NORC Supportive Service Programs:
An Overview and Literature Review
Barbara Joyce Bedney, Ph.D., M.S.W.
Robert Goldberg, Esq.
April 22, 2023
We live in a time of unprecedented growth in the nations’ older adult population. In 2006, 37 million people age 65 and over lived in the United States, accounting for just over 12% of the total population. By 2030, that number will likely double, and grow to 71.5 million. At that point, older adults will represent nearly 20% of the total U.S. population (Federal Interagency Forum on Aging Related Statistics, 2008).
These demographics will present a number of opportunities for the United States, but also a number of challenges, not the least of which is health care costs. It is currently estimated that one-third of total U.S. health care expenditures is for older adults (Agency for Healthcare Research and Quality/Centers for Disease Control, 2002). Health care expenditures for people aged 65 years or older are four times that for 40-year-olds. By 2030, health care spending will increase by 25 percent, simply because the population will be older (Agency for Healthcare Research and Quality/Centers for Disease Control, 2002).
There are ways to reduce the health care costs associated with the burgeoning older adult population, however. Reducing the risk and incidence of heart disease, falls, Alzheimer’s disease, post-hospitalization re-admission; increasing knowledge of available community-based resources; and promoting volunteerism, positive perceptions of health, and positive expectations about community living, may all be efficient and effective ways to reduce the incidence and cost of health care conditions among older adults.
NORC supportive service programs (NORC-SSPs), delivered on-site to older adults who live in ‘naturally occurring retirement communities’ (NORCs), are ideally suited to deliver the types of programs that can target each of the above outcomes, as we outline below.
Seven Ways NORC-SSPs May Be Able to Reduce Health Care Costs among Older Adults
1. Reducing the risk and incidence of heart disease among older adults
The cost of heart disease and stroke in the United States, including health care expenditures and lost productivity from deaths and disability, is projected to be more than $475 billion in 2009. Yet these conditions are among the most preventable health problems facing our nation today (CDC, 2009). Promoting a healthy lifestyle, including encouraging and facilitating participation in physical activity, is one way health care providers and social service agencies can reduce a person’s risk of developing heart disease or stroke. In addition, reducing loneliness and social isolation among older adults may also reduce their risk of heart disease, as research has consistently linked loneliness and social isolation to poor health outcomes such as cardiovascular disease (Hawkley et al., 2003; Sorkin et al., 2002).
NORC-SSPs are ideally suited to deliver interventions that promote physical activity and decrease social isolation among older adults, and may therefore be an efficient and effective way to reduce the risk – and the cost – of heart disease among this at-risk population. Socialization and recreation, for example, are two of the core elements of NORC-SSPs. Both encourage older adults who reside in NORCs to participate in local activities, community forums, neighborhood events, socialization programs, among others. In a recent evaluation of participants from 24 NORC-SSPs across the country (Bedney et al., 2007), 72% of study participants agreed or strongly agreed that they leave their homes more than they used to, and 84% agreed or strongly agreed that they participate in activities or events more than they used to as a result of participation in a local NORC program.
2. Reducing the risk of falls among older adults
In 2000, the total direct cost of all fall injuries for people 65 and older exceeded $19 billion. The financial toll for older adult falls is expected to increase as the population ages, and may reach $54.9 billion by 2020 (CDC, 2008).
Unintentional falls are a threat to the lives, independence, and health of adults aged 65 and older. Every 18 seconds, an older adult is treated in an emergency department for a fall, and every 35 minutes, someone dies as a result of their injuries. (Gerontological Society of America, 2009). Although one in three older adults falls each year in the United States, falls are not an inevitable part of aging. Being inactive results in loss of muscle strength and balance and increases the risk of falls, and inactivity increases with age. By age 75, about one in three men and one in two women engage in no physical activity (CDC, 1996).
NORC-SSPs, as outlined above, promote activity among older adults through recreation and socialization programs and by encouraging participation in various community events and activities. They may, therefore, be an inexpensive way to decrease the risk and the cost of falls among older adults.
3. Reducing Alzheimer’s disease among older adults
In 2000, there were an estimated 411,000 new cases of Alzheimer’s disease. That number is expected to increase to 615,000 new cases a year by 2030, and to 959,000 new cases a year by 2050. By 2050, the number of individuals age 65 and over with Alzheimer’s could range from 11 million to 16 million (Alzheimer’s Association, 2007).
Direct and indirect costs of Alzheimer’s and other dementias, including Medicare and Medicaid costs and the indirect costs to business of employees who are caregivers of persons with Alzheimer’s, amount to more than $148 billion annually, including $36.5 billion in costs to businesses from lost productivity, missed work and cost to replace workers who leave their jobs to meet the demands of caring for someone with Alzheimer’s (Alzheimer’s Association, 2007).
