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Concept of Senior Living and Care

Demographic pattern and the changing social norms make it mandatory for us in India to look at the issue of old age more clearly. Unlike in the West, in India, it is the family that is responsible for taking care of the elders in their old age.

Colonel Achal Sridharan, VSM

CONCEPT OF SENIOR LIVING & CARE

“RETIREMENT COMMUNITIES – NOT A REAL ESTATE PROPOSITION,

BUT A LIFESTYLE FOR THE ELDERLY”

General:

Demographic pattern and the changing social norms make it mandatory for us in India to look at the issue of old age more clearly. Unlike in the West, in India, it is the family that is responsible for taking care of the elders in their old age. This tradition is prevalent in rural areas to a large extent, where family as one entity, is very much the concept. Joint family system was indeed a boon to senior citizens in that family. Unfortunately that system is no longer popular and there are very few families, which still follows the joint family system.

In urban India, because of the rise of the Middle class and the circumstances, which force children to take up employment opportunities far away from home, senior citizens are forced to live alone without much of the support systems, which are necessary. Children are also unable to do anything because of working far away from home. Parents are also reluctant to lose their independence by moving out of their place of residence and live with their children. As one grows old, there is a tendency to be fiercely independent. Besides, many do not want to keep moving with their children from place to place.

For the children too, life with parents after marriage is not an easy proposition. Every one needs space and when the space gets reduced or impeached upon, problems in relationship develop. If parents desire freedom, children demand the same.   

The situation gets further aggravated because senior citizens find it difficult to manage their daily chores and do not get the requisite services that they desire when they live alone. There is a feeling of insecurity in old age. Social interaction decreases, as the younger generation does not have time for the senor citizens. Senior citizens need group cohesion and support from the community, which unfortunately is not available when they live alone.

In a few years, the situation will worsen when India finds large number of younger population and an increasing number of graying older population with enhanced longevity thanks to the advancement in the medical field. India also has a growing Middle Class population whose expectations are matched by their ability to spend. Retirement Communities will be essential and that too in larger number, where service and care should be the main criteria so that the comfort levels that the senior citizens desire can be given. Such retirement communities in India are not available in the numbers that are required.

With longevity, a person who retires at 60 years and, may live beyond 90 years of age. This translates to leading 1/3rd of one’s life after retirement. With longevity, cost of care increases and one may need Assisted, Memory or Palliative Care (See below). We need such facilities for good geriatric care. These are unheard of in vanilla real estate projects or ever seen in Old Age Homes.

Retirement Communities came into being to address these needs of senior citizens around year 2000. In the past 17 years, lot of advancement has been made in this segment. Today we see a variety of such communities offering various facilities and there is no uniformity in the facilities offered, care components, services offered as well as design of dwellings to suit seniors who are wheel chair dependent. We are now seeing an evolution of Senior Care Centers where not only services but care requirements to match the geriatric needs are getting implemented. Very soon, we may have only Senior Care Centers with lot of emphasis on care and witness lifestyle changes of seniors, which would also dictate the design of dwellings. Retirement Communities or Senior Care Centers will have a huge demand with the changes in demography in India.

The Middle Class

By definition, the middle class is the broad group of people in contemporary society who fall socio- economically between the working class and upper class. This socio- economic class encompasses the sub-classes of lower middle, middle-middle, and upper-middle. It includes professionals, highly skilled workers, and management experts. As in all socio- economic classes, the middle class is associated with a shared and complex set of cultural values.

The middle class is also any social group in history who are neither the class of common laboring people, nor the ruling class.

Brief Historical Perspective:

Not so long ago, the Indian Middle class belonged to the so-called Forward communities in the caste ridden Indian society. This class had and continues to have ambition and desire to do well in life. Education was the route that the middle class took to fulfill its ambition. Children were told to work hard, study and get ahead in life. Parents sacrificed for the sake of children’s well being. The threat of competition and the need to get ahead was emphasized to the children. Marks in examinations mattered and recognition of parents through the performance of their children in academic field was a matter of pride and honor. Parents toiled and so did the children. When the time came for jobs, the children left their homes for greener pastures leaving their parents behind in their homes. Parents in fact were proud of the fact that their children got good jobs and were doing well even though it meant living alone.

