Psychogeriatrics: Naturally Occurring Retirement Communities

Gary J. Kennedy, MD

Professor, Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Director, Division of Geriatric Psychiatry, Montefiore Medical Center

Introduction

In 1985, Hunt and Hunt¹ introduced the term NORC to refer to buildings, apartment complexes, or neighborhoods not originally planned for older people, where over time 50% of the residents have become ≥50 years of age. NORCs differ from the stereotypical retirement community, yet they are the most common form of retirement community in the United States. There are two definitions of NORCs, one sociologic and the other legislative. The sociologic definition describes a phenomenon in which seniors have become concentrated as a result of “aging in place,” in contrast to continuing care retirement communities and assisted-living facilities where the elderly have purposefully relocated to seek services.² The legislative definition describes communities to which government in collaboration with private housing entities provide socially supportive services to defined geographic concentrations of seniors. Geographic areas in which 50% of households are ≥60 years of age or at least 2,500 heads of households are ≥60 years of age meet the New York State definition of a NORC. The New York City definition of a NORC includes areas in which at least 45% of residents are ≥60 years of age with a minimum number of 250 seniors; or if <45% of residents are ≥60 years of age if there are at least 500 such senior residents.³ According to Frazier,⁴ the largest NORC is located in Co-op City in the Bronx.

In 2001, the Administration on Aging made grants to Jewish Federation agencies to develop NORC supportive services programs (SSPs) in five cities followed by an additional nine cities in 2002.³ Local entities were required to provide 25% of the funding, with Title IV of the Older Americans Act providing the remaining 75%. The goal was to create partnerships among housing entities and their residents with health and social service providers, government agencies, and philanthropic organizations. As of 2006, there were >40 officially recognized NORC-SSPs across New York State. The Senate version of the reauthorization of the Older Americans Act, S. 3570/H.R. 5293 would provide the states with grants for the development of model “aging in place” projects for NORC-SSPs. It would also provide competitive grants for the development of mental health screening and treatment for seniors who lack access to these services.⁵

Why Are NORCs Important?

There are three key elements of the NORC phenomenon that draw attention. First, seniors overwhelmingly prefer to age in one place rather than transit to retirement communities of other support institutions. Second, the age-related density provides an opportunity to redesign service delivery to achieve economies of scale. Last, seniors who once retreated from cities in retirement are returning because of increased access to services which address health and disability as well greater opportunities for recreation and social interaction.⁶

NORCs are also a population-based laboratory in which to examine the biomedical and psychosocial threats to older adult autonomy. For example, Adams and colleagues⁷ examined potential adverse drug-alcohol interactions among 454 retirement community residents and found that 38% reported using both alcohol and a high-risk medication such as an antihypertensive, sedative, narcotic, or anticoagulant. Six percent were at-risk drinkers who consumed at least one drink every day. The increasing number of NORCs is particularly noteworthy to mental health specialists. The concentration of many seniors in one geographic area means home-based mental health services become much more feasible as the cost of transportation from one home to the next decreases. As earlier diagnosis and more effective treatments of dementia emerge, an aggressive community outreach initiative could forestall the disability of dementia considerably, reducing costs to both seniors and their families. In addition, social support moderates depression, suicidal ideation, and the risk of suicide attempts.⁸

Perspectives from the Largest NORC

Co-op City is a Mitchell-Lama public housing project for people of low and moderate income. It houses an ethnically and racially diverse NORC including more than 8,300 older adults. The geographic area encompasses zip code 10475. The Jewish Association of Services to the Aged (JASA) Co-op City Senior Services Program provides direct services to the elderly. It is the New York State and New York City NORC-SSP contract agency. Case management services are provided by two masters of social work case managers, two bachelors level case assistants, and a supervising social worker. The SSP works closely with the Visiting Nurse Service of New York (VNSNY), which provides skilled nursing services. Montefiore Medical Center provides specialized geriatric care and mental health services in Co-op City-based offices as well as in NORC residents’ homes. Both the Montefiore Medical Center and VNSHY work directly with the SSP staff in the interests of shared clients or patients. The Montefiore Medical Center component of the effort is supported through philanthropic and educational grants as well as the medical center’s Contract Management Organization, which assumes full risk capitation for the healthcare costs of a substantial number of Co-op City residents both young and old. The goals of the medical center are to improve the quality and reduce the costs of care provided to Co-op City seniors, to train healthcare providers to work in the NORC setting, and to increase the share of hospital admissions to the medical center. The successful partnership between the Montefiore Medical Center and JASA in clinical training and in-home services initiatives resulted from motivated leadership, shared needs for community-based mental health care, and ongoing philanthropic support. As a result, the development of both the training and service experiences could evolve without depending on fee-for-service revenues.

Expanded Collaboration

Other areas of collaboration for medical and social service providers beyond training and services may also exist, provided mutually desirable goals are identified. One such area is hospital length of stay of NORC residents who are also clients of the NORC services programs. A system of automated communication linking the hospital-based and community-based providers would have obvious advantages to older NORC residents as well as their concerned family members who prefer they age in place rather than in a nursing home. And if the link could be Web based, activated automatically upon the admission event, and not dependent on manual input, the incentives for medical centers and community-based social service agencies are also easily envisioned. Because close to 100% of the Co-op City NORC residents live in zip code 10475, a simple identifier of “≥60 years of age residing in zip code 10475” would reliably capture all the admissions.

