supportive services. Many of these elders suffer from deficits that include problems with

bathing, toileting, cooking, using the telephone, shopping for personal items, and

transportation. Although these impairments may not constitute serious medical

conditions, nonetheless, many elders and housing managers consider such impairments to

be the basis for judging and definingfrailty.

The absence of standard measures of frailty creates a variety of difficulties in

understanding how frail elders cope day-to-day. Though frailty remains an ill-defined

term, and is often regarded as a "condition or syndrome," new conceptualizations are

emerging. To best grasp frailty--as a concept--it must be understood from the standpoint

of the elders and managers. Rather than simply identifying frailty in terms of objectively

measured ADL and IADL deficiencies, researchers need to have the "actors" define this

term in their own words. To that end, a more insightful examination of frailty demands

that the two actors "construct" frailty through conversations. By engaging the issue of

frailty in this manner, meaning is attributed to the people involved daily in assessment

behavior. Residents and managers must explain and describe events from their own lives









and those of others in the residential facility to clarify issues of frailty, aging-in-place,

and other relevant events that influence day-to-day life.

To best understand the issues of aging-in-place and frailty in Florida's

government-subsidized housing, this study uses managers and residents' own words to

describe their day-to-day situation. To protect their identities, pseudonyms are used

throughout this research.


Frail Elders: A Desperate Need for Services

Not surprisingly, much variation exists in the abilities of housing managers and

sponsors to offer supportive services to delay low-income, frail elders need for relocation

or premature institutionalization (Davis et al. 1998, Griffith et al. 1996, Lane 1995).

Similarly, community-based service providers inconsistently provide services to this

group (Wolch 1996, Struyk et al. 1989). Exactly how to best provide services to this

population continues to be the subject of much debate.

The poor elderly have consistently faced many obstacles trying to lead their day-

to-day lives. Before government programs intervened to provide housing and medical

assistance, poor seniors had trouble obtaining adequate shelter and healthcare. Though

the past decades have seen improvements in the financial status of seniors, particular

segments of this population continue to have problems accessing the services needed to

maintain health, well-being, and financial independence, especially in times of medical

crisis. The poorest of the poor--like those in government subsidized housing--cannot

afford to make supportive, home health care arrangements to help with illness, or

recovery from surgery.

When an elderly resident of government housing breaks a hip and must spend
months recovering in a rehabilitation center, the housing manager may decide it is








too costly to keep the patient's apartment vacant and rent to someone else....
(Keen, 1997, p. 1)

Because this subgroup has such low income, seemingly minor events become major life-

changing catastrophes. Without access to services like housekeeping, transportation, and

bathing assistance, people become trapped in their homes fearing management will

consider them "unfit" to continue living in their homes. This fear translates into hiding

"needs" from friends, family and neighbors until the situation truly requires a more

supportive environment. With current state and local supportive service programs,

however, this does not have to be the case.

By understanding how issues of frailty, poverty, need for supportive services, and

increasing elder populations come together in low-income housing, researchers can better

understand how to support this group to age-in-place, or remain in their home as they

age. By encouraging this population to "remain at home," and supporting them to

"remain at home," premature institutionalization costs can be minimized and quality of

life can be maximized.


A Strategy to Deal With Frailty and Service Need

According to Stephen Golant, "Sometimes if an elderly person can receive just a

little assistance, perhaps in the form of a personal aide coming to help with grooming or a

bath, it may mean the difference between staying in what has become home and having to

move out" (Keen 1997, p. 2). Increasingly, as the average age of seniors in HUD

subsidized housing has steadily increased, so too has the demand for supportive services.

Those without family are especially in need (Golant 1999, Wilson 1998, Lanspery 1997a,

1997b). Without access to supportive services, this group is at much greater risk of

having to enter a nursing home. This premature institutionalization not only lowers









quality of life, but could cost taxpayers significantly in the long run, because the occupied

beds usually require funding from the federal-state Medicaid program.

Aging-in-place sometimes merely refers to how elders become concentrated in

communities and neighborhoods over time. It is, however, also a strategy for dealing

with frailty. By encouraging elders to age-in-place in federally subsidized rental housing,

managers are better able to help tenants maintain their independence. Morrison (1992)

states the following:

As AIP [aging-in-place] becomes more prevalent and widespread at local scales,
significant numbers of older inhabitants will be staying put, living independently
as long as they can. Future elder aging in place will express needs in place. Their
needs will be met either through various forms of assistance in place or through
expenditures in other places (e.g. retirement and nursing homes) where many of
today's elderly now live out their dependent years. The latter options are one
approached to achieving economies of scale. AIP poses a challenge for the nation
to devise additional possibilities and, through research to identify where in space
those possibilities might become feasible in the future. (p. 1)

By encouraging aging-in-place, states minimize costs of premature institutionalization.

A single statistic from a study by the Institute of Medicine dramatizes the massive
cost implications of dependency: If it were possible to postpone for one month
the onset of disability that leads to an elderly person being placed in a nursing
home, the resulting savings would total $3 billion [1991] dollars. (Morrison
1992, p. 2)

The advantages of aging-in-place link together three important criteria: maximum

benefit, minimum cost, and maximum quality of life.

Successful aging-in-place (AIP) will occur only where programs maximize the

personal dignity and functional independence of the resident being "retained," and only

where this person has real housing alternatives that have been fully explored before a

choice of "staying put" is made. Furthermore, this will only occur when aging-in-place

programs minimize "unnecessary or inappropriate" support. Residents must be

encouraged to accomplish tasks on their own, rather than waiting for caretakers to









immediately provide assistance. Only support provided at the margin of need as defined

by an individual's personal inclination and efforts to live independently should be offered

by aging-in-place programs. Any more or less support undermines the individual's

efforts to remain independent (Golant 1991, Golant 1984, Lawton 1989).

For aging-in-place initiatives to really work, a wide variety of housing choices

that address the needs of the local aging population and that serves the full continuum

form assisted to independent living are necessary. The aging-in-place concept works best

as part of a comprehensive approach to support the needs of the frail low-income elders

of Florida's government-subsidized housing to age-in-place. This type of program is the

most dignified and cost-efficient ways to provide long-term assistance. Too many state

and local governments have mistakenly believed that extended family support, minimum-

wage home assistance, and occasional professional services are all that are needed to

allow frail elders to age-in-place.


Alternative Service Models and the Role of Economies of Scope and Scale

The delivery of supportive services to government-subsidized housing often

benefits from two economic principles. The first, economies of scale, relates to the

ability to offer a single, low priced service to a specific population. In Florida's

government-subsidized housing, an off-site service provider usually does this; however,

some facilities are assuming this responsibility on-site. As one manager interviewed for

this study explained:

We have a [community-based] service provider supply service because they can
come onto our site and give our residents the service they need at a low price. We
rely on ABC Senior Service [not their real name] because they take care of five or
six projects in the area, know what they need to do, and give a good price. Our
residents are very pleased. (Manager 19)









By providing a single type of service to a large population, delivery costs can be reduced.

In turn, this reduction in costs translates into a lower cost to the resident needing services.

This economic advantage is highly significant in geographic areas where elder

populations are highly concentrated, particularly in south Florida. The second,

economies of scope, relates to the ability of a single housing project to provide multiple

services to the residents found in one location. Another manager puts it this way:

[We provide service to our residents because] we can give them the services they
need, a price they can afford, and know exactly how to address their changing
needs. This is better than bringing someone [on-site] because we are dealing with
our own residents. They know me and staff and don't have to worry about having
someone unfamiliar in their homes. (Manager 4)

One housing facility is able to harness its staff, knowledge and resources to provide two,

three, four, or more services to residents as on-site services.

The term economies of scale embraces a variety of relationships between unit

costs of production and the size of the organization producing it. According to the theory

of economies of scale, this concentration of elders should allow service providers to

deliver services in a cost-efficient manner.

Proficiency is gained by concentration of effort. If a plant is very small and
employs only a small number of workers, each worker will usually have to
perform several different jobs in the production process. In doing so he is likely
to have to move about the plant, change tools, and so on. Not only are workers
not highly specialized but a part of their work time may be realized by expanding
the scale of operation. Thus important savings may be realized by expanding the
scale of operation. A larger plant with a larger force may permit each worker to
specialize in one job, gaining proficiency and obviating time-consuming
interchanges of location and equipment. There naturally will be corresponding
reduction in the unit cost ofproduction [emphasis added]. (Gould & Ferguson
1980, p. 198)

By taking advantage of clustered senior populations, service providers are better able to

provide specific services at lower costs. This programmatic advantage fosters aging-in-








place in a greater number of facilities regardless of population or age-density of the

facility.

Where economy of scale works to the advantage of community-based supportive

service providers to reduce costs when bringing services to residential projects, economy

of scope offers cost advantages to the facility sponsors and managers in providing

services on-site. These internal economies of scope offer incentives to "providers" that

can supply two or more different, related services more inexpensively than in isolation

(Malecki 1991). This allows housing projects to offer services, and the possibility of

maintaining control over those services, as an on-site profit-making center using current

employees. This is important for four key reasons: (1) the variety of services available,

including number of each needed service and scheduling, (2) the complexity of needed

service (i.e. certified nursing assistant versus skilled nurse), (3) the uncertainty of outside

conditions, and (4) the dynamic situation of implementation and control over service

provision process (after Hitomi 1989).


Research Objectives

The purpose of this research is to gain a greater understanding and clarification of

the meanings both managers and frail elder tenants attribute to frailty and aging-in-place

and to explore how these meanings are influenced by their occupied buildings' contexts.

These insights are essential because they offer a view of management's attitude and

philosophy of aging-in-place--the desirability of helping their older tenants to remain in

their current homes--and conversely, the resident's views of the housing manager's

policies.








Researchers must find ways to understand better the "triggering" mechanisms

used by housing managers to judge relocation decisions for tenants. Similarly, there must

be an understanding of the criteria residents use to judge their own abilities to live within

the HUD environment. The success of any aging-in-place program in rent-assisted

housing rests on the success of avoiding these "triggering" incidents and supporting low-

income elders with services to remain in their homes. The major research objectives to

be addressed in this study are as follows:

1. To understand how managers and residents define frailty.
2. To understand how managers and residents define aging-in-place.
3. To understand how project size and density influence issues of frailty and aging-in-
place.
4. To identify major service delivery models in Florida's government-subsidized
housing and how they are linked to economies of scope and scale.

To address these questions and best understand the data, a qualitative

methodological approach was undertaken. The strongest "reason" for using this

orientation method is that it allows the researcher the ability to "detect, represent, and

explicate the meaning" of each individual's meaning of frailty and aging-in-place (Sankar

& Gubrium 1994). Qualitative methods function best

in situations where variables are unknown, where cultural issues are key, where it
is important to understand the texture of differences within the study population,
where the focus is on the dynamics of a situation or the development of a
relationship, or where the very meaning or definition of issues under study is
unknown or not agreed upon, then qualitative research can bring clarity and
understanding through its attention to meaning, process, and context. In
particular, its flexibility and sensitivity to process allow it to respond to issues and
directions that emerge in the course of the research. This includes attention
through all states of the research, from design to analysis to the interaction
between researcher, informant, and research context as a source of data.
(Gubrium & Sankar 1994, p. x)

The use of this methodology is important in gaining a unique perspective of the process

and situation of the participants surrounding and structuring these aging-in-place and









frailty issues in the context of congruence in Florida's HUD housing facilities. By

learning about these issues from the actors--in their own words--we gain insight into the

narrative of people "constructing meanings" of the issues at hand. To support the

qualitative data interpretation, I used the computer program NUD-IST to search and

structure the "talk database" (Gahan & Hannibal 1998, Denezin & Lincoln 1994, Miles &

Huberman 1994) looking for common meanings, ideas and categories for aging-in-place

and frailty. In addition to the flexibility in coding the interview transcripts, the strengths

of this program allow for the creation and management of ideas and categories found

within them. The NUD-IST program functions well for clerical maintenance, and allows

the data to be manipulated to "uncover" alternative and "new" views in the interview

records. The primary qualitative data will be supplemented by an examination of

secondary data generated by gerontological and geriatric researchers, senior housing

researchers, and policy makers at state and national levels.


Impact of the Project

The results of this project are expected to produce the following programmatic

impacts:

* A more complete understanding and definition of frailty from managers and residents
of Florida's low-income, government-subsidized housing projects.
* A more complete understanding and definition of aging-in-place from managers and
residents of Florida's low-income, government-subsidized housing projects.
* A better understanding of the relationship between project size and density and how
these factors influence issues of frailty and aging-in-place.
* A better understanding of the role of economies of scope and scale in supportive
service models of Florida's low-income, government-subsidized housing projects.









Dissertation Outline

Chapter 2 develops the conceptual framework and methodology for this study.

Chapter 3 presents the conditions in Florida's low-income, subsidized public housing,

issues regarding supportive service programs, including the service coordinator and the

congregate housing services programs (CHSP). Interview data are analyzed in Chapters

4, 5, and 6. I attempted to link the interview data with the evidence presented in Chapters

2 and 3. Chapter 4 examines the social construction of aging-in-place as developed

through the interviews with the 48 managers/sponsors and the 105 residents. Chapter 5

examines the social construction of frailty in the same manner. Chapter 6 examines the

impact of economies of scope and scale on environmental supports, noting the positive

correlation between high concentrations of elders and the availability of supportive

services. Lastly, Chapter 7 summarizes the approach and findings of this research.













