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Health, housing and assistive technology : Their roles in British Columbia’s elderly independence Lao, Adrian 1995

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HEALTH, HOUSING AND ASSISTIVE TECHNOLOGY THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE by A d r i a n L a o B . A r c h . , Univers i ty o f H a w a i i @ Manoa , 1990 A T H E S I S S U B M I T T E D I N P A R T I A L F U L F I L L M E N T O F T H E R E Q U I R E M E N T S F O R T H E D E G R E E O F M A S T E R S O F A D V A N C E D S T U D I E S I N A R C H I T E C T U R E i n T H E F A C U L T Y O F G R A D U A T E S T U D I E S Schoo l o f Archi tec ture W e accept t h i j ^ h e S f c as yconforming / to k the required standard T H E U N I V E R S I T Y O F B R I T I S H C O L U M B I A A p r i l , 1 9 9 5 © A d r i a n L a o , 1995 In p resen t ing this thesis in partial f u l f i lmen t o f the r e q u i r e m e n t s fo r an advanced d e g r e e at the Univers i ty o f Brit ish C o l u m b i a , I agree that t h e Library shall make it f reely available f o r re ference and s tudy. I fu r ther agree that pe rmiss ion f o r ex tens ive c o p y i n g of this thesis f o r scholar ly pu rposes may be g ran ted by t h e head o f m y d e p a r t m e n t or by his o r her representat ives. It is u n d e r s t o o d that c o p y i n g o r p u b l i c a t i o n o f th is thesis fo r f inancial gain shall n o t be a l l o w e d w i t h o u t m y w r i t t e n pe rmiss ion . D e p a r t m e n t o f C4fa T^Jy The Univers i ty o f Brit ish C o l u m b i a Vancouver , Canada Date DE-6 (2/88) HEALTH, HOUSING AND ASSISTIVE TECHNOLOGY THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE ABSTRACT Heal th , housing and much more recently, assistive technology, are key determinants o f e lder ly independence i n Br i t i sh C o l u m b i a . Th i s thesis discusses these three determinants i n some detai l , and also stresses their interrelat ionship wi th each other. Throughout the entire thesis, the elderly 's preference to age-in-place ( B l a c k i e , 1986; Wheele r , 1982) is stressed. In the issue o f health, the current community-based health care del ivery system o f the Br i t i sh C o l u m b i a M i n i s t r y of Health 's Con t inu ing Care D i v i s i o n is compared and contrasted with a "counterpart" i n the Uni ted States: the O n L o k Heal th Services System in San Francisco, Cal i forn ia . O n L o k is discussed to highlight its effectiveness in de l iver ing a communi ty-based hol i s t ic health care system for a group o f aging-in-place elder ly in need o f long term care wi th re la t ively l ow cost. In the issue o f housing, the thesis investigates three avenues i n wh ich architects can apply their sk i l l s to max imize aging- in-place poss ib i l i t i es for our elderly i n the context o f Br i t i sh Co lumbia . Constraints by b u i l d i n g codes, health care regulat ions, real estate market expectations and the aging characteristics o f B r i t i s h Columbia ' s e lder ly are also highl ighted to br ing context to the discussion. In the issue o f assistive technology, g iven the huge range o f product i i development, the thesis focuses on one par t icu lar ly interest ing communica t ion device - the Videophone . The Videophone is discussed to explore its potential impact for e lder ly independence, especia l ly for the future. i i i HEALTH, HOUSING AND ASSISTIVE TECHNOLOGY: THEIR ROLE IN ELDERLY INDEPENDENCE TABLE OF CONTENTS A b s t r a c t i i Tab le o f Contents i v L i s t o f Figures v i A c k n o w l e d g m e n t s v i i i I n t r o d u c t i o n 1 Chapter One BC ' s Elderly and Independent Living 5 • Bas ic Characterist ics o f Canada's E l d e r l y 5 • The e lder ly and independence 1 0 Chapter T w o Health Care for the independent elderly 1 4 • Health Care in Canada: A B r i e f His to r ica l O v e r v i e w 1 4 • O N L O K Senior Health Services -A U . S . Prototype 2 0 • The Br i t i sh C o l u m b i a M i n i s t r y o f Health's Cont inu ing Care D i v i s i o n 3 0 • C o n c l u s i o n 4 4 Chapter Three Housing for the independent elderly 4 9 • M o d i f i c a t i o n o f exist ing dwel l ing to p r o l o n g independence 4 9 i v • Cus tom designed single fami ly dwel l ings : G o l i n Residence & Shedbolt Residence 6 8 • Pu rpose -Bu i l t M u l t i - D w e l l i n g D e s i g n : A s s i s t e d L i v i n g 9 5 Chapter F o u r Assistive Technologies for the independent elderly (AT) 1 1 7 • A u d i o V i s u a l Communica t ion and E l d e r l y Independence 1 1 9 • The V i d e o p h o n e 1 2 4 Chapter F i v e Conclusions and Recommendations 1 3 9 B i b l i o g r a p h y 1 4 4 v HEALTH, HOUSING AND ASSISTIVE TECHNOLOGY: THEIR ROLE IN ELDERLY INDEPENDENCE LIST OF FIGURES Chapter 3 3 - 1 . Before and Af te r : Crea t ing manuver ing room for handicap access ib i l i ty 5 6 3 - 2 . Before and Af te r : R e m o v i n g Obstacles i n a home for e lder ly movement 5 7 3 - 3 . Before and Af te r : R e m o v i n g dangerous stairs for e lde r ly movement 5 9 3 - 4 Before and Af te r : Ins ta l l ing l o w parti t ions to con t ro l Dement ia e lder ly wander ing 6 3 Golin Residence: 3 - 5 • Axonome t r i c o f basement, main and second f loor 7 3 3 - 6 • Site P lan and overa l l axonometric v i ew 7 4 3 - 7 • M a i n F loo r P lan 7 5 3 - 8 • Second F l o o r P lan 7 6 3 - 9 • Basement F l o o r P lan 7 7 3 - 1 0 • B u i l d i n g Sect ion 7 8 3 -1 1 • Par t ia l M a i n F l o o r P lan o f entry and future elevator 7 9 3 - 1 2 • Par t ia l Second F l o o r P lan o f future elevator 8 0 3 - 1 3 • V i e w o f suite 8 1 Shedbolt Residence: 3 - 1 4 • Ex i s t ing M a i n F l o o r Plan 8 6 3 - 1 5 • Ex i s t i ng Second F l o o r Plan 8 7 3 - 1 6 • Proposed Elevator A d d i t i o n @ Basement F l o o r 8 8 3 - 1 7 • Proposed Elevator A d d i t i o n @ M a i n F l o o r 8 9 3 - 1 8 • Detai led Plan o f Elevator A d d i t i o n @ Second F loo r 9 0 3 - 1 9 • Proposed Eleva tor A d d i t i o n @ T h i r d F l o o r 9 1 3 - 2 0 • Garden E leva t i on showing elevator core 9 2 3 - 2 1 • B u i l d i n g Sect ion through elevator core 9 3 Speculative Market Condominium Project: v i 3 - 2 2 • B u i l d i n g F l o o r Plan 9 9 3 - 2 3 • B u i l d i n g E l eva t i on 1 0 0 3 - 2 4 • T y p i c a l Un i t Plan (F) 1 0 1 3 - 2 5 • T y p i c a l Un i t P lan (B) 1 0 2 3 - 2 6 • T y p i c a l Un i t Plan (A) 1 0 3 R o s e w o o d E s t a t e : 3 - 2 7 • B u i l d i n g F l o o r P lan 1 1 1 3 - 2 8 • T y p i c a l U n i t P lan 1 1 2 Chapter 4 4 - 1 • Picture o f Videophone and screen at actual size (Singapore T e l e c o m V i d e o p h o n e Brochure) 1 2 6 4 - 2 • V i e w o f videophone in open posi t ion (Hong K o n g Te lecom Videophone Brochure) 1 2 7 4 - 3 • V i e w o f videophone's functions (Hong K o n g Te l ecom Videophone Brochure) 1 2 8 4 - 4 • Exp l ana t i on o f videophone's p r ivacy feature (Singapore T e l e c o m V i d e o p h o n e Brochure) 1 2 9 4 - 5 M a i n F l o o r Plan o f a house showing typ ica l progression o f spaces from publ ic to private 1 3 8 V 1 1 A C K N O W L E D G M E N T S I am indebted to many for the successful completion of this thesis. I extend my gratitude to my supervisory committee, consisting of Sandy Hirshen, FAIA, Dean of the School of Architecture at University of British Columbia; Gloria Gutman, Ph.D., Director of the Gerontology Research Centre, Simon Fraser University @ Harbour Centre; and Anna Marie Hughes, Ed.D., Faculty Member of the School of Nursing at University of British Columbia. Their expertise in the three disciplines of architecture, gerontology and nursing was critical in guiding the research and development of my graduate thesis toward a more collaborative and multidisciplinary perspective. Numerous people helped me with their input in the areas of health, housing and assistive technology for the elderly. In particular, I thank Leah Shapiro, R.N and Debbie Ram Ditta, R.N., Mount St. Joseph's Hospital, Vancouver; Marie Louise Ansak, President, On Lok Senior Health Care Services, San Francisco; Doug Shedbolt, retired Dean, School of Architecture, University of British Columbia; and Dr. & Mrs. Peter Golin, Anmore. Above all, I thank my wife Soo, whose patience, love and encouragement made the entire process enjoyable and possible. H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E HEALTH, HOUSING AND ASSISTIVE TECHNOLOGY: THEIR ROLE IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE INTRODUCTION Canada's elderly are potentially on the eve of a major challenge in regard to their health and well being. This forecast may be attributed to a number of social, demographic, health and political factors that potentially threaten the well-being and vitality of Canada's elderly as they age independently: First, there is an unprecedented increase in the number of elderly in Canada's demographic profile: in British Columbia, for instance, the older population (defined as aged 65 and above) has grown consistently from over 4,000 persons in 1901 to almost 300,000 in 1981, a growth rate of over five times that of the total population in the province in the same period. Furthermore, the increase in elderly aged 80 and above was more than double that of the elderly aged 65 and above (Gutman et. al., 1986). The reality of an aging society has numerous implications, not the least being economic. For instance, society may find it increasingly challenging to continue the traditional supports for the elderly if the ratio of the elderly to the work force continues to climb [from 1:7 to 1:3 by 2031, (Statistics Canada, 1978)]. Second, the cost of health care in North America is growing at what may potentially be increasingly unsustainable rates. It has been estimated in l H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E America, for instance, that the inflation rate of health care costs in the last ten years outpaced the general inflation rate. Furthermore, there is concern regarding the added impact of increasing numbers of elderly. For instance, the Economic Council of Canada (1979) reported that the public expenditures per capita are three times greater for the elderly than for the young. Third, gerontological research has determined that the elderly prefer to age-in-place for as long as possible (Blackie, 1986). This is so even if their physical dwellings may be less than conducive for their lifestyle and needs in later years. The preference by the elderly to age-in-place is complemented by society's concurrent questioning of the need to have costly and dehumanizing institutional arrangements for the frail and sick elderly (Regnier, 1992). Nevertheless, the numbers of elderly in need of institutional care of some kind exceeds the current supply of such institutions. While this need isn't new, the gravity of the problem, given the increasing numbers of such elderly, has increased. As a result, increasingly more frail and sick elderly are being forced to age-in-place in the community for longer than anticipated. This means that there are increasing numbers of the not-so-well elderly living independently in their own homes despite their failing mental and/or physical capacities. As a result, the need to focus on the design of the elderly's home and its potential in enhancing therapeutic and orthopedic functions has assumed a greater urgency. Finally, these troubled economic times in Canada has resulted in an erosion of revenues collected by provincial and federal governments. There has 2 H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E thus been an increasing need to seek ways to cut costs in all aspects of government. In this climate of fiscal restraint, the traditional social programs of Canada's health care and old age payments for the elderly are being seriously scrutinized at all levels of government. Fortunately, there have also been positive developments that are emerging to counteract the negative factors described above. To begin with, the recognition of the close interrelationship between health and housing toward the elderly's well-being has resulted in the emergence of new and innovative community based health care programs for the elderly. Secondly, assistive technologies to aid elderly independence continues to improve and increase the options available to them, and promises a whole gamut of exciting possibilities in the future. This thesis is focused on these two positive developments. In general terms, it discusses the three distinct yet interrelated issues of health, housing and assistive technologies. Regarding the issue of health, I will discuss a relatively recent development in health care delivery in the United States called the ON LOK Health Services Program, which is an excellent case study of a community-based health service program for a group of aging-in-place elderly in San Francisco, California. I will then briefly compare and contrast this model with what is interpreted to be the its "counterpart" in British Columbia: The BC Continuing Care Program. In the issue of housing, within the context of BC's model, I discuss three 3 H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E types of applications in which architects can apply their skills to enhance the aging-in-place elderly's health and well-being. These three applications are in the area of existing housing modifications, custom designed and built single family dwellings, and purpose-built multi-residential projects for assisted living. In the issue of assistive technologies, given the tremendous range and complexity of such devices on the market, I will focus on one particularly interesting device: the videophone, and a discussion on the potential impact this type of device can have on the future design of the elderly's home. I will conclude by making some interpretive judgments on possible pros and cons of future technology trends. In addition, I stress the importance of the , interrelationship of health, housing and assistive technology, and how we as architects should reexamine our roles in future in light of such interrelationships. 4 H E A L T H . H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S IN B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E C H A P T E R O N E C A N A D A ' S E L D E R L Y A N D I N D E P E N D E N T L I V I N G This chapter gives a general overview of the elderly in Canada and the basic characteristics of the current cohort. It is important to describe Canada's elderly first so that the reader will have a proper understanding for the rest of the thesis. I will then discuss the established criteria for elderly independence. This introductory chapter concludes by summarizing several key guidelines for maximizing elderly independence. B a s i c D e m o g r a p h i c C h a r a c t e r i s t i c s of C a n a d a ' s E l d e r l y The last few years have seen attention focused on older Canadians. Th i s is p r imar i ly because we are exper iencing a rapid increase i n the number o f e lder ly Canadians, stat ist ically defined as those aged 65 years o l d and above (Havens, 1985). The terms ' e lde r ly ' , ' senior ' and 'o lder ' w i l l be used interchangeably to refer to those aged 65 years or older unless noted otherwise. The f o l l o w i n g are key demographic trends: • Canada's population is aging. A nation's population is considered 'aged ' when those 65 years and over exceed 7% o f the populat ion (Havens, 1981). A c c o r d i n g to the 1991 Canada Census, the proport ion o f the popula t ion aged less than 15 years dropped from 23% to 21% between 1981 and 1991, whi le proport ion o f the populat ion aged 65 years and above increased from 10% to 12%. It is projected that by the year 2030, 5 H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E approximately 20% o f a l l Canadians w i l l be over the age o f 65 years ( B a l d w i n , 1993). T h i s project ion assumes that Canada 's bir th rate, wh ich has dropped since the Baby B o o m years, w i l l maintain a fert i l i ty rate o f 1.8. •78% o f elderly Canadians l i ve in urban centers (Br ink , 1985). There are indicat ions that this percentage w i l l increase i n future as the rura l communit ies in Canada go into relat ive decline, and as increasing numbers o f Canadians continue to migrate to urban centers in search o f employment. The relat ive d i f f i cu l ty o f accessing medical care, transportation and other amenit ies o f rural areas is also a mot iva t ing factor toward urban migra t ion o f seniors. • The majority (91.2%) o f e lder ly Canadians l i v e in private households (Gutman et. a l . , 1986). There is a strong preference o f Canadians to l ive independently (also known as ' s tay ing put' or aging-in-place) versus l i v i n g i n an insti tutional care home (B lack ie , 1986; Wheeler , 1982). It is important to recognize the strong preference o f the elder ly to l i v e i n their own private residences for as long as possible. The majority (75.3%) o f older men l i v e i n famil ies w i t h a spouse and/or wi th never-marr ied chi ldren . A m o n g older women , the percentage l i v i n g i n fami ly arrangements decreases wi th age (60.4% in the 65-74 age group, 32.5% over the age o f 74). There is an increase in the proportion l i v i n g in non-fami ly households, many o f w h o m are alone i n private households (31.5% of women aged 65-74, 40.98% o f women over the age o f 75). It is important to stress that l i v i n g independently requires a support ive 6 H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E communi ty and phys ica l infrastructure that w i l l offer services to compensate for the e lder ly ' s frai l ty. A s B l a c k i e ' s (:1986) notes the opt ion o f "s taying put": . . . involves more than just strongly advocat ing that older persons be a l lowed to remain in their homes. It requires services wh ich help e lder ly homeowners wi th repairs, improvements , modi f i ca t ions and adaptations to their homes. It requires organiza t ion and coordinat ion o f tradesmen and the appropriate mix o f f inancia l assistance. It also needs to extend to p rov id ing the famil ies o f older persons wi th advice on retrofit t ing their homes for aging parents, (p. 1). • T w o thirds o f older Canadians own their own home (Br ink , 1985). A c c o r d i n g to the 1991 Canada Census (Statistics Canada, 1992), this figure was 75% in Br i t i sh Co lumbia . • Current ly , 60% o f older Canadians l i ve in single fami ly detached homes, whi le 12% l ive in mult iple dwel l ing units (Br ink , 1985). There is apparently s t i l l a clear preference for the independence and p r ivacy associated wi th single detached homes. The elderly who are renting generally l i ve in one or two bedroom dwel l ings that are suitably s ized for their needs. The elderly who own their dwell ings tend to l i ve in two or three bedroom units that are too big for their needs. •50% of elder ly homeowners l i v e in homes buil t in the 1940's (Br ink , 1 9 8 5 ) . Out o f this group, 72% o f the dwell ings needed only regular 7 H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E maintenance, 15% needed minor repairs and 13% needed major repairs (Stat ist ics Canada, 1982). • In 1981, 50% o f e lder ly households had an annual income under $15,000. 57% o f single elderly indiv iduals , the majority o f whom are women, had an income below $7000 (Br ink , 1985). B y 1985, the income for the average male and female over 65 years was $17,114; and $10,780 respect ive ly (Statist ics Canada , 1991). • Accord ing to the 1991 Canada Census, the ratio o f elderly women to elder ly men was 138:100 respect ively. In the 85 years and above category, the ratio o f elderly women to elderly men is over 2:1 respec t ive ly ( B a l d w i n , 1993). W h i l e there are more w idows than widowers i n every age category, the propor t ion o f widows among the e lder ly is dramatical ly higher. Near ly 80% o f women aged 85 and over are widows (Havens , 1981). Over the lost several decades there is an increasing tendency for this group to l i ve alone. • The ' o l d e lder ly ' female sub-group (aged 85 and above) is generally v iewed as being 'less healthy' than men o f the same age as reflected by a number o f indicators: they have more days per year o f restricted ac t iv i ty , more days o f bed-d isabi l i ty , more doctor ' s v is i t s , higher expenditures for health care are more l i k e l y to experience depression, and are more l i k e l y to be ins t i tu t ional ized than men (Havens, 1981). • It is a myth that older people as a group are high consumers o f health care (Novak, 1988). Different groups o f older people use different amounts 8 H E A L T H . H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E o f health care. (Eg . women 85 and above use more health care than men o f the same age as explained in the above paragraph.) F r o m the Manitoba Longitudinal Study on Aging ( M L S A ) , Roos and Shapiro (1981) offered the f o l l o w i n g data: 1) The M L S A showed that older people do not form a single group. Some groups use more health care than others. M o s t elderly use a smal l amount o f formal health care, or none at a l l . The patterns o f this use was found to be stable. (Mossey et a l .1981, 557) 2) Less than 25% o f Mani toba ' s elderly stay in a hospital in any given year. Out o f this group, 5% o f the elderly used up to 59% of a l l the hospital days. 3) 01der people as a group do not make large numbers o f vis i ts to doctors; this cohort makes only 1.7 more vis i ts to the doctor per year than the 15-44 age group. It was concluded from the M L S A that most elderly do not need or use excessive inst i tut ional or medica l health care. Furthermore, the health care that is needed can often be del ivered in the communi ty (Novak, 1 9 8 8 ) . • There is concern as to the impact o f our increasing numbers o f elderly on our health care costs. W h i l e the contributory factors to increases i n health care costs are numerous and often interrelated, it has been suggested by Douglas E . Angus (1984) in his paper entitled 'Health-Care Costs: A Review of Past Experience and Potential Impact of the Aging Phenomenon' that: "...perhaps one o f the most important determinants o f the increase in health-care costs.. .have been a reduct ion i n mortal i ty and an increase in l i fe expectancy. Conven t iona l 9 H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E wisdom suggests that the increasing number o f e lder ly people have increased the demand for routine medica l care, especia l ly for chronic condi t ions , and this produces greater than proport ionate increases i n health costs." In light o f Canada's changing age structure, the ratio o f the elder ly to the work force (persons aged 18-64) w i l l c l imb from 1:7 to 1:3 by 2031, whi le the youth dependency rat io w i l l f a l l s ignif icant ly (Statistics Canada, 1978). The Economic C o u n c i l o f Canada (1979) reports that pub l ic expenditures per capita are three times greater for the elderly than for the young. In addi t ion , Gross and Schwenger (1981) further concluded that by 2001, the elderly w i l l consume 46.5% o f health care services and by the year 2026, 5 6 . 6 % . The Elderly and Independence H o w do the e lder ly perceive independence? The term "independence" has few expl ic i t definit ions. However , there are three major cr i ter ia i m p l i c i t in the research o f e lder ly independence (Kea t ing , 1991): The first is the ab i l i ty o f the elder ly to maintain control over their near environment; their ab i l i t y to meet personal needs (Alber t a Senior C i t i zen ' s Secretariat, 1986) and to maintain responsibi l i ty for decisions i n these areas ( M c C l e l l a n d and M i l e s , 1987). Main ta in ing "control" includes the abi l i ty to carry out Ac t iv i t i e s o f D a i l y L i v i n g ( A D L ) , and the abi l i ty to l ive i n a home environment w i th enough faci l i t ies to enable the e lder ly to 10 H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E manage their A D L . The second cri teria o f independence is the abi l i ty o f the elderly to remain part of the community (Keat ing , 1991). The preference o f elderly to "stay-put" versus staying in an inst i tut ional setting is a good example o f them remaining part o f the communi ty . Beyond just l i v i n g i n their o w n homes however, remaining in the communi ty also includes the integrat ion o f the e lder ly into the communi ty (Ontar io A d v i s o r y C o u n c i l for Di sab led Persons, 1988). C o m m u n i t y in tegrat ion w o u l d inc lude main ta in ing separate households as opposed to l i v i n g wi th chi ldren ( K i v e t and Learner , 1980); not being homebound (Fr i tz and O r l o w s k i , 1983); and not l i v i n g in an inst i tut ional setting (Neufeldt , 1974). Other issues o f communi ty integration include the ab i l i ty to do work and leisure act ivi t ies , and having the adequate mental and phys i ca l health to part icipate in the communi ty (Kea t ing , 1991). The third cr i ter ia o f independent l i v i n g involves the ease o f use to services, such as groceries stores, banking, health care etc. (Keat ing , 1991). Havens (1980) argues that accessible services are seen to be the biggest need o f independent l i v i n g e lder ly . W h i l e there is disagreement over what factors best measure this access (e.g.. distance, cul tura l barriers, cost), research suggest that lack o f transportation is one o f main obstacles to services, and hence e lder ly independence (Keat ing , 1991). G i v e n the c loser p rox imi ty and greater abundance o f services i n urban areas, coupled wi th better pub l ic transportation fac i l i t i es , it wou ld appear that urban d w e l l i n g elderly are more l i k e l y to have easier access to services that rural dwe l l ing e l d e r l y . 1 1 H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E • Conclusions F r o m the demographic characterist ics o f the elderly i n Canada, three useful conclusions can be drawn. One, the r is ing numbers o f elderly i n our country mandate that careful attention be focused on understanding and prov id ing for their needs. T w o , given the desire for independent l i v i n g o f the elder ly , effective social po l ic ies for the elderly must max imize aging-in-place possibi l i t ies (Nat ional A d v i s o r y C o u n c i l on A g i n g , 1983:84). Three, the increase in health care costs mandate that society help the elderly to remain healthy and independent for as long as possible . Ins t i tu t ional ized health care should be u t i l i zed only when it is no longer feasible for the e lde r ly to l i v e independent ly . In summary, to max imize e lder ly independence, we can thus deduce four key gu ide l ines : First, the elderly must be allowed to age-in-place in their own homes for as long as possible. Institutionalization should be used only when it is no longer feasible for the elderly to live independently. Secondly, the independent elderly must have access to medical and social support to maintain health and well being while living in their homes. In other words, the health care they receive must be community-based. 