How Forward-Thinking Philanthropists at RWJF Are Helping Older Americans

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As Americans approach retirement, their fears for the future become more real: Will I be able to stay at home, or must I move into a nursing home? Who will care for me? How will I pay for this? The Robert Wood Johnson Foundation has been tackling these questions – and finding answers. A leading funder in healthcare, the Robert Wood Johnson Foundation identifies trends early and supports compassionate and responsive solutions that increase public understanding and influence systems change. Its work in the field of aging is no different; with the 85-plus population projected to more than triple from 5.7 million in 2010 to more than 19 million by 2050, the American healthcare system is at a tipping point. We must find more humane and cost-effective ways of caring for our most vulnerable individuals, especially older adults.

Kristin Schubert, director of the Vulnerable Populations Portfolio, talked with us about the foundation’s forward-thinking work on issues related to aging.

RWJF’s mission is to improve the health and healthcare of all Americans. How does that apply to older adults and their caregivers?

Kristin Schubert: All Americans, of every age, deserve the opportunity to live healthy, independent lives. At the Robert Wood Johnson Foundation (RWJF), we recognize that there is much more to health and well-being than medical care. We believe that our health is shaped by where we live, learn, work, and play. And in order for us to create new opportunities for better health, we need to consider how factors outside the healthcare system affect people’s health and develop solutions within that context.

In that sense, the issues facing older Americans are no different than those facing other people. We all need safe and nurturing places to live, meaningful social connections, stimulation in our everyday lives, and a sense of dignity and self-worth. These things are essential to health. Over the years, RWJF has supported innovative solutions to these issues that advance not only the health but the overall quality of life that older Americans enjoy.

What changes does RWJF want to see happen in the next decade in regard to healthcare and the aging population?

KS: RWJF believes that older Americans deserve a high quality of life. Yet we know that, as people age and approach retirement, they worry about their future and, in particular, about the quality of life they will have.

In 2011, RWJF released results of a poll conducted by the Harvard School of Public Health on what worries people who are in – or nearing – retirement. Their greatest fear was: What will happen to me if I have to move into a nursing home? The huge majority – nearly 80 percent of survey respondents – feared that they wouldn’t be able to afford long-term care, whether for themselves or their spouse. They also feared that the quality of care and the quality of their lives would get much worse. They worried about being around sick people, losing their privacy, and not getting the care they needed because of too few nurses. Their number-one fear was that being forced to live in a nursing home would make their scariest nightmares about growing old come true.

We believe that older Americans should be able to live at home for as long as possible – with dignity and with as much independence as possible. Where, how, and from whom they get the care they need are important factors to their overall health and happiness. In addition, we believe that older Americans deserve to have choices as they age, regardless of their financial resources.

The Green House Project is a recent addition to RWJF’s work on aging. As people grow older, they wonder how they will be able to maintain their autonomy, especially if they can no longer live independently. How does the Green House Project address those concerns?

KS: At some point, many of us will no longer be able to take care of ourselves and will need long-term care of some kind. We fear for ourselves and for our loved ones that ending up in an institution will mean loss of dignity and independence and living out our days as merely patients.

The Green House model calms those fears and turns those old stereotypes upside down. Green House homes are designed, from the ground up, to replace large, depersonalized institutional facilities with what look and feel like real homes, so that the elders who live there can retain their dignity and independence. The homes are small, with six to twelve elders, who have their own private rooms and bathrooms. There is a family room and hearth and an open kitchen and dining area.

Green House residents have the freedom to set their own daily routines and wake up and eat when they want to. They can choose to help out with cooking and other household tasks if they want to do so. Medical and clinical equipment that typically clutters hallways and rooms in more traditional nursing homes is tucked away from view or built directly into the beds, so that the interior designs better resemble real homes.

Most importantly, Green House residents enjoy all the social and personal benefits of a small-home environment, without sacrificing that same full range of personal care and quality clinical services offered by large, traditional, hospital-style facilities.

Green House homes are staffed by universal caregivers who have caring relationships with the elders and their families. In addition, Green House homes maintain high staff-to-elder ratios, so that elders get more personal contact. In fact, research shows that in Green House homes, elders get four times more personal contact than elders in typical nursing homes.

All these factors explain why Green House elders are happier and healthier than those who live in traditional nursing homes. In addition, research shows that elders get better care and enjoy a higher quality of life for the same or less than a traditional nursing home would cost to operate.

Furthermore, when informal caregivers were asked what they thought about the Green House Project, responses were overwhelmingly positive. In 2012, RWJF released results from a survey conducted by Edge Research of 1,065 informal caregivers on what they thought of the Green House Project. More than 60 percent of informal caregivers for elders currently in long-term care believe that the Green House model is “a lot better” than in-home care, a live-in facility, or adult daycare.

To date, nearly 300 Green House homes are open or in development in 31 states.

Tell us about some of RWJF’s other recent and/or current priorities that address the needs of older populations. What lessons did you learn that you think would be helpful to older adults and their caregivers?

KS: In addition to the Green House Project, RWJF invested in Cash & Counseling, a highly successful demonstration program that established participant direction as a breakthrough for long-term care in the United States. Under the Cash & Counseling model, elders and people with disabilities receive a monthly budget, based on what Medicaid would have paid a home care agency, and develop a plan for how they will use that budget to best meet their needs. They may use their budgets to pay family members or friends to assist them, or make purchases that will help them live more independently. In this way, people of all ages and disabilities can have the long-term care and support they need to remain independent.

An evaluation showed that consumers in Cash & Counseling were happy and satisfied with their care, yet participant-direction programs need not cost more. Today, these programs operate in all 50 states.

Another national program supported by RWJF was the Coming Home program, which developed affordable assisted living models with a focus on low-income seniors in smaller and rural communities. Assisted living can be a viable alternative to institutional long-term care for people with very low incomes. State and federal subsidy programs save an average of 62 percent when a nursing home-eligible Medicaid recipient is served in affordable assisted living. As of September 2008, Coming Home had supported completion of 50 projects comprising 2,144 units of affordable assisted living in 13 states.

In addition, RWJF funded Community Partnerships for Older Adults (CPFOA), a national program that engaged 15 communities to develop innovative solutions and options for how best to care for their older adult populations. Each community established a partnership that developed ways to help older citizens remain in their homes and neighborhoods and to continue to live full, rich lives. These partnerships brought everyone to the table – older adults, family members, informal caregivers, and a number of other partners – to create greater connectedness in the community on behalf of older people.

RWJF also supported the Program to Promote Long-Term Care Insurance for the Elderly, a national program that supported the efforts of eight states – California, Connecticut, Indiana, Massachusetts, New Jersey, New York, Oregon, and Wisconsin – to plan and implement private-public partnerships aimed at increasing the availability of high-quality, private, long-term care insurance. This kind of insurance protects people against impoverishment from the costs of long-term care – including nursing home care and home care. An evaluation showed that more than 30 percent of consumers who purchased policies through the partnership programs said they would not have otherwise.

Overall, our experiences have shown us that growing old does not have to mean living in an institution. There are choices out there for elderly people, as shown by models like the Green House Project, Cash & Counseling, Coming Home, CPFOA, and the Program to Promote Long-Term Care Insurance for the Elderly. We urge older adults and their caregivers and families to explore the options available to them and find out what works best for them.

Where can people go to learn more about RWJF’s work in the field of aging?

KS: They can visit our website at and type in “aging” or “long-term care” to find program descriptions or reports on various topics associated with aging.

Next up: 7 Keys to Growing Old in Your Own Home

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