CHAPTER 2
CONCEPTUAL FRAMEWORK AND METHODOLOGY

We shape our dwellings and afterwards our dwellings shape us.
Winston Churchill


Conceptual Framework

An important mission of this research project is to understand the mechanisms

used by managers to decide when to move low-income, frail residents out of their

housing complexes. To adequately understand these mechanisms, it becomes important

to access personal conceptions offrailty and aging-in-place. The strategies to access and

understand these concepts require comprehension of the following:

Environmental congruence
Transactionalism and the Transactionalist approach to understanding frailty
Theories of competence: environmental impact


Social and Behavioral Science Models

Housing for low-income elderly is an important yet unappreciated issue

confronting state and local governments.

Older persons place special importance on housing because they are likely to
spend more time in it, have more difficulty taking care of it, and have stronger
psychological attachments to it (having lived in the same place for many
years)..... (Pynoos & Regnier 1991, p. 91)

If there is a poor fit between the capabilities of older persons and their environments,

daily life activities may change unnecessarily or dangerously contributing to accidents,

isolation, and premature institutionalization (Pynoos & Regnier 1991).








Traditionally, understanding the human-environment relationships has been based

on environment-behavior interactional approaches employed by psychologists (Golledge

& Stimson 1997, McAndrew 1983, Lawton and Nahemow 1973). Recently, some of the

most useful models have expanded upon classical competence models seeking individual

assessments of environmental congruence, and other issues of personal need in individual

space (Golant 1991, Parmelee & Lawton 1990).

By taking traditional competence models, their refinements over time, and the

potential offered through qualitative interviews, an in-depth understanding of the

relationship of an individual to his or her environment can be better understood.

Undertaking this investigation within the context of Florida's government subsidized

housing for seniors provides insight into the issues of frailty and aging-in-place.


Environmental Congruence: "Constructing" Low-Income Housing Environments

With current trends in aging in the United States, researchers, over the last three

decades, have demonstrated a great interest in assessing and matching planned housing

facilities with the needs of older Americans. In fact, this match--or congruence--

between lifestyles and the needs of older people and the supportive nature of housing

facilities for facilitating aging-in-place, directly influences the success, well being, and

quality of life of residents will experience in their housing environment. By examining

the interaction between residents, managers, and the environment it is possible to gain

insight into the quality and appropriateness of the supportive residential environment for

aging-in-place. One of the key approaches to understanding the residential facility's

appropriateness is found by examining the supportive services available to frail elders.








By their very nature, well-run facilities will attract a specific type of resident

desiring the services, amenities, and management style offered by that specific building

(Golant 1984). As a consequence, a residential facility is often homogeneous in terms of

the population's profile and needs. Once potential clients have become residents, they

have a role in shaping and modifying that residential environment. Inhabitants and

management of a congregate housing facility attempt to maintain the set of living patterns

and environmental qualities that existed on move-in (Golant 1991, Barker 1968). They

hope that maintaining similarity in lifestyles and activities will contribute to high

satisfaction with the surroundings, enhancing quality of life and, ultimately, contributing

to successful aging-in-place. If the facility loses homogeneity, the potential mismatch

between residents and their environment could create dissonance in the residential living

patterns of the facility

Like residents, management, too, have a part in the formation and construction of

this environment. Regularly they are faced with decisions to transition residents to a

more supportive environment, allow more supportive services into the building, create in-

house support systems, or simply evict residents that no longer abide by the terms and

conditions of the lease. Additionally, management has a vested interest in maintaining

the homogeneity of the facility's lifestyle and services. By attempting to satisfy too

broad a spectrum of needs, management faces a future of increasing costs, ultimately

cutting into the ever-important "bottom line" needed to successfully maintain any

housing facility. Too diverse a population increases the likelihood of a schism erupting

between different groups of tenants and creating an untenable situation as the manager

attempts to cope with the needs and desires of various splintered groups of residents.








Within the context of a facility's housing environment, both residents and management

are interdependent factors in the creation of a building's environment.

Attempting to understand this transactional relationship between managers and

residents is one basis for investigating the appropriateness of the supportive aspects of

residential settings for both homogeneous and heterogeneous populations (Golant 1991).

Elements of mis-match or congruence in a residential environment can be varied--

services needs and delivery, management style, quality of life, and perceptions of frailty

to name a few. Individually, each of the factors proves important, but does not

"construct" a congruent or mis-matched environment. Taken together, however, these

elements create a strong case for understanding the appropriateness of the environment in

relation to the tenants and manager.


Transactionalism: A Way to Understand the World

A central concept for understanding the dynamics of the resident/manager

relationship--generically classified as a person-environment relationship--is

transactionalism (Altman & Rogoff 1987, Wicker 1982). According to this paradigm

(see Figure 2.1), people and their psychological processes are embedded in physical and

social contexts (Altman & Rogoff 1987, Werner et al. 1985). Within the bounded and

ordered system of the rent-subsidized housing facility, people and "non-human

components [act and interact] to carry out an ordered sequence of events" (Wicker 1982,

p. 12). Thus, the residential setting is the slate (which could be anywhere) on which

scenes of life (of anything) are played out. The interactions of people, behavior, places,

and temporal dynamics combine to take on specific meanings in specific locations under

specific conditions and at specific times. These events --in turn--define future events to










Components

Holistic entities
composed of
"aspects," not
separate parts of
elements; aspects
are mutually
defining; temporal
qualities are
intrinsic features of
wholes.


Stability

Changes are
intrinsic and
defining features
of psychological
phenomena;
change occurs
continuously;
directions of
change are
emergent and not
pre-established.


Focus

Emphasizes formal
causes, i.e.
descriptions and
understanding of
patterns, shapes,
and form of
phenomena.


View

Relative observers
are aspects of
phenomena;
observers in
different
"locations"
(physical and
psychological)
yield different
information about
phenomena.


Patterns

Focus on event, i.e.
confluence of
people, space, and
time; describe and
understand
patterning and
form of events;
openness to
seeking general
principles but
primary interest in
accounting for
event; pragmatic
application of
principles and laws
as appropriate to
situation; openness
to emergent
explanatory
principles;
prediction
acceptable, but not
necessary.


Table 2.1. Transactional Axioms. Adapted from Altman & Rogoff 1987, p. 67.

create a collective assemblage of behaviors for a setting. The timing, events, and

elements of a particular residential facility combine with the psychological and social

transactions of the residents and management to constantly change the dynamics of the

facility.

Transactionally, the processes that are occurring in the HUD-subsidized

residential facilities create and reflect an intra-facility sense of meaning regarding frailty

and aging-in-place. These meanings occur at the level of action and at the level of

meaning; they can be events, activities, meanings, evaluations, or any other psychological

process. The key element that makes them transactional is that the environment is as

much changed by the behavior as often as the behavior is changed by the environment.

When examining the relationship between managers and residents transactionally,

both groups become active elements in creating and defining the residential environment.








The transformations in the environment these two groups bring about, change not only

daily, but moment-to-moment. The characteristics, as interpreted by managers and

residents, become an ever-changing canvas that cannot--therefore--be pre-established or

pre-determined. The crux of this research centers on the notion that observers and

participants in the constant re-creation of the residential environment can--and do--have

different information about the environment, depending upon their location, attachment,

and perspective. Each person "shapes" or constructs the environment to fit his or her

own purpose.

A transactionalist approach views the phenomenon of the person-environment

relationship as a holistic entity--a complete set of actions occurring in a physical setting

that cannot be separated without destroying meaning. At any facility, the residents

interact with an environment created not only by physical characteristics of the

surroundings, but manager and situational-created as well. This same coping process is

replicated in the ever-changing environment created by residents for the management and

staff to negotiate. After all, this is the major focus of any residential facility's

management and residents--to create and maintain a congruent type of environment. A

problem arises when residents' declining competence levels create an ever-increasing gap

among the varying abilities of residents. The variability of competence levels--while

being a broad spectrum--can be classified in terms of age, ability, health, and supportive

service utilization. Frailty--in this research--becomes one of the most important

dimensions.








Understanding Frailty from the Transactionalist Perspective

To understand frailty transactionally, researchers must break away from the

traditional medical model that shape's society's view of frailty. It must be understood

that frailty "is a condition that resides within the individual rather than a situation which

existsfor an individual" (Raphael, Cava, Brown, et al. 1998, p. 2). Accepting this

definition, allows elders to create and define their own conceptualization of frailty, rather

than simply being labeled with it. This definition can be changed or modified as they

encounter events, activities, and meanings that shift their perceptions either positively

with supportive services, or negatively with a senior-unfriendly physical plant. The

variability of this definition can be significantly influenced by the supportive nature of

the residential housing environment.


Understanding Aging-in-Place from the Transactionalist Perspective

The nature of aging-in-place, too, functions transactionally because of the

changeability exhibited by interactions between residents and management within the

facility's environment. As these two groups interact to construct the residential

environment, factors influencing the ability to remain in the complex change the

likelihood of aging-in-place. For example, if services such as housekeeping and

transportation are incorporated into the complex, elders may be able to remain in their

apartments years longer before needing a more supportive housing situation. The

potential for change becomes the constant elements. Meanings for aging-in-place, like

that of frailty, are found in the context of the residential housing environment, and that

environment itself is continually changing.









Theories of Competence in Environmental Impact

In the last twenty years, researchers have come to realize the importance of not

just the physical components of housing--i.e. design features--but the role of the broader

contexts of the constituent elements of the environment in which the dwelling exists

(Golant 1992, Golant 1991). Thus, in addition to the traditional notions of "environment"

like the physical conditions of the building, its location, and its proximity to recreational

and commercial facilities, the access to supportive services becomes key in

"constructing" an environment allowing seniors to age-in-place. An understanding of

what it means to be competent, thus requires an appreciation of how environments are

interpreted differently by low-income, frail elders. Two hypotheses, developed by

Lawton et al. (1984) offer insights into how environmental meanings define individual

competence.

The environmental docility hypothesis argues that as the competence of older

persons decline, a greater proportion of their behavioral outcomes will be explained by

the attributes of their environment. Golant (1991) highlights as an example what one

elder might believe ". . because I am frail, I am less willing to risk falling on a slippery

sidewalk after it rains; consequently [frail elders choose to] remain in [their] houses until

the sidewalk dries" (p. 32). This person does not want to risk an accident, a possible

broken arm or leg, and an ambulance ride to the emergency room. She lets the

environment dictate her actions so that she may remain safe. The greater the

environmental barriers, the lower the individual's ability to meet the challenges of the

environment. Supportive services provided to these types of individuals would offset the

fears generated by unstable environmental assessments. Other manifestations of this

hypothesis are found in residents from these complexes range from talking about not








leaving apartments for fear of crime, to avoiding showers or bathing because of fears of

falling.

The environmental proactivity hypothesis argues that the environment provides

more opportunities to realize the goals and needs for individuals who are more

competent. People with higher competence are seen as having more ways to manipulate

surroundings to one's own advantages. Wilson (1998b) recounts in the Orlando Village

interviews that one resident "was more willing to leave her apartment to travel to the

grocery store, drug store, and doctor's appointments after the bus started picking up

residents in front of the housing project" (p. 11). Supportive services brought residents

back to daily life activities because they became more confident in themselves and their

abilities.


Difficulties Assessing Supportive and Unsupportive Environments

Though these two hypotheses appear straightforward, they mask the complexities

of trying to achieve residential environments that match the needs of elder residents.

Management and support staff may create environments that are too supportive and

overly responsive to residents' needs. Indeed, transactional circumstances can and will

be interpreted differently among residents and management. It is argued that in

environments that are too supportive, those with high competency levels cannot exercise

and maintain needed life skills (Lawton 1985), a subtle encouragement toward passive

contentment is reinforced (Golant 1991, p. 33).

... Simply helping people may make them incompetent. While meaning well, it
communicates to the persons that he or she is not able to do whatever it is for
him- or herself. If the person faces no difficulty, if there are no challenges, large
or small, feelings of mastery are precluded and consequences such as involution,
depression, and premature death are real possibilities rather than mere
exaggeration. Helping the resident to get dressed to go to breakfast (either out of








concern for the resident or to save time for the staff) may only result in feelings of
incompetence and dependence for the resident and ultimately take more of the
staffs time, since the individual will soon come to assume the need for such help.
(Golant 1991, p. 33)

On the other hand, too autonomous an environment leaves the most frail and vulnerable

without the supports needed to maintain a high quality of life and completely negates the

major reasons for moving into more supportive residential surroundings. Any action to

accommodate one group over another has the potential to upset the delicate balance of the

residential facility and reinforce the division between residents.

This is argued by Lemke & Moos (1989) when they propose that "high

functioning residents are more active in settings where other residents are active,

functionally able, and have more social resources and where autonomy is greater,"

whereas the "very impaired residents in such settings may experience negative effects of

a too demanding environment. With reduction in their self-initiated activity to below the

level found for similarly impaired residents in a less demanding environment" (S146).

The insights offered by these hypotheses help shed light on how managers and

frail, low-income residents of Florida's subsidized housing interact to construct the

residential environment. It will be possible to discern better the influences of the

transactional environment on supporting frail residents to remain at the facility, or forcing

them to move to a more supportive environment. Attempting to understand the

residential environment and the relationship between managers and residents in this

manner allows a greater understanding of the "triggering" mechanisms that force elders

to move in the first place.









The Larger Environmental Context: Frailty and Aging-in-Place

It is expected that both elder and manager and sponsor's interpretations of frailty

and aging-in-place are at least in part a function of both the age-density of the project, the

overall number of elder tenants, and the particular HUD funding category of the facility.