12 H E A L T H . H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E Third, the nature of health care they receive should always be geared towards maximizing their independence as much as possible. For instance, if an older person can remain independent with a motorized wheelchair and subsequent minor home renovations, then giving this elderly person the wheel chair to prolong the person's independence is a more economical and preferable solution to institutionalization. In this regard, the use of assistive technology to help maximize their potential for independence may be very helpful. Fourth, the home of the elderly will have significant impact on their ability to remain independent, especially as they start to lose mental and physical capabilities. Thus, the design of the home to accommodate and support the elderly's needs becomes increasingly critical as the person ages, especially in light of the elderly's preference to age-in-place. 13 H E A L T H . H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E CHAPTER TWO HEALTH CARE FOR THE INDEPENDENT ELDERLY This chapter begins with a general historical overview of the health care system in Canada, from which the socialized health care delivery system in British Columbia draws its origins. It will then discuss the ON LOK Senior Health Services, a revolutionary community-based private health care delivery system for some frail but independent elderly living in San Francisco. It will be followed by a discussion of this health care delivery model's "counterpart" in British Columbia: that of the BC Continuing Care Division. The chapter concludes by highlighting some comparisons and contrasts between the two. Health Care in Canada: A Brief Historical Overview The provision of social services, of which health care is a prime component, was not an important issue during the time of Canada's confederation in 1867. It did not become an important issue until the early part of the twentieth century (Chappell, 1985). The British North America Act (BNA) enacted during confederation did not include provisions for welfare measures, and limited the government's minimal contribution to locally administered relief funds for the poor. Essentially, people were expected to fend for themselves. In 1927, the federal government initiated the Old Age Pensions Act, which established a 'national non-contributory, means-tested plan for providing some income' for the retired. This plan represented the first major attempt by the Canadian federal government 14 H E A L T H . H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E in social welfare. Af ter the enactment o f this A c t , welfare legis lat ion began to develop regular ly , and the federal government's share o f cont r ibut ion to such welfare plans began to increase as w e l l because many o f the poorer provinces were unable to contr ibute, especia l ly dur ing the Depress ion years (Chappe l l , 1985). O l d age security payments to ret i red elderly increased wi th the enactment o f the Guaranteed Income Supplement (GIS) program in 1960. Further legis la t ion fo l lowed , and the welfare legislat ion today is essentially a conglomeration o f a l l the different pieces o f legislat ion added to the O l d A g e Pensions A c t enacted i n 1927. Current ly , Canada has a three-tiered pension system cons i s t ing o f pr iva te income/ inves tments / savings (e.g. R R S P s ) , publ ic pension plans (Canada/Quebec Pension P lan C P P / Q P P ) and government transfers ( O l d A g e Securi ty i.e. O A S , G I S , and Spouse A l l o w a n c e i.e. S A ) (Novak , 1988). Without these government transfers, more than 50% of Canada's e lder ly wou ld l ive in poverty. A s the movement to provide income security was i n progress, the federal government also took steps to implement health care for everyone, inc luding the elderly. It is important to stress that the development o f the formal socia l ized health care system i n Canada is c losely related to the development o f the medica l profession (Chappel l , 1985). P r io r to the Depression, health care was the domain o f private schemes, and the services p rov ided var ied w i d e l y i n quali ty and ava i l ab i l i ty . The Depression forced many o f these schemes to f a i l , even as large numbers o f people became unable to afford the care. In his book t i t led 'Canada's War: The Politics of the Mackenzie Government, 1943-1945', G rana t s t e in (1975) 15 H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E argues that M a c k e n z i e K i n g was instrumental in making health care universal ly avai lable to a l l Canadians. H i s po l i t i ca l intentions inc luded avo id ing massive unemployment and popular unrest after the war, us ing socia l welfare legis la t ion to create w o r k for many government c i v i l service employees who feared d is loca t ion in returning to peacetime, and the desire to use health insurance as a tool to help the Libera ls get re-elected. M a c k e n z i e K i n g created a Commit tee on Reconstruction w h i c h argued for universal social security on the merits o f the costs being carr ied by the whole o f society. The work o f this committee, and others after it , u l t imately resulted i n the M e d i c a l Care A c t passed i n 1965/66 w h i c h p rov ided a nat ional insurance scheme for phys ic ian services (Chappe l l , 1985). The process toward soc ia l i zed medicine culminated wi th the Canada Heal th A c t o f 1984 that defined the five pr inciples o f Med ica re : comprehensiveness , un ive r sa l i t y , po r t ab i l i t y , a cces s ib i l i t y and p u b l i c adminis t ra t ion (Seaton et .a l . , 1991). The M e d i c a l Care A c t insured that health care in Canada wou ld be based on physician-centered services, i .e. the M e d i c a l M o d e l o f health 1 . W h i l e this plan is administered p r o v i n c i a l l y and is thus open to some inter p r o v i n c i a l variations, it remains that access and use are control led by physic ians . The treatment under Med ica re focuses on cure and acute care, and less l ln everyday use, the word 'health' is synonymous with physical and mental well-being, a healthy person being assumed to be of sound mind and body. However, the scientifically accepted definition of health, and its consequent scope of research and implications, has changed over the years to encompass many different but related issues. The traditional definition is the Medical Model, defined as an absence of disease, both mental and physical. The focus, and consequently the responsibility, is on the individual who succumbs to disease. This traditional view treats diseases only when the symptoms appear, and little or no attention is given to promoting healthy lifestyles or health promotion/disease prevention (HP/DP) activities (Health Education Unit, 1986). Still in wide acceptance in medical circles, the Medical Model thus gives the primary role of health care to doctors and nurses. 16 H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E emphasis is p laced on chronic condi t ions , health promot ion , disease prevention, or l i festyles. The pr imary role o f physicians in the Med ica re system is evidenced by the exclus ive control they have on the p rov i s ion o f hospital u t i l i za t ion , drug prescriptions, lab tests etc. (Chappel l , 1985). Th i s control has contributed in part to the dominance o f hospitals in p rov id ing health care services i n Canada. The re la t ively abundant provis ions o f hospital bu i ld ing programs in both Canada and the Uni ted States is in sharp contrast to the lack o f development o f communi ty services. Chappe l l (1985) further argues that the p r o v i s i o n o f communi ty -based programs have tended to develop as "add-ons" to exis t ing inst i tut ional and medica l c a r e . The dominance o f physician-centered health care is c lear ly reflected i n the health care budget. For instance, i n 1992, Br i t i sh C o l u m b i a spent 5.4 b i l l i o n dollars on health care, o f which 2.54 b i l l i o n was allocated to run hospitals. The M e d i c a l Services C o m m i s s i o n (from wh ich doctors and paramedical salaries are taken) took up an addi t ional 1.4 b i l l i o n , (second highest expense) wh i l e communi ty based efforts such as health p romot ion had only 389 m i l l i o n i n compar ison (Staff, 1993). The physician-centered nature o f Canadian health care has numerous benefits for us a l l , but one unfortunate aspect o f its cont inued development and emphasis has been, and continues to be, its consistent cost increases that outpace the cost increases o f other social services. The current health cr is is i n both A m e r i c a and Canada is a testament to the growing cost increases o f health care in the last 20 years. W h i l e the physician-centered nature o f health care i n these two countries have played a pr imary role in the cost increases, it is naive to blame the doctors alone. The problem is enormous 17 H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E and complex, and other contributory factors include the litigious nature of both countries (resulting in high malpractice insurance rates and wealthy lawyers as opposed to better health care), the conflict-of-interest associated with doctors and hospitals sometimes having to 'recruit' patients or requiring unnecessary visits to increase their billings, and the selfish nature of western society as a whole that demands many sophisticated and oftentimes unnecessary or questionable treatments and tests. It is cynically argued that current government initiatives on both sides of the border toward socialized medicine in the United States, and toward community based medicine in Canada, have been mandated not by progressive attitudes and knowledge of health care or health care delivery systems, but by increasing financial difficulties. • The Continuum of Care during the Aging Process A key concept associated with providing adequate health care for the elderly concerns the varying levels of care required by older people as they age. The Ministry of Health defines five levels of long term health care: Personal Care (PC), three levels of Intermediate Care (IC) and Extended Care (EC). Generally speaking, the elderly progress from Personal Care to Intermediate Care to Extended Care as they age and lose their physical and/or mental capabilities. Inevitably, as one progresses from one stage of care to another, there are overlaps in the levels of care required in the aging process. 18 H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : - — " T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E Personal Care involves assistance wi th Ac t iv i t i e s o f D a i l y L i v i n g ( A D L ) 2 . The elder in Personal Care is usual ly independently mobi le and needs m i n i m a l assistance (about thirty minutes o f lay help per 24 hours) wi th A D L . Personal Care is now increasingly being phased out o f inst i tut ional care settings. Intermediate Care is categorized into three progressive levels o f care. In Intermediate Care One, for example, elderly may have d i f f icu l t ies expressing needs, require some supervis ion (approx. 60 m i n . lay help, 15 min . professional help per 24 hours) wi th A D L , and may be m i l d l y depressed. They also need da i ly supervision o f medicat ion and other medical care. Intermediate Care T w o elderly may in addi t ion have severe d i sab i l i t y / medica l problems, incont inence and have an i n d w e l l i n g catheter. The l eve l o f supervis ion required increases to about 70 minutes o f lay help and 30 minutes o f professional help per 24 hour period. In Intermediate Care Three, the e lder ly may show ant isocial habits (e.g.. spi t t ing, v o i d i n g , and defecating i n pub l i c ) , destructive behaviors (shouting, screaming) and wandering i n addi t ion to the medica l condi t ions descr ibed in IC One and T w o . Extended Care applies to the most frai l and chronica l ly i l l e lder ly, and describes the formal health and care services avai lable i n nursing homes and chronic care faci l i t ies . In Extended Care, 24 hour lay and s k i l l e d professional care is required. Patients require some assistance wi th mobi l i ty , and total assistance wi th A D L s . They also need planned soc ia l s t imula t ion , protect ive atmospheres ( ins t i tu t ional settings) and a staff ratio o f one professional to every four lay aides. Mos t o f those ^Activities of Daily Living refer to the basic activities we are required to do everyday to sustain health and wellbeing to our bodies. Examples thus include activities involving eating, cleaning our bodies and sleeping. Instrumental Activities of Daily Living (IADL) describe those activities that we do in order to enhance our ability to carry out ADLs. Examples of IADL would include shopping, going to the bank, and d r i v i n g . 19 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE elderly in need of Extended Care can only be adequately cared for in institutional care settings like nursing homes. Within the above context, we will next briefly study two "models" of health care delivery: the On Lok Senior Health Services system, followed by British Columbia Ministry of Health's Long Term Care Division. We will discuss these two models not because they are equal counterparts of each other across the border, but because the two models do currently serve comparable patients: that of aging-in-place elderly in long term care. • ON LOK Senior Health Services On Lok is a free-standing community based long term care program serving the frail elderly in the Chinatown-North Beach community of San Francisco (Ansak & Lindheim, 1983). The name "On Lok" is Cantonese for "happy and peaceful". On Lok represents a revolutionary alternative to the traditional means of caring for frail elderly in the United States: that of the nursing home. On Lok delivers its senior health services in two basic ways. The first is through its Adult Day Health Centers . The second is through its housing for the frail elderly, also associated with Adult Day Health Centers. On Lok Adult Day Health Centers On Lok's Adult Day Health Centers (ADHCs) offer adult day health care to 20 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE eligible seniors in their neighborhood. These seniors are eligible for On Lok once they become State certified as eligible for nursing home. This care comes in the form of an organized day program of therapeutic, social, and health activities and services provided to elderly with physical and/or functional impairments. The overriding intent of the care is to restore and/or maintain the elderly's optimal capacity to live independently. When provided on a short term basis, On Lok's adult day health care serves as a transition from an acute health care facility e.g.. hospital to independent living. When provided on a long term basis, the same care serves as a viable alternative to institutionalization in nursing homes -where 24 hour supervision is not medically necessary or desirable (Ansak & Lindheim, 1983). There are currently four On Lok ADHCs in the Chinatown-North Beach community of San Francisco. They serve the frail elderly who qualify to live in long term care nursing homes, but have decided to remain in their own homes while being cared for by On Lok located in a densely populated community area with many elderly, these health centers are truly community based, and are within walking distance for many of their patients. For those seniors that may live too far away, On Lok vans pick them up at set times in the mornings and drive them home in the afternoon. The drivers of these vans get to know their elderly patients, referred to as "participants" on a personal basis, and physically carry them in wheel chairs if they have mobility problems. The elderly are encouraged to be as independent as possible, so the amount of help the driver gives is determined by how much the elderly wants (Steenberg et. al., 1993). 21 HEALTH. HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE The day health centers are open seven days a week, from 8.00 a.m. to 4.30 p.m. Most On Lok seniors attend their center about 5 hours a day, and about 14 days a month (Ansak & Lindheim, 1983). What happens at the centers? A comprehensive, multidisciplinary program of personal care, reality therapy, crafts, exercises and other recreational activities is provided. Patients also receive personal and regular monitoring by the On Lok staff physicians, nurse practitioners, nurses, therapists and other health professionals dedicated to individual therapy and counseling. Nutritional services, including meals and snacks designed to meet dietary requirements, are served three times a day. In short, what the seniors at these day health care centers get is personalized, high quality care of a medical and social nature during the day. At the end of the day's activities, they are driven back to their own homes to live their private lives. Should they need medical attention at night, On Lok's doctors and nurses are available on call. It is important to stress the variety of social and therapeutic activities in these centers, and the freedom the seniors have in choosing what activities they would like to participate in. They sit where they want to, and space gets filled up on a first come, first serve basis. Activities vary daily, and from center to center. Examples of activities include story telling, dancing and bingo. The seniors can choose to be active participants or passive observers. In short, these seniors, although state certified to long term care in nursing homes, are encouraged to have active, involved lifestyles at the center. 22 H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E The adult day health care centers are also equipped wi th faci l i t ies for p rov id ing medical care. Fo r instance, the Bush Street Center has separate areas for phys ica l therapy, soc ia l work , rest /treatment, nurse's off ice , dental room and d in ing/occupat iona l therapy. Rooms that require re la t ive i so la t ion and p r ivacy l ike the dental off ice and rest/treatments are careful ly designed as dist inct , private rooms. Other spaces function better i f they are adjacent to people and act ivi ty. Fo r instance, d in ing /occupat iona l therapy is located adjacent to the main ac t iv i ty r o o m . The main act ivi ty room is the hub o f senior act ivi ty in the center. The majority o f group activit ies are conducted in this space, which is idea l ly central ly located, wi th a bright, h igh ce i l ing , natural l ight, and an open, airy feeling. The designs o f the four O n L o k day health centers have been studied to evaluate their strength and weaknesses. F o r further informat ion , please refer to Ansak & L i n d h e i m (1983). The adult day health care ( A D H C ) centers are designed to accommodate 40-60 people each. For p lanning considerations, this translates to ' a p p r o x i m a t e l y 70-85 s.f./person, i f d in ing is not a separate space. It is argued in A n s a k & L i n d h e i m (1983) that i f the number o f participants per center gets larger than the recommended range, the personal re la t ionships between staff and participants suffer. Furthermore, i f the area o f the center gets too b ig , then the ideal spatial relationships suffer, and the center begins to loose its intimate scale. Th i s concept is c ruc ia l , because one o f the key reasons why O n L o k ' s health care delivery system is so successful is s imply because the participants l i ke to come to the centers. F o r most o f them, the activit ies at the center are what makes their day. In short, the center has to function as a home away from home for these 23 H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E participants. The activities of On Lok are funded though Medicare and Medicaid and private pay and private insurance. On Lok participants are required to sign over their Medicare and Medicaid coverage. In return, On Lok assumes complete control and responsibility' for their total health and social needs, as long as the participant agrees to use On Lok's multidisciplinary health care team, made up of doctors, nurses, therapists, and other paramedical staff (Lewin, 1994). On Lok gets paid the same amount per participant regardless of their actual health care costs for that participant. This amount is set by Medicare and Medicaid, and is based on averaged costs per elderly in the area's nursing homes. Because the amount On Lok receives per participant is the same regardless of actual care costs, there is an incentive to maximize senior independence and preventive health care measures. Furthermore, On Lok assumes full financial risk for the care of its participants. As a result, it has also assumed full responsibility for the participant's care, which means that it has the mandate and resources to cater to other health care related issues for the elderly: their housing and social/community support. The result is thus a holistic approach to the participant's well-being. This holistic approach is in the hands of On Lok's multidisciplinary health care team, made up of doctors, nurses, therapists, nutritionists, and other paramedical staff. Not only are they responsible for assessing the needs of a participant, they are also responsible for implementing the subsequent required services. In contrast to traditional approaches where multidisciplinary teams are physician-led, On Lok's team is truly an 24 HEALTH. HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE integrated team of collaboration (Zawadski & Eng, 1988). Each professional individually assesses the participant according to a defined protocol. Weekly team meetings are held to discuss and monitor the participant's progress, with complete assessments made of each participant every three months. The same assessment team also decides on the treatment plan, and is thus able to make necessary changes very efficiently. The dual role of the multidisciplinary team in both assessment and implementation of treatment plan is unique among community based long term care programs. What happens if for some reason, the On Lok participant becomes unwilling to come to the Adult Day Health Centers? On Lok classifies cases like this as home care cases, and assigns members of its multidisciplinary team to visit the participant to provide reassessment and to give some counseling and encouragement. Every case of this sort is unique depending on the individual and his or her circumstances. If efforts at persuading the participant to come back willingly to the Adult Day Health Centers fail, On Lok will not force the issue, but instead assigns a home care team for the participant for as long as it is effective. The needs of On Lok participants may change to the point where they no longer benefit from attending the Adult Day Health Centers. In terms of the B.C. system, the elderly participants in this category are those whose needs have progressed from Intermediate Care to Extended Care. These elderly need to be institutionalized. To meet this need, On Lok has contracts with some of the nursing homes in the area, and admits its participants to these nursing homes when there is no other viable 25 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE alternative of care within the On Lok system. Generally speaking, the elderly by this time are usually so frail physically or mentally, that the average stay at nursing homes is about a year.3 On Lok pays for the costs of keeping the participant at the nursing home. On Lok also has contracts with some of the hospitals in the area to allow it to admit its participants during after-center hours or for emergency acute cases. If a participant requires surgery, for instance, On Lok will arrange for the participant to be admitted to the suitable medical institution to carry out the procedure. This is because it is not cost-effective nor pragmatic to equip the Adult Day Health Centers to deal with such intensive acute care facilities. Like the case of nursing homes, On Lok also pays for the whole cost of hospitalization for the participant. On Lok Housing and Adult Day Health Centers The other way in which On Lok provides care for its participants is in the area of housing. This development occurred after On Lok's multidisciplinary team faced numerous obstacles in arranging suitable housing for some of its frail elderly in the neighborhood. Problems encountered included unsuitable rental accommodations and fearful landlords unwilling to assume risks associated with old, frail people. On Lok House was opened in 1980 as a community based purpose-built housing for its frail elderly. Located in the same neighborhood as the day health centers, the important concept to stress about On Lok House is that it is designed basically as a 3 The average On Lok participant is 82 years old and has 5 medical conditions. 26 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE hotel . A six story bu i ld ing , the top four floors are dedicated residential f loors wi th studio and one bedroom apartments. On L o k in i t i a l l y wanted to design each residential f loor as a family unit wi th a common sitting area, ki tchen and laundry. The residential units w o u l d each have smal l Pu l lman- type kitchens for those who preferred to cook alone, designed for the needs o f one person only . The common area wou ld thus be a gathering place for the residents o f that f loor , p rov id ing an opportunity for soc i a l i z ing , games, and entertainment o f famil ies and friends. In return, the i n d i v i d u a l residential units w o u l d be smaller , meaning that more units c o u l d be bui l t from the same f loor footprint. Unfortunately, On L o k was not a l lowed to bu i ld On L o k House wi th this concept. Instead the Federal department o f Hous ing & Urban Development ( H U D ) , wh ich was the pr inc ipa l funding agent for the project, insisted upon i ts own m i n i m u m mul t i - res ident ia l design standards, w h i c h i nc luded each unit to be designed as an independent dwel l ing wi th a functional k i tchen. T h i s caused the ind iv idua l residential units to become much larger, the result being that the common areas in each f loor had to be almost e l iminated to a l low the cost ratios to work. In short, the typ ica l residential f loor plans became bas ica l ly apartment-type designs l i n k e d on ly by c i rcu la t ion corridors. It was most unfortunate that a c ruc ia l concept i n independent l i v i n g supplemented by generous env i ronmen ta l opportunities for social and communal interaction was not rea l ized. The insistence o f H U D on those m i n i m u m standards is even more di f f icul t to understand when one considers that not on ly were the residents f ra i l seniors wi th various mental and phys ica l incapacit ies , but that the majority o f them were l i k e l y to have their meals i n the accompanying 27 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE adult day health center located on the first floor of the building! On Lok had designed the residential component not as a separate endeavor to its health care delivery system, but as a supplement to the adult day health center concept. In other words, the On Lok House was built to cater to the housing needs of the participants, but the primary vehicle for delivering the health care is still through the centers. The only difference here is that both operations are located in the same building for obvious reasons. In summary, the characteristics of On Lok's health care delivery system through its adult day health centers is unique and revolutionary for the following reasons: 1) It encourages the e lder ly to cont inue l i v i n g in the ir own homes, even though m a n y of them are o ld a n d f r a i l , a n d are s tate-cert i f ied to be e l ig ib le for n u r s i n g homes. T h e average O n L o k p a r t i c i p a n t is aged 82 years , a n d has m o r e than five ser ious m e d i c a l c o n d i t i o n s ( A n s a k , 1990) . 