A Practical Methodology for Improving the Aging-Friendliness of Communities: Case Studies from Three U.S. Communities.

BACKGROUND AND OBJECTIVES: In this paper, we present a series of three case studies to illustrate an innovative and practical approach to improving the aging-friendliness of communities. These three communities used the AdvantAge Initiative to "listen" to the voices of older adults in their communities and to identify and prioritize aging-related issues. This approach was developed by the Center for Home Care Policy and Research at the Visiting Nurse Service of New York (VNSNY), the largest not-for-profit home health care organization in the United States, and has been implemented in over 60 communities throughout the United States. The methodology involves tools such as conceptual frameworks, survey questionnaires, focus groups, and technical assistance to help stakeholders interpret data and find solutions to identified issues. RESEARCH DESIGN AND METHODS: We interviewed VNSNY program staff and community partners involved in three AdvantAge Initiative projects that commenced at varying time points: Memphis and Shelby County, Tennessee (2012); New York City's Chinatown neighborhood (2006); and the state of Indiana (2008). We also collected and reviewed secondary materials associated with these projects (e.g., meeting notes from community planning meetings, annual reports from grant recipients, press coverage).
RESULTS: In this case study, we begin by providing an overview of the AdvantAge Initiative framework and the AdvantAge Initiative key indicators. We then present a more in-depth look at the three communities and how they approached and implemented the AdvantAge Initiative. DISCUSSION AND IMPLICATIONS: These case studies demonstrate that this methodology may be implemented in diverse communities and geographic locations. By looking at the longer-term outcomes and by comparing the strategies employed by each community, we see that communities, regardless of size, can bring stakeholders together to promote health and implement meaningful changes that make the community a better place to live for older adults and their families.

Translational Significance: As illustrated in these case studies, communities of different sizes and with different levels of resources may target different areas for enhancing the aging-friendliness of their communities in a manner that promotes the health and well-being of older adults. Examples include improving transportation options and changes to the built environment such as providing more benches and sidewalk repairs, making necessary home modifications to improve safety and comfort in the home, expanding housing options, and improving opportunities for socialization. Those involved in community-engaged planning may find these case studies useful in the development of their own efforts to improve community aging-friendliness.

Background and Objective

Age-friendly community initiatives, or AFCIs, often involve stakeholders from multiple sectors within a typically local geographic area to make social and physical environments more supportive of older adults’ health and well-being (1). They tend to move beyond the delivery of services to targeted individuals and are distinct from the efforts of single organizational entities such as municipal offices on aging or single nonprofit institutions (1). Most AFCIs aim to change older adults’ broader physical and social environments to allow them to remain in their homes and maintain independence (2).

Over the past few decades, there has been rapid growth in the number of local, state, national, and international AFCIs aimed at helping communities become more aging-friendly (3), with some referring to these initiatives as a social movement (4). There are many different approaches for forming AFCIs (1). Some of the most well-known program models include the following: the WHO Global Network of Age-Friendly Cities and Communities and its affiliate, the American Association of Retired Persons (AARP) Network of Age-Friendly Communities; AARP’s Livable Communities Initiative; Village to Village Network; The Visiting Nurse Service of New York’s AdvantAge Initiative; N4A (National Association of Area Agencies on Aging) Livable Communities; Robert Wood Johnson Foundation’s Community Partnerships for Older Adults; the U.S. Administration on Aging Community Innovations for Aging in Place; and Grantmakers in Aging partnership with Pfizer Foundation’s Community AGEnda, among others (4–8). Grantmakers in Aging has developed tools and resources (4,5), including a searchable database of AFCI programs across the United States, to support any funder, planner, or group seeking to undertake an age-friendly community initiative. Grantmakers in Aging notes that there are a number of ways to structure a successful program, and that planners and communities should consider a number of factors when choosing their own approach, such as whether funding is available, whether they wish to run a “leader-driven” project or a more grassroots effort, and whether success will require a lot of structure, such as developing, following, and monitoring success, and working with subcommittees (5).

The Visiting Nurse Service of New York’s AdvantAge Initiative was an early pioneer in the aging-friendly communities movement (4,7,9,10). The AdvantAge Initiative may be best classified as a community planning approach (1). It has also been characterized by Grantmakers in Aging as a “staffed, leader-driven, and structured” approach (5). In the current paper, we describe the foundational work that led to the development of the AdvantAge Initiative framework and indicators, and present a series of three case studies from the AdvantAge Initiative. These projects—the Plough Foundation’s Aging Initiative, supplemented by the AdvantAge approach, AdvantAge Chinatown Neighborhood Naturally Occurring Retirement Community (NNORC) in New York City, and AdvantAge Indiana—demonstrate how communities that differ greatly can all implement a similar community planning approach to improve the aging-friendliness of their communities. We explore how these communities have made changes over time to make their communities better places to live for older adults. The case studies demonstrate an approach that other communities may find useful as they develop their own aging-friendly community initiatives.

The AdvantAge Initiative approach is congruent with the goals and framework of the discipline of public health and aging. Public health and aging is a relatively new and interdisciplinary field (11). It uses the methods and tools from the discipline of public health in order to promote healthy aging (11). In societies where an increasing proportion of the population survives to older ages, public health approaches help create the conditions necessary for the optimal physical, cognitive, and social functioning of older adults (11). Public health approaches to aging may involve promoting measures to prevent or delay disease and disability and to help maximize function among older adults (11). The current paper illustrates how three communities have used the AdvantAge Initiative to create the physical and social environments that better support the health, functioning, and well-being of older adults.