These three characteristics are influential because the facility shapes the expectations of

management. Managers that are accustomed to dealing with elders, and their problems,

probably have experiences in places like Section 202s, specific training, and an

understanding of the available services required by and available to the elder population.

Due to the nature and characteristics of each facility type (see Appendix A), the housing

environment will variously offer levels of supportive services (see Table 2.2).

Section 202s offer the greatest likelihood for supporting aging-in-place of low-

income, frail elders with supportive services like personal care, health services,

transportation, and meals. Sponsors of this type of housing are often private nonprofit

organizations. While targeted to seniors, occupants can include nonelderly disabled

tenants (who occupied these apartments before 1990). Many of the projects provide

congregate common areas like dining rooms, community rooms, and libraries; as well as

supportive services. The other housing types, not only often lack supportive services and

design modifications, but also are more likely to have highly heterogeneous populations

that will contribute to increased supportive service costs. Section 8 non-insured facilities

assist very low-income groups with no restrictions on age. These projects were designed

both to assist tenants with income too low to obtain decent rental housing in the private

market and to encourage new construction. Similar to Section 8s are Section 221 (d) (3)

and (d) (4) buildings that assist all groups of people regardless of income limits. The

principal difference between (d) (3) and (d) (4) programs is the amount of insured









mortgage available to nonprofit and for-profit sponsors. Section 236 facilities offer a

clear difference from Section 221s and Section 8s, in that they can include self-contained

apartments, congregate facilities, or a combination of the two. They can also have on-site

dining halls, community rooms, and healthcare services. Perhaps the biggest limitation

of these projects is the smaller rent revenues. They severely restrict the operating

budgets of facilities and, in turn, the resources that can be allocated to staffing and

services.

Section 202 Section 236 Section 221 Section 8

Supportive Yes, most Limited Limited No services
Services supportive of supportive supportive available.
Available these four services services Services may
housing types. available-- available-- be available in
Usually on-site usually offsite. usually offsite. the community.
and
community-
based services.
Target Elders only. All age groups. All age groups. All age groups.
Population Individuals and Individuals and Individuals and
families families families
needing needing needing
housing. housing. housing.
Heterogeneous No, elderly Yes Yes Yes
Population only.
Income Limits Low-income Low-income Low-income Very low
income
Service Yes No No No
Coordinator
Physical Plant Yes, beyond Only required Only required Only required
Modifications those required to be ADA to be ADA to be ADA
to Assist by the compliant, compliant, compliant.
Elderly and Americans with
Disabled Disabilities Act
(ADA).
Congregate Yes Yes No No
Areas
Sponsor Type Usually non- Profit and non- Profit and non- Profit and non-
profit. profit. profit. profit.
Table 2.2. Government-Subsidized Housing Types and Characteristics.









The advantages of Section 202s over other housing types hinge on their ability to

generate economies of scope and scale. It is expected that high concentrations and

populations of elder tenants will allow economies of scale and scope to decrease

supportive service costs, yielding a more regular and consistent delivery. For this

housing type, economies of scale allows a single, lower cost service to be brought on-site

from community-based providers--maximizing the cost per service expense ratio. For

facilities with the ability to offer multiple services on-site--economy of scope allows

multiple services, usually three, four, or five, to be supplied on-site with significant cost

benefit to the tenants.

When services are delivered to an elder-occupied building with a combination of

high population/high concentration low-income, elder housing, a two-fold benefit can be

realized. First, housing managers can provide supportive services more cheaply to elders

in need. Managers in effect "gain more time" to devote to physical plant matters,

staffing, and overall facility maintenance. Second, service providers can offer a variety

of lower cost services to larger numbers of residents at lower prices.

In settings where this occurs, managers and residents may be less likely to view

ADL and IADL deficits as "triggers" for relocation. Other benefits of elder population

concentrations include facilities specifically "designed" for elders, better trained

managers and support staff, and more supportive facilities for aging-in-place.

Conversely, however, where population numbers and concentrations are low, or facilities

do not directly support elders, service provision costs could be prohibitive, limiting the

aging-in-place prospects for this population. In both cases, frailty becomes the key

identifier for triggering relocation and limiting the prospects for aging-in-place.








Preliminary Findings: The Florida Village Case Study

Earlier preliminary research (1998) in a Florida HUD subsidized housing facility

illustrates how a disparity can occur between management and residents' views of the

housing environment. Florida Village is a fourteen story, 197 apartment high rise

building with on-site wellness and health centers, library, chapel, and other recreational

rooms for crafts, activities, and meetings. At the time of the interviews in 1998, there

were 235 residents (288 maximum) living in the non-profit facility with all units

occupied. The current waiting list for this facility was six to nine months. According to

management, the average age of residents in the facility was 76.5 years old with residents

ranging from the mid-sixties to the upper nineties. The inquiry demonstrated a case of

environmental mismatch, or lack of congruence. Residents and management each had a

different conception of the "best" residential environment. Each saw problems in how

the actions of others were influencing the housing environment and changing the

demeanor of the project. By failing to agree on how to best create and maintain the ideal

housing environment, neither group was satisfied.

Interviews with residents and management--both with "good" intentions--sought

different avenues to satisfy wants and desires of daily living. The two groups of

residents--the young-old (under age 75) and the old-old (age 75 and older)--sought to

define environments that maximized their potential. The young-olds sought an emphasis

on amenities and services that addressed active retirees, primarily centering on

independence with little or no oversight. The old-olds sought a highly supportive

environment that provided supportive services, healthcare, and a service coordinator to

ensure safe, long-term residency. These polarized groups had very little understanding of









the other's perspective, much less a realization of the benefits each group had to offer to

the overall creation of the Florida Village environment.

The active, independent residents of the young-old group were fearful that

management was changing the demeanor of the facility by addressing too many needs of

frail, dependent elders living in the project.

Resident: He [Florida Village Manager] is changing things too much. He is
making this place like a nursing home . a morgue. Suddenly, we are all on
death watch..... I didn't move here to be watched over... to live with my
mother. They [frail residents] need to realize this place is for people who can do
things ... who have a life. (Florida Village Resident 3)

Similar comments come from other residents, feeling that they are being "squeezed out"

by service dependent tenants.

Resident: I think it's good to help the others in this apartment building, but it is
too much for them and not enough for us. We need other things around here, too.
More things than just service, programs, canes and walkers. We [a resident
committee] have suggested that improvements in the lobby, library, and
recreation] room be considered. The manager has said they will be considered,
but that there are other priorities. Huh, I know what those priorities are ...
keeping them happy. (Florida Village Resident 7)

This group of residents--the young-old group--worry that the long-term population

group-- the old-old--have too much of an influence in creating and maintaining their ideal

environment. By creating too supportive of an environment, some resident worry that

people will become complacent and service dependent.

Resident: If we can get things ... meals ... delivered to our apartments ... that
prescriptions can be picked for us ... that we never have to leave our apartments,
what is the incentive to live. I don't want to live like a china doll packed away in
some cabinet. I don't just want to be taken out on some special occasion. I'm
here to live the best way I know how. It's how I want to live. It's how I'm going
to live. (Florida Village Resident 9)








The young-old residents fear that the changing residential environment will change the

way they want to live, change their lives from active, independent seniors into service

dependent shut-ins that have no life outside of the building.

The old-old group viewed their predicament much differently. "I am still

independent, but I need help. I want help" (Florida Village Resident 6). Many of the

members of this group were long-time residents of the building and had close ties to the

manager and his staff. They expected him to help them stay in their apartments.

Resident: We've been here a long time. My wife and I want to continue living
here. Granted, we need some help doing things ... maybe we get some
considerations from [manager], but we are living our lives just fine. I know that
Bob, Anna, Tim [not their real names] have said things about us and others.
There's nothing wrong getting a little help to stay here. (Florida Village Resident
5)

If anything, this group felt that more services needed to be brought into the building to

help buttress changes in their lives. This group challenged the younger residents to

realize that more services, like transportation and continued supervision and assistance by

a service coordinator, would make Florida Village a better and safer place to live. The

old-old residents believed that in the long run these services would help the other group

(young-old) to stay in Florida Village, too.

The manager of Florida Village was caught in the middle. No matter which

group's needs he tried to address, he was likely to alienate the other.

Manager: Residents don't realize that we [management] have a difficult job
trying to juggle [building] costs, recreation, health services, and other needed
things all the while maintaining high-quality surroundings and care. (Florida
Village Manager 1)

One key weakness in this housing project was that the manager did not have a clear

concept of the role of supportive services in addressing needs of the residents. Instead,

he tried to "play the politician" and be all things to all people. The reality of this








situation was that a congruent housing environment could be created in this manner.

Instead, this manager and his staff needed to set out clear service priorities and strike

middle ground to create a strong, supportive environment with clear demarcations when

residents needed to move to other surroundings.

Attempting to create congruent housing environments is difficult and can come

apart at a variety of seams--physical plant, supportive services, recreational or social

activity issues. Residents should be able to influence the "residential environment," but it

is up to the manager to unify the various groups' environmental perceptions to meet the

needs of the majority of residents. No view is more right than another, but in order to

have successful residential environments, management must build a consensus among the

residential factions.

Unfortunately, management did not present a unified perspective that had clear

objectives to satisfy not only residents' needs, but also "bricks and mortar" issues,

financial obligations, and federal, state, and local housing guidelines. Not surprisingly,

the residents' perspectives break along age-lines. Needs of these two groups--recognized

in this research as the young-old and old-old--create unique age-graded desires. By

discussing desires with these two groups--through formal and informal interviews--

research uncovered a highly diverse population that for the young-old group sought more

autonomy and control over events at the facility; while on the other hand the old-old

preferred management to "run things" as they saw fit. From this perspective, each

individual's influence on the "goodness of fit" in the congregate environment becomes

clear. Golant (1991) notes:








The congregate housing experience has variously been linked to: a person's
willingness to association with persons of similar social identity ... patterns of
age identification... individual needs for privacy, control, and order.... (p. 34)

Without understanding or appreciating the other's perspective, management and residents

have created an environment that offered inadequate benefits to both groups. The young-

old group did not want their complex catering to the most disabled segment of the

population for fear that the it would become over-medicalized, changing the residential

character. The old-old group sought a more supportive environment that could

"encourage" them to do more, while choosing to let the manager make the decisions

about how the facility would be run in the day-to-day scheme. Management sought a

supportive environment that would engage all residents. No single group of actors in this

case was happy with the direction the HUD facility was going.


Research Methodology

Target Population and Site Selection

This research project will focus on two groups of participants: (1) 48 on-site

managers/sponsors of Florida's subsidized housing facilities and (2) residents (age 62

years and older) living in these facilities. Managers are most influential in the decisions

regarding the transfer of frail, low-income residents to more supportive surroundings and

have the greatest influence in the "construction" of the building's residential

environment. This case study sets the stage for a greater understanding of how

management perceives their residents along two key dimensions: frailty and aging-in-

place. By understanding how management acts upon these perceptions, there can be a

better understanding of how to support and maintain frail residents in their homes, as well

as understanding how they perceive themselves and their place in the housing








environment. The second study group is comprised of 105 elder low-income tenants

from the same regions and facilities. Though managers have a greater influence in the

"decision making" of the housing project, residents have equally important influences in

the maintenance of the project's demeanor and shaping housing policies. A minimum of

two residents were interviewed from each facility.

Both groups' participants were selected from the CASERA Project database

(Golant 1999), recommendations of the housing manager/sponsor, or as a result of

residents encountered in common areas of the facility. For this research, N = 105

residents and N = 48 managers/sponsors. Only those managers and residents who

indicated a willingness to participate in future research projects were contacted. The

members of these two groups participated in individual qualitative interviews regarding

their own conceptualization of aging-in-place and frailty issues.

Site-Selection Criteria

According to the CASERA Project database, there are over 500 HUD housing

facilities created under these programs in the state of Florida (Golant 1999). Because of

the characteristics of each of the HUD facilities--i.e. Section 8, Section 202, Section 236,

and others--deciding how to select the housing facility types to be included in this

research was straightforward. To best understand the issues associated with aging-in-

place, frailty, and access to supportive services, the housing projects, management, and

the residents needed to be compared along specific dimensions. The matrix in Figure 3.2

depicts the site selection criteria for this project. This classification is based on two

dimensions by which HUD buildings can be distinguished--age density and number of

elderly tenants. Each cell represents a unique category of subsidized rental housing,

associated with a unique set of conditions for the frail elder residents. Different









supportive service issues in each housing type--and, therefore, each cell--lend themselves

to different supportive service interventions to facilitate the aging-in-place of their

residents.


Age Density


Number
of
Elderly
Tenants


Low High Total
Larger 12 Non-202s 6 Non-202s 24 sites
6 Section 202s
Smaller 4 Non-202s 10 Non-202s 24 Sites
10 Section 202s
Total 16 Sites 32 Sites 48 Sites


Table 2.3. Site Selection Criteria.

For this research, small population sites will be defined as having less than fifty

frail elderly tenants and large as having over 100 frail elderly tenants. High age-density

facilities will be defined as having 80% or greater elder concentrations. Low age-density

facilities have 40% or less

A total of 48 sites were visited based on the criteria in Figure 2.2. Thirty-two of

the facilities were high age-density (HiAD)--this larger group was stratified into larger

and small numbers of elderly tenants in both Section 202s and non-Section 202s. Sixteen

facilities were low age-density (LoAD), and these two subgroups of non-Section 202s

were further stratified into facilities with large and small elderly populations.