2) T h e care p r o v i d e d is ho l i s t i c . T h e medica l mode l of hea l th is d i s c a r d e d i n f a v o r of a prevent ive a n d progress ive one that r e c o g n i z e s c o e x i s t i n g needs s u c h as h o u s i n g , p s y c h o - s o c i a l s u p p o r t s a n d i n - h o m e s u p p o r t s . W i t h s u c h c o m p r e h e n s i v e m e d i c a l , r e s t o r a t i v e , s o c i a l a n d s u p p o r t i v e serv ices p r o v i d e d , a l l acute a n d long t erm care opt ions are thus u t i l i zed to create a m u c h b r o a d e r serv ice r a n g e t h a n c o n v e n t i o n a l c o m m u n i t y b ase d serv ices a n d n u r s i n g h o m e s . 3) T h e i n t e g r a t e d m u l t i d i s c i p l i n a r y t e a m w o r k a p p r o a c h that is not p h y s i c i a n - l e d a n d is d u a l - r o l e d in f o r m u l a t i o n a n d i m p l e m e n t a t i o n of t r e a t m e n t p l a n s is c l e a r l y p r o g r e s s i v e a n d 28 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE quite unique. 4) Funding is integrated. All payments from Medicare, Medicaid or other private insurance sources are pooled together to provide services. Not only is this collective pool larger, it also is free from restrictions of individual health plans that complicate administration and reduce efficiency and uniformity. 5) On Lok assumes financial risk as a provider of care. As a result, it assumes full responsibility for the complete care of its participants. The financial risk provides a powerful incentive for it to increase it's service system's efficiency and effectiveness. Obviously, the participants are the primary beneficiaries in this endeavor. The perceived strength of the On Lok method of health care delivery is evidenced by many pilot projects across America that are replicating On Lok's model. On Lok is currently the prototype for PACE, the Program of All-inclusive Care for the Elderly, which also purports to offer a solution to the sharply rising health care costs in America. It is estimated that both federal and state governments achieve savings through On Lok's program, with Medicare saving about 6%, while the State of California saves up to 30 % 4 . Through PACE, the On Lok model is now being replicated in Colorado, Illinois, Massachusetts, New York, Oregon, South Carolina, Texas and Wisconsin. Additional PACE sites are also being developed in Oakland and Sacramento in California, in Illinois and in Hawaii. 4 The numbers are obtained from On Lok's "A Celebration of Life - The Campaign for the Dr. William L. Gee House" Brochure. 29 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE • The British Columbia Ministry of Health's Continuing Care Program Under the BC Medical Act, the provincial government carries out its mandate of universal health care for all residents of BC through the Ministry of Health. Community-based care under this Ministry is served at the municipal level by local health departments. We will use the Vancouver Health Department as our model for discussion. While there are minor variations between all municipal health departments, discussing the Vancouver Health Department will give the reader a good overall understanding of how the other municipal health departments operate. The Vancouver Health Department is made up of two major departments: The Continuing Care Division and the Prevention Division. Under Continuing Care are found two services: Home Care and Case Management (which used to be called the Long Term Care Division). The majority of BC's aging-in-place elderly in need of continuing care are under the British Columbia Continuing Care Division (BCD). The BCD provides a variety of in-home support services, residential care services and special support services to assist people whose ability to function independently is affected by health-related problems, A simple, straightforward comparison of On Lok and BC's Continuing Care Division (BCD) is not possible. There are a few important reasons. First, On Lok is a private, non-profit organization, while the BCD is a government agency. While the former is smaller and easier to describe and categorize, the 30 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE latter is not. Second, the resources available to aging-in-place elderly in B C extend beyond that offered by B C D , which we w i l l discuss later. T h i r d , the health care rules i n the Un i t ed States are different from those i n Canada. W h i l e health care in the Un i t ed States has largely been funded by the i n d i v i d u a l and/or private medica l insurance (and is thus prone to free market forces and var iab i l i ty i n services paid for), Canadians have had the good fortune o f universa l , soc ia l i zed medicine wh ich provides uni form services to a l l . Med ica re and M e d i c a i d provides selected services to specific popula t ion , disabled, poor and e lder ly . T w o qual i fy ing statement are in order. Firs t , given the size and complex i ty o f the health care del ivery system for seniors in B C , the ensuing discussion is not intended to be comprehensive or defini t ive. Rather, it represents the in format ion and subsequent conc lus ions drawn from numerous conversat ions and in te rv iews w i t h selected health care profess ionals , government bureaucrats, volunteers , lay aides, and seniors f rom the different governmental and pr ivate agencies and departments that a l l p lay some role in the delivery o f health care to the elderly in B C . Secondly, the entire B C health care system is currently i n a state o f reorganizat ion, and many decisions on how the system w i l l be structured in future are yet to be made (see discussion on B C ' s communi ty based health care de l ivery below). Consequently, the fo l l owing discussion is o f a system i n f lux . In recognit ion o f the e lder ly ' s preference to age in place (Wheeler , 1982; Priest, 1985), the Cont inuing Care Program was set up to help the p rov ince ' s e lder ly wi th chron ic health problems by b r ing ing the necessary support to their homes or p rov id ing care in a residential fac i l i ty as close to 3 l HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE their home as possible (Min i s t ry o f Heal th , 1985). E lde r ly residents in the province are e l ig ib le for program benefits i f they are unable to cope or funct ion independent ly because o f heal th-related prob lems , and inc ludes adults from the age o f 19 and up. T o in i t ia l ly get services from the B C D , the elder ly must first contact their munic ipa l health department. F o r instance, an elder l i v i n g in Vancouver w o u l d contact the Vancouver Heal th Department 's Con t i nu ing Care D i v i s i o n . U p o n referral , either by the e lder ly themselves or their famil ies , a Case Manager (formerly ca l led the L o n g Te rm Care Assessor) w i l l then v i s i t the person to evaluate their cond i t ion and make the necessary recommendations. The assessor acts as the elderly 's case manager, and is responsible for setting up the r ight support agencies to help the e lder ly . Some o f these support services, l i ke respite care, adult day care and faci l i ty care, are M i n i s t r y o f Health funded and bear no cost to the elderly. Other support services, l ike Mea l s -on-Whee l s , L i f e l i n e , and R e d Cross equipment (e.g.. wheelchairs) are ava i lab le on ly on a pa id-by-e lder ly basis. Thus, many poorer elderly may not be able to take advantage o f some o f the paid-by-patient services p rov ided by the B C D . A s mentioned above, the B C D provides a variety o f in-home support services, residential care services and special support services to assist people whose ab i l i t y to function independently is affected by a health related problem. In-home support services inc lude home maker se rv ices 5 , 5homemakers provide personal assistance with A D L . 32 H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E m e a l p r o g r a m s 6 and c l i n i c a l serv ices 7 . Residential care services include n u r s i n g h o m e s 8 , fami ly care homes 9 and group homes 1 °. Special support services inc lude adult day care centers, respite c a r e 1 1 and assessment and treatment centers ( S S A T C ) to be discussed further below. (Heal th , 1994). These services are thus targeted to help people who want to age-in-place without constant professional care. Examples o f home care services inc lude nurs ing care, occupa t iona l therapy, physio therapy, speech therapy (for chi ldren only) and nutr i t ion. Communi ty services include M e a l s on Whee l s programs, Telephone Contact Services, and R e d Cross L o a n services for s ickroom equipment etc. Some telephone contact services a l l o w an elder ly to easi ly access an emergency response center o f a nearby hospital by pressing an emergency c a l l button usually worn around the neck ( M E R L , 1993; L i f e l i n e , 1993). Others offer counseling support services e.g. Carel ine . Homemakers vis i t the home o f an elderly and do day to day chores to help the person remain independent in their home (Pa ra -Med 1993). Th i s care team is usual ly headed by a nursing supervisor who does the in i t i a l assessment o f the e lde r ly ' s needs based on the Case Manager 's ( C M ) plan o f care. It is important to stress that many o f the above programs are stand-alone services that may be run by different for-profit , non-profi t pr ivate , semi-6Meals-On-Wheels is available on a paid by patient basis and delivers hot, nutritious meals to the elder's home. ^clinical services include nursing, physiotherapy and occupational therapy. ^nursing homes provide institutionalised 24-hour care. 9 homes that provide care and supervision in a family atmosphere 1 °for young adults with disabilities to maintain their independence by living in a private residence and pooling resources to save on expenses like rent and groceries. 1 temporary substitute for primary non-professional caregivers (eg. family member) either through home respite service or by admiting the client to a care home for a short period. 33 H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E private or government agencies. Fur thermore, because they provide their services as per the instructions and recommendations o f the C M , these different services may not know or understand the entire range o f services that is being provided for the e lder ly . General ly speaking, there is potential for lack o f coordinat ion between these separate services, thus impact ing their co l l ec t ive eff ic iency or effectiveness for the e lder ly . Nevertheless , these different, dis t inct services together form a communi ty -based pool o f communi ty supports that the Cont inu ing Care D i v i s i o n C M accesses to customize a suitable program o f home-based care for the elderly. Thus, str ict ly speaking, the C M is the pr imary conduit o f communi ty-based supports, i .e. the specia l ized centers designed to do qu ick assessment and treatment o f ind iv idua l s exper iencing a change i n their health status wi th the intent to provide early and appropriate in tervent ions and po ten t ia l ly a v o i d hosp i t a l i za t ion . A s var ied as the programs described above are, their pr imary function tends to be more o f social and community support for the elderly. Heal th care services for the independent e lder ly as defined by the M e d i c a l M o d e l is s t i l l p r imar i ly i n the hands o f the elderly's family physic ian (FP) . The elderly 's fami ly physic ian (FP) is a v i ta l contributor to health care needs. W e can conceive o f the F P as the gatekeeper to health care i n this province. F o r instance, i f an aging-in-place elder ly woman feels i n need o f medical attention, she usually w i l l first v is i t her personal doctor. The doctor then decides i f further care is required, and i f so, a referral is made to the appropriate source. FP ' s continue to play an active role even after ins t i tu t ional izat ion. Fo r instance, the Burqui t lam L i o n ' s Care Center i n 34 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE Coqui t l am al lows its residents to retain their own F P even though the nursing home provides 24-hour supervised Intermediate Care . The role of the F P is an excellent example o f how the B C D uses exist ing resources form the health care de l ivery system to f u l f i l l its manda te 1 2 . Yet it is important to stress that the role of the FP is somewhat determined by the willingness of the elderly to visit. Thus, i f a sick elderly chooses to be reclusive, there is no systematic way for the F P to be kept abreast o f the development. In complicated cases the F P may refer the patient to a hospital-based Short Stay Assessment and Treatment Center ( S S A T C ) , especia l ly i f the patient has a change in their health status that is more chronic than acute in nature. The S S A T C can be conceived o f as an emergency pit stop i n a car race. The intent is to f ix up the patient as quick as possible so that they can then be discharged to go back to their i nd iv idua l , independent l ives . T o further understand the central role played by the S S A T C , let us further examine a good example o f one: the Moun t St Joseph's Short Stay Assessment and Treatment Center , V a n c o u v e r . MOUNT ST JOSEPH'S SHORT STAY ASSESSMENT AND TREATMENT CENTER, VANCOUVER. Thi s center is a specia l ized health unit offering assessment and treatment services to older adults exper ienc ing health changes that interfere w i th their functioning and independence. The center is staffed by a 1 2 Family physicians are paid according to fees charged to BC's Ministry of Health as part of the province's system of socialized health care, as opposed to the privatized health care in the United States where doctors bill their patients or their private health care insurance companies directly. 35 H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E m u l t i d i s c i p l i n a r y health care de l ive ry team, and is further supplemented by the range o f medical and diagnostic services avai lable at Moun t St. Joseph. ( M S J , 91) The goal o f the S S A T C is to a l low community l iv ing e lder ly i n the L o w e r M a i n l a n d to maximize their funct ioning and i n d e p e n d e n c e . The geographic location o f M o u n t St. Joseph Hosp i ta l means that it serves a large propor t ion o f e lder ly ethnic groups not necessarily proficient in E n g l i s h . T o overcome possible communicat ion barriers, S S A T C provides interpreter services, as w e l l as literature printed in Chinese. M o u n t St. Joseph's S S A T C is one o f the few S S A T C s in B C that offer translation services i n Chinese . L i k e On L o k , the S S A T C has been moving away from the traditional phys ic ian-domina ted health care approach i n favor o f a m u l t i d i s c i p l i n a r y team approach. The team consists o f doctors, nurses, occupat ional therapists, physiotherapis ts , soc ia l workers , and other paramedica l staff. The intent, l i ke O n L o k ' s , is to a l low these different yet overlapping d isc ip l ines to complement each other 's expertise and thus de l iver the most hol is t ic and comprehensive health care possible to the e lder ly patient. The staff meet regular ly to discuss patients at the S S A T C , assess their needs, and determine the appropriate course o f act ion. Another feature to note about the S S A T C is its communi ty orientation, which is also in keeping wi th the B C Government 's new health care strategy. M o s t o f the patients at the S S A T C are communi ty l i v i n g elderly. Often, the friends and relatives o f these elderly contact the S S A T C to vis i t 36 H E A L T H . H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E the elderly to assess their needs. Th i s is because the elderly may not be aware or be w i l l i n g to seek medical counsel themselves. The S S A T C ' s communi ty assessment staff w i l l v i s i t the elder ly to go through a prepared l i s t o f questions to develop a comprehensive assessment o f the patient's soc ia l , f inanc ia l , emot iona l , phys i ca l environment , mental environment and medical needs. Depending on the e lder ly ' s condi t ion , relatives may be present to a id the assessment process. Th i s assessment w i l l then be shared wi th the mul t id i sc ip l ina ry team at S S A T C , who co l l ec t ive ly decide the appropriate course o f ac t ion. The Mount St Joseph's S S A T C offers a In-Patient Program , and a Day Hospi ta l Program. The In-Patient Program is for those that need to be hospi tal ized for short stays. The intent is diagnose and treat and return the patient back to health as soon as possible, after wh ich the patient is discharged back to his/her home. The care g iven is predominant ly for patients wi th chronic problems. Acute cases are admitted to the Acu te Care D i v i s i o n o f the Hospi ta l . The Day Hospi ta l Program is s imilar , but patients do not spend the night. Th i s program has two streams. The Phys ica l Stream is held on Mondays and Wednesdays, and is focused on treating patients wi th phys io log ica l problems. The C o g n i t i v e Stream is he ld on Tuesdays and Thursdays, and caters to patients wi th mental or p s y c h i a t r i c d i so rde r s . Al though there are many s imilar i t ies between On L o k and M S J ' s S S A T C , there are c ruc ia l differences that need to be noted. T o begin wi th , the care provided by the S S A T C is p r imar i ly medical in nature. Even though the Day Hospi ta l Program has some socia l and therapeutic act ivi t ies , it differs 37 H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E from On L o k ' s program in important ways: Firs t , the patients are admitted to the Day Hospi ta l Program only i f they are assessed to be in need of medical treatment by the S S A T C . Thus, patient vis i ts may be frequent enough to treat medica l problems, but not frequent enough to provide social and communi ty relationships o f significance. Second, the setting is s t i l l geared toward treating the problem. It is not as focused on health promot ion, preventive measures or social supports. G i v e n that the S S A T C is not solely responsible for the elderly patient, treatment is g iven on an as-required basis, and only i f the patient qualifies for B C ' s Cont inu ing Care P r o g r a m 1 3 . Furthermore, the treatment o f the patient stops after discharge. The patient is then referred back to their F P , who is then expected to carry through on the recommendations o f the S S A T C . However , this passing o f respons ib i l i ty may mean breaks i n the cont inui ty o f care. For instance, i f the patient is in need o f community support, the social worker assigned w i l l try to organize the necessary supports, but there again is no mandate to track the progress o f the patient unt i l there is another med ica l p r o b l e m . W h y are recommendations by the S S A T C a discharged patient general ly given to the patient's F P and not the patient's C M ? In my opin ion , one reason may be the nature o f the recommendation, i .e. medical . G i v e n the medical role o f both F P and S S A T C , it seems reasonable that the recommendations are passed onto the F P for carry through. Unfor tunate ly , there seems to be no central ized system in place to ensure a continui ty o f 1 3Elderly are considered as Continuing Care eligible only if they have been resident in the province of British Columbia for at least ten years prior. The current policy strictly requires non-eligible seniors to receive Day Hospital Program treatment only, with the In-Unit Program offered only if beds are available. This has been a controversial issue highlighted recently due to funding cuts. 38 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE care. However, there may be a much more important reason for this discontinuity of information flow, which I believe is a great inherent weakness of the existing system of care under the BCD - the case load of the CM. Many CM's in BC have huge caseloads. For instance, in the City of Vancouver, some CMs may have as many as 1000 cases at one time. It is impossible for anyone to keep consistent, effective tabs on the well being of 1000 elderly in continuing care even on an infrequent basis. It is not infrequent for CMs to contact their individual cases only once a year, and these cases tend to be the ones that are deemed to be at risk. We described above how the CM is the primary conduit of community-based supports, i.e. the case manager for the elderly patient. Well, in many cases, once the CM sets up the required services for the elderly, there may be no further contact between the two until another referral or request is made, either by the elderly, their family and/or the people providing the community supports described above. In other words, the impetus for feedback and monitoring of health and well-being lies not on the CM but the elderly and their family. In short, there is no individual or organization fully informed about all aspects of the elderly's well-being at any one time. The lack of a consistent follow-through on the discharged patient's progress is a fundamental weakness in many SSATCs, yet is reflective of the same lack of follow-through by the elderly's FP or CM. The basic reason is that unlike On Lok, none of these agents are singularly responsible for the continuing health and well-being of the aging-in-place 39 HEALTH. HOUSING & ASSISTIVE TECHNOLOGY. THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE elderly patient. The above discussion on the role of the FP and SSATC further illustrates a fundamental difference between On Lok and the BCD. While On Lok centralizes its health care delivery to its Adult Day Health Centers, the BCCCD has no centralized systems and health care is fragmented among FPs, SSATCs, and health departments. This makes the system much more complicated. Not only are the FPs, SSATCs and health departments located in different geographic locations, they are also separate financial, legal and administrative entities. Just because they all bill BC Medical does not mean that they are all of one collective agenda or purpose. Not all of the FPs and SSATCs provide similar types of medical services, or with comparable expertise or capacity. For instance, St. Vincent's Hospital has a comprehensive psychiatric medical team of over 20 Psychiatrists, while Mount St Joseph's SSATC has only one psychiatrist on duty during the Day Hospital Cognitive Stream on Tuesdays and Thursdays. The above condition reflects one central point about the BC Continuing Care Division: there are so many different, separate agents involved in the health care and community support of BC elderly in long term care that there is no organization singularly responsible or effective in keeping track of it all. One can argue that this should be the case, that the primary responsibility for caring for the elderly lies within themselves. After all, the freedom to seek and choose medical care and community support is an inherent, personal right. However, how can the elderly be expected to adequately seek the right services if the overall model of health care is so complicated? How can we expect them to 40 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE understand what to do when many o f the professional health care people in te rv iewed admit ted being confused or overwhe lmed by the complex i ty o f the ove ra l l system themselves? The above condi t ion clearly brings up the next issue: eff iciency. There is an underlying urgency to discharge a S S A T C patient as soon as possible, p r imar i ly for cost reasons. One way i n which O n L o k day health centers have been successful in keeping their costs in control is their daytime hours o f operation. W i t h physicians on ca l l at night, they are able to ensure that their participants have access to care at night, but are s t i l l able to save on the costs o f 24-hour care operations at hospitals l ike Moun t St. Joseph. A s a s implis t ic , crude comparison o f cost, care at the S S A T C s In-U n i t Program costs C d n . $540.00 U . S . / d a y / b e d 1 4 (Ram-Di t t a , 1994) compared to $37.68 U.S. /par t ic ipant for On L o k ' s adult day health p r o g r a m 1 5 in 1981 (Shen & Zawadski , 1981). Some may say that the comparison is unfair because the types o f patients i n both programs are not comparable. Fo r instance, one cannot do surgery in O n Lok ' s day health center l ike one wou ld i n a hospital . This however is a false argument. It must be clearly understood that the S S A T C is not set up to do acute cases. L i k e O n L o k , i f an elderly is in need o f acute care, e.g. surgery, the S S A T C transfers the elder ly to the Acute Care department o f a hospital . 1 4This amount is what BC Medical pays per bed in the SSATCs In-Unit program. The care afforded here is usually for chronic cases. 1 5This comparison is simplistic ($540 U.S. or $724 Cdn. approx.), but the degree of difference is significant. On Lok's cost figures are based on a study of its long term care costs conducted during a six month period from January 1 to June 30, 1981. During this period, a total of 295 participants were served, of which a sample of 269 participants in the program for over a month were selected for this cost study. In this study period, On Lok spent a total of U.S. $1,628,432 for medical, social and supportive services for the 269 participants. This translated to an average of $l,143/month/participant or $37.68/participant/day. (Shen & Zawadski, 1981). 