For many older Americans and their families, the devastating COVID-19 outbreak — which caused more than 200,000 deaths in nursing homes nationally — was a persuasive argument for living at home as long as possible.
Now, as the pandemic grinds into its third year, a loose-knit band of tech gurus, gerontology researchers, and volunteer-powered elder support groups, called “villages,” is seeking to overcome the obstacles to aging in place. Among the toughest: a worsening shortage of home care workers, who can assist the oldest residents with walking, dressing, or showering.
Coronavirus sped up the deployment of “age-tech,” technology that helps older people age in place, by seven to 10 years, said Joe Coughlin, director of MIT AgeLab in Cambridge.
Coughlin’s lab is designing prototypes of “smart homes” for older residents, equipped with social robots, voice-activated speakers that give medication reminders, motion sensors embedded in carpets to detect falls, and intelligent doorbells that double as security cameras. The innovations are being adopted piecemeal, but over time they’ll be integrated, and today’s comparatively primitive devices and wearables will go the way of the horse and buggy, he said.
“The house itself will become the technology, and it will be ambient and proactive,” Coughlin said. “The pandemic served as a propellent. We learned as caregivers and individuals that ‘I can extend my stay at home.’”
At the same time, the grass-roots village movement — a network of community groups where volunteers in their 60s and 70s help older neighbors live independently — is seeing a fresh burst of interest, 20 years after the first such group, Beacon Hill Village, started in Boston.
The number of villages operating or being organized nationally fell sharply in the first year of the pandemic, from 338 to 313, but has since rebounded to an all-time high of 364, said Barbara Sullivan, national director of the Village to Village Network. There are 18 villages in Massachusetts serving thousands of elders, a growing though still small fraction of the state’s oldest residents.
Villages dispatch volunteers to take older residents shopping or to doctor’s appointments or to help with simple home repairs. Most subsidize low-income residents, and some run food pantries. And many sponsor social activities ranging from high teas and happy hours to book clubs, lectures, and outings to museums — all designed to foster a support system of neighbors, allowing them to live normal lives outside of nursing homes or assisted-living facilities for decades.
“We had a lot of need for services and activities that create community,” said Heidi Whear, founder of Seaglass Village, serving Swampscott, Marblehead, and Nahant, one of the villages that sprang up during the pandemic. “People feel like a village is going to help them stay in their homes. There was such a fear of going into nursing homes.”
Still, the new technologies and community resolve to help has only gone so far to overcome the care worker shortage, dearth of transportation options for many older folks, and lack of public investment in home health services that make it so difficult to age in place in Massachusetts and across the country.
“People realized how broken the entire system of long-term care is,” said David Grabowski, health policy researcher at Harvard Medical School.
Grabowski co-authored an unsparing April 5 report from the National Academies of Sciences, Engineering and Medicine that concluded US nursing home care is “ineffective, inefficient, inequitable, fragmented, and unsustainable.” It also decried the struggles faced by many who try to grow old in their own homes. In addition to recommending that the country overhaul how nursing home care is delivered and paid for, it proposed a federal long-term care benefit to help older folks afford health care at home or in a congregate setting.
“We both need to improve nursing homes and invest in resources that let individuals age in place,” he said.
Low-income residents seeking home health care have to be approved by social service organizations known as Aging Service Access Points before Mass Health, the state’s Medicaid agency, will cover the cost. Even then, it will typically cover only a limited number of hours. For those paying out of pocket, home health care cost about $32 an hour in the Boston area last year, according to a Genworth Financial survey.
Even if residents can afford home health care, finding it isn’t easy. The average hourly base salary in Massachusetts is $15.95 for a personal care assistant and $20.71 for a certified nursing assistant, the job site Indeed reports. With wages that low, care workers can often earn more working in fast-food restaurants or warehouses.
Many immigrants who worked in the field returned to their home countries during the pandemic, exacerbating the labor shortage. People seeking home care often have long waits or have to make do with a rotation of several care assistants from different agencies.