Section 202 facilities, i.e. the category of housing facilities that are specifically

and solely designed to provide supportive housing to elders (62 years of age and older),

were selected as the baseline project category against which other projects would be

evaluated (Appendix B). Based on the Florida Village case study and the CASERA

Project data, Section 202 housing should provide the maximum supportive environment








for elders, including programs such as service coordination, meals, and recreational

activities. Also, these facilities would provide the greatest level of support for aging-in-

place with highly trained management and staff that could deal with the conditions and

problems of an aging population.

In contrast to the high levels of support offered by Section 202 housing, the other

housing programs like Section 8 Noninsured, Section 221 (d) (3) and (d) (4), and Section

236 (see Appendix B for full explanations of housing types) do not offer consistently the

types of design modifications, services, and other amenities to help frail elders to age-in-

place. Additionally, non-Section 202 housing environments often do not benefit from

economies of scale, thus, limiting the feasibility of delivering low cost services. This is

because they are not entirely dedicated to an elderly population. For example, Section 8

Noninsured combines a variety of populations--young, old, families with children, and

other groups--all of which have very different lifestyles and day-to-day needs. They also

are less likely to have the physical infrastructure (e.g. dining room, rooms for health

check ups, etc) to support aging-in-place responses.

All sites in the research project were from cities and counties north of Lake

Okeechobee in four broadly defined areas of the state: panhandle, north, central, and

south central. HUD housing facilities south of this lake were eliminated for three key

reasons: (1) project expeditiousness, (2) minimization of costs, and (3) elimination of the

language and translation barriers.








Major Constructs and Data

Primary Data

Primary data were obtained through the use of open-ended, qualitative, individual

interviews with both HUD managers/sponsors and elder tenants. This technique has been

proven successful at probing how these actors construct meaning, structure their world

within the HUD housing facilities, and make sense of their day-to-day lives regarding the

concepts raised by this research (Wilson 1998b, Gubrium & Holstein 1997, Cresswell

1994, Denzin & Lincoln 1994, Gubrium & Sankar 1994, Kaufman 1994, Miles &

Huberman 1994).

Secondary data used in this research project were compiled from the CASERA

database; specifically the age density of the Florida subsidized housing facilities, the

project manager contacts list, and the facility frailty percentages. The secondary data was

used in the initial selection of projects and provided a backdrop against which frailty and

age-density percentages were judged.

Aging-in-place

Aging-in-place, or assisting older people in maintaining their residence as they

grow frail and impaired has become one of the primary missions of the aging

establishment. This term--highly variable in its definition--is expressed in written

documents and everyday policies and action of a housing facility's management team, as

well as by the lifestyle and beliefs of the residents themselves.

Managers will be asked a series of questions that examine their aging-in-place

philosophy of the housing facility, physical infrastructure, on-site and delivered

supportive service programs, and other practices that contribute to elders remaining on-

site. From these responses, an understanding can be achieved not just how the manager









feels about aging-in-place and frailty, but how these feelings are turned into actions

within the project.

Elder residents, on the other hand, will be questioned regarding their personal

feelings toward aging-in-place, and the availability of both informal personal assistance

and community-based supportive service resources. Much like the managers, elder

tenants' responses will be examined to understand how they put their beliefs and attitudes

into everyday coping behaviors in the facility.

Frailty

Though frailty is often conceived in medical terms, this study seeks to understand

how residents and managers define frailty themselves--how they live with it, how it is

defined by them, and sometimes imposed on them. By looking to understand frailty from

this perspective, it becomes more than simply objectively measured ADLs, or functional

limitations, or a medical report. Rather, frailty becomes personalized and identified by

those having to live and deal with it every day.

Qualitative Data Analysis

The meanings that managers and elderly tenants give to frailty and aging-in-place

are key aspects of this research and will be assessed through qualitative open-ended

interviews. To that end, this research seeks to identify and describe patterns and themes

that center on the themes of frailty and aging-in-place as two key elements of the HUD

subsidized housing experience.

Interviews with management/sponsors and frail elder residents were coded and

analyzed manually and with the computer program NUD-IST searching for key words

and phrases relevant to each individual's "construction" of the conceptions of aging-in-

place, frailty, supportive service utilization, and related beliefs.









Managers will be questioned about their facility's frail elder tenant supportive

service policy and the methods of identifying and defining frailty. Elder residents will be

asked a series of questions on self-estimated frailty and dependence.

Throughout the process of data organization, the data was re-examined and re-

coded as more interviews were completed and new avenues of interest were uncovered.

At the conclusions of interviews in April 2000, a list of "major ideas" was compiled to

provide a reference chart of interview data. In addition to the manual coding, the data

analysis process was aided by the use of a qualitative data analysis compute program

called NUD-IST. By utilizing the computer program, the researcher was able to directly

enter elements from the field into a database that could organized and re-organized, and

re-assembled into meaningful chunks of information for interpretation. At a later time,

these "chunks of data" could be categorized and coded to provide insight into the social

construction of the two variables.

The primary strategies utilized in this research to ensure external validity are: (1)

thick, detailed descriptions so that anyone interested in transferability will have a

framework for comparison, and (2) data collection and analysis strategies will be reported

in detail to provide a clear and accurate picture of the methods used in this inquiry.














CHAPTER 3
MANAGEMENT AND FRAIL ELDER TENANTS IN FLORIDA'S LOW-INCOME,
RENT-SUBSIDIZED HOUSING: A LITERATURE REVIEW


Florida's government-subsidized housing managers and their senior tenants

confront a variety of obstacles every day trying to access services, maintain

independence, and secure funding for continued programmatic support. These problems

arise not only out of state or local interests, but national ones, as well. Understanding

how these needs, and the issues of frailty and supportive services come together, allow

for a greater understanding of aging-in-place in Florida's low-income senior population.

Until the research of the CASERA Project (Golant 1999), much of this problem

was inadequately understood to render intelligent commentary. This study is much more

than understanding concentrations of elders in particular types of housing facilities. Only

upon closer examination can the numbers reveal the unequal presence of affordable units

across Florida. According to Golant (1999), understanding this pattern of unmet need

and the opportunities for cost-effective service delivery are central findings of the

research. First, it indicates the extent to which certain locations in the state are without

an equal share of affordable elder housing relative to the size of the at-risk, low-income

population. Second, the extent to which facilities are found in a relatively few locations

and administered by a few sponsors/owners, there is an increase in the chances that

economies of scope and/or scale might be achievable when it comes to supportive service

delivery. In areas where these economies are not achievable--in dispersed and isolated

locations or low population numbers--the service costs tend to be higher. In turn,









services are likely to be delivered less frequently. Understanding the potential benefits of

concentrating populations to take advantage of low-cost services, more frequent delivery,

and the potential for co-location of offices and clinics highlight the advantageous nature

of economies of scale.

To understand the full scope of Florida's government-subsidized housing

situation, national, state, and local contexts must be examined closely to reveal the

critical elements of this problem.


Rent-Subsidized Housing and the Frail Elder Resident

According to the U. S. Department of Housing and Urban Development (2000),

the elders assisted by their program number approximately 1.6 million persons. These

elders are living in HUD-assisted housing, housing covered by HUD mortgage insurance,

rental assistance, or other housing services. An additional 102,000 elderly persons in

rural communities are served by what are essentially parallel programs on the Farmers

Home Administration (FmHA) side of the assistance equation. During the 1960s, senior

housing programs served a much "younger" senior population--usually younger than

sixty-five years of age. Most of this group was in relatively good health. Since the

1970s, however, the average age upon admission to these types of housing have become

older and required more personal assistance and help to remain in their independent

households. Currently, many residents are in their mid-to-late seventies, and early

eighties, when they move into a HUD subsidized housing project. This group is usually

described as older and less affluent than their counterparts in the general community.

This group also tends to be female and a member of a minority group (HUD 1999, Golant

1999, Wilson 1998b). The trend of this population has been for the average age of the









tenant in HUD housing to increase one year of age for every two and one-half years that

passes. As of 1999, HUD estimates the average age of elderly residents in their projects

at about 78 years of age.

From the broad view of national statistics, housing providers are faced with

residents that have--or likely will have--needs beyond the average elderly population.

Issues surrounding frailty become key factors regarding the ability of these seniors to

remain in their homes.


Shifts in Housing for Frail Elders

Since the late 1980s, policy began to respond to the changing patterns of living

arrangement, housing problems, and project demographic changes by the senior

population. During this most recent twenty-year period, several pilot programs for frail

elders were developed to link housing and services, modify residential environments, and

repair unsafe buildings. Major legislation was also passed to make housing more

accessible to disabled persons, including the elderly. Three key areas have risen from

this time period to aid frail elders in their pursuit of housing alternatives--linking housing

with services, developing approaches to providing services, and creating environments

where frailty is minimized and aging-in-place maximized.

Overall, national and Florida housing policies for the elderly can be divided into

two distinct groups: (1) those that seek to establish comprehensive policies of housing

and management and (2) those that seek to provide housing for groups that cannot be

served by private builders, usually a supplemental policy like vouchers (Pynoos & Liebig

1995, Heidenheimer et al. 1983). Accordingly, the former programs have focused on the

housing needs of entire populations of the aged subgroup; the latter on groups unable to









secure housing in the private market usually those sub-populations that end of residing in

subsidized housing, i.e. the poor elderly. Typically the United States has been

characterized as having supplementary elder housing policies.

Frail elders are likely to require housing that adapts to diminished functioning,

reduces social isolation, and offers a range of supportive services (Gall et al. 2000,

Golant 1999, Dreyer 1992, Staebler 1991, Clapham & Smith 1990, Pastalan 1990, Golant

1986, Lawton et al. 1985, Lawton 1976, Bennett et al. nd). Housing that is suitable for

this group has to focus on low-to moderate-income levels to promote optimal functioning

and safety in the residential population (Bechtel 1997, Fonda et al. 1996, Pynoos &

Golant 1996, McAndrew 1993, Golant 1992, Pynoos & Regnier, Lawton 1989, Lawton et

al 1984). To avoid the harmful effects of relocations (Wilmoth 2000, Golant 1992,

Birren et al. 1991), aging-in-place must be encouraged. Currently these objectives can be

met through a variety of programs for low-income elders, particularly by connecting

seniors with non-institutional alternatives and community supportive services.

The new trends in housing frail elders is to bridge the "traditional gap" between

housing and services. This is realized by recognizing that housing is much more than

shelter, particularly for special needs populations like frail seniors (Feder et al. 1992,

Callahan & Lanspery 1991, Pynoos & Regnier 1991, Bennett et al. nd). Simply reaching

this conclusion re-shapes the way researchers, planners, and policy makers approach the

long-term housing needs of frail seniors.

The long-standing assumption in the field of elder housing has been that as

persons become more frail, they will have to be moved from one housing environment to

another to accommodate the changes associates with aging. This assumption has resulted









in the development of a continuum of housing types for persons with different

capabilities (Proeger 2000, Pynoos & Golant 1996, Pynoos & Liebig 1995, Golant 1992,

Redfoot & Gaberlavage 1991).

For example, in the United States, the continuum of services persons with
increasing service and environmental needs, ranging from single-family
homes and apartments, through board and care homes and assisted living,
to nursing homes. (Pynoos & Liebig 1995, p. 8)

Those people needing greater assistance with ADLs and IADLs, though requiring

assistive services, can live in a variety of settings. This, according to researchers, is

becoming more possible due to technological and medical advancements that were once

only available in institutional settings. This fact alone has fueled the enormous growth of

home health care services and the potential economies of scope and scale surrounding

their existence. Older people themselves express a strong desire to age-in-place.


The Elderly in Florida's Rent-Subsidized Housing

The CASERA Project focused on the age 62 and older tenant population in

Florida's conventional Public Housing Authority (PHA) and its privately owned

multifamily subsidized rental facilities, administered by HUD. These types of housing

include Section 202 (including 202 and 236), Section 221, Section noninsured, and

Section 236 programs. Golant (1999) highlights the fact that Florida's low-income

seniors are not represented equally in these programs--they are found in 38% of the units

of PHA facilities, but in 52% of the housing units funded under the multi-family HUD

programs. This simple division of the low income elder population speaks volumes as to

how and where to target services in the state.

The findings from the CASERA Project (Golant 1999), as they relate to HUD

senior housing, highlight the staggering effects of the unequal size and availability of this









type of elder-occupied rental units and the extent to which different organizations own

and manage them. Over 75% of the elders served by HUD housing programs live in less

than one-third of all sites in Florida. More importantly, however, is the fact that 19% of

the HUD facilities are occupied by 100 or more elder-occupied apartments; and about

39% of the HUD facilities are each occupied by as many as 50 elder-occupied

apartments.

Regarding this research, these findings indicate that significant elder populations

exist in relatively small numbers of projects within the state. Golant's results for the

state's elder low-income housing are significant along four key lines: (1) presence of

elders in HUD sites, (2) elder concentrations in HUD sites, (3) county locations in which

HUD facilities exist, and (4) organizational concentrations of HUD's elderly units.

The presence of elders at HUD sites

Only about 19% of the HUD facilities are each occupied by 100 or more elder-

occupied apartments in the state of Florida. And about 39% of the HUD facilities are

each occupied by as many as 50 elder occupied apartments. Of the elder-occupied

apartments, 75% of these units are found in less than one-third of all the HUD sites. This

information highlights the fact that a few select sites are serving high populations of

elders.

