Senior Living Business--September 2011
Working With NORC Programs And Villages--
An Aging-In-Place Option With Opportunities For Providers
The term “Naturally Occurring Retirement Community,” or NORC, describes a community not specifically developed for seniors but having a significant proportion of older adult residents. In a dense urban area, a NORC may occur in a single apartment building, a housing complex with common management, or a cluster of apartment buildings in close proximity; in a less urban area, it may be a neighborhood of apartments and/or single-family homes. Generally, a NORC forms as one of two quite-different models:
1. NORC supportive-services program. A public/private partnership involving a housing or neighborhood organization, health-care providers, social-service providers, and the residents themselves, the purpose of a NORC supportive-services program is to coordinate a broad range of free or low-cost social, health management, and wellness services and to provide educational and recreational activities for the residents in order to maximize the health and wellbeing of the community as a whole. Funding for a NORC program may come from a combination of government agencies, housing authorities, grants, philanthropies, corporations, and/or local hospitals. Residents pay fees for certain services such as nursing care.
Eligibility is based on residence and age; all older adults living within the geographic boundaries of the NORC are served. Legislative criteria, regulations, and language vary from state to state; e.g., half the residents in the defined area must be over age 50, or 40% of the heads of households in a defined area of at least 200 qualifying individuals may be age 65 or older. NORC programs have been established in more than half the states; New York has about 50, with more than half of those in New York City.
NORCs are not about senior living communities; rather, they’re about communities in which seniors are already living, according to Fredda Vladeck, Director of The Aging In Place Initiative at the United Hospital Fund in New York City and one of the founders of NORC programs in New York State.
“A senior living provider will continue to appeal to a segment of the population that desires to be in an age-specific community and that also has the means to pay for it,” she said. “It remains to be seen, though, what will happen to future generations. While they may be more numerous in terms of sheer numbers, I’m not sure they’ll be in the same economic position as people who are 10, 15, or 20 years older.” That situation has consequences for senior living communities across the country, and that’s where a NORC program or a Village model can work.
NORC programs do not duplicate existing service groups, but are for seniors who need more than just help managing event-based care or even their primary condition. They need help understanding their medications, negotiating assistance, and managing other types of services not covered by Medicare. “A NORC program is not about medical care,” Vladeck stressed. “It’s about health-care management—counseling, navigation, education, support, training, and some hands-on services.”
A NORC program is also not fixed in stone. It reflects and responds to what’s happening in the community, both demographically and according to the needs. Back in the 1990s, for example, about four NORCs in New York City dealing with a very old population had set up onsite adult day programs funded through user fees. The population changed after about 10 years and no longer had that need, so the adult day programs were dissolved. A NORC program is able to determine which resources, strengths, and social capital can help shore up and support the community.
“Some segment of the senior population will always require assisted living or skilled nursing care,” Vladeck acknowledged. “It may be in the business interest of nursing homes, therefore, to get to know their potential patients by becoming a NORC health-care partner—perhaps donating the services of a nurse.” It’s not clear whether the partners actually benefit from referrals; but when community service is part of a facility’s mission, a local NORC may be an obvious recipient. Also, as nursing homes begin to think about their role in the expected transition to accountable-care organizations and the new requirements for those facilities, building a relationship with the community may be a very important move. And since some NORC programs receive foundation support or other kinds of grant money to support the nursing function, not all health-care partners fully donate those services.
“Getting very old and more and more frail is a natural progression,” Vladeck remarked, “but are NORC programs making it less catastrophic? I hope so. If you’ve got diabetes, you don’t necessarily need to have your leg amputated. NORC programs are all about helping people maintain their functionality and manage their health as much as possible.”
2. NORC village concept
A NORC village is a self-governing, membership-based organization that coordinates services for adults ages 50 and up residing in a defined geographic area. The single goal of a village model is to help seniors remain within the community, in their own homes, and to avoid institutionalization. It works best in an affluent urban or suburban community; it’s less clear, at this point, how well it might work in a low-income community.
The village provides concierge services—vetting vendors and negotiating discounts, making recommendations and referrals, providing social connections, and perhaps coordinating transportation, housekeeping, and other ancillary services. Most members don’t require regular assistance with their personal care or household chores, according to A Demographic Profile of Village Members, a report published in June 2010 by the University of California Villages Project. Fewer than 10% of members, on average, were hospitalized in the year prior to the study, suggesting that members tend to be in good health.
A concept originated in 2001 by Beacon Hill Village in Boston, Massachusetts, nearly 50 villages are now operating throughout the country; hundreds more are being formed. Membership ranges from a few dozen members to nearly 500 per village. While 90% of current members are age 65 or older—mostly female and mostly white—about half the villages target people age 50 and older. Annual membership dues range from $50 to $900 for an individual or $100 to $1,200 for a household, with the average about $600. Some villages offer discounts based on income.
