Bring the health care into the housing
By David A. Smith
6 min read
A hundred years ago, it was unremarkable to be born at home, and to die at home. Fifty years ago, it was unremarkable for a doctor to make house calls, and the equipment he brought was nothing more than a mysterious black bag, a stethoscope, a tongue depressor, and hands as cold as if he kept them permanently in a freezer.
That all changed over the ensuing decades. Health care went high-tech, and as it did, its capital costs rose dramatically – expensive surgeries, complex diagnostic and treatment machines like MRIs. Coupled with the expansion of America’s bollixed approach to health insurance – employer-paid, therefore insensible to customer choice and cost savings, and tort-based, therefore litigation-defensive rather than health-proactive – that in turn has led us to place-based health care. It has now reached the point where we signal someone’s well-being by using locations as code words. We’re moving her to assisted living (we say with sorrow); to a nursing home; to a hospital; to a hospice.
We’ve place-based our high-tech health care, depersonalized treatment, and taken the person out of the process. She is a “patient”’ (a demeaning term connoting passivity and dependency) who can’t heal herself and must therefore be trundled from one location to another for the convenience of the “health care professionals” (a pompous neologism) who speak in a dual arcana – first medical and then Medicaid/Medicare. The result is a health care system that no one defends because no one understands it, its costs are soaring (and going higher under Obamacare), and it cannot show progress by any common-sense measure.
Meanwhile, when we look at the nation’s inventory of existing elderly housing – both purpose-built and NORCs (Naturally Occurring Retirement Communities) – we look back to the past. These properties and their occupants are aging side-by-side. What was designed for persons with an average age of 65 is now occupied by people (mainly single women) averaging 75 or older. The corridors are narrow; the electrical wiring disco vintage; the pipes possibly lead or PVC; the bathrooms small; the appliances turquoise and avocado; and the carpeting a harvest gold deep shag that still shows the footprints of the since-vanished Zenith console television. Yet, to this individual who has lived here for decades, it is home, and familiar, and beloved.
More importantly, this apartment is home to the resident because here she is surrounded by a home-grown community – her fellow residents. By now she knows them as well as her children or grandchildren, and they see her more often and know her better. As a result she is happiest when at home and she doesn’t want to move. Yet, as her physical mobility diminishes, she may be forced at some point (by medical or insurance circumstances) to move out of her home to a new, alien environment, on the grounds that this will be better for her health, when you and I know (as does she) that staying put in her home is what she wants.
So, if we want to maximize people’s healthspan (because that enhances their lifespan), we want to keep them living at home, by bringing change in to their homes rather than moving them out.
To do this, and in light of the increasing predominance of preservation and acquisition-rehab projects in low-income housing tax credit transactions, our imperative should be to use every financing or recapitalization as an opportunity to retrofit the physical space within properties to maximize wellness and to be health-care-delivery compatible. This implies the following four dimensions:
- Apartment configurations. Frailty is not illness. But it changes living rhythms. Doorknobs become handles. Lights get brighter. Bells get louder. Stove-top controls are in front, not in the back. Bathtubs have either lower rims or side entrances. All of these features make the home gentler for a frail person to live in by herself.
- Hallways and corridors. They should be brighter and wider, with sitting areas at intervals of every 50 or 100 feet, with different wall colors on each floor or wing and possibly railings along the walls. Corridors should not be mere passages to be hustled through, but rather be a series of front stoops where the internal community can gather.
- Common areas and gathering places. Dispose of the sagging couch, the two bookcases filled with dog-eared large-print romances and westerns, and the warped ping-pong table with the rickety leg. Make the common areas into service spaces that nurture both the aging body and aging mind. Create some medical stations, with a bit of visual and auditory privacy, where a nursing practitioner or health care aid can dispense advice, sympathy, and common sense. Add or refurbish a kitchen or pantry that can serve light meals or deliver meals brought in from the outside. Bring in broadband work stations with headsets (and bright young people to set up the Skype), a big-screen plasma television with a camera (for virtual museum tours), and free Wi-Fi throughout the building.
- Activities and activity hubs. People die in part because they no longer want to keep living; depression kills slowly and quietly. Social connections and society lead to mental alertness, better spirits, and better eating. These lead to increased activity (like group walking or tai chi) that leads to lower blood pressure, lower obesity, and less incidence of adult diabetes. Better mobility means fewer falls, fewer broken hips, fewer traumatic ambulance rides to the hospital – meaning longer and happier lives, greater independence, and substantially lower Medicare and Medicaid bills for taxpayers.
In short, an acquisition-rehab transaction that fails to retrofit an elderly property for compatibility with service enrichment has blown an irreplaceable opportunity: The developer who sponsors such a project has been asleep at the switch and the tax credit allocator who approves it without thinking has fallen down on the job.
A lot can be done with very old properties. At Recap we’ve proven it, in a thought experiment we recently commissioned at our own expense – a retrofit physical feasibility analysis of an existing elderly property in Upstate New York. Drop me an email and I’ll send it to you.
David A. Smith is Chairman of Recap Real Estate Advisors, a Boston-based real estate services firm that optimizes the value of clients’ financial assets in multifamily residential properties, particularly affordable housing. He also writes Recap’s free monthly essay, State of the Market, available by emailing dsmith@recapadvisors.com.