NORC-SSPs may be able to help reduce the risk of Alzheimer’s disease by decreasing social isolation among older adults through the mechanisms and activities outlined above. One recent study (Wilson et al., 2007), for example, found that elderly people who report being lonely were twice as likely to develop Alzheimer’s disease as those who were not lonely. By decreasing social isolation, NORC-SSPs may be able to reduce the sense of loneliness that may contribute to an increased risk of Alzheimer’s disease among older adults.
4. Preventing post-hospitalization decline among older adults
According to recent research (Mahnoey et al., 2000), decline in function in activities of daily living (ADLs) occurs in one third of hospitalized older adults, and frequently heralds an end to community living. Available data also suggests that adequate social support is essential for functional recovery and maintenance of community living, and that patients discharged from the hospital to home alone are more likely to be admitted to a nursing home in the month following discharge (Mahnoey et al., 2000).
NORC-SSPs are ideally suited to target older adults who live alone and may be able to help with post-discharge support of these vulnerable seniors, thereby reducing costly re-admissions to hospitals or nursing homes. In the NORC-SSP evaluation cited previously, 66% of respondents sampled lived alone, including 79% of respondents age 80-89 and 84% of respondents age 90-99. As such, the NORC-SSP model has a demonstrated ability to target and access vulnerable older adults who live alone – those at high risk of post-hospital decline and nursing home admission.
5. Increasing awareness and use of community resource and services among older adults
In a recent study (Keyes et al., 2005), older adults who believed that help was available reported fewer physically unhealthy days than those who perceived that help was not available to them. In addition, research suggests that improving access to care for the ‘oldest old’ may help to reduce the need for care in higher cost settings (Stewart, 2004).
NORC-SSPs, typically provided by collaborations of multiple community-based agencies, are ideally suited to increase awareness of, and access to, social service and health-related programs and services. In the evaluation of the NORC-SSP model cited previously, 95% of survey respondents agreed or strongly agreed that they know more about community services available to them than they did prior to participating in the program, and 81% agreed or strongly agreed that they use community services more than they used to (e.g., senior transportation, congregate meals, case management, health promotion, home repair and modification, physical and recreational activities, volunteer programs, health screening, information and referral services, among other services.)
6. Promoting volunteerism among older adults
According to Gruenewald et al. (2007), older adults often believe that an important component of successful aging is contributing to and helping others. In their study of relatively high functioning older adults, participants who reported that they rarely or never felt useful to others were more likely to experience increases in mobility disability or the onset of an ADL disability compared to older adults who reported feeling useful to others. In addition, those older adults with low feelings of usefulness had less favorable scores on measures of psychological and social well-being, and were more likely to report poor health behaviors, such as low rates of physical activity and higher rates of smoking, which can contribute to heart disease and other chronic conditions.
NORC-SSPs are ideally suited to promote feelings of usefulness among older adults, as volunteerism is a core component of the NORC model. Older adults who participate in NORC-SSPs are encouraged to participate on community advisory councils, awareness-raising campaigns, outreach efforts, and a myriad of other efforts on behalf of their local NORC projects. In the NORC-SSP evaluation cited previously, almost half (48%) of respondents agreed or strongly agreed that they volunteer more than they used to as a result of participating in their local NORC project.
7. Encouraging positive self-perceptions of health, aging, and community living among older adults
According to recent research, older adults with positive perceptions of aging have better functional health over time than those with negative self-perceptions of aging (Levy et al., 2002). In addition, self-assessment of health has been shown to be an important predictor of a number of future health outcomes, including functional ability and hospitalization (Benyamini et al., 2000), and poor self-reported health has been established to be a risk factor for hospital admission and nursing home placement among older adults (Weinberger et al., 1986). Even expectations about nursing home placement can have an influence on placement itself. According to Akamigbo et al. (2006), individuals’ expectations for placement reflect their personal risk factors. In their study, expectations of placement were strongly associated with actual placement over a 5 year period. Based on their research, they conclude that “the addition of expectations to the list of risk factors for nursing home placement has implications for care planning and policy.”
NORC-SSPs are designed to promote the health and well-being of older adults and their ability to age in place, and are therefore ideally suited to targeting these risk factors as well. In the NORC-SSP evaluation cited previously, 70% of respondents agreed or strongly agreed with the statement that they feel healthier than they used to as a result of their participation in a NORC-SSP program. In addition, 88% of respondents agreed or strongly agreed with the statement that they believe they are more likely to stay in the community than they used to as a result of their participation in a NORC-SSP program.
NORC supportive service programs have the ability to tackle four conditions associated with high health care costs – heart disease, falls, Alzheimer’s disease, and post-hospitalization nursing home admission. They have the added ability to promote awareness of and use of community resources that can promote positive health and aging, to increase volunteerism and feeling of usefulness among older adults, and to increase self-perceptions of health. Each of these outcomes may be able to reduce costs associated with the rapid growth of the U.S. population.
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