41 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE Thus, it is our contention that the patients in both the SSATC and On Lok's Adult Day Health Centers are comparable. Thus, even accounting for inflation, the cost difference is significant. To further complicate the overall picture of the resources available to aging-in-place elderly, the municipality's Parks and Recreation Board also organizes programs for them. Many of BC's well elderly go to elderly community centers. These centers are run by the municipality's Parks and Recreation Board. These centers have a mandate to provide programs that cater to the social and recreational needs of the elderly. Numerous programs are carried out at these centers, which are planned by the center's staff and steering committees. Steering committees are usually made up of informed volunteers who provide leadership and guidance to the center's programs. Volunteers also play a big role in staffing many of the community outreach programs. Elderly community centers play a vital role in the social lives of many well elderly who attend such centers. There are some community centers that go beyond their typical mandate of social and recreational activities for elderly. Ray-Cam Co-operative Center is an excellent example of a community organization that demonstrates innovation in its policies and programs for the elderly in its catchment area. Located in 920 Hastings, Vancouver, the population mix and density of the area makes Ray-Cam comparable to On Lok's location in North Beach, San Francisco. Like On Lok, Ray-Cam is in a high density area. The majority of people in the neighborhood tend to be lower-income. There are a few senior housing buildings nearby, and an Adult Day Care Center and doctors office down the street. Some of the people working 42 H E A L T H . H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E with seniors at R a y - C a m are highly dedicated to their tasks. Fo r instance, Bob W o n g , a long-t ime social worker at R a y - C a m , tries his best to help some o f the elderly in need o f money by finding out how they can get legitimate government funding for some of their needs. B o b may do this by ca l l ing up different governmental agencies (e.g.. M i n i s t r y o f Soc i a l Services, M i n i s t r y o f Hea l th , B r i t i s h C o l u m b i a Hous ing Management Commiss ion) to see wh ich o f them may be responsible and w i l l i n g to provide funding, and then coordinates the required paperwork. Some o f the social and communi ty supports provided by R a y - C a m include the T a g Program, w h i c h describes a systematic method o f keeping track dai ly o f seniors l i v i n g in independent senior housing. The i r we l l -be ing is monitored by volunteers who v i s i t the elderly da i ly . The Tag Program was started after some seniors died in their apartments and were not discovered unt i l a few days later. There are also attempts to br ing medica l care to the center. Fo r instance, the staff has a Podiatrist v is i t the center once every six months to see patients. A t first glance, it appears that Ray-C a m is somewhat comparable to the On L o k model o f health care del ivery. However , this compar ison is not appropriate. W h i l e having some medical services, R a y - C a m is not a center to deliver comprehensive health care. A Podiatr is t v i s i t once every six months, wh i l e undoubtedly very useful and desirable, does not qual i fy Ray C a m as a health care fac i l i ty comparable to O n L o k 1 6 . Furthermore, it is important to realize that many medical 1 6It should be noted that such medical clinics at Ray-Cam are possible only due to the deliberate efforts of Ray-Cam's Staff who submit written proposals to the appropriate governmental agencies. However, these proposals for are granted on a case-by-case basis, and usually only for a limited time only, regardless of the program's success. Ray-Cam tries to tailor the clinics to meet the unique needs of the elderly in the area. However, the time taken to review these proposals, plus the approval required by all appropriate government and health care administrative boards complicates the process, and makes it difficult for Ray-Cam to provide the services regularly or 43 H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E faci l i t ies are nearby (e.g. the adult day care center and the doctor's office) because of the high density o f the area, not because o f some pr ior administrat ive imperat ive. In other words, the doctor moved into the neighborhood to tap into the loca l market, not because R a y - C a m paid for h i m to come to the neighborhood. W h i l e the service and care o f the workers at R a y - C a m toward their seniors is h igh ly commendable, i t brings up another important point - that the R a y - C a m system is not easily replicable, unlike On L o k ' s . Some o f the reasons are geographic and demographic i n nature. I f another communi ty center l ike R a y - C a m was set up in a less dense suburban setting in M a p l e R idge , for instance, the locat ions o f medical services, senior housing and community services may not be so c losely clustered. A s a result, it may be impossible for the staff at this communi ty center to keep track o f the elderly in their area the way R a y - C a m is able to, or for the elderly to even attend the communi ty center convenient ly . Furthermore, i f the area has very few seniors, the communi ty center may have less o f a mandate to provide for their needs. Another reason is the center's staff. Bob Wong's care, dedication and experience is not necessarily shared by the person who replaces h im, or by the other people at other communi ty centers. • Conclusion In summary, the current health care system for the elderly in Bri t ish Columbia is stil l predominantly institutional. Most frail consistently. 44 H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S IN B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E elderly in need of medical care are sent to nursing homes, space permitting, where they are supervised on a 24-hour basis in an institutional environment. For those elderly living independently, their options of community-based support services are quite extensive, but these supports tend to be more social than medical in nature. Strictly speaking, medical care of any significance is still dominated by personal doctors, hospitals and nursing homes. In view of the above constraints, and coupled with the urgent need to control spiraling institutional health care costs, the Government of British Columbia recently announced a new community approach to health care. (Then) Provincial Health Minister Elizabeth Cull proclaimed the government's desire to downsize hospitals and remove unnecessary beds . In addition, British Columbia's health care is to become "..less hospital oriented and more community based, with community health councils taking over the roles now played by health boards, hospital boards, and regional districts. Extended-care beds will be built for elderly patients now occupying acute beds, and less unnecessary surgery will be done..." (Baldry and Wigod, 1993). This concept is further elaborated in the Report of The British Columbia Royal Commission on Health Care and Costs which declares that ..."Medically necessary services must be provided in, or as near to, the patient's place of residence as is consistent with quality and cost-effective health care..."(Seaton et. al., 1991 :A-6). The shortfall of funding, followed by the above direction of BC's government are two major reasons why the health care system in British Columbia is currently in a state of flux. 45 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE In the above state of flux, there is potential for some of On Lok's strengths to be perhaps incorporated into the model in BC. The above health directive of the provincial government has resulted in the call for the creation of community health councils. These councils are to be made up of individuals elected by the public and individuals appointed by the Minister of Health. The intent is eventually to allow the council to assume responsibility for integration and management of services now delivered by the Ministry of Health, hospitals and health provider organizations17 At this early stage, however, the extent of the council's influence in making important decisions on health care delivery models is still unclear. Regardless of the roles played by the councils however, the fact that they are only just being formed opens up opportunities to introduce progressive ideas and concepts. Central to progress for BC's model of health care delivery is the need to consolidate health care, community support and housing services. Because all three areas play a crucial role in the well being and health of the independent living elderly, it is only sensible for all three to be managed and administered by one source. This way, the central source of administration can look at the aging-in-place elderly's holistic well being, and take the appropriate action. On Lok's progressive 1 7The formulation of the community health council is briefly described as one of the reforms recommended by the BC Government's : "New Directions for a Healthy British Columbia", a paper that sets out a plan for a renewed health system for British C o l u m b i a . The paper was issued in part as a response to the Royal Commission of Health Care and Costs's "Closer to Home" (Seaton et. al., 1991) report which reported, among other things, that not all British Columbians are equally healthy, and not all have reasonable access to the health system. Furthermore, Closer to Home also noted that within the BC health system, there has never been an overall plan, and that the structure that has evolved lacks coherence, (and sometimes) logic, and the ability to objectively assess itself for efficiency and effectiveness in providing health care. 46 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE model o f consol idated services i n health care, communi ty supports and housing is in sharp contrast to the comparable yet fragmented services in health care, communi ty support and housing in B r i t i s h C o l u m b i a . C l e a r l y , the aging- in-place e lder ly residents o f B C are tremendously blessed wi th an abundance o f medical and communi ty resources to a id them i n the process o f l i v i n g independently. It is not the contention o f this discussion that B C compares unfavorably to On L o k in terms o f the range or types o f services available to its elderly. Rather, the point made is that there are too many different, separate agents i n v o l v e d i n the health care and community support o f B C elderly in long term care that there is no organizat ion s ingular ly responsible or effective in keeping track o f it a l l . A s a result, there are inherent overlaps and gray areas o f responsib i l i ty , creating confusion and ineff ic iency. In this mi l i eu , the inherent importance o f the aging- in-place elderly 's housing to their health and w e l l being is often over looked , ignored or regretfully passed over due to the above pressing issues. I f B C is to adopt the strengths o f On L o k , it is clear that changes have to be made i n the management and administrat ion o f its health care programs. Central to this change is the need to restructure the annual health care budget to include housing concerns. Current ly , the health care budget is dominated by ins t i tu t iona l care costs, w i th many communi ty -based health promot ion support in i t ia t ives competing for a much smaller piece o f the pie . There is thus inadequate emphasis on health promotion/disease prevent ion measures, even though it is c o m m o n l y accepted that prevention is a lways better than cure. Furthermore, the non- inc lus ion o f 47 H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E housing needs i n the health care budget is a fundamental weakness because i t fails to l i n k the importance o f the aging-in-place elderly 's phys ica l home environment to their overa l l health and w e l l b e i n g 1 8 . Because o f this lack o f a housing component, many aging-in-place e lder ly continue to either l i v e i n inappropriate housing that further deteriorate and/or endanger their health, s imply due to lack o f funding. U n t i l very recent ly, this sad si tuation led to premature ins t i tu t iona l iza t ion i n nurs ing homes, wh ich is i ron ica l ly much more expensive. Current ly , the lack o f funding for new inst i tut ional beds has reduced the number o f cases o f premature in s t i t u t iona l i za t ion , but the p rob lem o f inappropr ia te hous ing for ag ing- in -p lace remains . In the above context o f health care delivery in B C , what is the responsibi l i ty o f the architect wi th regards to housing for the ag ing- in-place elderly? There are three clear areas o f appl icat ion, wh ich we w i l l discuss in the next chapter. 1 °"New Directions for a Healthy British Columbia" further argues that one way of bringing health care closer to home (a key initiative of the Royal Commision on Health Care and Cost's "Closer to Home" {Seaton et. al., 1991} report) is by the creation of "community health centers", described as one-stop centers for a wide range of community health services, with links with other services such as housing and income support. These community health centers are thus intended to consolidate services like On Lok's model, and include not only housing, but income as critical determinants of a person's total health. 4 8 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE CHAPTER THREE HOUSING FOR THE INDEPENDENT ELDERLY This chapter describes the three areas in which architects can apply their skills in designing appropriate housing sensitive to the needs of aging-in-place elderly. These three areas are in the modification of existing housing for the independent elderly, designing customized single family dwellings, and designing new purpose-built multiple housing types for the independent elderly. • Modification of existing housing to prolong elderly i n d e p e n d e n c e Home modifications to prolong their independence are extremely important to independent elderly because they allow them to age-in-place. It is unfortunate that many independent elderly are asset rich yet cash poor, and are thus unable to finance required home modifications on their own without financial aid from other source. The majority of seniors in BC own their residences and are free of mortgage debt (Scholen, 1985). Their residence now represents their single most important financial asset. However, it is also true that most seniors are on fixed incomes, and that many will experience affordability problems. For instance, in 1981, half of all families with senior heads had incomes under $15,000. Single elderly (particularly single senior women) were also concentrated in the lower income group, with 57% of them having incomes below $7,000 (Brink, 1984). According to projections form the BC Research Council (Forrester 49 . . . . . . H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E and Hamanea, 1983) and from Statistics Canada (September, 1984), as many as 49, 692 seniors in 1985, 55,117 seniors in 1990 and 64,312 seniors in 1996 will experience such a problem, defined as families having to spend 62% or more of their income on food, shelter and clothing (Evans and Purdie, 1985). Some seniors aging independently in their own homes suffer from physical dwellings in need of repair and/or adaptations. Yet, while the homes they own are valuable equities, many of these senior homeowners do not have adequate incomes to allow them to carry out the work. Architects choosing to provide design services for renovations of existing elderly housing may find it necessary to help educate the elderly on possible sources of funds. Some of such sources are briefly explained in the following chapters. They include government and private funds. FUNDING SOURCES FOR HOME MODIFICATIONS Government funds are generally in great demand but short supply for independent elderly in need of home renovations. Part of the frustration faced by aging-in-place elderly under the BC Continuing Care Program is that the program does not have a mandate to provide resources to make necessary alterations to the elderly's existing physical dwelling. This is the case despite strong research evidence linking the elderly's housing and their well-being (Regnier & Pynoos, 1987; Regnier et. al., 1992; Calkins, 1988; Cohen et. al., 1991). As a result, if an elderly's home is assessed (eg by a BCCCD Occupational Therapist) to be in need of some modifications, the family or the elderly is usually expected to provide the funding. The relatively low income levels of many aging-in-place elderly as described in 50 HEALTH. HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE Chapter One makes this an onerous task. The British Columbia Housing and Management Commission (BCHMC) previously had a home renovations program called HASI (Home Adaptations for Seniors in Independence) but it received its last application for funding in December, 1993. HASI was discontinued after its funding was stopped. Currently, the only source of government funding an aging-in-place elderly can apply for is the Canadian Mortgage and Housing Corporation (CMHC) Residential Rehabilitation Assistance Program (RRAP) and the RRAP for the Disabled. This federal government program provides low-income homeowners (including seniors) loans to repair residences, including mobile homes and condominiums. These loans, which may not have to be paid back, cannot be used for repairing rental units. Both the RRAP and the RRAP for the Disabled are given based on the gross income and geographic location of the applicant. The amount loaned ranges up to $25,000 in rural areas for the RRAP to $10,000 in urban areas. RRAP for the disabled has a maximum loan amount of $10,000. In order to qualify for CMHC's RRAP, the elderly's home must first be deemed to be substandard or deficient and in need of major repairs or lacking in basic facilities in the following categories: structural, electrical, plumbing, heating and fire safety. Normal maintenance or modernization work like painting or replacing old carpets would not qualify for RRAP funding. In order to qualify for CMHC's RRAP for the Disabled, the elderly must demonstrate their disability and the subsequent special modifications 5 t HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE required to improve the accessibility of their residence. In this program, the disabled is defined as "any person who, because of one or more persistent physical, psychiatric, learning or sensory disability is unable to ensure by himself/herself the necessities and social life of a person without a disability." 1 Under this program, most special modifications that make it easier for disabled persons to live independently in their homes are eligible. Such modifications however do not include therapeutic or supportive care-related items like whirlpools, baths, and swimming pools. Furthermore, items designed to facilitate housekeeping such as central vacuum systems or dishwashers are also not eligible. Private sources of funding for elderly usually involve some sort of loan with the elderly's house used as collateral. Several innovative financing alternatives have been developed, of which the Home Equity Plans is probably the most applicable for home renovations. Other financing alternatives do not create income for senior homeowners, instead, they lessen housing-related financial burdens. These options include the Land Tax Deferment Act and Shared Appreciated Mortgage. Home Equity Plans (HEP) are designed primarily for seniors who own their homes free and clear . A lending institution appraises the home and determines a loan amount. This loan amount is then paid out to the senior in monthly payments (and/or a lump sum) over a loan period of 5, 7 or 10 years or a lifetime (Evans and Purdie, 1985, Rogers, 1993). At the end of the payout period, the total loan has been paid to the senior, and now, ^hi s definition of disability is obtained from CMHC's "The Residential Rehabilitation Assistance Program (RRAP) for Disabled Persons (Homeowner)" Information Bul let in . 52 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE repayment o f the loan commences. I f a l ifet ime term is chosen, the loan is repaid out o f the proceeds o f the home when the senior dies, or i n the case o f a couple, when the second person dies. The balance o f the value o f the home, inc luding any increase in the value o f the home, is retained by the senior or the beneficiaries. H E P s are also referred to as Reverse A n n u i t y M o r t g a g e s . H E P s a l low a person who own their homes to spend some o f their home equity whi le s t i l l l i v i n g in it. They are most appropriate for seniors who: 1) own their property and have l i t t le or no debt against it; 2) wish to remain l i v i n g in their home, and 3) l ike to unlock some o f their home equity either in the form o f a lump sum or regular payment. Despite the options above to raise income levels whi le staying put, many seniors end up sel l ing their homes to move into smaller ones. Reasons for mov ing inc lude increased d i f f i cu l ty i n maintaining their ex is t ing homes, the desire to cash in on their exist ing home and buy into a smaller, less expensive home, and the reluctance to incur more debt. In addi t ion, many mun ic ipa l by- laws do not permit l ega l ized in-house suites or granny flats (Evans and Purdie , 1985), and thus make i t very diff icul t for seniors to l i v e i n their exis t ing homes whi le adapting part o f it for rental purposes. The Land Tax Deferment A c t i n Br i t i sh C o l u m b i a a l lows seniors to defer paying their property taxes unt i l the death o f the senior or conveyance o f the property. The M i n i s t r y o f Finance pays the amount required to reimburse the mun ic ipa l i t y , and registers an encumbrance on the property i n favor o f the C r o w n to the value o f the deferred tax and interest. 53 HEALTH. HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE Shared Appreciation Mortgages (SAM) give a reduced interest rate to the senior's mortgage. In exchange, the lender is given an interest in the property (Evans and Purdie, 1985). When the property is sold, the lender shares in any appreciation in the value of the home. HOME MODIFICATIONS TO REMOVE PHYSICAL BARRIERS With financing in place, what are worthwhile home modifications? Modifications to this built environment fall into two basic categories: adaptations involving removing physical barriers to counteract physical impairment, and adaptations to account for cognitive impairments of the person. Design adaptations to remove physical barriers are applicable to all senior aging-in-place dwellings. Design adaptations to account for cognitive impairments fall into two basic categories: those for the elderly suffering from changes in their sensory perceptions, and those suffering from dementia. Because most seniors suffering from dementia also suffer from changes in their sensory perceptions, solutions for these two categories overlap, the difference is the degree to which the solution is applied. Any home adaptation must begin with basic hygienic requirements. For instance, if the elderly's home is filthy, any modifications to the built environment is likely to have limited impact on the health or well being of the person. At a minimum, the elderly's home should be clean, well ventilated, and serviced with heat, treated (hot and cold) water and sanitation. The lack of any of these necessary services pose a grave threat to the health of the elderly. Fortunately in Canada, most elderly homes are 54 HEALTH. HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE adequately bui l t and serviced. Thus, the first step is to maintain and repair the dwe l l i ng of the senior R e m o v i n g p h y s i c a l barriers goes beyond des igning handicap-access ib le spaces: a key intent is to m i n i m i z e potent ial ly preventable falls that have an environment component (Pynoos et. a l , 1987). M o s t accidents among the elderly occur at home, and home accidents are the fifth leading cause o f death for persons aged 65 and above (Nat ional Safety C o u n c i l , 1980). Because fal ls are a major source o f accidents among older people, related research (Sheldon, 1960; C l a r k , 1968; Gray , 1966; Rubenstein, 1983) has suggested that the ident i f ica t ion and e l imina t ion o f environmental r i sks at home could reduce fall-related accidents i n the home by 25-50%. The fo l lowing is a part ial l ist o f suggested design adaptations to a l l spaces i n the e lde r ly ' s home: • Remove a l l f loor items that cou ld cause falls, (e.g. throw rugs, low stools); store unnecessary objects (e.g. brooms, shoes, clothes). Remove a l l loose w i r e s . • Place furniture against the wal l s to create more open spaces for easier movement (this a l lows for dementia wandering as we l l ) . • Instal l rubber treads on ins ide and outside stairs to improve tract ion (Gnaed inge r , 1988) • A d d safety ra i l ings on ins ide and outside stairs and verandahs (Gnaed inge r , 1988) • Widen exist ing corridors to a min imum of 4 ' - 0 " to a l low walker use. I f 55 HEALTH. HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE I bedroom bedroom BEFORE scale: l/4"=l'-0" 1 I r -lu • o © 5 ' D (T) Bathroom swing door replaced by pocket door. Q) Closet removed to create 5'-0" turning radius for wheelchair. (3) Interior partition wall removed to create one big room out of two small ones. (4) Door swing reversed to take advantage of greater maneuvering room outside AFTER scale: 1/4"= T-0" a .5« tf> s1 « c — o = O ns ^ o .E 3 • - in s a « o s ! T 3 tf) J i ' 5 56 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE BEFORE scale: l/4"=l'-0" f 1 i i open circulation AFTER scale: l/4"=l*-0" 57 -New sealed direct vent fireplace gives warmth and visual focus for room -Add plants to give the room a more homely cozy feeling Remove double doors to aid In free movement. Remove freestanding throw rugs, especially those with knotted or loose ends, to prevent tripping. Relocate furniture closer to perimeter walls to create more open space. HEALTH. HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE the person is confined to a wheelchair, use Section 3.7, 1992 B C B C as a g u i d e . • Remove split levels i n floors. Install code standard ramps wi th guard ra i l s i f necessary • In cases o f dementia, use removable low partit ions to prevent the elderly from accessing potent ia l ly dangerous spaces, (e.g. kitchens). L o c k up these rooms i f necessary. • In cases o f dementia, fence up the yard to contain wandering outside. The fo l l owing are some design adaptation guidel ines pertaining to spaces i n the dwel l ing most problematic for seniors: • The elderly suffer from more serious falls per use o f stairs than any other age group. Acc iden ts occur more frequently on stairs where the first few treads are different from the remainder o f the f l ight , or when the design o f stairs is v i sua l ly distracting or deceptive (Archea et.al, 1979). In such cases, the stair should be redesigned i f possible to el iminate the above. The tread edges should also be emphasized by using tactile and v isua l warning strips. • Burns are the second most common injury among the elderly, wi th 93% o f these accidents occurr ing in the home ( N B I E , 1983). C o o k i n g , smoking, the use o f matches, and bathing provide the greatest r i sks . P rov ide c lear ly marked and v i s ib l e faucet regulators and turn down hot water heaters to 120 degrees (Pynoos et. a l , 1987). • The ki tchen oftentimes has the most access ibi l i ty problems. Mos t accidents arise due to having to bend over, or to reach too high up for things. F loo r mounted