Elder concentrations at HUD sites

The elders at Florida's HUD sites occupy 52% of the available apartments. These

elder-occupied apartments comprise at least 80% of their building's rental units in 44%

of the HUD facilities. Not surprisingly, over 84% of all the elder tenants found in

Florida's HUD facilities are located in these building sites.








County locations of elders in HUD sites

For elders living in Florida's low-income HUD housing, 91% of the elder-

occupied units found in these facilities are located in just 17 counties. This percentage

points to the skewed county distribution of these low-income assisted elder renters.

These county locations become even more important when compared with the fact that

only 69% of Florida's total low-income elderly population (below the 150% poverty level

and not in federally subsidized rental facilities) lives in the same 17 counties.

Organizational concentrations of HUD's elderly units

Despite Florida's 67 counties and large low-income elder population, only 16

sponsors/managers own or administer the HUD facilities that represent over 51% of all of

HUD's elder occupied units. There are only 45 sponsors/managers administering the

HUD facilities that serve 75% of all of HUD's elder occupied units. Conversely, as

Golant notes, 123 sponsors/managers are administering the HUD facilities containing

about 25% of all of HUD's elder occupied units.

CASERA Project: An Impetus for this Research

The importance of the CASERA Project is that it provides a base line of

information for understanding and addressing the situation in Florida's low-income

subsidized elders. "With Florida's aging demographics leading the rest of the nation, and

with an estimated 80,000 elderly tenants in rent subsidized housing, it is critical to

establish service delivery approaches that successfully address the needs of older tenants

to age-in-place" (Golant 1999, p. 37). This idea becomes crucial in a state where an

ever-larger Medicaid expenditure crisis looms on the horizon. To properly prepare for

the demand for services, changes in housing provision, supportive service delivery

approaches, and interagency collaboration need to be explored.









The Need for Services in Florida's Subsidized Housing

Florida's aging population--reflecting national patterns--includes significant

proportions having functional and supportive service limitations. Of the 80,000 elder

persons (62+) in the state's government-subsidized rental housing, managers/sponsors

identified small--though significant (from 14% to 17% of senior tenant population)--

segments of their population as having critical unmet needs. Most often, according to

Golant (1999), these needs included getting assistance to temporarily ill residents, getting

assistance with housekeeping chores, affordable self-care, and family member assistance

(p. 16). Without these services, residents will likely be moved from subsidized housing

into the more supportive environment of a nursing home.

When similar questions were posed to residents, many indicated that support

around the home was one of the key services needed. Specifically, residents cited

handrails in the bathroom and shower, transportation, housekeeping services, and access

to hot meals. Additional questions probing ADL and IADL performance indicated that

while many residents (68%) could perform without assistance, roughly one-third of the

population would benefit from supportive services.

This evidence suggests that elderly residents in this type of housing may be at

increased risk over time because their service needs are not being met. This is especially

true because the population at risk lives alone, is poor, and has difficulty accessing the

complex bureaucratic community-based human service network. As the widening service

gap threatens continued independence and occupancy of subsidized housing apartments,

a critical demand for supportive services will arise in Florida government-subsidized

housing projects. If these needs are not addressed, this subgroup of elders will have

reduced quality of life, and saddling taxpayers with an unnecessary fiscal burden.









Definitions of Frailty

While there is no concrete definition of frailty--medical professionals,

gerontologists, and lawyers all differ on the term's conceptualization--HUD defines

frailty on the basis of the performance of Activities of Daily Living (ADLs). A person

who is deficient in three or more ADLs is defined as frail. Currently, the frail elderly in

HUD-assisted make up less than 10% (HUD 1999), but as many as 30% of the residents

are "at-risk" of becoming frail (HUD 1999, Golant 1999). These individuals represent

the most important subgroup in terms of policy decisions and it is clear that this group

will require additional attention in the near future. Based on these HUD (1999) figures,

estimates suggest that as many as 300,000 to 320,000 are deficient nationally in at least

one ADL (HUD 1999, see also HUD 1989, Struyk et. al 1989, Struyk 1985). Those who

are "near frail" in that they need some assistance to carry out ADLs comprise an

additional 365,000 to 400,000 (HUD 1999) elderly tenants. From these figures, future

incidents of need could balloon as the Baby Boomers begin to enter old age soon after

becoming at-risk of becoming frail and requiring assistive and supportive services. These

concerns become very important for states like Florida that already have high percentages

of seniors.

Traditional definitions of frailty center on a medically-based model that equates

frailty with chronic illness, disease, and disability (Rockwood 1999, Raphael et al. 1998,

Campbell 1997, Rockwood et al. 1994, Birren et al. 1991, Winograd et al. 1991,

McAdam et al. 1989). Based on this medical view of frailty, health care and allied health

professionals identify frail elders in hospital and rehabilitation settings to determine who

is most at risk for adverse outcomes and most in need for discharge planning.









Frailty is best regarded as a condition or syndrome which results from a multi-
system reduction in the reserve capacity to the extent that a number of
physiological systems are close to, or past, the threshold of symptomatic failure.
(Campbell, 1997, p. 315)

By viewing frailty from the medical perspective, it further incorporates: loss of reserve,

feebleness and vulnerability that often cannot be overcome. Instead, persons deemed

frail are often said to be: "failing, worsening, beyond a level of help that necessitates a

move toward constant care..." (Campbell 1997, p. 317).

Frailty--though often viewed as functional limitations--has, recently, taken on an

expanded meaning (AARP 1999, Fineman 1994, Kaufman 1994, Rubinstein et al. 1992,

Birrent et al. 1991, Kaufman 1986, Knight & Walker 1985) From a more holistic

perspective, many researchers alter the view from "frailty as disability" to that of

functional dependence that can be overcome through supportive environments, i.e.

specially designed and modified living environments like those found in assisted living

and board and care facilities and supportive services, i.e. homemaker and housekeeping

services, as well as shopping, medical and care assistance.

Other--more radical--views of frailty move beyond the traditional, medically-

based conceptions equating frailty with chronic illness and disability to engage a

convergence of physical, social, and environmental factors that come together in

individuals construct frailty (Raphael et al. 1998, Gubrium & Holstein 1997, Kaufman

1994, Gubrium 1993). This functional approach to understanding frailty is viewed in

terms of the individuals' lived experiences rather than presence or absence of medical or

health conditions. From this perspective, the notion of frailty is viewed as a state residing

within the individual.









Definitions of Aging-in-Place

Aging-in-place is term that possesses many meanings in the gerontology

literature. Among the most common definitions include: aging at [my] home, making

decisions to stay in current [home] for many years, or choosing to remain at home.

Gerontologists like Callahan (1993), Golant (1992), Lawton (1990), Pynoos (1990), and

Morrison (1992) have stressed the dynamic nature of the term for both the individual and

the housing environment. Instead of focusing solely on the environment, however, a

better relationship between individual and environment must be understood and explored.

In the course of understanding this complex relationship, a continual re-assessment of the

person-environment relationship must take place (Bechtel 1997, Golledge & Stimson

1997, Golant 1984, Lawton, Lemke & Moos 1989). From this continual re-assessment,

more effective and efficient use of social services, access to housing choices, and

supportive services can be opened up. By understanding how elders interact with their

environment--successfully or poorly--greater options for keeping them safe and at home

can be offered.

When the United States government and HUD developed programs such as

Section 202, 236, and public housing, the assumption was that tenants' needs could be

addressed through basic physical plant design modifications (Pynoos 1995, Pynoos 1992,

Bernstein 1982) and additions to the physical plant common area spaces such as dining

rooms and rooms for a nurses, as well as the addition of assistive devices like call buttons

and grab bars. Projects could also be located nearer to neighborhood amenities like

shopping, transportation routes, grocery stores, and banks to facilitate mobility and ease

issues of transportation. Senior housing planners, developers, and government housing

officials felt that as tenants aged, they could be moved to more supportive surroundings








that offered more congruent staff attentions, design, and services. This model--known as

the constant model as opposed to the accommodation model--was pioneered and

developed by Lawton (1980) to assert that the character of the resident population can be

maintained through three key mechanisms--(1) stringent medical and behavioral

standards for admission, (2) competence of tenants is monitored carefully and termination

of tenure is initiated as impairment becomes evident, (3) new services are not added, and

incentives are offered to encourage continued and independent behavior. Though Lawton

(1985a, Lawton 1985a) admits that this is not always prudent and practical.

Of course, in actual practice, most housing is neither extreme in constancy or in
accommodation. It is very probable that a middle group of less-than-complete
independence is tolerated by most "independent" housing administrators, and that
few housing environments accommodate totally to the changing needs of tenants
(Lawton et al. 1984, p. 63)

Recent inquiries into Florida's HUD-assisted seniors demonstrates that this is not entirely

the case and that often housing administrators--when exhausting all of their alternatives

and patience--move residents out of independent living facilities into board and care

facilities, nursing homes, or a relative's home (Golant 1999, Wilson 1998b). Alternatives

that accommodate low-income, frail seniors are also difficult to find. Congregate

housing offers the alternatives of meals, housekeeping assistance, and recreational/social

activities is usually unaffordable. Thus, residents of HUD-assisted housing are facing

limited options if they cannot age-in-place.


Frail Elderly: A Dilemma for HUD Managers

With increasing age comes an increased demand for services. Bartlestone (2000),

Proeger (2000), Golant (1999), and Bernstein (1982) suggest that elders in the 75 years

and older age group are three to four times more likely to require supportive services









assistance than those in the 64 to 74 year old age group. Some of the most common

indicators of increasing dependence, according to Bernstein (1982) are:

1. Tenant has accidents that may be dangerous to him/herself and to the safety of other
tenants.
2. Tenant is forgetful; not thinking too clearly, and sometimes wanders aimlessly and
gets lost.
3. Tenant often stumbles or falls down.
4. Tenant is having problems with cooking, cleaning, and taking care of daily
necessities.
5. Tenant seems to have psychological problems such as being depressed or anxious or
being emotionally unstable.

Interestingly, though not surprisingly, many managers indicate that facilities that are able

to bring services on-site are better able to accommodate residents in all facets of their life

and allow them to age-in-place.

Since the early 1980s, gerontologists and elder housing researchers have focused

much attention on the managers of senior residential facilities and the factors that

influence when residents must move to more supportive housing environments (Golant

1999; Merrill & Hunt 1990; Pastalan 1990; Barker, Mitteness & Wood 1988; Ryther

1987; Bernstein 1982). With increasing numbers of tenants in the 75 years and over age

group entering HUD facilities, including public housing--and the impending increased

numbers in the near future--housing managers must make daily assessments about the

capability of the residential setting to accommodate the abilities of the older and more

frail tenants. Over the long-term these decisions will influence the conditions under

which future elders are admitted to facilities and the length of time they can stay. The

research of the last decade has demonstrated considerable interest (Federal Interagency

Forum on Aging Related Statistics 2000, Golant 1999, AARP 1998, Polivka et al. 1996,

Lane 1995, Callahan 1993, Barker et al. 1988, Lawton et al. 1985, Bernstein 1982,








Malozemoff et al. 1978) hoping to maximize the likelihood of aging-in-place, while

better understanding and developing supportive services to minimize costs and maximize

quality of life (Griffith et al. 1996, Holland et al. 1995, Fischer & Frank 1994, Callahan

1993, Feder et al. 1992, Callahan & Lanspery 1991, Clapham & Smith 1990, Blandford

et al., 1989, Avant & Dressel 1980, Harel & Harel 1978, Bennet et al. nd).

Managers of these facilities recognize that not all health problems place their

elder residents at risk of having to relocate. Some housing managers have responded to

the needs of vulnerable older tenants through expansion of their "bricks and mortar" roles

to include the delivery of both formal and informal support (Golant 1999, Wilson 1998b,

Brice & Corey 1991, Barker et al. 1988, Heumann 1988, Lawton et al. 1985). Even

minimal intervention--assistance in the forms of transportation, housekeeping, or

personal care services) becomes critical in enabling residents to maintain themselves in

subsidized housing.

Managers have only recently begun to engage in these tenant service-related role,
and not all have done so. Even among those subsidized housing managers
involved in tenant problem-solving activities, there is great variability in the
nature and extent of their involvement. (Brice & Corey, 1991, p. 487)

Unfortunately, in many cases, other needs, lack of on-site support or lack of knowledge

about local services work against the elder resident to eventually force a tenant relocation

(Brice & Corey 1991).

Typically, many managers are most concerned about those conditions that are

most likely to threaten the older person's ability to take care of either their apartment or

their everyday personal needs. In addition to supportive functions like grocery shopping,

lifting, running errands and basic housekeeping, managers are concerned about age-

related health issues like vision impairment, hypertension, and heart conditions.









Combined with other health problems like stroke, alcohol abuse, and depression (Golant

1999, Merrill & Hunt 1990, Barker et al. 1988, Bernstein 1982), the complications from

these conditions lead managers to believe that multiple functional impairments will

necessitate 24-hour care. Many facility manages consider "heavy care demand to be

inconsistent with independent living" (Golant 1999, Barker et al. 1988, Bernstein 1982).


Linking Housing With Services to Encourage Aging-in-Place

For home and community-based services to be effective in the lives of needy

seniors, services must be cost-effective, convenient, easily accessible, and provide the

highest level of assistance in the least restrictive environment. Residents of subsidized

housing are often perceived to be relatively well taken care of--their housing is often

better than poor elders in the community at-large, and they are perceived to benefit from

the nearness of neighbors and housing staff.


