Victor Regnier is, perhaps, the nation’s leading authority on the design and development of senior housing with service across the LTSS continuum. A joint professor at USC’s School of Architecture and Leonard Davis School of Gerontology, Regnier is the only person to achieve fellowship status in both the American Institute of Architects and the Gerontological Society of America.
As a designer and practicing architect, he has provided consulting advice on more than 400 building projects in 38 states and several foreign countries. As an academic, he has written 10 books or monographs and directed more than 20 research projects. Regnier’s latest book, Housing Design for an Increasingly Older Population, was published in September 2018.
Gerontology Institute Director Len Fishman recently talked with Regnier about northern European models of senior housing with supportive services and their influence on housing for older adults in the United States. The following is an edited version of their conversation.
Len Fishman: Your view of housing and services for older adults has been deeply influenced by models from Northern Europe, especially Denmark, Sweden, Finland and the Netherlands. How did this happen?
Victor Regnier: I had been working on a research project with the head of geriatric medicine at UCLA in the late ‘80s, early ‘90s. I wanted to examine new housing models and had an upcoming sabbatical. He said I should go to northern Europe. He had been impressed by their attitudes and perspective on creating non-institutional circumstances for older people, especially older frail people. I ended up going to five countries. I asked to see the most non-institutional or residential housing for the frailest individuals and visited 100 buildings.
LF: You were coming from a country where, at that point, there was no assisted living to speak of and the idea of housing with supportive services hadn’t emerged yet. What were your impressions?
VR: I was blown away. The most shocking thing was how different their perspective was. Part of it had to do with the idea of risk and freedom of choice. Both seemed to be much greater in Europe, where their interest was in trying to keep people as independent as possible. The default was not the nursing home. It was trying to figure out how to keep those people in their own homes, in the community for a longer period of time. It was very hard for me to find a standard nursing home like I would find in the United States.
LF: And the alternative looked like what?
VR: Like small apartments — 500 to 600 square feet — some a bit smaller, like studios. They were operated by home care organizations that took care of people living in these housing arrangements and others in the surrounding community. They would keep them in their unit as long as they thought it made sense and the individual wanted to stay. The trigger for leaving was really the older person saying, “I really don’t feel secure anymore,” or, “I’d like a place where there’s more continuous support and assistance.”
LF: For people who made that decision, how much did their living arrangement really change?
VR: It would basically be an apartment not that different from the one they were living in, but with more assistance. Those places were kind of amazing – single-loaded corridors, not double-loaded, relatively large units and doors that locked. Scheduled visits were set up based on the kind of services they needed. It seemed to me so much better than what we were doing, which was taking away things from people and making them conform to an institutional lifestyle.
LF: Was there much disagreement about this approach in the countries you visited?
VR: Everybody got it. The professional community, as well as the people involved in establishing these systems, believed strongly this was the best choice. When you talk with politicians, they would say it was cheaper to do it their way than to create an institutional lifestyle. Of course, these countries had long-term care entitlements so they were on the hook for everything. When I told them how things worked in the United States they asked why we would do something so awful. It was kind of hard to explain that.
LF: It seems that what enables this approach in northern Europe is a radically different model of home care. Is that right?
VR: Discovering how the home care delivery system operated in northern Europe was an epiphany. Frail people lived in neighborhood housing served by caregivers who visited them up to three to five times daily, sometimes in 10 to 15 minute increments. Rather than living in a nursing home, they lived in a normal dwelling with autonomy and it was less expensive.
LF: How does the European model of homecare differ in respect to the treatment of caregivers?
VR: They pay people more. They have a guaranteed wage there. That has always been considered an important thing – that people have an adequate income.
LF: One of the concepts you feature in your book is the “Apartment for Life.” Describe that.
VR: The first Apartment for Life building was Humanitas Bergweg. It opened in 1996, in downtown Rotterdam. It has 195 independent living units and 29 units of dementia housing. It’s a mixed-use building with a supermarket on the ground floor, and an atrium above, with activities and day care for residents and others in the neighborhood. The provision of meals in the atrium is the glue that holds the community together. The first residents were equally recruited from three groups: independent people over 55 years of age, individuals in need of assisted living, and residents in need of skilled nursing care.
LF: You make a critical distinction between the Apartment for Life (AFL) and the continuing care retirement community which you call “the closest building type to the AFL available in the U.S.” Explain the difference.
VR: Both presume the older resident’s health care status will require more help over time. The AFL concept deals with this by increasing home-delivered services and equipment to maintain the person’s independence. The CCRC relies on the idea of anticipating difficulties and then relocating the resident to a more supportive environment based on changing needs. In that sense the system is counter to the desire of older residents to stay in their independent units.
LF:You observe that residents in AFL are socialized to be both self-sufficient and communitarian.
VR: There’s a lot of choice associated with how you live your life. But residents are also responsible for doing as much as they can for themselves. I don’t know if it’s a requirement but it is a lifestyle component of the place. What they get is help when they need it, not to do things they can do themselves — even if they would struggle to carry out some of those tasks. There’s also an attitude about friendliness and living in a group arrangement where you should feel that helping other people is the polite thing to do.
LF: One other striking difference between the housing for older adults in northern Europe and in this country is that it’s somewhat typical to find small dementia cluster units embedded within independent housing. Is that right?
VR: Especially in Sweden because they’ve developed a quite robust program of small group homes. Most of them have clusters of seven to nine people. If they chose to do something that was stand-alone in the community, they would have two or maybe three of these clusters together to achieve economies of scale. But in the Apartments for Life, almost all of them have one to three small group homes that are in that same range, 10-12 people.
LF: You are less enamored with assisted living today as opposed to what it was many years ago. Why?
VR: It’s the attitude. When I go to assisted living conferences, there’s more of an emphasis on business and recruitment and less about how to create settings that are happier and more family-friendly.
LF: Is it your view that assisted living communities in general should provide more extensive care?
VR: I think it’s inevitable. There should be a simple idea about continuity of care and commitment to the individual.
LF: What difference do you think our extended longevity will have on the future of senior living?
VR: The upper third of society will have an advantage because they have the necessary financial resources to plan for a longer life. The rest of the older population is in big trouble because they have no savings. They think they can live off of social security. They often don’t have family supports either, or family that’s in a position to provide adequate financial support. I don’t think it’s going to be that far in the future when we see an increase in the number of homeless seniors. It is a major concern.
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