The Joint family system, which was prevalent, broke down with economic prosperity, division of properties and wealth.  This again can be attributed to the ambition of the members in the joint family wanting their own children to excel.  If parents lived only for the well being of their children, children when they left their parents looking for greener pastures, lived for the well being of their families, in which the parents did not find a place. Nuclear families became the order of the day. Yet the love for the parents remained but the responsibility of taking care of them in their older age could not be fulfilled because of the circumstances, which compelled them to live far away from their homes.

Another point, which we need to be taken note of, is the reduction in the growth of population. In good old days, women were homemakers. Today women work shoulder to shoulder with men in all fields. It has become almost a necessity for husband and wife to work to meet the requirements of their families.  Not only do they need to look after themselves and their children, they also need to support their parents in their old age, and perhaps, even grand parents since all of them are living for more number of years.

With longevity, the saving for the post-retired life has increased enormously and this has affected in postponing marriage, late marriages, living-in relationships out side marriage and postpone children and worst still, have no child at all or restrict with one. What the Chinese Government enforced by law of not having more than one child is being done voluntarily in India today. The Chinese have realized the disastrous consequences of their policy and we in India are going to fall into the same trap soon.

If the older generations had more children, the current generation has lesser number of children or postpones having children or is content with one child. Many young people are also postponing marriage and many prefer to remain single. The resultant reduction in population will have a direct bearing on the responsibility of looking after ageing parents by the younger generation. Consequently the younger generation may find it being responsible for looking after larger number of older people (parents and grand parents), but may not be able to do so because of increased cost of looking after senior citizens and their own families. This is a problem that is being faced by China, where until recently not having more than one child was mandatory by law. India will reach that stage not in the distant future but soon, unless we maintain balanced and desirable growth in population.

Misconception of the word “Home”

Senior communities in India were started as an act of charity. They were called “Old Age Homes” or “Home for the Aged”. They were set up to look after the poor and destitute who had no family or their families abandoned them because of old age. In many cases it was due to the effects of urbanization and lowering of values in life and the senior citizens were asked to leave their homes. In many cases the younger and older generation could not get along with each other, as each felt that their space was being trampled upon.

The rules that we have today are for Old Age Homes run by NGOs or charitable institutions. The Retirement Communities that we see today are not the same as Old Age Homes.

Independence and life style of the younger generation was affected when elders were present at home. In urban India, privacy was also affected because of higher cost of dwellings, which resulted in more number of people living in smaller houses. This led to conflict situations and in the end the elders simply left their homes and took shelter in one of the Homes for the Aged.

A house is a dwelling place, constructed as a home for one or more persons. Whether it is a crude hut or an elaborate mansion, a home provides protection from weather and adversaries. If that were so, then why should the word “Home” in the context of providing shelter to elder citizens be unacceptable or resented?

Living in an Old Age Home had stigma attached to it, especially to the Middle Class. More than the elder citizens, the children and close family members resent the very idea of the elders moving into a “home”. On the one hand, the children cannot take care of their parents in their old age due to compulsions of life but at the same time they do not want others to know that their parents are living in an Old Age Home.

Many elder citizens were caught between their own comfort and care and the family honour if they chose to move into one of these Homes. One was forced to see the photographs of elderly living in these Old Age Homes and it left a lasting impression of old people clutching and clinging to every thing in life, yearning for love and care. They were shown as if they have forgotten how to smile. The more pathetic the pictures of old people were, more charity one was willing to give. We hid our guilt by paying to these charitable institutions, which looked after the aged. May be they were not the best that the Middle Class would have liked to live in but they cared for the aged with their meager resources. In India, when the State does not provide any social security, these Homes for the Aged are indeed a boon for thousands of old people who cannot afford to live alone in their old age.

The conflict is more pronounced when one belonged to the Middle Class and age caught up with them. Many of the elder citizens from the Middle Class continue to live in their villas or apartments and are dependent on their neighbors or the domestic helps to take care of them. In many cases, in spite of paying for the services, they do not get what they want and are forced to live a life of misery. This leads to depression in many elder citizens and living is becoming a difficult proposition.