The Need Will Only Increase

Currently seniors are demanding more health care and supportive services than

ever before--partly due to the sheer size of the population and partly due to a longer

lifespan (Golant 1999, Feder et al. 1992, Bennett et al. nd). The last decade has seen

fundamental changes in the way the home healthcare industry does business concerning

accessibility and service delivery. One researcher (Gonzalez 1997) suggests that there

are an:

... [E]xtraordinary number of mergers involving vertical and horizontal
integration. The managerial response of healthcare providers to change has
typically been to expand the numbers and types of services offered in an attempt
to remain competitive and to better service the needs of the healthcare referral
sources. (p. 313)








As a whole, this industry has attempted to keep pace with the medical needs of a

population by "broadening the array of services the firms offer, so that they can service

all the needs of a [segmented population pool]" (Gonzales 1997, p. 314), as well as other

service needy segments of populations. Several service providers indicate that they have

only recently realized the significant levels of need, and potential for significant profits as

well, in government-subsidized housing. Surprisingly, however, it has been even more

recently that project managers have negotiated contracts to encourage stronger

relationships between provider and project. Both groups closely scrutinize the financial

benefits gained through partnerships.

If supportive services cannot be found and brought into housing projects, this

population segment will have a greater likelihood of being prematurely relocated to a

nursing home (Golant 1999).

[In the state of Florida,] the frail elder population age 65 to 69 will increase by
37.7%, while the frail elder population age 85 and over will increase 89.6%, to
142,283 persons in 2010. This is the population group at the greatest risk of
needing publicly supported long-term care services. Clearly, the need for long-
term care services will continue to increase steeply over the next decade, putting
extreme pressure on the state's capacity to provide an adequate level of care
within the current framework of nursing home dominated care. (Reynolds-
Scanlon et al. 1999, p. 37)

Together these factors generate significant attention to the need for affordable, long-term

supportive services to supplement independence.

Despite the obvious costs of long-term care, continued development of supportive

service networks and the creation of economies of scale and scope within those network

contribute to improving seniors' lives, quality of life, and well being that restores

independence to service dependent frail elders of low-income, government-subsidized

housing. By putting these service networks into place, managers and residents can take








advantage of lower operating costs and a wider variety of on-site and community-based

services to support aging-in-place. More importantly, however, these economies of scope

and scale will improve the quality of supportive service and reduce their costs to the frail

elders who depend on them.

Economies of scope and scale: home health and home-based supportive services

The home healthcare industry is currently undergoing fundamental changes

concerning payment, accessibility, and service delivery. Literature has reflected an

extraordinary number of mergers involving vertical and horizontal integration. The focus

on comprehensive service delivery needs to be examined in the light of the economic

concepts of economies of scope and scale. Economies of scope "imply that the cost of

producing all outputs is strictly less than the cost of producing the same levels of output

in separate--specialized--production units" (Cowing and Holtmann 1983, p. 647). On the

other hand, economies of scale imply that the cost of producing one specialized output--at

sufficiently large quantities--can reduce the overall cost of production of that specific

unit. With increasing nature of healthcare competition and the emphasis on

comprehensive service delivery, economies of scope and scale become crucial in the

effort to provide efficient delivery of these services.

Home delivery of health services represents a large and rapidly growing segment

of the U. S. health care market. In 1983, Medicare and Medicaid expenditures on these

services exceeded $2 billion, representing a 27% increase over 1982 (Kass 1987, Hay &

Mandes 1984). Approximately 4,500 home health agencies are currently certified to

provide services to Medicare beneficiaries who in turn receive 70% of all home health

services (Kass 1987).








There are two major studies that have addressed the issues of scale economies for

home health service agencies.

The first study, Kurowski et al. (1979) find economies of scale in the delivery of

home health services in cities in Pennsylvania and Massachusetts. While this study

uncovered "weak economies of scale," critics of the study state this study suffers from

two key problems. First, meaningful adjustments for case-mix differences were not

included in the model itself. That is, no distinction was made between offering skilled

nursing services versus those of a home health aide. Second, the study examines the

relationship between firm size and cost per unit by looking at only four firms in each

market. Such a small number of firms make it difficult to determine the causes of any

differences among the costs of the firms. By examining the data from this perspective,

they did not allow for variation within their class categories.

The second study, Hay and Mandes (1984), estimate a home health agency/

service provider cost function based on cost reports for 74 non-profit agencies in

Connecticut for 1981. Their analysis demonstrates U-shaped average cost curves for

agencies' provisions of skilled nursing visits, with substantial diseconomies of scale in

the observable range. These researchers estimate that the average cost curve for firms,

offering skilled nursing services, reaches its minimum at 7,159 visits--about 1,000 visits

more per year than the sample representative agency. Like the first study, this one is

plagued by problems. First, the researchers incorrectly choose to ignore the complexities

inherent in the appropriate analysis of economies of scope and scale.

Instead of analyzing the entire range of services, skilled nursing visits was
focused on as the output measure because it is the only services that al agencies
could provide, and it constitutes 45% of the business for the study agencies. (Hay
and Mandes 1984, p. 113)









These authors have ignored the interactions and possible efficiencies in the provision of

multiple service categories.

With an increasing emphasis on home health as a less costly care alternative,

utilization of home health services has increased over the last seven years. Despite this

increase, few attempts have been made to study the issues of economies of scope and

scale in this industry. Given recent business trends in this industry and the increasingly

competitive nature of the environment, cost and efficiency are important considerations

for the resident population and managers of low-income, government-subsidized housing.


Approaches to Providing Services

While many elder advocates--both inside and outside government--offer solutions

that address the needs of frail elders in government-subsidized housing, real solutions can

only come at the state and local levels. Competing jurisdictional interests have made it

difficult to get Congress to focus on the issue of linking housing and supportive services,

particularly for the more frail elders in HUD housing (Pynoos 1992, Callahan &

Lanspery 1991, Struyk et al. 1982. While many people believe that HUD housing

programs are outside of the long term care system, more and more residents of these

projects are becoming incapable of aging-in-place without supportive services.

Understanding how to best "support" this group of low-income elders is a key

question that has been inadequately researched and addressed, particularly at the low-

income level. Essentially, there is a housing system, represented by HUD, and a

supportive service system, represented by the Department of Health and Human Services

(HHS). Traditionally, each of these systems has operated independently of the other with

little programmatic policy overlap. Locating the best and most long-term mechanism for








interdepartmental interaction between these two agencies has been a major--though

unresolved--political issue.

Congress has encouraged a very basic approach to providing supportive services

to seniors in this type of housing. By and large the major source of support comes from

the coordination between HUD and human services organizations--like those funded

through HHS.

There is substantial legislative history of congressional mandates for interagency

coordination both for HUD and HHS agencies. The major congressional mandates

include:

1. Section 203 of the Older American Act of 1965, as amended, required the
Commissioner "advise, consult and cooperate with the head of each federal agency or
department proposing or administering programs or services substantially related to
the purposes of the Act .... (U.S. Senate 1989, pp. 7-8)

2. Section 202 (f) of the Housing Act of 1959 required that "housing and related
facilities assisted therein will be in appropriate support of an d supported by,
applicable state and local plans ... providing an assured range of necessary services
for individuals occupying such housing." (U. S. House of Representatives, 1991, p.
300)

3. Section 209 of the Housing and Community Development Act of 1974 required that
HUD "consult with the Secretary of the HHS to insure that special projects for the
elderly and handicapped ... shall meet acceptable standards of design and shall
provide quality services and management consistent with the needs of the occupants.
(U. S. House of Representatives, 1991, p. 234)

4. Section 162(c) of the Housing and Community Development Act of 1987, since
repealed, required "supportive services plans for all Section 202 housing describing
the served populations, range of necessary services, manner in which services will be
provided, and the extent of state and the extent of sate and local fund availability for
services provision." (U. S. Congress, 1988, p. 101)

Nonetheless, there has agreement that interagency coordination has been unsuccessful.

HUD housing has a history of complaints from housing authorities about the difficulty in

accessing supportive services for the elderly. According to Golant (1999), Nachison








(1985) and others (Pynoos 1992, Callahan & Lanspery 1991, Struyk et al. 1989), there

has been little evidence of a partnership in linking housing and services together. In fact,

many researchers and public policy analysts have suggested that federal policy has

discouraged the effective and efficient linkages between elder housing and supportive

services (Pynoos 1990).

On a local level, there are a variety of reasons for difficulties getting services to

residents in HUD facilities. Often many people believe that since housing projects are

HUD supported, they contain supportive services. According to Nachison (1994) there

are two major barriers to securing services in government subsidized housing. First,

government funds are allocated on an annual basis, and not usually in multi-year

contracts. By funding projects in this manner, there is a lag between initial funding,

construction, and full occupancy. Over this period of time--often five or more years--

funding sources and service providers have extremely lengthy periods to "survive" and

choose not to support these types of development. Further, non-profit and other owners,

usually local housing authorities, have been reluctant to build congregate housing for

low-income elderly or market low-income housing to the frail elderly because of the

apparent shortage of subsidized supportive services. This occurrence can be quite

common and has been documented in the unpublished case study by Wilson (1998b) and

highlighted in the discussion of former service coordinators and home health care

providers at the 2000 Florida Geriatric Care Manager Association convention

(Bartlestone 2000, Proeger 2000).

The second major barrier deals with how federal government funds are allocated

to local jurisdiction on a formula basis. Until the early 1980s, when Section 202s became








formula based, projects that were approved for HUD insurance and those directly funded

by HUD were not funded on a formula basis. This produced a major mismatch of dollars

at the local level--especially between the number of HUD projects in a particular areas

and the availability of services in that area.

Because of the fragmented policy making at the federal governmental level, a

number of state and local governments have taken steps to subsidize supportive service

programs for frail elders, pay for service coordinators, and train managers and staff

(Struyk et al. 1989). In the late 1980s:

The Robert Wood Johnson Foundation's "Supportive Services in Senior Housing
Programs" provided $4.5 million to ten state housing finance agencies (HFAs) to
test a market-driven, consumer-oriented approach that used coordinators as
service brokers. The demonstration found that HFAs and housing sponsors were
willing and able to commit funds to hire service coordinators, and that, likewise,
tenants were able to pay for some services. (Feder, Scanlon & Howard 1992, p.
61)

This demonstration legitimized and encouraged HFA attention to issues that move

beyond providing bare minimums in safety and financing sound housing. Furthermore

HFA staff could move owners in a positive direction in five distinct ways: (1) apprising

housing developments of service availability within a geographic region; (2) surveying

tenants to determine the types of services needed; (3) training and assisting managers and

service coordinators (SC) to ensure high standards of care and assistance; (4) recognition

of supportive services costs so they may be incorporated into residential site operating

budgets; (5) encouraging co-payment programs to reduce "excessive burden" on clients.

Several approaches to dealing with frail elders have proven successful at the local

levels. However, these demonstration programs have not been widely adopted

throughout the country. The most significant contribution to allowing elders to age-in-

place has the introduction of the service coordinator program in the early 1990s. This









program provides a caseworker to assess elders and link them with desired or needed

service. Two important programs that have contributed to elders remaining in their

homes has been the development and continued refinement of the Section 202 supportive

housing program and the Congregate Housing Services Program (CHSP). Both have

sought innovative ways to delay institutionalization of elderly tenants and allow them to

retain independent lifestyles. Lastly, I review of significant contributions of Florida's

most successful approaches to supporting aging-in-place by Golant (1999) from

CASERA Project findings.


Service Coordinator Approach

H92-40 (HUD) defined a Service Coordinator as "the individual who does
casework with the frail elderly and nonelderly disabled residents in need of
support, refers them for assessment, links them with service providers in the
community and monitors the provision of services." (U. S. Department of
Housing and Urban Development 1992.

One of the most innovative approaches to encouraging elders to age-in-place in

subsidized senior housing has been the development and implementation of the service

coordinator (SC) program. The Department of Housing and Urban Development (HUD)

created the service coordinator position to address frail elders' needs in this population.

According to Schulman (1996) the Service Coordinator's job at its inception was a four-

pronged function:

Identification that resident need exists,
Arranging for supportive services to cover needs,
Monitor the quality of services,
Reassessment of resident need. (p. 6)

Until the creation of this position, supportive services for the elderly were only available

through the Area Agencies on Aging (AAoA), subsidized by the Older Americans Act of








1965, yet residents of Section 202s and Section 8 noninsured housing projects had no

direct access to these services. Residents were dependent upon the site manager's

initiative in finding needed supportive services, or their own potentially inefficient and

haphazard efforts. The role of the Service Coordinator became a vital link between

available services and residents filling a conspicuous gap that severely isolated seniors.

They were to make the area's programs known to the residents, and it was understood

that, while the program was available to all residents, emphasis was to be placed on the

at-risk and frail. No resident was required to partake of the services offered. For

example, an individual might use the Service Coordinator to obtain a housekeeper, and

not allow the Coordinator to monitor the work of the housekeeper once in place.

With the recognition of the need for a more formal link between residents and

supportive services offered by Area Agencies on Aging, Service Coordination for Section

202 and 202/8 federally assisted housing became widely available for the first time in

1992. In the 1980s HUD field offices allowed buildings--through their own funding

mechanisms--to implement the positions. Since the early 1990s, HUD headquarters has

taken a leadership role by refining and funding the position of service coordinator to

those projects that could document at least 25% of their resident population was "at-risk"

or "frail." At-risk was defined as being deficient in one or two ADLs, but not three or

more. Frailty was defined as being deficient in three or more ADLs. This definition

became the baseline definition for frailty for this research project.