ovens should be replaced by countertop models that 5 8 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE den BEFORE scale: l/4"=l'-0 "Replace spiral s ta i r winders with s t ra igh t runs Remove non load-bearing interior walls if possible t o create more open spaces — > AFTER scale: l/4"=l'-0" 59 HEALTH. HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE eliminate the need to bend over. Bending over to open a hot oven is a frequent problem reported by seniors. They should also have control buttons located in the front. Overhead cabinets should also be lowered according to the ability of the elderly resident to reach up and get something without using a step stool. As a general rule, overhead storage should be avoided to prevent possible objects from falling and hurting the senior. Research (Steinfield, 1978) has failed to determine a compromise countertop height acceptable for different seniors with different levels of impairment. The preference ranges between 26" - 36", and varies for different tasks: eg. a higher countertop for work in the sink, lower countertops for mix centers where more force from upper body strength is required: eg. mixing dough. For more detailed information on kitchen design, see Steinfield's(1978) 'Adapting Housing for Older Disabled People'. • Add assistive devices in bathrooms such as grab bars, bath seats, long hoses for bathing a seated person and non-slip mats (Gnaedinger, 1988; Pynoos et.al, 1987). In cases of very frail elderly, it is better not to use the bathtub. Handicap accessible showers (48"x48w clear turning radius) without curbs are more useful with the frail elderly seated in a shower seat. Doors should swing out to create more maneuvering space in the bathroom. Generally speaking, the use of handicap toilets as per section 3.7 of the 1992 BCBC is not recommended because many physically impaired seniors have difficulty in lifting themselves onto such high toilet seats. Thus, rather than changing the existing toilet to the handicap toilet, it is better to add a booster toilet seat (to raise the height of the seat) if necessary. The placement of grab bars should also consider the physical strength of the senior. For instance, placing a grab bar on the left hand side of toilet will have limited help if the person has a weak left hand. For 6 0 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE more detailed informat ion on bathroom design, see S te in f ie ld ' s (1978) 'Adap t ing Hous ing for Older Disab led People ' . Des ign modif icat ions are also important to counteract for the decreasing sensorial perceptions o f e lder ly (Sheehan, 1992). The majority o f these compensatory design changes are intended to counteract the v i s i o n and hearing impairments o f the e lder ly . T y p i c a l v i s i o n impairments inc lude increased sensi t ivi ty to glare and reduced sensibi l i ty to l igh t ing , contrast and color (see Chapter III: B i o l o g y o f Ag ing) . T o reduce glare, practical suggestions include not using glossy paint or shiny surfaces (eg. on tabletops, f loors) ; using shades, b l inds or other w indow treatments to reduce bright sunshine ref lec t ing through windows ; indi rec t l igh t ing and focused task l igh t ing (Sheehan, 1992). Increased l igh t ing levels should be focused on work areas without creating bright and dark spots. The use o f contrasting co lo r and textures also helps to overcome v i sua l impairment (see next section: Adap t ing the Home for E l d e r l y wi th Dementia) . The e lder ly wi th hearing impairments are often more susceptible to the disruptive effects o f background noise (Sheehan, 1992). In modi fy ing the home, the use o f acoustical ce i l ing tiles, carpeting, draperies and w a l l hangings can absorb unwanted background noise. In addi t ion , acoust ica l d r y w a l l wi th air spaced studs should also be used to contain par t icular ly noisy areas (eg. laundry room). F o r more detailed informat ion, see Hia t t ' s (1987) 'Des ign ing for the V i s i o n and Hear ing Impairments o f the E l d e r l y ' . Despite the wide abundance of guidelines for barrier free design (eg. B C B C , 1992; C M H C , 1992, 1990, 1987; B C H M C , 1992; Ca lk ins , 1988; Cohen and 61 H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E Waisman, 1991; Sheehan, 1992 and Regnier and Pynoos, 1987), there is confusion created when these guidelines provide contradictory information. For instance, Sheehan (1992) and Calkins (1988) recommend removing throw rugs on the floor to prevent elderly falls in the home, while the CMHC (1987, 1990) diagrammatic plans show one or more such rugs per bedroom, some of which appear to have thick knotted ends. Furthurmore, the CMHC bedroom design guidelines show closet corners with fin walls that would make it difficult for elderly with impaired mobility to access. Such are the types of discrepancies that one has to look out for; and guidelines that do not appear in different sources may be less reliable than those that do. ADAPTING THE HOME FOR ELDERLY WITH DEMENTIA AND THEIR CAREGIVERS Research has indicated that the built environment can have a significant influence on the quality of life of people with dementia and their caregivers (Cohen and Weisman, 1991). This influence is therapeutic in nature. In creating this therapeutic environment, the term 'therapeutic goals' is used to describe the desired relationships between people with dementia and their built environments. The theoretical support for the potential role of built environments includes Lawton's Environmental Docility Hypothesis, which states that 'the less competent the individual, the greater the impact of environmental factors on that individual' (Lawton, 1980). Environmental factors here include both built and social environments. As a person with progressive dementia ages, he or she becomes progressively less competent, and becomes increasingly 62 •HEALTH. HOUSING A ASSISTIVE TECHNOLOGY: THEIR ROLES IN ELDERLY INDEPENDENCE / /// dining nook BEFORE scale: l/4"=r-0" kitchen dining Install removable low partitions at all entriues into the kitchen to prevent Dementia patients from endangering themselves Using removable partitions ensures minimum disruption to the existing dwelling, and can be stored when not needed AFTER scale: l/4"-l'-0" H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E responsive to even modest changes i n the environment (Cohen & Wei sman , 1991). Consequent ly , as i n d i v i d u a l competence decreases, the environment assumes increas ing importance in de te rmin ing the person 's w e l l - b e i n g ( C a l k i n s , 1987). In v i e w o f the e lder ly wi th dementia 's increased responsiveness to the bui l t environment, what are ideal therapeutic goals? A c c o r d i n g to research undertaken by Cohen , Kennedy and Eisdorfer (1984): . . . 'the treatment objectives for the care o f older persons aff l ic ted wi th (dementia) are to m a x i m i z e their funct ional effectiveness, freedom and human digni ty . . . . a l though the i n d i v i d u a l becomes less competent, the chal lenge. . . . i s to recognize res idual strengths i n the pa t ien t . . .Main ta in ing phys ica l health and m o b i l i t y are p r imary objectives. . .other (needs are) main ta in ing d ign i ty , be ing accepted by others, mainta in interpersonal re la t ionships , and to establish a sense o f self-control was w e l l as control over the immediate ( inc lud ing buil t) envi ronment . . ' . C a l k i n s (1988) has further defined these therapeutic goals to include predic tabi l i ty o f the bui l t environment to enhance one 's perceived sense o f con t ro l , and m a x i m i z i n g the functional independence o f the i nd iv idua l to maintain his freedom and human digni ty. In l ight o f the above, i n addit ion to the home adaptations to remove phys ica l barriers for seniors wi th dementia as discussed in previous pages, modif icat ions are also required to compensate for the cogni t ive impairments. Due to these impairments, the person wi th dementia w i l l see or understand the bu i l t environment differently f rom people who are cogni t ive ly intact (Calk ins , 1988). One way o f helping these people understand the environment is to p rov ide mul t ip le way-64 • • • — H E A L T H . H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E finding/orientation cues directed to their different senses to reinforce the necessary information. The key intent here is to maximize the cognitive ability of the person by providing multiple environmental stimuli to create the ideal amount of environmental press (Lawton's Environment ProActivity Hypothesis) without confusing the person. The most important environmental stimuli are those that trigger vision, hearing and touch. Because vision impairment associated with aging include reduced sensitivity to light with increased sensitivity to glare, basic design solutions to compensate for such impairment involve increasing the lighting level 2-3 times using diffused or indirect lighting fixtures to reduce glare. Dimmer switches are useful to customize the lighting level to suit the elderly with dementia. Bright and dark spots, including sudden, high-contrast shifts in lighting levels should be removed (Sheehan, 1992). Using different colors, intensity, outlines, highlights, and textures on surfaces and objects will also increase the perceived visual contrast. This will help to compensate for the visual impairment while providing opportunities for multiple environmental cues. For instance, a possible solution for the elderly's bathroom would be for its door to be painted a non-glossy finish whose color will contrast clearly with the adjacent wall. It should be labeled 'toilet' in large bold letters. The door frame should also be highlighted with a different color as well, and a consistent deodorizing scent should be used with this particular bathroom. All these stimuli would serve to reinforce in the elderly with dementia the identity and significance of this particular space - his bathroom. This approach is consistent with the therapeutic goal of maximizing the functional independence of the individual by stimulating his cognitive abilities. 6 5 HEALTH. HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE As dementia progresses, the elderly also becomes increasingly sensitive to noise. Sudden noises can startle them, and provoke an unpleasant reaction. Within a home situation, design solutions include noise reducing floor finishes like carpets (as opposed to hardwood floors), insulating walls with acoustic gypsum wall board, and using heavier fabrics that absorb sound. If certain windows face noisy roads or neighbors, it may be better to keep them shut, or build a solid fence to block some sound transmission. It is important for the occupants of the home to limit their noisy activities (eg. watching TV., stereos, parties) to rooms or areas where the noise can be contained. On the other hand, chiming clocks and preprogrammed music can be used to provide therapeutic auditory stimulation (CMHC 1992). The elderly with dementia also experience increasing difficulty in staying oriented in their environment. Purpose built housing designs attempt to reduce this problem by repetition of spatial elements, thus creating predictable spaces. While this may be difficult to do in existing homes, one possible solution is to create open spaces that flow into one another, allowing the elderly to see different spaces to orient himself/herself. Ways to achieve this visual link include removing unnecessary interior partitions, replacing some walls with interior windows or low partitions, or configuring furniture to reinforce a 'strategic' wandering path. It is not recommended that mirrors be used because the viewing of their own reflections may startle the elderly with dementia (CMHC, 1992). Visual links also create an opportunity to emphasize certain spaces over others. For instance, two useful spaces to reinforce include the person's bedroom and bathroom. If these two spaces are properly design adapted, and can 66 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE be viewed consistently from different locations in the house, the orientation of the person in regard to these spaces will be reinforced. In all design adaptations, it is important to keep the home as home-like and comfortable as possible. Excessive adaptations (e.g. redecorating rooms) may over-stimulate or produce a negative reaction from people with dementia (CMHC, 1992) rather than reinforce their previous memories or cognitive abilities. It is recommended that the advice of a professional (e.g. architect) be sought before any major adaptations are attempted. For more information on design adaptations of the built environment, please refer to Calkins (1988), Cohen and Weisman (1992), Sheehan (1992), Gutman (1992), and CMHC (1992, 1990 & 1987). Design adaptations for the caregiver also fall into two categories: adaptations that help the task of providing care and supervision for the elderly with dementia, and adaptations that enable the caregiver to get some respite. Monitors/alarms should be installed in the home to help the caregiver provide surveillance. The alarms may be wired to sound if the elderly attempts to wonder into potentially dangerous or problematic areas, e.g. kitchens or bathrooms. These monitors can also be set up to automatically access professional services if necessary (eg. via an Emergency Medical Alert type program). Another solution is to install interior windows in the partition walls of an existing house. A good example is the 'open house' concept by CMHC (1992). This will allow the caregiver to monitor the person without being in the same room. Other safety and security related 67 HEALTH. HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE changes include ins ta l l ing inconspicuous locks on a l l doors that need to be moni tored ( C a l k i n s , 1988). It is also important to provide spaces in the exist ing home that the caregiver can 'escape' to. Th i s cou ld be a room reserved for noisy act ivi t ies mentioned above. The intent is to make this room private for the caregiver, some place to ' . . l o c k oneself away and rest or read or cry when frustrated and exhausted. . . ' (Gnaedinger , 1992) • Custom designed single family dwellings GOLIN'S RESIDENCE Gol in ' s Residence is a custom designed large single fami ly dwe l l ing located i n Anmore , Br i t i sh C o l u m b i a . Th i s project is discussed i n this thesis because it reflects the real l i fe experience o f a young couple wi th their two pre-school ch i ldren who decided to poo l f inancia l resources wi th their parents to b u i l d a large home for they and their parents to age-in-place together. The task o f creating a custom-designed/built residence for D r . and M r s . G o l i n was uniquely chal lenging: that o f bu i ld ing a single fami ly dwe l l ing that w o u l d be home for the changing aging-in-place needs o f the grandparents, yet s t i l l be home to two precociously active pre-school boys and their busy parents, yet ul t imately s t i l l be an marketable and desirable home for the mass housing market (in other words, be affordable to b u i l d , yet be attractive to sel l) . A br ief description o f the Go l in s is first in order. Peter and Natal ie G o l i n 68 HEALTH. HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE are or ig ina l ly from Russ ia , but grew up i n Aus t ra l ia before coming to Canada a number o f years ago. Peter has a fu l l time medical practice wh i l e Natal ie is currently a homemaker. The i r two boys, Mat thew and D a n i e l , are aged four and two respectively. Natalie 's father, M r . Turka , is currently 65 years o l d and in excellent health. M r s . Turka is 50 years o l d and also i n excellent health. In ant icipat ion o f future aging-in-place needs, however, I had to design the home to feel l i ke a large home, yet be able to eas i ly accommodate the necessary changes i n future. One o f the first ironies one learns i n designing a home for the elderly is denial o f aging-in-place reali t ies. Perhaps i n v iew o f his excellent health, Peter and Nata l ie were very careful in making sure that their dad was not around when we discussed aging- in-place design issues. T h i s surprised me at first., after a l l , one wou ld expect the father to be the best person to provide feedback! Ye t what I found out soon after was that the father had insisted that he was fine, and that nothing be done to the home to make i t an "o ld folks home"! Furthermore, even i f he was to admit that he might have d i f f icu l ty i n negotiating stairs in future, he was adamant that the house wou ld have stairs l i k e any other house unt i l the day that he just wasn't able to walk up stairs anymore! Thus, the first lesson learned in designing a home to accommodate the aging-in-place e lder ly is that there is no "perfect solut ion", and that the best solution is ult imately one o f compromise . The interplay o f human emotions and sensit ivi t ies, denial o f aging (and ul t imately , death), and an unwil l ingness to deal w i th future needs unti l the need forces i tse l f on the person a l l converge to make it very d i f f icul t for aging- in-place e lder ly , especial ly those s t i l l healthy and mobi le , to accept we l l -p roven and researched design solutions for their 69 HEALTH. HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE home environment. Within the above context, there are other compounding issues. First , the home must ultimately feel like a welcoming and attractive home. For most of us who are young and healthy, a grand, winding staircase in a large foyer with high ceilings and stepped-down living rooms are synonymous with a large, prestigious, yet welcoming home. For Peter and Natalie Golin, this was precisely the case, as it would be for the majority of other health, young, able-bodied home buyers. On the other hand, the more stairs there are, the harder it is for a physically-impaired person to move around. Second, the needs associated with raising young children very often conflict with those of progressive aging-in-place. Natalie was anxious to be able to see her children from as many areas in her house as possible, which mandated a large, open, two story foyer. However, this solution also means that sound will travel freely throughout the interior of the house, making it difficult for someone to rest in quiet. The conflicts of sight and sound transmission are one of the more difficult challenges in residential design, and are further compounded by fire separation regulations in multi-dwelling residential projects, as we will discuss later. Third, the home has to be marketable, which means that it has to appeal to the majority of home buyers. All things being equal, this majority almost always categorizes the value of homes, among other things, according to physically definable assets such as the number of bedrooms, number of bathrooms, sizes of rooms such as bedrooms, living rooms, family rooms, kitchens, and other amenities. Most homes can only build a maximum 70 HEALTH. HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE floor area based on the lot's Zoning, Floor Space Ratio (FSR)2 and other code and bylaw constraints. Within this fixed square footage, the designer has to decide how to "cut up the pie", i.e. how the square footage will be distributed. In this scenario, the conflicting mobility requirements of able-bodied persons verses mobility-impaired persons create a problem. "Accessibility needs"3, such as those mandated by Section 3.7 of the 1992 British Columbia Building Code (BCBC)4 require, among other things, wider hallways and bathrooms. However, if hallways and bathrooms get bigger, then the other rooms in the house will have to correspondingly get smaller to fit the total square footage within the FSR. Unfortunately, a larger bedroom or living room is generally much more marketable and desirable than a corresponding larger hallway or bathroom. As a result, the design of mass market housing is generally unwilling to adopt such accessibility guidelines because they tend to conflict with the preferences of the general housing market. Another challenge was to keep construction costs down. Initially, the intent was to keep the portion of the home for the grandparents on ground 2 The FSR is also called Floor Area Ratio, depending on the municipality. "Floor Area Ratio" means the figure obtained when the gross floor area of all buildings on a lot less the exclusions permitted in accordance with section 6.20 as divided by the are of the lot. (as defined by the Buraaby Zoning Bylaw, September 1992) 3 In the 1992 BCBC, "accessible" means that a disabled person is, without assistance, able to approach, enter, pass to and from, and make use of an area and its facilities, to either of them. "Disabled person" means a person who has a loss, or a reduction, of functional ability and activity and includes a person in a wheel chair and a person with a sensory disability, which includes visual and hearing impairments. 4 Generally speaking, effective as of September 2, 1992, all municipalities in British Columbia conform to the requirements of the 1992 BCBC to govern the design, construction, occupancy, alteration, addition, demolition and reconstruction of any building or portion thereof, as per the Building Regulations of British Columbia persuant to Section 740 of the Municipal Act. Any municipality that has not adopted the 1992 BCBC as its standard has typically used it, or previous versions of it, as a basis for its own building code. The Village of Anmore. in which Golin's residence is located, uses the 1992 BCBC as its standard. 7 1 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE level to eliminate the need for stairs. However, another part of the programmatic requirement was to provide a three car garage (two for Peter and Natalie, one for the grandparents); an enclosed mechanic's garage with a sunken service bay (grandfather likes to tinker with cars), and an enclosed storage area for a possible boat in the future. The spatial requirements of the "garage" portion of the home was like that of a five-car garage, the equivalent of a large three bedroom apartment (1400 sf approx.)! Finally, the design had to conform to the existing slope of the site, which dropped about twenty feet over a distance of about 158 feet from the east property line to the west. The realities of the sloping site forced the entire project to be stepped, with the suite and garage portion occupying one finished grade level, and the rest of the home another grade level. Furthermore, the amount of structural fill also required the main residence itself to be stepped into two levels, with a basement open to the lower west portion of the site (see building section). In the final design that evolved, the grandparent's suite was located above the five-car garage to save costs. This arrangement also allowed the grandfather to easily access his mechanic's space without bothering anyone else. The stairs leading up to the suite from the garage level were designed to be a "gentle" as possible - with minimum rises and maximum runs.5 In order to 5 The stair rise is the vertical distance measured between two adjacent stair treads. 72 U J u >• a o -4 o z. X o ia H GO ~ $ % a < 3 1 HEALTH. HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE — SEAM FOR EDGE OF FLOOR ABOVE (FLU5H BEAM) Golin Residence: Partial Main Floor Plan showing suite entry & future elevator scale: l/4"=l'-0" 79 H E A L T H . H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E (7FIREPLACE ;3'-6" GUARDRAIL 'WTBm VERTICAL BALUSTRADES LMNG / STEP DN: DINING BOTLIHE^F: PUT UREIIIII ELEVATOR SHAFT WALL < = < •Si @ LU Hi i n ^ (FUTURE SHAFT FOR HYDRAULIC ELEVATO:R^?