Recent Growth of the Global Middle class

In February 2009, The Economist magazine wrote that over half the world’s population now belongs to the middle class, as a result of rapid growth in emerging countries. It characterized the middle class as having a reasonable amount of discretionary income, so that they do not live from hand to mouth as the poor do, and defined it as beginning at the point where people have roughly a third of their income left for discretionary spending after paying for basic food and shelter. This allows people to buy consumer goods, improve their health care, and provide for their children’s education. Most of the emerging middle class consists of people who are middle-class by the standards of the developing world but not the rich ones, since their incomes do not match developed country levels, but the percentage of which is discretionary does. By this definition, the number of middle class people in Asia exceeded that in the West sometime around 2007 or 2008.

The Economist article pointed out that in many emerging countries, the middle class has not grown incrementally, but explosively. The rapid growth results from the fact that the majority of the people fall into the middle of a right-skewed bell-shaped curve, and when the peak of the population curve crosses the threshold into the middle class, the number of people in the middle class grows enormously. In addition, when the curve crosses the threshold, economic forces cause the bulge to become taller as incomes at that level, grow faster than incomes in other ranges. The point at which the poor start entering the middle class by the millions is the time when poor countries get the maximum benefit from cheap labor through international trade, before they price themselves out of world markets for cheap goods. It is also a period of rapid urbanization, when subsistence farmers abandon marginal farms to work in factories, resulting in a several-fold increase in their economic productivity before their wages catch up to international levels. That stage was reached in China some time between 1990 and 2005, when the middle class grew from 15% to 62% of the population, and is just being reached in India now.

The Economist predicted that surge across the poverty line should continue for a couple of decades and the global middle class will grow enormously between now and 2030.

This is very true in the case of India. Along with the growth of the Middle Class, the problems of senior citizens will also increase for the reasons that are explained in the succeeding paragraphs.

Changing Perceptions in India to Retirement Communities

In India, there is a noticeable change to the perception of living in retirement community by the Middle Class. Today, many elder citizens are looking forward to living in a retirement community and, many children do not object to this because they see merit living in such a community. If children are not living with their parents it is very difficult for them to provide the necessary support system to them in their old age. But, the Middle Class expectations are more.

Expectations:

The expectations of the Middle Class include the following:

> Give what the Senior Citizens Need and, not ask them to Take what is given

> Dignity & Respect

> Opportunities for Social Interaction

> Quality infrastructure & Amenities

> Design to meet the needs of Senior Citizens

> Quality Care and Support Services in various Stages

> Freedom and Independence

> Group Cohesion & Activity without compulsion

> Life not in isolation but part of the society

> Emphasis is on Care, Services and Comfort

> Avenues to use talent of Senior Citizens

Stages in Life of Senior Citizens:

Anyone above 60 is a senior citizen. The retirement age in India is 60 years. However, a senior citizen goes through three distinct stages as follows:

> Independent Living Stage: During this period, the senior citizen is active, independent and productive. Many of them work and can take care of themselves. They may have a few medical problems but these are not life threatening. They cherish freedom through independence and this includes the feeling of having fulfilled their responsibilities to their children. They want to enjoy life and do all that they could not do for various reasons. In effect they lead a normal life like any one from the younger generation. However, they need some group cohesion, occupation and protection besides emergency medical care.

With longevity, the age when actually a person retires to lead retired life has now increased to between 65 and 70. Yet, in India the age of retirement has been maintained at 60 years. Thus, it is possible that a senior citizen, especially women, who outlive men by approximately 10-12 years, may have to spend 1/3rd of their life in retirement. This brings with it the cost of care and the amount of saving that one has to make for post retired life. With decreasing interest rates and erosion in value of money due to inflation, this amount will increase and this puts pressure on senior citizens.