The incentive to reduce lengths of stay while assuring safe discharge belongs to the social workers and discharge planners on the hospital side of the equation. Prior knowledge of community-based services either utilized or available to the NORC resident might expedite the discharge planning process and marginally reduce either the length of hospital stay or the effort expended by hospital staff on discharge planning. Repeated admissions to other hospitals in which the plan failed or cases in which elder abuse or neglect were suspected could be conveyed to hospital staff, increasing the probability that the new plan would indeed be safe. On the community-based side, awareness that a NORC services recipient was hospitalized would mean that case management activities, meals on wheels, and home-care services could be redirected to seniors remaining in the community and could reduce wasted effort trying to contact and serve the NORC resident who had been hospitalized. In addition, advance knowledge of the discharge plan and date would allow services to be reinstated with a minimum delay and loss of continuity.

However, for the Web-based communications link to be incorporated by agency and hospital staff, it must require less effort than prior fax or telephone communications. There would need to be sufficient volume of NORC resident admissions such that the linkage event would be seen as routine rather than novel. It would need to alert the hospital and agency social workers of the hospitalization of a NORC client, but be compliant with Health Insurance Portability and Accountability Act requirements. It would need be a service automatically available to the NORC residents without sign-up procedures that would be cumbersome for them and time consuming for agency staff. Lastly, it would need to bridge the divergent responsibilities of hospital and agency employees. Hospital staff are responsible for insuring that the NORC resident ages in place out of the hospital. A discharge plan including skilled nursing services of a home-care agency or nursing home does not require contact with the NORC services providers. Indeed, the NORC providers are responsible for services that stop short of providing skilled nursing care and are focused on aging in place in the community. As a result, the overlap between the responsibilities and the potential for improved planning for hospital and community staff may not be sufficient to sustain the linkage.

Meeting the NORC Challenge

The need to reduce the gap between biomedical and psychosocial services for older adults is widely accepted.^9,10 Yet, the value of NORCs may lie more in their capacity to promote social cohesion and a healthy environment which is preventative rather than restorative. Masotti and colleagues⁶ argue this perspective but add that not all NORCs are necessarily healthy. Without urban policy that promotes the ongoing social integration of seniors, including accessible transportation, zoning, senior friendly signage, safe traffic patterns, safe environments for exercise, and opportunities for seniors to assert greater involvement in community decision making, the hoped for benefits of NORC residence will not be realized. Nonetheless, the mention of naturally occurring retirement communities in the proposed reauthorization of the Older Americans Act signals their arrival on the public policy scene. The two challenges for providers of biomedical and psychosocial services to NORC residents will be integrating their divergent approaches and joining the community to advocate for more senior-friendly urban policies.

Disclosure: Dr. Kennedy has received research support or honoraria from AstraZeneca, Eli Lilly, Forest, Janssen, and Pfizer.

Acknowledgments: This work was made possible in part by support form The New York Community Trust, The United Hospital Fund, and the United Jewish Appeal/Federation of Jewish Philanthropies.

Please direct all correspondence to: Gary J. Kennedy, MD, Director, Department of Geriatric Psychiatry MMC, 111 East 210th St, Klau One, Bronx, NY 10467; Tel: 718-920-4236; Fax: 718-920-6538; E-mail: [email protected].

References

1. Hunt ME, Hunt G. Naturally occurring retirement communities. Journal of Housing for the Elderly. 1985;3(3/4):3-21.

2. Hunt ME, Ross LE. Naturally occurring retirement communities: a multiattribute examination of desirability factors. Gerontologist. 1990;30(5):667-674.

3. Vladeck F. A Good Place to Grow Old: New York’s Model for NORC Supportive Service Programs. New York, NY: United Hospital Fund; 2004.

4. Frazier I. Utopia, the Bronx: Co-op City and its people. The New Yorker. June 26, 2006:54-65.

5. Senator Hillary Rodham Clinton. Statements & Releases. Key senate panel approves Clinton initiatives to support older Americans. Available at: www.clinton.senate.gov/news/statements/details.cfm?id=258037&&. Accessed July 10, 2006.

6. Masotti PJ, Fick R, Johnson-Masotti A, Macleod S. Healthy naturally occurring retirement communities: a low cost approach to facilitating healthy aging. Am J Public Health. 2006;96(7):1164-1170.

7. Adams WL, Barry KL, Fleming MF. Screening for problem drinking in older primary care patients. JAMA. 1996;276(24):1964-1967.

8. Nisbet PA, Duberstein PR, Conwell Y, Seidlitz L. The effect of participation in religious activities on suicide versus natural death in adults 50 and older. J Nerv Ment Dis. 2000;188(8):543-546.

9. Leutz W. Reflections on integrating medical and social care: Five laws revisited. Journal of Integrated Care. 2005;13:3-11.

10. Wells K, Miranda J, Bruce ML, Alegria M, Wallerstein N. Bridging community intervention and mental health services research. Am J Psychiatry. 2004;161(6):955-963.