|§vi i l l A . X y - Q X L E A R ' ^ j ^ G o l i n Residence: Part ial Second F loo r P lan showing suite l i v i n g & future elevator scale: l / 4 " = l ' - 0 " 80 •HEALTH. HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE VIEWS TO FOREST BEYOND K.ITCHEN OPEN RAILING TO BELOW VIEW OF THE SUITE WITH OPEN SPACE FEEL OF LIVING/DINING 8 1 HEALTH. HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE allow for mobility problems in future, the house was framed to allow for easy installation of a hydraulic elevator. It was decided that the elevator would be installed only when needed. The type of elevator provided for was a 4'-0"x4'-0" elevator cab large enough to accommodate a person in a wheelchair and another person standing, such as a nurses aid (see main and second floor plan) In order to not let the elevator overwhelm the feel of the home after installation, we deliberately created an 'elevator lobby' on the garage level, and opened the elevator door into the den/bedroom on the second floor, which at the time of elevator installation would also act as an elevator lobby/storage area. That way, one cannot see the elevator in the suite unless one is in the elevator bedroom. The intent was to subtly incorporate the elevator and not overemphasize the realities of aging-in-place to the grandparents. The den also served another purpose: the grandparents had another son who they hoped would visit them more often, thus the guest bedroom. Another design intent was to separate the grandparent's suite from the rest of the residence to allow for privacy. The site was unique in allowing the equivalent of a duplex development. By creating a fire and sound separation party wall between the two areas, it became clear for the children the areas in which they could behave with and without reserve. It also allowed for the Golins and the grandparents to easily live their private lives, yet be able to do things together at appropriate times. The grandparent's suite was designed to be as open as possible, with the living/dining space being one big room. Homely touches were incorporated, such as a sealed unit gas fireplace and grandma's piano, which occupies a central location in the room. The master bedroom was 82 H E A L T H . H O U S I N G & - A S S I S T I V E T E C H N O L O G Y : THEIR ROLES I N BRITISH COLUMBIA'S ELDERLY INDEPENDENCE located to allow some privacy from the kitchen and living/dining areas. Although the walk-in closet may be too small for wheelchair access in future, it was felt that grandma, who is much younger than grandpa, would much prefer such a layout since she had been used to one all her life. An unfortunate result however, was that the master bedroom door became less accessible as I would have preferred. The dining nook was designed to be a visual draw from the living/dining room, as both grandparents anticipated spending much time there. Beyond the dining nook is a great view of mountains too, so this view also acts as a powerful draw. The rising sun from the east floods the nook and makes it an ideal breakfast corner as well. The double French door separating the kitchen and nook from the living/dining room was incorporated to allow for visual, acoustical and sensorial privacy in the kitchen in the event of a party. As suggested by the Golins during a design meeting, it also allows for " the women to talk in the kitchen without being interfered with by the men". The bathroom was framed to allow for future grab bar additions. A shower was incorporated into the design because although they much preferred showers to baths, we felt that the bathtub was more marketable than only a shower. We agreed upon a stackable washer/dryer unit to save space. It is likely too that this unit will be more accessible for a person in a wheelchair as well. In the kitchen, ordinary cabinets as opposed to adjustable ones were decided on cost. Furthermore, it was feared that installing adjustable cabinets at the present time would only increase the stigma of the aging process, especially for the younger grandma. Perhaps as needs warrant in future, the grandparents may redo their kitchen. I suggested that they at least buy an oven with the controls 83 H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E in front, yet even this suggestion was not without conflict, for the Golins did not want their two young boys to be able to touch the controls. In summary, it is clear that the final design of the Golin1 s residence reflected more the current needs of the grandparents than their future aging-in-place needs. It also reflected the many different issues that impacted the design as discussed above, many of generated conflicting solutions. In the end, the design was a compromise that reflected the above realities. The changing needs of an aging-in-place elderly person places a tremendous challenge to the designer of a largely static physical environment. This challenge is further exacerbated by the psychological impact of over-designing the environment, or of doing "too much" before needs warrant it. I believe the tendency of human nature to deny or avoid the realities of aging until the needs actually arise to be one of the biggest challenges faced by designers in the custom design of an elderly's home. Throughout the entire design process, I always had to weigh conflicting needs - how do you make a home feel like a home for a senior without the associated "reminders" of aging, yet be able to be sensitive to the changing needs of the aging process? The more I thought about the issue, the stronger I became convicted that in the final analysis, the designer should never over-design for the elderly's needs. For instance, in Golin's case, putting the elevator in before grandpa really needed it was interpreted as being insulting by the grandparents, despite the fact that it would have been cheaper to do so. Consequently, I believe that there is no real alternative to retrofitting the home of an independent 84 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE elderly person over the course of the aging process. Perhaps one of the best ways the built environment can reinforce elderly independence, and minimize the rate of aging either mentally or physically, is for the home environment to be as much like a typical home as possible, and not overcompensate for the elderly. SHEDBOLT RESIDENCE As useful as the Golin's residence is for aging-in-place, only a very select few families can afford this type of environmental solution. In the next example of a custom design, we will look at a more modest home, where the needs of aging-in-place have mandated design changes that are more affordable, yet also effective. The Shedbolts are a retired professional couple. Doug Shedbolt, aged 69, was formerly the Dean of the University of British Columbia's School of Architecture. Sydney Shedbolt, who used to teach, is 72. In 1979, the Shedbolts bought their existing home in Vancouver because they fell in love with the location, the views the home afforded, and the quiet, restful neighborhood. Never mind the fact that the home was a three-story home with stairs that had no guardrails either inside and outside. At the time of the purchase, the home was perfect for the needs of the Shedbolts. Recently, Sydney began to suffer from osteoarthristis, a typically elder bone condition causing pain and mobility difficulties with the limbs. She was diagnosed as needing a hip and knee replacement. Immediately, the Shedbolts were faced with problem, for Sydney could no longer climb the 85 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE Shedbol t Res idence : Exis t ing M a i n F loo r Plan scale: l /8 '*=l ' -0" 86 HEALTH. HOUSING & ASSISTIVE TECHNOLOGY THEIR ROLES LN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE Shedbolt Residence: Existing Second Floor Plan scale: l/8"=l'-0" 87 HEALTH. HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE Shedbol t Res idence : Proposed Eleva tor A d d i t i o n @ Basement scale: l/4"=r-0" 88 HEALTH. HOUSING > THHH S O L E S rN BRnTS^CCiUVBIA^cT^ ^ H N O L O O Y : L U M B U S ^ R L Y I N D E P E N D E N C E Shedbolt Residence-A d d i , i ° " • M - "oor 8 9 H E A L T H . H O U S I N G & A S S I S T I V E T E C H N O L O G Y : " -T H E I R R O L E S LN B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E o CU S o o c o < i— O et > b O rn c -•S ^ b rt §.» T 3 "5 -o J O •a J=- « g H E A L T H . H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E Tff" iH ; D E CK. IS - " L E V E L O .1" Sua ft\ I'• 5& 6* ©Afc-FA'/p ty-V/A, 11 • - 4" © r L I f T. A4r vfce u s e H M V T M J ^ Shedbolt Res idence : Proposed Elevator A d d i t i o n @ T h i r d F loor scale: l / 4 " = l ' - 0 " 9 l H E A L T H . H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S IN B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E LL Shedbolt Residence: Garden Elevatio showing elevator core scale: l/8"=l '-0" 92 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE 11 t>L'[ ION A- A :scu*V+'.i'o (\:» ii). Shedbol t Residence: B u i l d i n g Section through elevator core scale: l/8"=l*-0" 93 H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E stairs in their three-story home easily. The Shedbolts grappled with the choices of either selling their home and moving to a "retirement home" or redesigning and rebuilding their existing home to allow for Sydney's mobility problems. In the end, they decided that their preference to age-in-place was more important, and so the challenge became how to redesign their home to allow Sydney to move comfortably with a limited budget. It was first decided that guardrails had to be installed throughout the home to allow Sydney to grab and steady herself. Although very basic, the Shedbolts had never "needed" these before, and had always wanted as little as possible (i.e. no guardrails) to get in the way of views, etc... Two inch diameter metal guardrails were installed, which only costed about $1,000 Cdn. Next, Doug designed for the addition of an electric elevator to allow Sydney to go between floors easily6. The cost of the elevator and the necessary renovations was estimated to be $9,000 Cdn. As the drawings indicate, Doug has skillfully incorporated the proposed elevator so that it does not become too imposing on the existing home, and is also relatively easy and cost efficient to install. Incidentally, the Shedbolts are waiting until they absolutely need the elevator before they install it, because they know that they will never recover this financial investment when they sell their home. Like the case of the Golins, it is interesting to note that despite his training as an architect, and his appreciation of aging-in-place issues, Doug Shedbolt did not begin to modify his home until Sydney began to suffer from osteo-arthritis. It confirms my earlier statement that in the final analysis, the designer should never over-design in anticipation of the 6 The elevator, supplied by Chimo Lifts Inc. is customised for each residential application, and is most suitable for retrofits. 94 H E A L T H . H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R ROLES I N BRITISH COLUMBIA'S ELDERLY INDEPENDENCE elderly's future aging-in-place needs. R a t h e r , the cha l l enge is to des ign the home so that it easi ly i n c o r p o r a t e s the necessary changes as par t of a phased c o n s t r u c t i o n process for f u t u r e a g i n g - i n - p l a c e n e e d s . T h e Shedbol t example also indicates that on a m o r e modest sca le , s k i l l f u l l y d e s i g n e d a g i n g - i n - p l a c e c o m p o n e n t s i n a house are often not very expensive to b u i l d . Idea l ly , the intent s h o u l d be i n c o r p o r a t e d in to the des ign f r o m the b e g i n n i n g to m i n i m i z e d i s r u p t i o n . • M u l t i - D w e l l i n g P r o j e c t s : P u r p o s e B u i l t A s s i s t e d L i v i n g versus S p e c u l a t i v e M a r k e t D e s i g n s In the last two sections, we have looked at single family dwelling solutions to maximizing independence for aging-in-place seniors. This emphasis reflects the fact that currently, 60% of older Canadians live in single family detached homes, while only 12% live in multiple dwelling units (Brink, 1985).7 Furthermore, two thirds of older Canadians own their own home (Brink, 1985). According to the 1991 Canada Census (Statistics Canada, 1992), this figure was 75% in British Columbia. In addition, 50% of elderly homeowners live in homes, built in the 1940's (Brink, 1985). Out of this group, 72% of the dwellings needed only regular maintenance, 15% needed 'See Chapter One for more information on current living arrangements of Canada's seniors. 95 H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : — — T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E minor repairs and 13% needed major repairs (Statistics Canada, 1982). Thus , wh i l e there is preference among the aging-in-place e lder ly for the independence and pr ivacy associated w i th single detached homes, it is clear that there is also a need to develop alternate aging-in-place solutions for renters and/or when the single fami ly dwel l ing is no longer a p p r o p r i a t e . I be l i eve that m u l t i - d w e l l i n g hous ing arrangements 8 can be an ideal alternate solut ion for aging-in-place seniors for a number o f reasons. F i rs t , these housing projects can be custom-designed purpose bui l t for ag ing- in-place. Thus, there is the potential o f creating ideal phys ica l environments that w i l l support aging-in-place. W h i l e some may argue that there w i l l inevi tably be some loss o f p r ivacy or square footage compared to single f ami ly dwel l ings , many other compensatory opportunit ies (eg. for meeting peers or sharing better pub l ic amenities) are also created. Second, many single fami ly homes may be unsuitable for the required home modif icat ions discussed earlier. These dwel l ings may be o l d and non-code c o m p l i a n t . 9 Unfortunately, the majority o f these homes have been bui l t for the mass market with l i t t le or no design considerations for the needs o f the aging-in-place senior. T h i r d , many senior home owners are asset r i c h but cash poor. They may f ind it too expensive to upkeep their o w n homes by themselves. Thus, they may be forced to sell their homes i n order to 8 Multi-dwelling housing arrangements refer to a building that contains more than one dwelling unit. A dwelling unit means a suite operated as a housekeeping unit, used or intended to be used as a domicile by one or more persons and usually containing cooking, eating, living, sleeping and sanitary facilities (BCBC, 1992). 9 Homes built before current building codes are usually non code compliant in many categories, including structural standards, insulation, heating, energy and plumbing. This means that if the home is being rennovated, some municipalities may force the home owner to upgrade deficient portions of the dwellings to meet existing codes. 96 H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E l i ve in dwell ings more appropriate to their needs. Four , many seniors l i v i n g alone may f ind m u l t i - d w e l l i n g housing arrangements at tractive because it may be easier for them to make friends. Some o f these housing arrangements may also p rov ide support services that may be needed by the aging-in-place senior. F i f t h , many seniors bought their homes in younger years as security for their retirement years. W i t h their ch i ldren grown up and gone, many o f their homes are too big for their needs. Thus, many cash in on their home investment and "buy down" into purpose bui l t m u l t i - d w e l l i n g homes that may be much more affordable than comparable s ingle fami ly dwe l l ings . There are many different types o f m u l t i - d w e l l i n g housing arrangements avai lable , and they meet different needs during the aging process. In general, they fa l l into two big categories. The first category includes care fac i l i t ies , nursing homes and other inst i tut ional health care type housing arrangements for seniors i n need o f cont inuing c a r e . 1 0 These seniors are no longer able to l i v e independently without r isk. The housing and care for such seniors are the respons ib i l i ty o f our p r o v i n c i a l government's M i n i s t r y o f Heal th , wh ich has a number o f regulations in e f f e c t . 1 1 These 1 0 Continuing Care is defined by the B.C. Ministry of Health as the provision of health care services, designated by the minister, to a person with an acute or chronic illness or disability that does not require admission to a hospital as defined in section 1 of the Hospital Act, or to a person with a frailty. 1 Canada's Constitution gives the power to regulate health care to the provincial government, which acts through the Ministry of Health. The key regulatory statutes applicable to those delivering health care and housing to seniors in this category include the Community Care Facility Act, the Adult Care Regulations, the Continuing Care Act, the Hospital Act, and the Hospital Act Regulations. The majority of care facilities for seniors are regulated under the Community Care Facility Act and Continuing Care Act, which includes those that provide skilled care on an "occasional" basis to the seniors (Fenlon, 1993). In addition, the design and construction of such facilities need to comply to all relevant building codes and municipal bylaws. 97 H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A N E L D E R L Y I N D E P E N D E N C E regulat ions cont ro l the design, cons t ruct ion , management and administration of a l l facil i t ies i n this category. I w i l l not focus on this category because the seniors here are no longer able to age-in-place. They thus fa l l beyond the mandate o f this thesis. The second category includes the aging-in-place senior who is able to l i v e independently i n a m u l t i - d w e l l i n g housing arrangement. The housing projects in this category are not regulated by the M i n i s t r y o f Heal th because there is no "health care" component (i.e. cont inuing care). Thus , these housing projects need on ly comply wi th relevant bu i ld ing codes and munic ipa l bylaws , which govern the design and construct ion o f bu i ld ings i n the province (see footnote #4 in this chapter). The net result is that the code requirements for these housing projects are much less stringent than that o f the first category, meaning that there is opportunity to design such projects to reflect the typ ica l res ident ia l homes that the aging- in-p lace elderly much prefer. The remainder o f this chapter w i l l deal wi th mul t i -d w e l l i n g projects of the second category. The vast majority o f mu l t i -dwe l l i ng projects being bui l t and sold i n B r i t i s h C o l u m b i a are townhouses and c o n d o m i n i u m s / a p a r t m e n t s . 1 2 General ly bu i l t for the mass market, such projects typ ica l ly target young first t ime home buyer who cannot afford single family houses yet. In recent years, projects that speci f ica l ly target seniors have been bui l t , but they have 1 Condominiums are apartments that are sold to different owners under the Condominium Act. Owners of such units own the interior of their unit, while common properties like the lobby are shared by all owners and maintained by an owner-elected Strata Council. Apartments buildings, on the other hand, are owned by one entity and individual apartments in the building can only be rented out to tenants. Tenants in apartment buildings have less control over the maintainence of their units. 9 8 — — H E A L T H . H O U S I N G & A S S I S T I V E T E C H N O L O G Y . T H E I R R O L E S I N BRITISH C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E A typical Speculat ive Marke t Condomin ium Project: Bu i l d ing Elevat ion @ l / 8 " = l ' - 0 " 100 ——HEALTH. HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE A typical Speculat ive Marke t C o n d o m i n i u m Project: Typ ica l Unit Plan @ l/8"=l*-0" 101 HEALTH. HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE UNIT B F L O O R P L A N 6 C * 1 £ V 4 " . r - 0 " A typical Speculat ive Marke t Condomin ium Project: Typ ica l Unit Plan @ l/8"=l'-0" 1 0 2 HEALTH. HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE r Balcony Al j A2 AI A2 a w i far crmn bctban & •ac*. A5 A5 * 1 / ' '• 1 A CViflin* f«f i t iat Icefoot* M UNIT V » are ««*aHy ttde. 1 UNIT A FLOOR PLAN Living Unite 101.201.301 &-4C1 | See Partial Plan this drawing | 1 Balcony PARTIAL UNIT A FLOOR PLAN SCALE ;M-.T.C (UNITS m. 211.311.4 -+11 ONLY) A typical Speculat ive Marke t Condomin ium Project: Typ ica l Uni t Plan @ l /8"=l ' -0" 103 H E A L T H . H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E been the exception rather than the norm. The typica l first t ime home buyer is usually seen as being a young, energetic, upwardly mobi le career oriented i n d i v i d u a l , and as a result, aging- in-place design considerat ions are given li t t le or no pr ior i ty . In a l l fairness, it is l i ke ly that a healthy, aging-in-place senior w i l l have l i t t le or no problem l i v i n g in a typ ica l townhouse or condomin ium. Furthermore, from a design perspective, there need not be major changes i n the design o f such a project even i f it was geared toward the senior market when the senior is s t i l l healthy. A s discussed in the second por t ion o f this chapter, many "young-old" senior home buyers may prefer to ignore their future aging-in-place needs, and may prefer to buy typ ica l mass market townhouses and condomin iums to ensure that they have a b ig market for resale. Consequent ly , many typ ica l m u l t i - d w e l l i n g projects sel l w e l l to seniors without speci f ica l ly targeting them as customers. In addi t ion , many so-ca l led "senior communi ty" housing projects are no different from typica l housing projects from a design perspective. M a n y o f these projects may s imply be located near to some type o f publ ic or private health-service fac i l i ty . The faci l i ty is then marketed as an inherent part o f the services p rov ided by the senior project. Such projects may also stipulate m i n i m u m buyer 's age requirements i n order to create an "retirement communi ty" . W h i l e being very attractive places to l i ve in i n i t i a l l y , aging- in-place e lder ly may f ind the housing arrangement to be unsuitable as they grow older . Unfortunately, many seniors buy into these projects for a number o f reasons, inc lud ing the impression that their future needs w i l l be met elsewhere, poor ant icipat ion o f their needs, or s imply because o f a preference to deny future needs unt i l the needs arise. Fo r 104 H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E this thesis, I w i l l not focus on the typical mul t i -dwel l ing project because it is our be l ie f that these projects are suitable l i v i n g arrangements for the independent elderly for only a short period of time. I will assume that the aging-in-place elderly has already maximized the length of stay in their previous single family dwelling, so that when the move is made to a multi-dwelling arrangement, there must be the inherent ability to cater to their needs until the time when continuing care is absolutely necessary in a care facility. It is in this context that we w i l l discuss a relat ively recent concept i n mul t i -d w e l l i n g housing arrangements for the independent e lde r ly : Ass i s t ed L i v i n g . Ass is ted L i v i n g is a long term care alternative wh ich involves the de l ivery o f professionally managed personal and health care services i n a group setting that is residential in character and appearance in ways that op t imize the phys ica l and p sycho log i ca l independence o f the residents (Regnier, 1992). W h i l e the concept i tself is not new, it is only recently that projects using the Ass is ted L i v i n g model have now been bui l t i n several places in the Uni ted States. S i m p l y stated, it is the be l ie f that appropriately designed m u l t i - d w e l l i n g housing projects can p lay a key ro le i n pro longing the independence o f aging-in-place seniors i f they contain the right dose o f personal and health care services - services that are not so health care intensive that they have to be control led by the M i n i s t r y o f Heal th . Assis ted L i v i n g thus provides housing and care for the aging elder ly i n the per iod between independent l i v i n g and inst i tu t ional care. It c la ims its niche on the premise that many seniors who f ind their single fami ly dwell ings no longer suitable for their needs end up being put into 105 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE nursing homes and other ins t i tu t ional care homes prematurely and against their own personal preference. Proponents o f Ass is ted L i v i n g bel ieve that i f the project is designed w e l l , and is complemented by the right blend o f management, personal and health care services, it offers its residents a much superior qual i ty o f l i f e , and potent ia l ly prevent ins t i tu t iona l iza t ion u n t i l absolute ly essent ia l . Sui table candidates for Ass i s t ed L i v i n g arrangements inc lude seniors who need assistance w i t h bathing, dressing, medicat ion superv is ion , to i l e t ing , ambulat ing, eating, and grooming (Regnier, 1992). W h i l e assistance is needed regular ly , the leve l o f assistance needed stops short o f 24 hour supervised nurs ing c a r e . 1 3 What differentiates Ass i s ted L i v i n g housing projects from typ i ca l mu l t i -dwe l l i ng projects? One important component is management. U n l i k e typ ica l mu l t i - dwe l l i ng projects where the senior home buyer is left alone after the purchase, the management o f an Assis ted L i v i n g project has the task o f creating an idea l , therapeutic environment that w i l l support the needs o f the aging- in-place senior, yet provides an unrestr ict ive environment that encourages the freedom o f choice , d ign i ty , independence, p r ivacy and ind iv idua l i ty o f the aging senior (Regnier et.al, 1991). Some key management act ivi t ies i n v o l v e p rov id ing residents wi th a sense o f home and communi ty , i n v o l v i n g famil ies i n resident's l ives , a l l o w i n g residents to take an active role i n decis ion making, p rov id ing act ivi t ies that st imulate the m i n d and body, p r o v i d i n g opportunit ies for vo lun tee r i sm and interdependence. See Regnier et. a l , (1991) for more informat ion. 1 3 See "The Continuum of Care during the Aging Process", Chapter Two. 106 H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E The personal and health services avai lable on Ass i s ted L i v i n g projects are also not found i n typ ica l mul t i -dwe l l ing projects. These services are focused on the A D L , I A D L , Heal th , M e n t a l Heal th , Behavior and M o t i v a t i o n o f the r e s i d e n t s . 1 4 Ass is ted L i v i n g provides personal and health services short o f 24 hour nursing supervision found in cont inuing care fac i l i t ies . Nevertheless, a major challenge faced by Ass is ted L i v i n g projects may be conv inc ing authorities having ju r i sd i c t ion l i k e the M i n i s t r y o f Heal th to a l l ow them to provide personal and health services, yet not be regulated by the requirements o f the Communi ty Care F a c i l i t y A c t or the Con t inu ing Care A c t . The differences between Ass i s ted L i v i n g ( A L ) projects and typ ica l continuing care facil i t ies ( C C F ) such as nursing homes are as fo l lows. Firs t , A L projects are designed and managed from the beginning to foster max imum independence and self rel iance for the elder ly person. A s such, the regulations for l i v i n g i n A L projects are much more lax and free compared to C C F s . Secondly, l i v i n g in an A L is comparable to l i v i n g in the elderly 's own home wi th in a communi ty wi th some health and socia l support services provided as needed. L i v i n g in a C C F , on the other hand, is more comparable to l i v i n g i n a hospital wi th a few homely touches. W h i l e there are usually some attempts to make the elder ly feel at home, (for instance, by a l lowing them to br ing their own pictures or a few smal l pieces o f furniture or ornaments), the overa l l ambiance is s t i l l predominant ly ins t i tu t ional and re la t ive ly unfr iendly , i n part due to the 1 4 A D L are Activities of Daily Living. IADL are Instrumental Activities of Daily Living. See footnote #2 from Chapter 2. 