Many patients in that situation wind up living on the streets or in shelters, despite efforts to find them permanent housing. A surprising number of older adults, however, find themselves in a nursing home—even if they don’t need or want that level of care.
It’s an expensive housing solution: One year in a nursing home costs $119,340 on average, compared to around $16,000 per person per year for subsidized permanent supportive housing that includes some services.
“She didn’t want to be institutionalized,” says Synovec, who is now assistant director of medical respite at the National Health Care for the Homeless Council. “She wanted to be in the community.”
Shelters often house people in bunk beds. Their bathrooms typically aren’t designed for people with disabilities. And shelter residents must leave early each morning and fend for themselves until the shelter reopens in the evening.
“They get to a point essentially where there’s not a place in the community for them to go,” says Synovec. “The option is long-term care—nursing home care—or they die on the street.”
As a social worker and researcher, Ian Johnson interviewed dozens of social workers, nurses, and other professionals in Seattle who were helping unhoused older adults cope with serious medical conditions. Many of the older adults feared being in a more restrictive environment if they went to a nursing home, and nurses and social workers told of patients who chose to return to the streets from a hospital or rehab unit rather than enter long-term nursing home care.
At the same time, stories also abound of nursing homes discharging vulnerable older adults to homeless shelters—or to no destination at all. The triggering event could be a violation of rules, such as smoking or substance use, or depletion of insurance.
An age-friendly option
One answer to this predicament is to build subsidized housing that meets the mobility and care needs of older adults with very low incomes but preserves their sense of independence. In other words, age-friendly, low-income housing would give people who are aging and homeless the “4 Ms” framework that seeks to address mobility, medication, mentation, and what matters most to older adults.
Hospitals tend to discharge patients as soon as they’re medically stable, so nursing homes, also known as skilled nursing facilities, became providers of short-term rehabilitation. When they leave rehab, most patients rely on family caregivers or paid aides for any ongoing help.
Farber envisions a remake: Hospitals would provide the sub-acute care and only discharge patients when they are ready to go home. People who are homeless and aging with manageable medical conditions would have access to subsidized housing and special programs tailored to their needs.
The oldest Baby Boomers turn 80 in 2026. By 2030, every Baby Boomer will be 65 or older. Just as they have impacted so many aspects of society, they will overwhelm the capacity for senior housing, long-term care, and emergency shelter.
“The system is fundamentally broken,” he says, “and we’re not going to fix it with band-aids.”
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