> Assisted Living Stage: This is the stage, where because of age or some disability, the elders need assistance in daily chores like eating, bathing, toileting, dressing etc. Some elders may get Dementia, which leads to Alzheimer, and they will need Memory Care.  The Assisted Living Stage thus, will require Assisted Care and Memory Care Centers, which are not hospitals but has doctors, nurses and Care Givers who are trained to provide specialised care for such elders. This is a stage between total independence and dependence. They need security, emergency assistance and access to health care. It is not necessary for all senior citizens to pass through this stage.

> Continuous Care Stage: In this stage, the elder citizens need total nursing care and doctor’s attendance. In effect they will need to be hospitalized and provided necessary care. The care could also include Memory Care– patients suffering from Dementia and Alzheimer disease as mentioned above or those requiring End of Life or Palliative Care.

Options for Housing Continuum:

Most of the people from the Middle Class prefer Independent Villas in a Retirement Community. However, villas are not suitable for a retirement community due to following reasons:

√ Women out live men on an average by 7 years. There is an age difference of 3 to 5 years at the time of marriage. Therefore, a time retirement community will have larger number of women than men. When the demography in the Retirement Community is in favor of women, villas are not ideal especially because of illness that one may suffer with advancing age and the problem of immediate attention in an emergency.

√ Villas also prohibit group cohesion. The tendency is to assemble at the Dining Hall for meals, spend a few minutes with other residents and then retire to one’s villa. Group Activity becomes less and the senior citizens become couch potato in front of their TV.  Villas, by their very nature with compound wall , makes barrier between the residents.

Apartments:

Apartments, which are specially designed to meet the requirement of senior citizens, are a better option than villas. The design, besides catering for such routine  features like non-skid tiles, grab rails, lighting, toilet design to cater for wheel chair movement, lighting, emergency alarm systems etc, should provide for two lifts in each block – an eight-passenger lift which can enable travel in a wheel chair and a stretcher lift. Standby generator for living quarters, common amenities, lifts etc should be provided. Streetlights could be of Solar so that in case of load shedding, there is no problem for streetlights.

Apartments enable greater group cohesion and interaction among the residents. This is very essential in a community living. To a large extent, apartments negate the problem of living of senior citizens when the demography is more of women than men.

Covai Care Suites:

We have specially designed suites of single and two bedrooms. These are designed in such a manner that the common amenities are in the Ground Floor and the entre Block surrounds a large beautiful Garden so that the residents have a lovely view from the Balconies. Also, each floor has open spaces for indoor games, TV viewing, reading, chairs to simply sit and relax or converse with others etc. The advantage of this design is that everyone has to meet others whenever they are not in their rooms, the corridors are naturally lit and there is greater group activity and Group cohesion. The design also reduces costs on common amenities and is easy to maintain

Housing Options for Various Stages of Life of Seniors

Based on the stage given above which a senior citizen may have to pass through, we need housing options to suit each stage. The following options are available:

> Independent Living: These are the normal colonies that we see with villas or apartments or a combination of both. The apartments could be Studio Type with a Living Room, Bedroom with attached toilet, a closet, a balcony and a small kitchenette. The colony is gated with security arrangements and it has facilities for dining, recreation etc. Various services like transportation, housekeeping, concierge etc will be provided.  The dwellings can be owned by the occupant or can be given on lease.

> Assisted Living Facility: Assisted Care is for those who are frail due to age or require long-term assistance (recovery and rehabilitation from stroke) or short-term assistance after a senior citizen undergoes surgery such as Heart, Knee or Hip replacement surgery etc. The assistance would include specialized care by Care Givers, Physiotherapist, Nurse, Doctor ion regular call, emergency evacuation to hospital etc. The care would also include toileting, bathing, feeding, and timely administration of medicines, taking the patient in wheel chair to activity center etc. Because of the additional assistance that the senior citizens would require, those needing Assisted Care will have to live in the same block. Otherwise, the assistance that would be necessary cannot be given. Please note that Assisted Living is not akin to Hospital Care. In Assisted Care, no facilities are available for treatment of illness or specialist doctors. As the term indicates the Assisted Care Centers provide care to those needing assistance to live.

>  Continuous Care: This is the state, when the patient is bedridden and requires constant care including nursing care under Doctor’s advice. The residents will have to vacate their existing premises and move into this facility, because the patient would need constant care like in a Nursing Home. It is not necessary for any resident to go through these three distinct stages since the nature of illness may force them to move directly from independent living to Nursing care facility.