Ecumen’s “NORC village” relationship
If it looks like a NORC and acts like a NORC, is it a NORC? Mill City Commons is a not-for-profit membership organization founded by a group of residents living in a redeveloped district that stretches along the Mississippi River in Minneapolis, Minnesota. Except that its membership is not age-restricted, the organization’s description and mission (“to build community and meet the lifelong health and lifestyle needs and desires of our members”) certainly resemble the NORC village model. The organization is an aggregator/navigator of services for its members and builds relationships with providers—medical, compassion, and other services.
Steve Ordahl, Senior Vice President of Business and Fund Development at Ecumen in nearby Shoreview, doesn’t see much difference. Mill City Commons was naturally occurring, there’s a geographic aspect, and people have gotten together to follow through on things that they need. “Any difference between that and a NORC is a little blurred,” he said. Ordahl’s view is significant, because Ecumen—which currently operates nearly 70 senior communities in Minnesota and elsewhere—is a strategic partner, sponsor, and supporter of Mill City Commons. Jumping on board at the initial stage, back in 2008, Ecumen provides office space and contributes telephone and other services. And while the executive director of Mill City Commons works, in practice, for the organization’s board of directors, she is an Ecumen employee who reports to Ordahl. “They do reviews and reimburse us for her salary,” he explained, “but she participates in our staff meetings and in our benefits program. It’s a good relationship.”
For annual dues of $750 ($950 for a couple), members are entitled to full website access and participation in certain activities, programs, and events. Whether the need is for an electrician, a dog walker, medical care, transportation, or assistance with activities of daily living, those services are vetted by the organization and, because of the potential customer volume, often discounted.
“A NORC is really a concept rather than a thing,” said Ordahl, “and I believe that senior living providers should embrace them, as we’ve done with Mill City Commons. To the extent that a senior community can develop a relationship—perhaps providing meeting spaces, programming, transportation, and/or other services, it’s a great way to remain relevant.” Ecumen provides seminars on various health-care issues, for example, so that members know about and are comfortable with Ecumen.
“We’re not selling to them,” he emphasized. “It’s a passive relationship…a matter of trust. We want them to share issues with us and to know that we’re thinking about something other than nursing homes.” Ecumen’s mission is, in fact, “to create a home for older adults, wherever they choose to live.” So if Mill City Commons members want to continue to live in their condos, Ecumen wants to do everything it can to help them do just that.
“We don’t mind if they don’t move into our communities,” he added. “Given the demographics, we couldn’t build enough, finance enough, nor have enough money for the expected influx of demand for senior housing. There’s no way that we—or any other senior living provider—could build enough bricks and mortar to accommodate all the seniors, so why not embrace the fact that people want choices. Let’s do it on their terms.”
Competition for CCRCs—or not?
If providers continue to build and operate their properties the way they’ve done for the last 25 years, then it won’t just be NORCs that take away market share, observed consultant Art Carr of Progressive Retirement Lifestyles in Franklin, Tennessee. “The aging-in-place concept is a significant challenge to senior living communities, which will have to treat residents a bit differently as we move into succeeding generations,” he said.
NORCs are really attempting to formalize the lifestyle of 50 years ago, when families were much larger and not as geographically diverse as they’ve trended in recent years, according to Carr. “Daughters and daughters-in-law, who used to take care of parents and parents-in-law, are now in the workforce,” he noted.
Clearly, moving into a CCRC is a life decision, the main selling point being that the provider will take care of the resident’s needs for the remainder of his or her life. Would individuals with those concerns be attracted to a NORC? And would those attracted by a NORC concept ever have chosen to move into a CCRC? In Carr’s opinion, the controlled environment offered by a CCRC may do a better job meeting all of the mental, physical, and spiritual needs of its residents with less risk than a NORC setting. But an aging person who moves into a CCRC gives up some control over his or her independence in exchange for that peace of mind. A NORC allows the independent person, especially the younger elderly individual, more latitude to make decisions.
In addition, the onsite health-care partner (usually a nurse) in a NORC supportive-services program can evaluate situations and assess the member for medication adherence, hypertension, gait, balance, and proper fitting of mobility devices over a sustained period of time. “In fact, that’s not too dissimilar from what the best CCRCs do: taking into account the overall health and wellbeing of the residents and helping them maintain a healthy status as best they can.
So NORCs are simply another option—and smart senior living providers will find ways to get involved. (For further information: www.NORCBlueprint.org.)