107 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE strict and uncompromis ing nature o f bu i ld ing codes for health care institutions. T h i r d , the services provided in an A L home are not meant to overburden the i n d i v i d u a l , o r to overcompensate their A D L and I A D L needs, rather to assist only i f needed. The guiding philosophy o f these services is to maximize the elderly 's abi l i ty to remain independent. In the same ve in , v i s i t ing fami ly and friends o f the elderly are encouraged to help the elderly i f desired as opposed to depending on the staff. The health care services in a C C F , on the other hand, are t ightly regulated by the province's Hospi ta l A c t , the Cont inu ing Care A c t , and the C o m m u n i t y Care Faci l i t ies A c t , among others. Fo r l i ab i l i t y reasons, there is far greater reluctance to a l low the elderly to fend for themselves. In such a h igh ly regulated care environment , the e lder ly ' s desire and preference for independence or d igni ty may take a secondary pr ior i ty to the fac i l i ty ' s need to ensure that no chances are taken wi th the elderly 's health care. N o t surprisingly, the support staff o f an A L home is composed o f fewer health care professionals compared to a C C F . F r o m the above paragraph, it is easy to see why Assis ted L i v i n g is becoming popular among the e lder ly . It seems to offer an ideal compromise between the complete independence o f l i v i n g i n one's home, and the complete "surrender" o f independence i n an ins t i tu t ional setting. However , it is c ruc ia l to stress that the very nature o f Assis ted L i v i n g means that it is not ideal for the severely cogni t ive ly and/or phys i ca l ly disabled e lder ly who need the 24, hour supervised health care general ly available only in inst i tut ional care homes. The question is , when is that point reached? Even i f an elderly 's doctor is convinced o f the need for inst i tut ional izat ion, what i f the e lder ly refuses? Perhaps for the first t ime, 108 • • • • • • H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E such issues become very important because up t i l l now, one cou ld argue that the e lder ly who were incapable o f l i v i n g independently had no satisfactory choices o f l i v i n g arrangements besides l i v i n g wi th f ami ly , or l i v i n g in a continuing care faci l i ty or a nursing home. Clear ly , as Assis ted L i v i n g projects become more commonplace , the range o f choices avai lable to seniors become much more attractive. F i n a l l y , let us consider the design differences between a typ ica l speculative market condomin ium project wi th that o f an Assis ted L i v i n g project. F r o m a design perspective, assisted l i v i n g projects have some important differences to typ ica l m u l t i - d w e l l i n g projects. I have already discussed earl ier how typ ica l m u l t i - d w e l l i n g projects target the young, first time home buyer and thus pay l i t t le or no attention to aging-in-place design considerations in the d w e l l i n g unit . Beyond this fundamental difference however, other important differences remain. F i rs t , Ass i s t ed L i v i n g projects are usual ly kept as smal l as the m i n i m u m number o f residents required for affordable management, personal and health care services. The number o f dwe l l i ng units required for economies o f scale may range from 25 i n a smal l town to over 40 in typical urban settings (Regnier, 1992). In contrast, a typ ica l mul t i -dwel l ing project may have hundreds o f units. Second, the design precedent o f an Assis ted L i v i n g bu i ld ing type is the mansion house, country v i l l a , or bed-breakfast hotel . It usually takes its character from the his tor ic architectural heritage o f its setting. Th i s usual ly means more care is taken to create details and materials that reminisce past res ident ia l ambiance. Mass market m u l t i - d w e l l i n g projects, on the other hand, are bui l t w i th current housing market trends and cost cut t ing measures as be ing p r imary generators o f design and construct ion. 109 H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E Let us compare and contrast br ie f ly the designs o f a typical speculative market condomin ium project (see diagrams on pages 99-103) wi th an example o f a w e l l designed Ass i s ted L i v i n g project - the Rosewood Estate i n Rosev i l l e Minnesota by A r v i d Elness Archi tec ts , Inc., Minneapo l i s , M i n n e s o t a 1 5 . In comparing the two typical floor plans (pg. 99 versus pg . I l l ) , the first major difference is that the corr idor i n a market condomin ium is typical ly set at close to the m i n i m u m width o f 1100 mm (3'-8") required for exit widths. Unless the project is a high-end project, very l i t t le extra space is given to the corr idor in order to maximize the available area for the l i v ing units. The corr idor exists merely as a u t i l i ta r ian and code feature. Furthermore, higher end market projects for condomin iums tend to be concrete construct ion high-r ise towers to take advantage o f v iews , meaning that general ly speaking, the ver t i ca l c i rcula t ion core and corr idor tends to be a higher percentage o f the floor area per floor due to the less units per leve l . In such cases, m in imum space is afforded to corridors to reduce the overa l l area occupied by non-saleable area. In contrast, the typica l bu i ld ing f loor plan o f Rosewood Estate shows the central "corridor" to be designed to be wider , and to "merge" into common spaces l i ke lounges. These lounges serve a twofo ld function: they break up the monotony o f a long, narrow corr idor , and they serve as a common meeting space in between unit clusters. The corr idor has also been deliberately staggered to reduce the perception o f long , narrow spaces that tend to be un inv i t ing . 1 5For a more detailed case study of the Rosewood Estate and other comparable Assisted Living porjects, please see Vic Regnier's Assisted Living for the Elderly (Regnier, 1992). 110 HEALTH. HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE 25 50 it n J l J l T L T U 10 J 2 0 m CASE STUDY DIAGRAM 5.6 Entry Floor Plan: Common spaces are clustered around the symmetrical entry. North and south buildings are treated as residential wings. Note how cor-ridors have been offset and intermediary lounges located to avoid the perception of long corridors.The wide eight-foot cor-ridors and the numerous undifferentiated lounges, however, make the building more anonymous and at times disorienting. Excerp from Regnier, 1992: Rosewood Estate, Roseville Minnesota Typical Unit Floor Plan (by Arvid Elness Architects, M N . ) scale: as shown 1 1 1 T H E I R R O L E S IM U N I T B UNIT A 5 1 0 I 5 H Exeerp from Regnier, 1992: Rosewood Estate, Roseville Minnesota Typical Building Floor Plan (by Arvid Elness Architects scale: as shown C A S E STUDY D I A G R A M 5.7 Unit Ousters: Four units are typ-ically clustered around an internal lounge. Careful planning has allowed these units to be fitted together with bedroom and living room spaces receiving perimeter lighting. The C unit uses a large cased portal opening from the bedroom to the living room to create greater identity for the bedroom in this studio unit. 1 1 2 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE The second major difference between the two plans deal wi th the bu i ld ing shape. It is clear that the market condominium plan on pg. 99 is re la t ively rectangular i n shape - being made up o f re la t ively s imi la r units stacked up against a double-loaded corridor - much l ike kernels in a corn cob. Th i s reduces the external w a l l surface area to bu i ld ing vo lume rat io, and means higher efficiencies (i.e. lower cost) i n terms o f total area o f wal l s , bu i ld ing heating costs, ease and repetition o f construction. W h i l e producing cost savings however , the bu i l d ing becomes monol i th ic and re la t ive ly bo r ing , w h i l e i n d i v i d u a l units lack ident i ty . In contrast, the Rosewood Estate bu i ld ing f loor plan shows a very staggered, "organic" organizat ion o f masses around the central cor r idor , w h i c h as mentioned above, was staggered and broken up. W h i l e less efficient i n nature, i t creates much greater design interest, and a l lows smaller , sub-components o f the b u i l d i n g to have i nd iv idua l identi ty. In the case o f Rosewood Estate, the sub components have been designed as four-unit clusters organized around a lounge. The lounge is an important area because it a l lows the residents o f the immediate cluster to treat it as their common extended " l i v i n g room" and thus encourages more socia l interaction. It is also easier to make good friends wi th three other neighbors i n one's cluster as opposed to twenty other neighbors along a long narrow corr idor. Needless to say, the efficiency o f the "corridor" decreases dramat ical ly when we consider the area taken up by the lounges, and the concept o f such "common interactive spaces" are an important difference between t y p i c a l market c o n d o m i n i u m projects and the Ass i s ted L i v i n g Project. 113 - HEALTH. HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE M o v i n g on to the ind iv idua l units themselves (pg. 101-103 versus pg . 112), it is clear that the Rosewood Estate unit has been designed to accommodate handicap access ib i l i ty . Note the 5'-0" turning radius i n the bathroom and the double doors into bedrooms. Further differences occur i n finishes and other details, but they also deal p r imar i ly wi th handicap access ib i l i ty . Other than handicap access ib i l i ty , typ ica l space p lanning pr inciples apply in the overa l l design o f the residential unit. Fo r more informat ion, please refer to the first section o f this chapter on handicap des ign gu ide l ines . In summary, it is clear that there are important differences between market condominiums and Ass i s ted L i v i n g projects. In compar ing and contrasting Rosewood Estate to the typ ica l market condomin ium project, I have h ighl ighted important design concept differences. However , it must be remembered that at this re la t ive ly early stage i n the evolu t ion o f Assis ted L i v i n g , there is as yet no " typ ica l" or "prototype" project model , on ly good examples. Fur thermore, w h i l e there are s imi lar i t ies between good examples o f Assis ted L i v i n g projects from a design standpoint, it must also be emphasized that there has been a great variety o f design solutions used i n attempting to achieve the goals o f independent assisted l i v i n g . Since I obviously cannot describe a l l these projects, the reader is encouraged to read Regnier 1992 for a ful ler treatment o f the issue. Unless society as a whole becomes exposed to, and consequently becomes w i l l i n g to, accept design solutions that i n v o l v e "compromises," (such as smaller unit sizes in favor o f larger corr idors wi th lounges or units designed for handicap access ib i l i ty) , i t w i l l remain a challenge for design 114 H E A L T H . H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E features associated wi th Ass i s t ed L i v i n g to become readi ly incorporated into market condomin ium projects. The task remains for architects i n particular, and for society as a whole , to accept that such compromises are necessary, and ultimately for the good o f a l l , in order to prolong independence for B r i t i s h Co lumbia ' s e lder ly . In concluding this chapter, it is clear that housing plays a key role i n determining the w e l l being o f aging-in-place elderly. In this context, I h ighl ighted three key areas o f housing i n wh ich architects can play a c ruc ia l role in enabling independence. Central to the role o f the architect is the responsibi l i ty o f setting up such an opportunity by a two-pronged approach - first, by removing obstacles to independence in an unsuitable phys i ca l environment, and secondly, by incorporat ing into the design from the beginning, design elements that can be constructed later to counter the effects o f aging. The first approach is somewhat passive and reactive i n nature, and focuses in "removing" the problem - as elaborated i n the section o f retrofit t ing the home environment to a l l ow for prolonged independence. The second approach is more pro-act ive and long-term in its approach, and a l lows for the phys ica l environment to "age" wi th the independent e lder ly , so to speak. W h i l e both approaches are important and appl icable , it is important to emphasize that wi th a l l things being equal , the second approach is superior i n concept, appl icat ion and ul t imately , cost. It is always easier and more successful in phasing a we l l designed home to have the "elements o f aging", l ike the elevator, when it was designed for f rom the very beginning . F i n a l l y , I reiterate my bel ie f that in the f inal analysis, the designer must 1 1 5 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE never over compensate for the aging requirements of the independent senior. While overcompensation appears to be a safer approach on the surface, it is my belief that this approach runs contradictory to everything I have learned about British Columbia's seniors. In my opinion, the preference of British Columbia's elderly to age-in-place is proof of their preference to remain productive, and hence their expectation of being treated as being such. Consequently, the physical environment must never be over designed to become so pro-active that the elderly is deemed to be not in control. In the final analysis, the best approach is still the second phased approach discussed above. 116 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE CHAPTER FOUR ASSISTIVE TECHNOLOGY AND ELDERLY INDEPENDENCE In the last two chapters, I concentrated on the issue of Health and Housing. I discussed a relatively recent development in health care delivery in the United States called the ON LOK Health Services Program, an excellent case study of a community-based health delivery system for some aging-in-place elderly in San Francisco. I also briefly compared and contrasted this model with what is interpreted to be the its "counterpart" in British Columbia: The BC Continuing Care Division. Within the context of BCs community based health care model, I then discussed three types of applications in which architects could apply their skills in housing to enhance the aging-in-place elderly's health and well-being. In short, I focused on health and environmental responses to the needs of aging-in-place. In this chapter, lets turn our attention to another type of response - that of assistive technology. Assistive technology is the term I will use in this thesis to describe the milieu of technological advances and their subsequent mass market products that have been developed to aid aging-in-place for. the independent elderly. I can categorize these technologies into three basic groups: a) health delivery assistive technologies, (e.g. diagnostic medical equipment in health care institutions.) b) mobility related assistive technologies (e.g., wheelchairs) 117 H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E and c) communication related assistive technologies (e.g., cellular phones) . It is beyond the scope of this thesis do justice to any one of the above categories. Rather, the point raised is that in today's Information Age society, a technological response to the challenge of aging-in-place is becoming as important as any health service or housing response to the needs of the independent elderly. Important advances in all three categories have significant impact on the present and future aging-in-place potential of BC's well elderly. For instance, in the second category of mobility-related technologies, electronic products now can enable a person to control any chosen number of environmental and psychometric factors in the home including lighting, heating, security and mechanized draperies though a hand held remote-control device. For this thesis, I have chosen to focus on a particular product in the third category, where recent advances in telecommunication technology have given birth to a whole range of communication devices that hold tremendous promise for enhancing the independence of the well elderly. I will discuss a particular communication device - the Videophone, a new, revolutionary communication device that holds tremendous promise for elderly independence. This device is so new that it has not even been mass marketed in British Columbia yet. I have chosen to focus on the videophone, and not on other comparable computer-based audio-visual communication devices, because I believe that as a technological and 118 H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E logical development of the telephone, the videophone is much easier to use than other comparable audio-visual communication products and also almost everyone has access to a telephone . Consequently, I believe it to be more acceptable to the independent senior as an improved way of communicating. This chapter has three components. First, I will discuss the concept of human communication, and how visual communication is a key, inherent part of the communication process. Second, I will discuss the current videophone product . Finally, I will speculate how the continued development of such audio-visual communication technology may aid the independence of future aging-in-place elderly. • Audio Visual Communication and Elderly Independence In chapter one, I defined the concept o f independence and the ab i l i ty o f the e lder ly to (1) "maintain cont ro l over their near environment, their ab i l i ty to meet personal needs (Albe r t a Senior Ci t i zen ' s Secretariat, 1986) and to maintain responsibi l i ty for decisions in these areas; (2), the ab i l i ty o f the elderly to remain part o f the communi ty (Keat ing, 1991) as active participants; and (3), easily access services such as groceries, banking , health care etc. (Keat ing, 1991). In a l l the three cr i ter ia , effective human communica t ion plays a key role. H o w is effective human communicat ion achieved? This is a very complex mul t id i sc ip l ina ry question, and is beyond the scope o f this thesis. 119 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE However , to appreciate the potential o f the videophone, I w i l l br ief ly discuss the importance o f being able to see the person I am talking to i n a typ ica l face-to-face interaction. There are two components in the message communica ted during this interact ion - verbal and nonverbal . V e r b a l communica t ion refers to the spoken component, concerned w i th the words that are conveyed. The abi l i ty to see the person and the messages conveyed is part o f nonverbal communica t ion . Nonve rba l communica t ion refers to a wide variety o f 'non-word ' signals wh ich may repeat, substitute for, contradict, or reinforce verbal izat ions (Carmicheal et. a l , 1988). The f o l l o w i n g are some important examples o f unique nonverbal communica t ion functions, a l l o f w h i c h can idea l ly be communicated using an aud io -v i sua l c o m m u n i c a t i o n dev ice . Personal Identity Carmichea l describes how nonverbal signals are used to convey, among other things, our identi ty (e.g. sex, age, personali ty and socioeconomic status). F o r instance, studies indicate that age, sex and socioeconomic status are often accurately judged from photographic or voca l samples (Nerbonne, 1967 & Dav i s , 1949). Furthermore, whether accurate or not, people tend to judge personal i ty characteristics based on body shape (Wel l s & Siegel , 1961; Sortes & Gat t i , 1965). T h i n people are perceived to be wi thdrawn, tense, suspicious, and sensitive, fat people are perceived to be sympathetic, dependent, sociable , and s luggish; muscular types are often be l ieved to be assertive, ac t ive , adventurous, and determined (Carmichea l & Knapp , 1988). Emotional States 1 2 0 HEALTH. HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE Nonverba l communicat ion also plays a key role in the expression o f emotional states (Bul le r , 1991). F a c i a l expressions are our chief source o f this information. Common quotes l i ke "why do you look so downcast today" or " Y o u look l ike you've just won a m i l l i o n dollars" clearly denote how we commonly interpret a person's emotional state by the person's facia l expression. Research by C o k e r and Burgoon (1987) even argues that evidence suggests such interpretations to be soc ia l ly universa l , i .e. that there are consensual ly recognized meanings for such nonverbal behavior . I bel ieve the abi l i ty of an elderly to v i sua l ly communicate his/her emot ional state on the videophone to be a tremendous improvement over the te lephone. Value Judgments and Attitudes People often convey their value judgments and attitudes by how they react nonverbal ly wh i l e communica t ing (Bu l l e r , 1991). V a l u e judgments and attitudes are often conveyed, for instance, when their nonverbal behavior communicates their l eve l o f interest. Other examples o f such nonverba l behavior inc lude tu rn - t ak ing , feedback, general attentiveness and eye contact. Fo r instance, one can determine what someone is l ook ing at by observing their eyes ( A n g o l i l l o , et. a l . , 1993). Constantly wandering eyes often communicate a l ack o f interest in the listener, or perhaps a discomfort o f some sort. Furthermore, general attentiveness may also be communicated by the person's gest iculat ion - are the hands fidgety? Does the person's body language communicate a sense o f comfort or discomfort? The above research c lea r ly support nonverbal communica t ion as an integral part o f human communica t ion . Furthermore, one can conclude 121 HEALTH. HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE that human communica t ion is much more effective i f both verbal and nonverbal communica t ion can be achieved simultaneously, as i n the case o f a face-to-face interaction. I bel ieve that the abi l i ty to communicate long distance i n a face-to-face interact ive manner is a tremendous improvement , plus a l o g i c a l , desirable progression to exis t ing telephone communica t ion . C o n s e q u e n t l y , I suggest that i n d e p e n d e n t e l d e r l y (especial ly those l i v i n g alone i n r u r a l areas) w i l l view the v i d e o p h o n e as be ing a n a i d to the ir i n d e p e n d e n c e because it po tent ia l ly a l lows t h e m m a k e "visits" they m a y n o r m a l l y not be able to m a k e due to l imits in t r a n s p o r t a t i o n or hea l th to the ir f r i e n d s a n d re la t ives yet s t i l l con t inue to have face- to- face i n t e r a c t i v e c o n t a c t t h r o u g h the v i d e o p h o n e . G i v e n that there is tremendous emphasis i n the research literature on the transportat ion needs of aging-in-place elderly (Havens, 1980), it is conceivable that despite l imita t ions to the device, the elderly may f ind the videophone an acceptable way o f overcoming some o f their transportation l imi ta t ions . U p unti l now, the on ly wide ly avai lable means o f long distance interactive communica t ion for independent e lder ly was though the telephone. In wide use today, the telephone a l lows effective verbal communica t ion between two callers, but does not a l low callers to see each other. In recent years, tremendous progress i n communica t ion technology as a part o f the I n f o r m a t i o n H i g h w a y 1 has a l l owed the development o f products that a l l ow l r n i e information highway is a broad term that refers to the many concurrent information delivery systems that are being currently researched and tested. These systems are all based ultimately on computer technology, and are about ways of linking up different parties in order to exchange information. To the general public, this information highway has expressed itself in the form of satellite communications, fiber optics, phone lines, cable television, interactive television, video telephony, and cellular phone technology. This great variety is evidence of 1 2 2 H E A L T H . H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E l i v e communica t ion between two participants through the use o f either personal computers , ce l lu la r phones, satelli te hookups, and advanced telephone systems. A u d i o - v i s u a l communica t ion for this thesis is defined as two p h y s i c a l l y separated parties communica t ing ve rba l ly and v i s u a l l y i n a l i ve , interactive manner using an appropriate electronic device. Current ly , there are several types o f such devices. One type is for computer users, and includes the software and hardware that a l l o w people to h o l d aud io-v i sua l communica t ion through their personal computers and modem lines. A log ica l progression o f this technology has been v ideoconferenc ing , w h i c h a l l o w s l i v e two-way interact ive audio v i sua l communica t ion between two or more parties through spec ia l ly set-up v ideo conference centers throughout wor ld . Current ly , it is s t i l l very expensive to video conference. Another such type o f device is the videophone, wh ich is a progression o f the telephone, and a l lows callers using the device to see each other as they talk. W e have chosen to focus on the videophone because we believe that as a progression o f the telephone, the videophone is re la t ively much easier to use, and is thus more l i k e l y to be fami l ia r and acceptable to the independent senior. Before extrapolat ing on possible applicat ions o f videophone technology for e lder ly independence in future, let us describe in greater detail the cu r r en t ly a v a i l a b l e v ideophone . the varied and sometimes competing fields of research involved, and also betrays a lack of consensus regarding what the "winning" technology will be. Ultimately however, the information highway is about a new, instant way of life for us all. It promises immediate and interactive communication (eg. shopping through interactive t.v.). It will mean us having more choices for services, entertainment, and information right at out fingertips. The world will become a much smaller place. 123 HEALTH. HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE T h e v i d e o p h o n e The videophone is a communica t ion device that transmits and receives video images as w e l l as audio signals over telephone lines to a l low callers to hear each other's voice as w e l l as see each other. It is a telephone wi th a bui l t i n min i -v ideo camera and video screen display to a l low two callers using the device at both ends to see each other. V i d e o telephony thus adds a v i sua l d imension to ordinary audio telephone service ( A n g i o l i l l o , et .al 1 9 9 3 ) . The origins o f video telephony can be traced back to 1927, when a historic one-way fu l l -mot ion v ideo ca l l was made by then Secretary o f Commerce Herbert Hoover in Washington, D . C . to A T & T executives in N e w Y o r k C i t y (Dorros, 1969; & Mainzer , 1984). Th i s video ca l l , made at 18 frames per second, became the forerunner for commerc ia l t e lev is ion , w h i c h was introduced i n 1936 i n A m e r i c a . There are two types o f videophones in the wor ld today. They are B C Tel 's "Relate 2000" model made by G E C Marcon i , Br i ta in ; and A T & T ' s VideoPhone 2500 ™, made by Compress ion Laboratories, San Jose, U S A (Fox, 17 A p r i l , 1993). G i v e n that both these models are very s imi la r in function and qual i ty , the term videophone w i l l refer to either o f these models unless noted otherwise. Both videophones p lug into a normal (analog) telephone socket. In addi t ion to typ ica l telephone functions, they both have a color camera and a 7.5 centimeter l iqu id-crys ta l display ( L C D ) screen for d isp laying pictures. The co lor camera records images o f the cal ler w h i c h are s imultaneously converted into d ig i t a l codes that are 124 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE transmitted through the telephone l ine at 14.4 kbit /s (k i lob i t s per s e c o n d ) 2 . The receiving videophone decodes the signal back into an image which i t displays on the L C D screen at 5 frames per second (fps) 3 . Using current compress ion t e c h n o l o g y 4 , the images transmitted and d isp layed on the videophone show facia l expressions and gestures s imul taneously w i t h the caller 's speech "with a high degree o f clari ty and naturalness" (Hong K o n g Telecom C S L ) . Its small screen restricts callers to seeing only the faces o f each other wi th c lar i ty . A n y movement o f the person w i l l "appear as a series o f jerks and blurs on the recipient's screen" (Fox , 6 M a r c h , 1 9 9 3 ) 5 . H o w easy is the Videophone to operate for the independent senior? W e l l , i t works l ike any other telephone, except that it has a v i sua l screen and smal l camera too. Thus, it takes two callers with the videophone to use the v i sua l function. The advantage o f the device is its relat ive s impl i c i ty : one buys the unit and plugs it into an ordinary telephone socket. I f one prefers to use it as a typica l telephone, one just keeps the screen in its folded posit ion. A l l calls start as normal voice calls only. I f both parties want to 2Kilobits are units that measure the amount of information transmitted per second. 