“It’s tough on families, particularly when they’re coming out of a rehab situation and they have to put care in place right away,” said Mark Friedman, owner of Senior Helper Boston and South Shore. His company only accepts private-paying clients, he said, because reimbursement rates from Mass Health are too low to earn a decent profit.
Jennifer Pilcher, who owns the Needham firm Clear Guidance, which advises families whose loved ones have dementia or complex medical conditions, said one of her clients is recovering from a broken collarbone but finds it hard to get home health care workers to come for only a few hours to help with showering and dressing.
“There are people waiting for services they aren’t getting,” she said. “There are people paying for more hours than they need just to get someone to come.”
Stresses on home care are likely to intensify as the oldest members of the giant baby boomer generation reach the age of 80 this decade.
The number of households occupied by people in their 80s is projected to more than double to 17.5 million in 2038, from 8.1 million in 2018, according to Harvard’s Joint Center for Housing Studies. And many of them will be women, who outlive men in the United States by an average of five years.
Surveys show that more than 90 percent of Americans want to remain in their homes as they age. “People want to live at home right to the end,” said Laurie Orlov, principal analyst at Aging and Health Technology Watch in Port St. Lucie, Fla.
Wendy Zenker, executive director of Arlington Neighborhood Village in northern Virginia, where membership grew from 220 to 355 during the pandemic, agreed: “To get someone out of their home, you need a crowbar — or a [health] crisis.”
That’s one reason Estelle Lindner, a retired school secretary who will turn 98 later this spring, and who still lives independently in her Newton Highlands home, walks a mile and a half each day when the weather permits. “I’m planning on 100,” she said. “I’m still pretty active. But I try to be careful at this age. I don’t want to fall.”
Lindner, a member of the Newton at Home village, still drives her car locally. But when she needs to see a doctor at Beth Israel Deaconess Medical Center in Boston’s traffic-clogged Longwood Medical Area, she accepts rides from a village volunteer. “I’m just lucky there are a lot of nice people in the world,” she said.
Last week, that volunteer was Arthur Glasgow, 81, who has been active with the village since it was formed in 2011 and sits on its board. “It’s a thrilling experience,” said Glasgow, a retired weight loss surgeon. “The people I drive are so interesting. I just look forward to every day when I drive a different person.”
The demographics of Newton at Home are similar to those of many villages. Members are about 60 percent women, and their average age is 82. Volunteers are a diverse lot, ranging from high school kids to PhD candidates to retired scientists. Maureen Grannan, the executive director, said membership increased by about 10, to 172, during the pandemic.
But that hasn’t been the case everywhere. Sullivan, at the national Village to Village Network, said some villages in other parts of the country closed or suspended operations before vaccines were rolled out, and many lost members or volunteers because of objections to vaccines.
Nauset Neighbors, which serves a half dozen towns on the Lower Cape, was among those forced to temporarily shut when the virus struck in March 2020. The village lost more than 100 volunteers and many older residents moved in with their adult children off the Cape, said Judy Gordon, its president.
Some volunteers and members later refused to be vaccinated, she said. But the village resumed operating last summer. It now has 333 members, below its pre-pandemic peak of 420.
The villages’ pandemic struggles underscore the limits of relying too heavily on local volunteers in the absence of a national commitment and strategy for funding and providing home health services, said Marc Cohen, a gerontology professor and researcher at the University of Massachusetts Boston.
“The pandemic showed in stark terms the cost of not investing in long-term care,” Cohen said. “It will be hard to meet the needs of a lot of middle-class folks who want to age in place. There is a shortage of workers to care for people who want to stay at home. The housing stock is often not conducive. And older folks have to be able to get to places if they can’t drive.”
For now, many of those who are able to stay in their homes until the end — or until deteriorating health requires more intensive skilled nursing care — have adult children or other friends or relatives watching over them.
Families and friends have long been essential supports in the aging journey. But more people today never marry, or divorce in middle age, and many have fewer children who live farther away than in the past. Technology and neighbors are helping to fill the gaps, but they won’t be able to recreate the traditional model of aging.
“The way we all aged well in the past was our oldest adult daughter,” Coughlin said.
Robert Weisman can be reached at firstname.lastname@example.org.