To incorporate a Service Coordinator into their facilities, HUD has two distinctive

models. Model 1: the service coordinator is hired and supervised directly by the facility








manager. Model 2: building management contracts with an outside agency to provide

on-site service coordination.

Model 1. In this model the coordinator answers to and is supervised by the building

management. There are several important advantages of this model, including: the

service coordinator is a management team member and is able to influence resident

oriented policies (Holland, Ganz, Higgins, and Antonelli 1995). Residents and

management come to realize the benefits of having a full-time, forty hour per week

person coordinating services for facility residents. Not only do residents have someone

working to connect residents with services, but they have the opportunity to create strong

bonds between residents and service coordinator--creating strong assurances that

"management" is interested in their well-being and good health. By being on-site, the

service coordinator can also monitor the day-to-day status of residents and the affects of

the provided services.

While there are many benefits to this model of connecting service coordinator and

management, there are several weaknesses. The greatest concerns--raised by residents in

the past--have been the perception of the service coordinator's allegiance to building

management. Though residents have raised this concern, especially when service

coordinators are newly introduced to a building, HUD's Office of Policy Development

and Research (see Volume II 1996) has never found a single incident of this occurring. A

second concern is the role confusion when the service coordinator must function as both

client advocate and management team member. The difficulties of the "divided role" has

been raised by service coordinators themselves, particularly when management wishes to

move clients from the facility. In private interviews (Golant 1999, Wilson 1998a), many









service coordinators say that they always tried to put the needs of the resident client

before the needs of a facility's management. Lastly, residents have the concern that the

coordinator will not be able to maintain client confidentiality. Though these three items

are often listed as the downfalls of an on-site service coordinator, the residents,

management, and research demonstrate the positive aspects almost always overshadow

the negatives of this model.

Model 2. In the second model, the building management contracts with an

outside agency to provide an on-site service coordinator presence. The service

coordinator is supervised and evaluated by an off-site supervisor. Often this service

coordinator will travel to a variety of housing sites spending only a couple of hours each

week at each facility. Some of the benefits of this contractual model include: client

perception of objective advocacy; outside case consultation and peer support; and greater

likelihood for confidentiality between the service coordinator and facility manager. The

greatest weakness of this model is that by not being part of the management team, often

the service coordinator will be left out of management meetings creating confusion in

terms of policy decisions that affect residents.

Both models offer advantages and disadvantages, but HUD evaluations (1996)

and research into the role of service coordinators (Wilson 1998b, Schulman 1996;

Holland, Ganz, Higgins, & Antonelli 1995) all indicate that facilities with service

coordinators have a greater likelihood for aging-in-place and staving off health issues that

force relocation of residents.

Understanding these models of service provision creates a context for

understanding exactly how the SC functions in developing and providing services.









Assessment of resident need has been handled in various ways by different SC programs.

The last five to seven years have seen three models of assessment rise to prominence.

The first assessment strategy utilizes the medical model to form the basis of the

evaluation. The Service Coordinator elicits information from the client. The decisions as

to what services are needed are those solely of the Service Coordinator. This client has

little part in the assessment process other than providing baseline information. This first

model has come to be called a Needs Driven Assessment Strategy.

The second model--the Consumer Driven Strategy--was developed through the

Robert Wood Johnson Foundation Service Coordinator Program. In this program, there

was no formal assessment, at least not like the one discussed above. Instead the SC

marketed the services available, and the residents chose which services they wanted to

purchase. The SC then arranged for those services. Quite innovative in its approach, the

Robert Wood Johnson Foundation gave residents to option of choosing services from a

"menu" of options. Critics of this model believe that residents do not always know what

they need, or how best to ensure their safety.

The final model was developed from HUD's program requirements that the

Service Coordinator programs emphasize services for those who are at-risk and frail.

This third choice--developed in Florida by the National Council of Senior Citizens

Housing Management Corporation--is an Interactive Assessment Strategy that involves

the residents in their own assessment process by informing them of all data collected on

intake, having them sign off on the data, and requiring that both SC and resident together

determine need and required services. This third model--growing in popularity--has two

key advantages. First, it limits SC liability because residents have significant









responsibility in the decision making process for supportive services. Second, due to the

interactive nature of the assessment, residents are more comfortable using the Service

Coordinator; and as a result:

[Residents] have a greater sense of positive self-image, in that they realize their
perceptions of themselves were valued ... and [they] have a greater experience of
control over their lives. (Schulman 1996, p. 8)

Though the basic function of Service Coordinators is the same, as individuals they have

the responsibility to gear programs to the needs of their clients and the facility.


Congregate Housing Services Program (CHSP)

To address elder supportive needs, several efforts have been made to better

integrate services into government-assisted housing (Golant 1999, Pynoos 1992). For

example:

In 1978 Congress created the Congregate Housing Services Program (CHSP) to
provide service coordinators and a variety of services to older tenants in public
and Section 202 housing. The program originally involved 63 sites, at which two
meals a day and services such as homemaking were provided to approximately
3,000 frail elders. The launching of this demonstration proved to be
controversial, because HUD did not consider payment for services its
responsibility. (Pynoos & Liebig 1995, p. 200)

The Office of Management and Budget (OMB) felt the CHSP program did not provide an

overall cost saving, arguing that it "did not demonstrate a saving of money that otherwise

would have been spent on nursing home care and was therefore not cost effective, a

finding similar to other home-care demonstrations" (Redfoot & Sloan 1991, Weissert

1988). This program--though continued--fell to cuts under the Reagan and Bush

Administrations, limiting the number of participants. The second phase of the CHSP

involved stricter targeting to clients, a greater tailoring of services, and the elimination of









the two meals per day requirement. Such actions highlight the "political" view of

supporting frail elders through service programs.

This congregate housing concept sought to create an atmosphere that existed

somewhere between the highly institutional environment of a skilled nursing home and

that of independent settings like retirement communities. The result has been a discrete--

though highly successful--set of services that elderly persons can take advantage of when

needed to help forestall premature institutionalization.

Though the kinds of services offered by this program vary from facility to facility,

all sites must offer some form of meal program. The typical CHSP package of services

in addition to meals includes housekeeping, personal care assistance, home delivery

services, counseling, and recreational activities. In addition to on-site services, many

programs seek relationships with community providers, on a fee for service basis, to

further enhance programming.

Early recommendations for improvement of the program fell along four distinct

lines: greater flexibility of the meals program, greater sensitivity to architectural design

issues of the building, more stable sources of funding, greater formalized training for

staff and management to better deal with aging topics.

Overall the CHSP has been a positive force in supporting frail elders as they age-

in-place, particularly in improving nutrition, prolonging independence, providing

companionship, increasing self-worth and socialization, and reducing isolation.

Additionally, the cost of the Congregate Housing Services Program has been

demonstrated to be more cost-effective than alternatives forms of supportive care--

particularly highly specialized institutional care--while maintaining high levels of









satisfaction among residents in the program. Unfortunately, it is a very small program

and it is now operating in just over 100 housing facilities nationwide.


Section 202 Housing

Section 202 housing continues to be one of the best federal programs serving

needy elders (U. S. Department of Housing and Urban Development 1999). While only a

small percentage have extensive on-site services, many offer daily meal programs,

laundry facilities, community rooms, recreational services, and special design features.

While the "service provision" comes from the residents themselves--except for those sites

offering a service coordinator--the overall physical design features create a more

supportive environment than other subsidized housing facilities. This housing type offers

the greatest likelihood for breaking down the barriers between long-term care and

housing. Unfortunately, while many facilities contain a supportive physical plan (e.g.

dining rooms, staff areas), housing sponsors must still initiate service delivery strategies

with community-based providers and secure outside funding.


CASERA Project Findings: Successful Service Delivery Programs

Social problems associated with elders in need of services, including

homelessness, poor medical care, housekeeping, and transportation, have spread across

the nation's metropolitan areas during the late 1980s and early 1990s (Wolch 1996). In

response, community-based services designed to provide relief expanded throughout

these areas in a variety of forms to assist elders with accessing services in a highly

fragmented market. Solutions to the service problem have proven to be as innovative as

they are needed.








The innovative approaches in-place across the state of Florida origination from

the panel of experts advising the CASERA Project was to "assist elder tenants in

maintaining their independent living arrangements in their current apartment settings as

long as it is economically, administratively, and legally possible" (Golant 1999, p. 19).

Central to the suggestions listed in the report was creating connections with community-

based networks of home care and service providers. Only by tapping into local resources

can these types of facilities truly create aging-in-place strategies. Whether these

opportunities come through residential facility networks to create economies of scope/

scale, negating locational effects through transportation services, or creating service

infrastructure through community and in-home services, solutions must bring together

residents, management, and community to create strong ties to keep elders in their homes.

The five major service approaches engage specific areas:

Model 1: The Basic Service Coordination Model

The core component of this model is the role of the service coordinator position in
each housing facility, to coordinate the work of case managers and volunteer
coordinators, and to create partnerships within the community. The function of
the service coordinator is to identify residents' needs and support them to age-in-
place.

Model 2: The Partnership Model

The goal of this model is to establish interagency collaboration that results in the
effective coordination of services. A key aspect of this model is the ability to
identify the mutual benefits to be gained work co-working.

Model 3: The Congregate Housing and Capitation Model

The goal of this model is to foster residents' independence through "one-stop
shopping" service packages. In the most effective forms of this program, all
services are offered on-site, targeting low-income frail elders at-risk who meet
nursing home criteria as established under the Medicaid Waiver program.








Model 4: The Two-Tiered Assisted Living Program Model

The goal of this program is to provide two levels of social and supportive services
within the HUD or PHA housing facility--providing a continuum of care for
residents as they progressed through the lifecourse.

Model 5: The Home Modification Program Model

The goal of the Home Modification Model is to act as a catalyst for
"organizations to make a long-term commitment to home modifications as a
priority issue at national, state and community levels." Funding of this program is
contingent on the composition and membership of the state and local coalitions to
develop and improve these services.

These major approaches to overcome the barriers to service access bring together the

needy elders, and providers through fiscal and administrative incentives to develop and

create supportive service partnerships. Accordingly, cultivation of service models brings

benefits to local housing and service providers and residents in seven key areas: (1)

funding service coordinators for housing facilities--though some service models, (2)

creating incentives for rent-subsidized facilities to provide aging-in-place services, (3)

strengthening the link between the Department of Elder Affairs (DoEA) and local human

services providers, (4) developing partnerships to expand supportive services to rent-

subsidized tenants, (5) providing managers of rent-subsidized housing with necessary

tools to meet the needs of less independent elders, (6) increasing the lobbying efforts of

housing professionals to effect changes at the state and local levels, and (7) continuing to

expand the research in supportive services for low-income elders.


Building Upon Past Research

This investigation into environmental congruence in Florida's government-

subsidized housing projects attempts to broaden traditional discussions of "triggering"

mechanisms that force frail elders from their homes by exploring social constructions of






76


frailty and aging-in-place with both residents and managers/sponsors. Instead of simply

"labeling" residents as frail, this research investigates ways the two groups define, frame,

and understand frailty as it relates to aging-in-place.














CHAPTER 4
CONSTRUCTING FRAILTY: HOW FRAILTY IS DEFINED

Frailty is one of those complex terms--like independence, life satisfaction,
and continuity--that trouble gerontologists with multiple slippery
meanings. The American Heritage Dictionary defines frailty as (1)
physically weak or delicate, and (2) not strong or substantial (1992, p.
720).

In gerontology, frailty is usually defined in opposition to independence.
(Kaufman 1994, p. 48)

In their study of frailty and the perception of choice among a sample of
old people who live alone, Rubinstein, Kilbride, and Nagy employ an
open, qualitative definition: "having one or more health or functioning
decrements that seriously affect the person's ability to carry out the
expected and usual activities of daily living" (1992, p. 4)


What is Frailty?

With the three definitions listed above, and scores of others in books and journals,

there is still no universally accepted definition of frailty. Everyone--literally--seems to

have their own meaning--doctors, social scientists, gerontologists, the government, and

the elderly themselves--but few researchers studying housing issues have taken the time

to appreciate what frailty means to elders and managers in Florida's low-income, rent-

subsidized housing. Specifically, few have taken the time to understand how elders, and

those around them, conceptualize their own frailty in their own words. This research

attempts to understand how two groups of people--low-income, frail elder residents of

Florida's HUD housing and their managers--conceptualize and live with frailty in daily

life. For this group of people, frailty becomes much more than deficits in ADLs and

IADLs--frailty is something they live with, is defined by them, and sometimes imposed









on them. And while these residents literally and figuratively define their own frailty, they

do not always understand the basis for their personal views.