Concept for Total Care:

From the time a senior citizen invests in a property in a retirement community, until he leaves either by choice or circumstances or because of death, he needs care i.e., continuing care. Yet, the Model should be so designed that at all stages of life the couple or the individual has the financial security and independence without taxing their children.

Therefore an ideal Model should have the following ingredients:

> The investor could be working at the time of investing in a retirement dwelling or may have retired or about to retire. The entry age could preferably be about 50 years so that the investor has time to pay back any home loans by the time he or she becomes a senior citizen. If the investor is working at the time of investment, he or she can get rent for the investment made, which can be used for paying back the housing loan or as saving for the post-retirement life.

> The model should cater for all stages of life of Senior Citizens

> The model should provide security of all kind – financial, care, comfort, services etc to the widow or the widower in the eventuality of death of husband or wife as the case may be.

> Provide financial security including meet medical bills and hospitalization care if it becomes necessary

> The heirs should benefit out of the investment made by their parents instead of being encumbered after their demise.

A Suggested Model: Based on our experience, we suggest the following Model:

1. The resident should own the dwelling as it gives him greater surety in getting the services. However, if there are checks and balances, even a leasehold model can work and the investment cost by the senior citizen will be less. In India today, both these models are operational. In fact, for a senior citizen entering a retirement community after the spouse is no more or because of old age, it does not make economic sense to buy a dwelling at an age of 75 yers and above but instead opt for a leased model, spend less for the dwelling and on demise the legal heirs get back the Lease Deposit less some percentage retained by the Service Provider, which could be based on the length of stay or a fixed percentage or a graduated percentage based on years of stay.

2. Though the Model could be freehold property, there should be certain rules binding on the sale of the property, as the management should know as to whom a resident is selling his or her property.

3. Inclusive Management for better transparency between the Service provider and the residents

4. The common amenities should belong to the Service Provider. From the total value of the dwelling unit an amount is set aside as “Refundable Deposit” (without any interest), which is a sort of membership for using the amenities. On the sale of the property, the amount is refunded and the same amount is collected from the new buyer so that he or she can be given the Membership for availing the services and uses the amenities after signing the Services Agreement. Services agreements are NOT transferable.

5. Every service provided is chargeable.

6. Have a Dynamic Costing System, which ensures transparency and also ice ensures that the Service Provider gets a fixed Management Fee (say 25%)

7. The Agreements have water tight clauses to protect the interest of the senior citizens.

Infrastructure and Amenities:

The residents should get good infrastructure and amenities. The community should be wheel chair friendly everywhere. There are no Building Codes for Retirement Communities and the ones for real estate is not suitable either. Over a period of time these codes have been evolved and generally are followed by those who provide care and services in the retirement communities or Care Centres. The following should be provided:

Basic Infrastructure:

> Internal Black topped Roads or Pavers

> Sewage Treatment Plant and recycling arrangements

> Compound Wall

> Storm Water Drains with Rain Water Harvesting Facilities

> Arrangement for Drinking Water including treated Bore well water

> Solar Street Lights

> Solar Water Heaters

Facilities:

> Club House with Lounge, Dining Room, Reading Room, Card Room,. TV Room, Indoor Games, Kitchen, Pantry etc

> Medical Center with Ambulance

> Activity Center

> Quarters for Manager, Kitchen staff, Supervisors, Ambulance Driver, Nurse, Care Givers

> Guest Rooms

Amenities:

> Green Belt & Landscaped Gardens with walk ways

> Sports Complex with Swimming Pool, Tennis, Indoor Badminton, Table Tennis, Cricket etc

> Amphitheater

> Library

> Ayurvedic Massage Center

> Assisted Care Center

> Doctors’ and Nurses Quarters

> Convenience Store

> 24X7 Security

Services:

If care beyond compare is part of the vision, the success of this model lies in providing sustained quality services, which are given below:

> Catering Services

> House Keeping Services

> Gardeners

> Security Staff

> Garbage Clearing Arrangements & Vermi Composting

> Travel Services including pick and drop, tickets etc

> Recreation Arrangements including Social Evenings, dance, music etc

> Religious Tours as well as organizing holidays through Travel Agents

> Picnics and Outings including Movies and restaurants

> Entertainment by organizing events

> Medical Check Ups

> Lectures on religion, spiritualism and common subjects of interest

> Assisted care for those who need

> Preventive maintenance by electrician, plumber and carpenter as well as on call services from them

> Payment of taxes, telephone and electricity bills

> Guest House facilities for guests

> Arrangements for celebrations like Birthdays, Wedding Anniversaries etc

> 24 hour care through in-living Manager and Assistant Manager

> Emergency services including evacuation to hospitals

> Maintenance of Health Record and periodic medical check up in hospitals

> Doctor facilities

> Structured supply of medicines and home needs

> Arrangement for banking facility, including ATM

> Insurance Services for home and household goods

> Funeral services

Keeping Elders Active:

Being old is not a disease. It is a natural process of ageing. Until the elder citizens reach the Assisted or Memory Care stage or the Nursing stage, they can be usefully employed. They have wealth of talent and experience. They are well qualified and can contribute a lot to the society in many ways.

Yet, they are not given the opportunities to share their knowledge, experience and qualifications. The Model therefore should provide these opportunities, which can either be with some honorarium or as social service for the cause of the community.

There should be inter-action with the younger generation. The elder citizens love freedom, independence, dignity and respect as well as inter-action with younger generation. The Model should consider these aspects and some of the ways that these opportunities can be created are as follows:

> Qualified elder citizens can give Guest Lectures in B Schools, colleges and Schools and share their practical knowledge. Tie up some of the colleges will be necessary

> Doctors among them can work in the Medical Center or the Nursing Home. They can also update the Medical Records of the residents and give lectures on various health related issues

> Professionals can give some talk on some current issues that can develop into a group discussion

> Those who are spiritually inclined and are knowledgeable can give lectures or discourse on religion etc

> Physical well being can be taken care of by organizing Yoga or Pranayama or the Art of Living Classes by the residents themselves.

> They can take up a social project in the nearby village and assist the community

> Classes can be organized for the children of house maids and staff which would help their parents who may not be that well educated. For example, if home work given by schools can be centrally got completed by these children with the assistance of some elders who were teaching in schools, the house keeping staff will find it of great help to them and also the children will learn better.

> Those who are intellectually inclined can even undertake study on Geriatrics. For this the Library will have to be suitably equipped and stocked and perhaps some coordination with the University near by would be of great help.

> Colleges teaching students on subjects like Sociology can work with the elders in various activities including running of the Assisted Care Center and the Center for Alzheimer Care. While the students will get practical knowledge, the residents will get to meet younger generation and also share their time with them.

> The list is endless and many ideas can come from the elder citizens themselves.

The Management will need to appoint some one who can plan and coordinate all these activities as well as organize entertainment, recreation, tours, picnics etc

Inter-Action with Younger Generation

This is an essential requirement. There is a need to strike a balance between the privacy that elder citizens cherish and the social inter-action that they enjoy with younger generation.

In all this it must be noted that the requirements of the elder citizens must always be met first and they must get the priority as is the custom and norm as mark of respect to our elders.

Conclusion:

Team CovaiCare.com and I  have tried to analyze the effect of senior citizens of the middle class population, which is expected to grow in huge numbers in the next decade. The Paper has also suggested a model to ensure that care is given to the elder citizens from the time they enter the Retirement Village until they leave. The Model suggested ensures that the financial security of elders is guaranteed along with care beyond compare and makes living as much enjoyable to the senior citizens without being a burden on their family or to the society. The Model will have to be refined to match the aspirations, customs and traditions of people who live in different part of India where culture is different.

What comes out clearly is that elder care or retirement communities are not extension of real estate. We need separate Building Codes, rules and regulations like RERA. We cannot have the same rules of RERA being applied to Real Estate Projects.

Colonel (Retd) A Sridharan, VSM
Managing Director
Covai Property Center (I) P Ltd
Coimbatore

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