3 In contrast to transmitted videophone images, regular television displays a typical clear image at 30 fps. The much narrower bandwidths of existing telephone lines i n Canada forces this digital signal to be simplified to allow it to be transmitted through the telephone line, consequently reducing its image clarity and size. Compression technology takes the digital image and compresses its size by "simplifying" the data contents to allow it to transmit over the phone line. The drawback is a resultant loss in image clarity. 5 How sharp and "jerkless" the image will appear will also depend on the transmission capacity of existing phone lines available. Hong Kong Telecom's claims about the visual clarity of its videophone is based on existing phone lines in Hong Kong. BC Tel has not made any public announcements of this nature because they have not begun the mass marketing for the product. 125 H E A L T H . H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N BRITISH C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E Excerp from Singapore Telecom's Videphone Brochure: Picture of Videophone & its screen at actual size. 126 H E A L T H . H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S IN BRITISH C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E Telecom CSL Videophone .a Excerp from Hong K o n g Telecom's Videphone Brochure: V i e w of Videophone in open screen posi t ion. 127 HEALTH. HOUSING & ASSISTIVE TECHNOLOGY. THEIR ROLES IN BRITISH COLUMBLVS ELDERLY INDEPENDENCE Hinged Video Unit iJMBiMtMqt*! Handset BIS Brightness Key • Function Key "ecrecy indicator. Secrecy Key »*f*s :a Keypad ma Recall Kev Microphone Used with the loudspeaking facility Telecom CSL Videophone ttlfl CSL r IgH Phone jiBISmSS Video Display Contrast Key Video Refresh Key *#«a Freeze Frame Key Sit a Self View Key gsitiKita • Timer On/Off Key Video On/Off Key • Video On/Off Indicator Pause Key Memory Keys sstsa Redial Key tetesjaa Volume Control Loudspeaking Key aa i sKa Loudspeaking Indicator f e J f i i l S P . ^ Excerp from Hong K o n g Telecom's Videphone Brochure: V i e w o f Videophone 's Funct ions . 121 H E A L T H . H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S IN BRITISH C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E ALL THE PRIVACY YOU'LL EVER NEED What if your Nucleus Visual 2000 rings but you don't want to be seen? It's up to you to press the video on/off button. And as long as the screen unit is folded down, the Nucleus Visual 2 0 0 0 functions as a normal phone. You're in the middle of a con-versation and wish to consult with someone in private? Just press the secrecy button and the person at the other end won't be able to see or hear you. Need to check your appearance before you make your call? Use the self-view facility. This shows you the exact picture that will be received at the other end. In addi-tion, there's a special picture-within-picture facility that allocs you to see yourself during the call. Excerp from Singapore Telecom's Videphone Brochure: Explana t ion o f Videophone ' s p r i vacy feature. 129 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE be seen, they activate the v ideo function by pressing the video button. There is even a secrecy button that prevents the person at the other end from either seeing or hearing you . A Se l f V i e w function a l lows callers to check themselves before v i sua l t ransmission during the c a l l . Other features include a brightness key and a contrast key to adjust the quali ty o f the image transmitted. H o w universal w i l l the videophone be? A new product i n the audio-visual communica t ions market, the v ideophone is s t i l l l a c k i n g comprehens ive , universa l standards that w i l l ensure wor ldwide compa t ib i l i t y . One exis t ing problem is compat ib i l i ty between the Relate 2000 and the VideoPhone 2500 ™, the only two videophones currently on the market 6 . One cannot hook up a Relate 2000 to a VideoPhone 2500 ™, and see the cal ler on the other end. Br i t i sh Telecom maintains that calls from a Relate 2000 w i l l pass through both M C I and A T & T lines, but calls from the A T & T model w i l l only work on A T & T lines (Fox, 6 M a r c h , 1993). Due to the newness o f the product, B C T e l has yet to mass market the Relate 2000. In A s i a n markets l i ke Singapore or H o n g K o n g , however, the product has been sel l ing very w e l l . Product affordabil i ty is another key issue. Currently, B C T e l sells the product for Cdn . $1300.00. It admits that the price is s t i l l too high for the mass market and is seeking ways to get G E C M a r c o n i , the Relate 2000 s manufacturer to lower the price. A s with a l l new technologies, it expects the price o f the device to come down over time as technology improves 6 l n developing their product, AT&T decided to get the best picture quality possible by choosing a modem that transmits at 19.2 kbits/s. GEC Marconi choose a slightly lower quality but more robust signal at a transmission rate of 14.4 kbits/s. 130 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE and production costs come down. B C T e l has ident i f ied the independent elder ly i n Br i t i sh C o l u m b i a as a potential market segment for its v i d e o p h o n e . Despite the issues o f cost, image qual i ty and compat ib i l i ty mentioned above, there is reason for op t imism when one looks at the overa l l picture. A n g i o l i l l o et. a l (1993) have ident i f ied the f o l l o w i n g developments since the video c a l l i n 1927 that now a l low videophone technology to become a real i ty for the mass market; i) Telephone cable bandwidth is now cheaper and more easi ly avai lable , e.g.. the Integrated Services D i g i t a l Ne twork , i i ) V i d e o compression technology is now vastly improved , i i i ) Pr ices for equipment and transmission are becoming affordable, iv) Saving time and travel expenses is more important than ever in today's g loba l economy, v) People are more comfortable today than ever wi th s imi la r or related technologies i n the home, inc lud ing the V C R and personal c o m p u t e r , v i ) Internat ional t ransmiss ion standards have been deve loped by the W o r l d w i d e In ternat ional Te legraph and Te lephone Consu l t a t i ve Commit tee ( C C I T T ) for different types o f vendor equipment to work 131 HEALTH. HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE together, and v i i ) The market for video telephony is g rowing: A s o f 1993, thousands o f v ideo conference systems w i l l have been ins ta l led w o r l d w i d e . M a n y other experts i n the te lecommunicat ions industry be l ieve that audio-v i sua l communica t ion w i l l become a mass market commodi ty . H e n r y K w o k o f Stentor Resources Center Inc. 7 believes that the videophone is a key g r o w i n g component i n today's t e l ecommunica t ion / in fo rmat ion age, w h i l e cautioning that there is s t i l l no clear "winning" technology in sight yet. However , whether o r not the videophone survives and flourishes i n its present form is not the issue, for i f it doesn't, another comparable product w i l l succeed it . In projecting the potential o f the device for B C ' s aging-in-place senior, we assume that two o f their demographic characteristics w i l l cont inue to be true. The first is their preference to age-in-place (B lack ie , 1986; Wheeler , 1 9 8 2 ) . 8 Th i s includes the elder ly i n rural areas where access to required services for independence is more diff icul t . The second assumption is that the senior w i l l continue to face dif f icul t ies i n getting adequate transportation, especial ly for those l i v i n g in rural areas. In this context, 7Stentor Resource Inc. was set up in 1992 by Canada's nine major telephone companies to establish a strong voice for the Canadian telecommunication industry and to meet the challenges of a fast-changing, complex, business environment. Stentor Resource Center is developing and delivering innovative products and services that will allow the telephone companies to compete effectively in this new environment while meeting the ; sophisticated demands of Canadian consumers (Stentor, 1992). 8see Chapter One for a more thorough summary of BC seniors' characteristics. 132 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE we believe that videophone technology w i l l be seen as one possible solut ion (among others) to the e lder ly ' s transportation d i f f icu l t i es by p rov id ing easy, instant access to friends, relat ives, and support services though audio-visual communica t ion l i nks . There are several factors that support such an assumption. F i r s t , demographic project ions c lea r ly indicate the elderly as a g rowing segment of society. 9 T h i s segment 's p o l i t i c a l and economic influence w i l l continue to impact society's decis ions. It is l i k e l y that the elderly 's challenge o f aging-in-place w i l l increas ingly become society's challenge. Thus, society w i l l be eager to develop and accept potential solut ions, i nc lud ing technological solut ions, to promote aging-in-place. Second, t echnologica l progress w i l l natural ly cont inue to produce more products for the benefit o f everyone, i n c l u d i n g seniors. T h i r d , the exponential rates o f change in our Information A g e w i l l continue to increase our expected quali ty o f l i fe . In this context, our demands o f an "instant grat if icat ion society" wi th more choices o f services avai lable instantly w i l l continue to grow. A s demand grows, so does supply. Te lev i s ion is a good example to illustrate this trend. In the seventies, te lev is ion in A m e r i c a was dominated by the three major networks (Amer i can Broadcas t ing Corpora t ion ( A B C ) , N a t i o n a l Broadcas t ing Corporat ion ( N B C ) and Corporate Broadcasting Station ( C B S ) ) . These three networks i n i t i a l l y p rov ided the l ion ' s share o f t e lev i s ion programs through just three channels. The eighties saw the growth o f entertainment, news and infomerc ia l cable networks. Specia l ty networks catering to niche markets became c o m m o n l y ava i lab le . The number o f channels ava i lab le grew to between twenty to thirty. In the nineties, this trend continues. It 9 It is projected that by the year 2030, approximately 20% of all Canadians will be over the age of 65 years (Baldwin, 1993). 133 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE appears that we will soon have hundreds of channels available through satellite broadcasting, thus providing us even more choices. Some of these choices will include interactive television shopping, program selections and access to all sorts of information through the information highway. As interactive audio-visual communication becomes more and more popular, increasing numbers of businesses will offer their services and products through such a medium. The aging-in-place senior, especially those in rural areas, would be key beneficiaries of such a development. It is conceivable for the senior in the near future to be able to buy services and products from their homes. Imagine them being able to select their weekly groceries from their favorite supermarket through the videophone and arranging for the groceries to be delivered to their homes. Imagine them doing their banking and bill payment directly from their homes by talking to friendly tellers over the videophone. Instead of a faceless, anonymous computer voice over the telephone, they can now feel really connected to the shopping center or bank. Suddenly, the lack of available transportation becomes much less significant. Thus, instant access to services through the videophone will promote and prolong elderly independence. Likewise, it is conceivable for them to feel more independent, yet still feel closer to their friends and relatives simply because of visual contact through the videophone. Furthermore, society as a whole may be more willing to allow more progressive assisted living arrangements1 0 for ailing aging-in-place seniors if friends, relatives and health care officials were able to 1 °see Chapter Three under "assisted living" 134 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE m a i n t a i n v i s u a l c o n t a c t w i t h sen io r s . W i t h regards to health care, audio-visual technology is a natural extension o f the 'help ho t l ine ' services that have been used to a l low the elderly to ca l l health care centers for informat ion , med ica l or soc ia l s u p p o r t . 1 1 It is even possible that this v isual l i n k can be useful i n enabling health care providers to access the immediate health care need o f the person ca l l ing in . Th i s can be cruc ia l in screening emergency ca l l s . S i m p l y weeding out c lea r ly unnecessary hospi ta l iza t ions through i n i t i a l v ideophone ca l l s can produce tremendous health care savings. What impact w i l l devices such as the videophone have on the phys ica l environment o f the aging-in-place elderly? A s architects, how do we incorporate such "instant" devices into the design o f a home? W h i l e these devices may be very easy to add to a home technical ly , the spatial and psycho log ica l impl ica t ions are immense, and w i l l potent ia l ly pose a huge challenge to the way we v iew space and privacy in our homes. Before cons ider ing the imp l i ca t i ons aud io -v i sua l c o m m u n i c a t i o n devices w i l l have on house designs, let us first think about what the home is psycholog ica l ly . The house is our abode, our shelter and our protection, not just from c l ima t i c elements, but it also provides security, p r ivacy and safety as w e l l . Ph i losophica l ly , we can say that our home is an extension o f ourselves, it is where we retreat to every night to rejuvenate and recover from our dai ly activit ies. It is where we let our guard down, and for the seniors l i v i n g alone, the ab i l i ty to be just ourselves in private is even more 1 ^he rising costs of health care in BC will likely encourage such a development. See Chapter Two for more information. 135 H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E fundamental. Thus, we can say that as we retreat into the privacy and protection of our homes, we also retreat into our private selves. The psychological functions of a house translate directly into how it is designed. Spatially, the typical flow of spaces and their functions in a home are a reflection of the layers of functions in our personality as well. For instance, the main entry and main door of a home is usually found in the front of the home, because this is where we formally meet our visitors. The entry foyer, which acts as a transition from the exterior entry area to the more private spaces of the house, is consequently located in between the main door and the living room. The living room, which function as a formal entertainment area, is usually kept clean, tidy and formal - in contrast to the family room, which is usually more cozy and informal. Homes that are well designed never allow a person who enters into the entry foyer or living room to see into the family room because the activities that occur there are more private, and should thus be visually shielded from the formal areas. For the same reason, private areas like bedrooms and bathrooms are usually located in a more private zone of the home. This gradual, progressive spatial flow from "public" to "private" in our homes is a fundamental expression of how we function as people. When we interact with other people, we are involved in "public" activities. When we are by ourselves, or with our own families, we are involved in more "private" activities. When devices such as the videophone become incorporated into our homes, they raise a fundamental dilemma - that of the need for our home 136 HEALTH. HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE to go from a "private" mode to a "public" mode instantly. The first key design question is where should the device be located? In the formal areas of the home l ike the l i v i n g room where we w i l l a lways show an ideal phys ica l environment to our friends? Yes , perhaps, but the disadvantage here is that we have always strived as a society towards convenience and access. Loca t ing the videophone i n the l i v ing room may not be the most central or accessible spot in the home, especially i f the home is a large one. What about the convenience o f our bedrooms? Perhaps, but are we psycholog ica l ly w i l l i n g to a l low someone to interrupt our pr ivacy and be able to see us in our bedrooms? Even i f the design challenges o f creating an ideal phys ica l environment for the videophone can be achieved in the home, what about the greater psychologica l issue o f los ing our pr ivacy instantly? W e have a l lowed our l ives to become interrupted anytime wi th the telephone. W i l l the same eventual ly be true o f the videophone? The questions posed above are important for architects and envi ronmenta l psychologists to research. C l e a r l y complex issues, they further i l lustrate that effective research w i l l mandate close m u l t i d i s c i p l i n a r y coopera t ion between related professionals. It is beyond the scope o f this thesis to deal wi th these complex questions, and much exci t ing work remains to be done by researchers. There remains much for us to look forward to. 137 "'"'HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE The numbers show the usual sequence of spatial experience for visiiors/non residents of the house: Main entry, Foyer. Living Room. Dining Room. Kitchen to finally, the Family Room-Conversely, the sequence can include the Foyer, the Library/ Office to the Family Room, but this is less likely as the Office is usually resen^ed for clients who generally do not go to the Farnily Room. Note that the Family Room, as the heart of the main floor, is not visible from the Main Entry and Foyer. Similarly, the bedrooms upstairs are also visually shielded from the Foyer. The staircase thus beyond functional reasons also acts as an important spatial transitional element as well as a privacy shield for the private spaces of bedrooms upstairs. 138 H E A L T H . H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E C H A P T E R F I V E C O N C L U S I O N Throughout this thesis, I have attempted to i l lustrate the important roles health, housing and assist ive technology play i n m a x i m i z i n g aging- in-place for the elderly, and their interrelationships to each other. I f we as a society are to address the challenges faced by the aging-in-place e lder ly , it is clear that effective solutions must encompass a l l these three areas. T rad i t i ona l ly , the health issue has been given the most prominence, sometimes at the expense o f the other two. This surely must change. Furthermore, the thesis has stressed that when effective housing is p rovided , many health-related problems o f aging can be prevented or m i t i g a t e d . W i t h the advent o f communi ty based health del ivery systems such as O n L o k Heal th Services in San Francisco and the Br i t i sh C o l u m b i a L o n g Te rm Care Program, society is now beginning to recognize the interrelation o f Heal th and Hous ing for the aging-in-place senior. Nevertheless, as illustrated by this thesis, there is s t i l l room for society as a whole to improve . The medica l profession, i n particular, must continue its struggle to redefine and reexamine its t radi t ional approach to health defined as being the absence o f disease. Preventative health care, healthy l i fes tyles , adequate income levels , and adequate housing are increas ingly being recognized as relevant key determinants o f health, but the momentum must material ize into concrete government funding and soc ia l p o l i c y before lasting changes can be expected to occur. 139 HEALTH. HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE It has also been stressed that many intel l igent design and construct ion solut ions for aging- in-place housing needs are not p r o h i b i t i v e l y expensive or necessarily unattractive. Choos ing 3 feet wide doors over narrower doors, or the design of wider corridors in a typical house do not add signif icantly to the overa l l cost o f construction, yet go a long way toward making the home suitable for wheelchair occupancy. Other key design ideas, l ike framing a home for a future elevator addit ion, only add marginal ly to the in i t i a l construction cost. I f the pre-framing was not done however, the cost o f adding the same elevator w o u l d be considerably more. Thus, architects and designers should strive to incorporate many suitable design elements into mass market housing that make them easi ly conver t ib le for future aging- in-place use. S i m i l a r l y , home buyers also need to be educated on the advantages i f such design elements are already incorporated into their market l eve l housing. Another concept that deserves mention is Universa l Des ign . It is based on the p r inc ipa l that certain elements o f design that have been shown by research to be helpful i n independence for aging-in-place e lder ly or those wi th disabil i t ies should be incorporated into a l l design. In a paper presented at the International S y m p o s i u m , T o k y o on 27 January 1994 Satya B r i n k describes the goal o f Unive r sa l Des ign as being ". .universal fit between household needs and household stock. Idea l ly , universa l hous ing is valuable through out its existence to house a variety o f households without major alterations." ( B r i n k : 10, 27 January, 1994). U n d e r l y i n g this p r inc ipa l is the be l ie f that these elements o f design (for instance, i nc lud ing wider hal lways, wider doors, and more accessible cabinets i n ki tchens, 140 H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : T H E I R R O L E S I N B R I T I S H C O L U M B I A ' S E L D E R L Y I N D E P E N D E N C E e tc . . ) should also be welcomed by the general public due to their general usefulness, and should thus be incorporated into a l l types o f designed environments . B r i n k describes the min imum requirements o f U n i v e r s a l Des ign to include elevator access i n multi-storey bui ld ings , bedroom and fu l l bathroom on the main f loor, f loor area in each story uninterrupted by changes in level and wider door widths. W h i l e there is s t i l l no general consensus on the exact extent and affordabili ty o f Universa l Des ign , it is without dispute that many good design pr incipals o f U n i v e r s a l Des ign should be incorporated in to a l l design. W h i l e the interrelat ion o f health and housing currently has some momentum and history to i t , the advent o f assistive technology into the equation is new and revolut ionary. It is so new that society s t i l l barely understands the impl ica t ions o f this interrelationship. Th i s lack o f awareness is exacerbated by the exponential rate o f technologica l change, thus creating a huge challenge for society as a whole, and the aging-in-place senior i n part icular , to understand and take advantage of. Profess ionals , academics and researchers in m u l t i d i s c i p l i n a r y f ie lds related to aging-in-place seniors are on ly beginning to grasp the potential o f new assistive technologies. M u c h s t i l l needs to be studied before any clear conclusions can be drawn. G i v e n how fast things are changing, however, we are qu ick ly los ing the luxury o f time, or the comfort o f appl ied research literature, to decide such fundamental issues. Nevertheless, we know that assistive technology is as much a part of society's response to aging- in-place as health and housing. W h i l e we currently may not be sure exactly the extent assistive technology w i l l p lay, it is l i ke ly that this role w i l l continue to grow as technology progresses. 141 HEALTH, HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE In the final analysis, stressing that health, housing and assistive technology are key components of successful aging-in-place is still not the most important issue. Ultimately, the fundamental issue that society must address is this: how far wi l l it go to al low seniors to age- in-place? W i l l society strive to do our best to allow our seniors to age-in-place with the resources they wil l need? Or wi l l we as a society choose to ignore the realities o f aging-in-place? The questions posed above are complex questions that offer no easy, instant answers. In attempting to deal with the issue of aging, I have gone back to first principles, where it is statistically proven that the elderly prefer to age-in-place (Blackie, 1986; Wheeler, 1982). In a c o u n t r y bu i l t on the p r i n c i p l e s of d e m o c r a c y a n d f r e e d o m , I stress that this preference of the e l d e r l y to age- in-p lace must be g iven the r e q u i r e d p r i o r i t y by society in genera l , a n d by o u r g o v e r n m e n t ' s social policies in p a r t i c u l a r . W h i l e one c o u l d argue that the B C g o v e r n m e n t is now c o m m i t t e d in this d i r e c t i o n , it r e m a i n s that the ent ire hea l th care system in the p r o v i n c e r e m a i n s in a state o f r e s t r u c t u r i n g , a n d c l e a r , c o n c r e t e g o v e r n m e n t po l i c i e s have yet taken place . F o r instance , unless hea l th care po l i cy begins to i n c l u d e a p p r o p r i a t e h o u s i n g i n its budget for the i n d e p e n d e n t e l d e r l y , the c l e a r i n t e r r e l a t i o n s h i p of h o u s i n g a n d p r o l o n g i n g a g i n g - i n - p l a c e w i l l not be a d d r e s s e d adequate ly . In o ther w o r d s , success ful a g i n g - i n - p l a c e c a n be m a x i m i z e d o n l y t h r o u g h the a v a i l a b i l i t y of the a p p r o p r i a t e f u n d i n g a n d o ther s u p p o r t s f o r r e i n f o r c i n g the s t r o n g i n t e r r e l a t i o n s h i p s of h e a l t h , h o u s i n g 1 4 2 HEALTH. HOUSING & ASSISTIVE TECHNOLOGY: THEIR ROLES IN BRITISH COLUMBIA'S ELDERLY INDEPENDENCE and to a growing extent, assistive technology. Only when there is recognition and acceptance of these interrelationships by society as a whole will we become more successful in creating a humane, caring and intelligent environment for aging. 143 H E A L T H , H O U S I N G & A S S I S T I V E T E C H N O L O G Y : THEIR ROLES I N BRITISH COLUMBIA'S ELDERLY INDEPENDENCE BIBLIOGRAPHY Alberta Senior Citizen's Secretariat (1986). The Preventive Approach, Preventive Programs and Alberta's Seniors . Edmonton, Alberta: Government of Alberta. Angiolillo, Joel S. et. al. (1993). 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