Frailty, though traditionally viewed as simply functional limitations associated

with health conditions, has come to be viewed much more broadly. Often elders in low-

income, subsidized facilities are relocated to more supportive environments because they

cannon accomplish tasks like housekeeping or shopping. These activity limitations,

however, may not prove to be as important as environmental forces outside the individual

in judging whether a person should stay on-site to age-in-place or be moved to a more

supportive environment. Simply put, "... the presence of frailty may result from the

presence or absence of numerous intersecting factors, many of which are external to the

individual" (Raphael, Cava, Brown, et al. 1998, p. 1). If, for example, services are

brought into a project, certain individually defined "frailties" may fade from the

residential scene. For example:

In Stockholm each subway stop has an elevator, and buses kneel low to the
ground to facilitate access. Contrast this with the Toronto system, where subway
elevators do not exist, escalators usually operate in one direction only, and
virtually all street cars and buses make no allowance for those whose physical
abilities may be declining. (Raphael, Cava, Brown, et al. 1998, p. 2)

Or consider the resident who relies on his wife to help him with day-to-day needs:

If I did not have my wife to cook for me, get groceries, and pick up my medicine
at the shop around the corer, I don't think I'd be able to stay here. That and
some of the help we can get for [clothes] washing keep me here. I worry what
might happen to me if she's not around. (Resident 53)

This reliance on outside service and assistance is nothing new, but recognizing its

presence may greatly change assessments of individual needs linked with conventional

frailty assessments. Thus in facilities with features that compensate for physical

limitations, residents can remain in their apartment units independently for longer periods








I'm not asking for special treatment. I want to do as much as I can, but they can't
say I'm frail and can't do for myself when I can... with a little help. (Resident
99)

Viewing functional dependence from this perspective creates a powerful argument that

supportive services in the right types of housing facilities can moderate the affects of a

diagnosis of frailty. Furthermore, if residential sites are occupied by homogeneous elder

populations, economies of scale allow greater varieties of services be offered at lower

overall cost to the residents. Specific types of housing with specific types of services

can--in various ways--influence conceptions of frailty.


The Literature of Frailty

Recent research conceives of frailty not simply as medical conditions exerting

negative influences on an individual, but as a holistic construct reflecting an interaction

of individuals with their environment. One research group from the University of

Toronto suggests that: "... frailty as a condition resides within the individual rather than

a situation which existsfor an individual" (Brown, Renwick & Raphael 1998, p. 1). By

engaging frailty from this perspective, this research project provides greater insight into

how individuals classify, understand, and deal with their declining abilities, and how

managers cope with the needs of their more needy residents. More importantly, however,

by studying frailty from the perspective of residents and managers, it is possible to

discern the importance and influence of supportive services as a response to the study

participants' perceptions of frailty.

To understand frailty, as a social construction, rather than a biomedical one,

researchers must view it from the perspective of individuals who live, work and deal with

it every day. By viewing frailty from this perspective, it becomes not only a highly








individualized concept, but one with multiple common threads of reference between

individuals. Focusing attention on these multiple common threads, researchers find many

sources for defining frailty beyond the medical model. It becomes clear that individuals

have their own definitions and managers have other definitions. The implications of the

acceptance of a multiple model approach to frailty for policy modifications within the

HUD housing environment and other senior housing facilities and service provisions are

striking. Viewing frailty in this multiple model construct, it becomes possible to increase

the awareness and importance of the individual's perspective and the role their building

the context. Thus, in addition to its individual components, frailty should be considered a

social construction that is specific to time and place (Raphael et al. 1998) across its

multiple originating sources.

By understanding frailty in this manner, there is an increased sensitivity to just

how significant people's relationship is with their environment. These interactions can

serve as a model for moving towards a more universally accepted definitions of frailty.

Instead of a singular medical model, frailty becomes viewed as a "dependence on others

for activities of daily living" (Raphael et al. 1998). Raphael et al. (1998) further argue:

These functional approaches advance our thinking from physiologically based
conceptions in that frailty is viewed in terms of individual's lived experiences
rather than presence or absence of a medical or health condition. But ultimately,
frailty is still seen as a state residing within the individual, and consideration of
social and environmental factors are limited to immediate proximal environments
such as attitudes of caregivers, availability of finances, or ability to get around
one's immediate home. Dependence on others for the activities of daily living is
the defining features in these views. (Raphael et al. 1998, p. 1)

By looking at the nexus of the individual and the environment, greater opportunities for

mitigating environmental and physiological limits can be addressed through supportive

services, facility types, and community supports.









We have things like grab bars around the toilet and in the shower, resident checks,
and meal programs precisely to ensure that residents can stay here as they need
more help... become more frail. (Manager 22)

In addition to the traditional medical model of frailty, this research has uncovered

three other models that contribute to a person's conceptualization of frailty, that will be

referred to as the manager model, service model, and individual model. Each of these

three models focuses attention on a particular aspect of the housing type, management,

and/or associated services. For example, the manager model examines the role

management plays in the construction of frailty in the housing project and the minds of

the residents. The service model attempts to understand how service access can change

residents and managements' notions of dependence and frailty. Lastly, the individual

model focuses attention on the individual conceptualizations of frailty and how they are

shaped by expectations and life experiences. Together these four models address the

variety of factors that low-income, rent-subsidized elders, and their managers, use to

describe frailty. These models are highly influenced by building type, population and the

size of the concentration of elders at the facility.


Medical Model of Frailty

Most of the traditional definitions of frailty are medically based conceptions that

equate frailty with chronic illness and disability (Raphael et al. 1998; McAdam,

Capitman, Yee, et al. 1989). Based on the medical model, doctors, case managers, and

geriatric care managers attempt to identify frail elder patients in hospital settings,

rehabilitation centers, and in their own homes to determine who is most at risk for

adverse outcomes and most in need for discharge planning. Medical professionals--in a

variety of capacities and from a variety of disciplines--work to evaluate seniors through









multidimensional assessments. While these assessments can be challenging for

clinicians, assisting elders and their families in this manner can have a dramatic and

positive impact on quality of life and well-being. The usual criteria used for judging

frailty are listed below.

Medical Indicators of Frailty

Independent
Independent in all ADLs with short-term acute illness
Frail
Meets any one of the following criteria:
o Cerebrovascular accident
o Chronic and disabling illness
o Confusion
o Dependence in ADLs and/or IADLS
o Depression
o Falls
o Impaired mobility
o Incontinence
o Malnutrition
o Polypharmacy
o Pressure sores
o Prolonged bed rest
o Restraints
o Sensory impairment
o Socioeconomic/family problems
Severely Impaired
Severe dementia and dependent in ADLs and/or IADLs
Terminal Illness

Table 4.1. Clinical Criteria to Identify Frailty in Elderly Patients.
Winograd et al. 1988 and Rockwood 1992, p. 903.

Though all of these conditions and diseases are commonly associated with elders

and the aging process, there is no dialogue to examine how other factors from the

individual's life impact the diagnosis of frailty or how they can be mitigated by changes

in the residential environment of low-income housing.








To understand frailty, in its traditional form, one must view its origins in the

health care system. Aging and health care have been intimately linked through

medicalization and the medical model.

The view that the problem of aging is primarily one of physiological decline
medicalizes old age; that is the phenomenon and experience of aging are brought
within the medical paradigm as individual pathology to be treated and cured....
By framing the problems of aging and therefore the solutions as biomedical, this
view of aging ignores nonmedical issues--such as poverty, isolation, the loss of
role and status--and thus effectively depoliticizes the problems of aging.
(Robertson 1990, p. 43)

Health care professionals and allied providers, as well as other observers of health care

delivery, have come to consider the broad spectrum of personal problems and behaviors

to be viewed as diseases or medical conditions that ultimately must be "treated." As Jane

[not her real name] observes, "When I can't do something [like an ADL], I'm labeled.

Jane (not her real name) can't walk to the mail box, watch her" (Resident 49).

Furthermore, they attempt to redefine or reinforce to the senior that this is how they

should view themselves. This elder has concerns that diseases, conditions, and ailments

"are stacking against her" to somehow make her a less desirable resident. She continues:

"My doctors say that I am frail--walking is difficult for me now. I'm 87 [years old]; who

wouldn't be having trouble?" (Resident 49). Other residents are in similar situations:

"My doctors has told me that I am slowing down and won't be able to do things like I

used to. I've already noticed that I can't do as much around the apartment" (Resident

101); "I'm spending more time accomplishing less. I don't drive as much because I'm

starting to get afraid. I got lost last week and had to drive around. My doctor says this is

to be expected" (Resident 97).

Scholars have described how medicine has permeated many behavioral aspects of
life, as social deviance, behavioral eccentricities, or moral problems and how they
are transformed into medical concerns, or as ordinary life processes (especially









birth and death) are reinterpreted as events requiring medical intervention (see
Arluke & Peterson 1981; Conrad & Schneider 1980; Zola 1972). (Kaufman 1994,
p. 46)

America's senior citizens--especially those in low-income subsidized housing--are

particularly vulnerable to this type of medical management due to their lack of financial

resources, family support, and coping abilities.

Resident: I've been talking with doctors about some things--about getting old
and dying. My world is closing in around me and I'm not able to do as much as I
would like. I've noticed that I've started getting anxious... nervous... I don't
know, but my doctor has started giving me a drug to calm me down. He told me
that it would help even out my moods.



Resident: The way he [doctor] is treating me, almost makes me think that my
emotions aren't natural and normal. I need medication to understand my own
moods and emotions. (Resident 72)

Because society has come to equate old age with illness, frailty, and disability, elders are

quick to be overlooked, ignored, pre-judged and pre-diagnosed, and dismissed without

having their needs addressed outside the context of a waiting room.

Resident's Daughter: Though no doctor ever said it, there were fewer
expectations of Mom ever getting better. After her stroke, they did not really
expect her to get better and made plans to move her to a nursing home instead of
trying to get her back to her home. (Resident 65's daughter)

These actions serves to reinforce a particular stereotype of old age and the traditional

notions of frailty--older people are somehow less capable of taking care of themselves.

This type of "care" reinforces a sense of hopelessness in the resident along with self-

limiting expectations. This type of assessment of aging limits elders' possibilities of

prolonged independent living with a positive outlook and quality of life.

Because of these medical interpretations, residents in low-income, government

subsidized housing become limited in their own expectations of themselves and their









capacity to perform in their building and maintain independence. Furthermore, they learn

that if they accept these medical "opinions," they will be forced eventually to move to a

nursing home.

Resident: I fell in my apartment last week and was taken to the hospital. The
doctors did not ask me what happened, they only looked at me, spoke to the
ambulance men... never did they ask me what happened... Now I have some
woman calling me asking about what I do all day, do I need help, am I eating?

Interviewer: What do you tell her?

Resident: Nothin'. IfI say too much, I know they'll try to put me in a home. I
know they will. They keep saying that I'm feeble and I shouldn't be living alone.
They say I need to move... closer to family ... someplace else ... I'm not
moving into a [nursing] home. I don't need that.

Resident 13 knows she needs help, particularly with day-to-day activities like

housekeeping, cooking, and grocery shopping, but she is not ready to surrender her life

into the hands of someone else. "This is not my end. I still have more to do. I don't

want to be someone's checklist" (Resident 13).

Interviewer: What did you tell the doctors while you were in the hospital?

Resident: They would not listen to me. I tried to tell them that I was okay ...
you know fine, but they kept asking me questions--days of the week, the president
... I could not get them to answer my questions. Is this who I am ... I don't think
so. (Resident 13)

The medical model may serve the medical profession well as a diagnostic tool for

underlying medical conditions, but is not an adequate judge of frailty. Simply having

health conditions, or not being able to accomplish specific tasks grossly oversimplifies

the person's own reality of frailty.

For all of its faults, the medical model is used the most and is one of the most

amenable to mitigation by supportive services, because these types of assistance are

simply linked to different frail conditions like ability, mobility, or health. This model is,








perhaps, the most ruthless in altering elders' perspectives because it has the authority of

the "medical community" or case manager behind it, supporting a notion of frailty that

inevitably communicate dependence and results in low self-esteem. A diagnosis of

frailty is--according to physicians--physiological deficit, not a convergence of physical,

social and environmental factors (Raphael et al. 1998).

The medical establishment approaches frailty as a signal for increasing length of

hospital stay, nursing home utilization, and mortality (Rockwood 1999), but this focus

does not correspond with the figures associated with nursing home utilization--less than

5% of the population nationally (Golant 1992). Geriatric care managers and case

managers, similarly focus attention on these components of the multidimensional

assessment attempting to provide services to community-dwelling elders with supportive

services to maintain independence. Professionals from these fields argue that assessment

findings must be linked to adequate and on-going treatment plans to ensure success.

Without this systematic approach to providing care and services, few care plans will be

successful in the long-run.

These traditional medical models continue to view frailty as a changing condition

of ever-decreasing abilities (Raphael et al. 1998, Rockwood 1999, Rockwood et al.

1994). Understanding the relationships between the medical model of frailty and seniors'

quality of life and functional ability, uncovered during these interviews, indicates that

seniors--particularly low-income seniors--can improve their quality of life, health, and

well-being, as well as their own appraisal of health by approaching frailty not as a disease

state, but as a reaction to a confluence of personal and environmental factors and viewing









it this ways offers--in some cases--greater opportunities and hope that vulnerabilities can

be overcome and compensated for.


Service Model of Frailty

Bringing supportive services into low-income, government-subsidized housing

projects provides much more than assistance. While services are the most important

component of the service model, an added benefit includes social interaction and

companionship for the resident. Often this includes someone "just being there" for

conversation, discussion of health services, and opportunities for the caregiver/service

giver to provide some extra motivation and emotional support. This model brings

together two very important aspects of services--the social and human components of this

industry.

The ease and difficulty of accessing supportive services influences greatly how

individuals understand their conceptualizations of frailty. For these residents, having

services mitigates the concern over not being able to accomplish activities of daily living

(ADLs) and day-to-day tasks. Thus, having on-site and community-based services

provide a level of security and comfort. For other residents, however, lack of services

and support translates into isolation and health complications.

Resident: If I could just have someone come and visit me once and a while, I
know that I would feel better. It gets so lonely in this apartment. I want to have
someone that I could call if I needed help. (Resident 75)

Because there are no family members nearby, the services coming into the apartment not

only provide help with tasks, but companionship and friendship to what otherwise might

be an isolated elder that cannot do for himself.