History and Overview of the AdvantAge Initiative by the Visiting Nurse Service of New York

The purpose of the AdvantAge Initiative project of the Center for Home Care Policy and Research of the Visiting Nurse Service of New York (VNSNY) is to provide community organizations with tools to help them measure the aging friendliness of their communities and develop plans and implement action steps to make their communities better places to live for older adults and their families. The components of the AdvantAge Initiative include: (1) a framework with four domains that define an aging-friendly community; (2) a set of 33 indicators that help measure aspects of aging-friendliness within each of those domains; (3) a survey questionnaire used to solicit perspectives from older community residents about the aging-friendliness of their communities; (4) a stakeholder engagement process; and (5) technical assistance to help organizations conduct the AdvantAge Initiative in their communities.

The AdvantAge Initiative (12) began as a project of the Center for Home Care Policy and Research of the Visiting Nurse Service of New York in 1999 with support from the Archstone Foundation, Atlantic Philanthropies, the John A. Hartford Foundation, the Robert Wood Johnson Foundation, the Retirement Research Foundation, and the Fan Fox and Leslie R. Samuels Foundation. As described in a 2003 publication by researchers with the Visiting Nurse Service of New York (9), qualitative research was conducted to inform the development of the model of an aging-friendly community and the set of indicators to measure and help improve community capacity to promote the health and well-being of older adults. A total of 14 focus groups were conducted in four U.S. locations, which varied along several dimensions (e.g., geography, size, and proximity to an urban center) and included Chicago (Midwestern, large urban center); Allentown, PA (northeast, dense suburban); Asheville, NC (south, rural/suburban), and Long Beach, CA (west, metropolitan/suburban) with both younger and older adults and community leaders who identified the attributes that make a community a good place to live for older adults. In each location, focus groups were conducted with three to four specific population groups: older-old (ages 75+), younger-old (ages 60–74), younger (ages 35–59), and community leaders. This last group included representatives from a variety of institutions, including government, philanthropy, public service, education, and business, among others. Participants in the age-based citizen groups were required to meet specific screening criteria, including age, income, ethnicity, and health status, so that a variety of demographic characteristics was represented in the groups. The focus group discussions were videotaped, transcribed and analyzed to identify common themes. Participants said that a community could be considered aging-friendly if it helped older adults continue active participation in the community, maximized their health and function, helped them to maintain their independence, and reduced their risk of social isolation. The model of an aging-friendly community, along with the corresponding 33 indicators to help measure aging-friendliness were created on the basis of these focus groups.

Organizations in each of 10 diverse communities from different parts of the country were invited to pilot test the AdvantAge tools and process, including the use of the 33 indicators (9). Each organization was required to form a stakeholder committee in its community to help shepherd the initiative through its various stages. A professional survey research company conducted a randomized telephone survey of older adults in each of the communities using the AdvantAge Initiative questionnaire. The consumer survey was designed not only to gather basic information about older adults, but also to elicit their perceptions of and experiences in their communities. This input from community residents helps stakeholders identify community assets and opportunities for action, set priorities, and develop responses to identified aging-related issues. The findings were analyzed by the AdvantAge Initiative team and reported back to the communities using the 33 indicators to express the survey findings. The representatives from the 10 communities traveled to New York City several times to meet with the AdvantAge Initiative team to learn about interpreting the survey findings, engaging stakeholders, using consumer-derived data to inform action, developing sustainable initiatives to make their communities more aging-friendly, and sharing ideas and experiences with one another (9,13). A national randomized telephone survey was also conducted to enable the 10 organizations to compare their own survey results with national “averages” (9,13).

Since that time, the AdvantAge Initiative team has worked with over 60 communities across the country to measure their aging-friendliness, using the same tools and processes but customized to the community organizations’ goals and available resources. In the past few years, the AdvantAge team has been offering an online survey option for communities that do not have the resources to support a randomized telephone survey.

AdvantAge Initiative Conceptual Framework: Four Domains of an Aging-Friendly Community and Indicators of Each Domain

The conceptual framework guiding the AdvantAge Initiative describes the four domains of an aging-friendly community as a community that (1) addresses basic needs, (2) optimizes physical and mental health and well-being, (3) promotes social and civic engagement, and (4) maximizes independence for the frail and disabled (Figure 1). The framework was developed based on the focus group findings described above during which participants were asked to critique their own communities and describe the ideal community for aging in place (9,14). These participants identified a broad range of community attributes that would allow them to age in place, with critical factors including financial security, health and access to health care, social connections, housing and supportive services, and transportation and safety (9). These domains and sample indicators from each appear in Figure 1, and a comprehensive list of the 33 indicators corresponding to each domain is presented in Table 1. The AdvantAge questionnaire and 33 indicators may be tailored to the specific needs of individual communities.

Figure 1.

The four domains of an aging-friendly community.

Table 1.

The AdvantAge Initiatives Indicators List—The Essential Elements of an Aging-Friendly Community Organized by the Four Domains of an Aging-Friendly Community, with Sample Data Points That Have Been Used to Measure Each Indicator

It addresses basic needs.
Affordable housing is available to community residents	1. Percentage of people age 65+ who spend > 30%/<30% of their income on housing
	2. Percentage of people age 65+ who want to remain in their current residences are confident they will be able to afford to do so
Housing is modified to accommodate mobility and safety	3. Percentage of householders age 65+ in housing units with met/unmet home modification needs
The neighborhood is livable and safe	4. Percentage of people age 65+ who feel safe/unsafe in their neighborhood
	5. Percentage of people age 65+ who report few/multiple problems in the neighborhood
	6. Percentage of people age 65+ who are satisfied with the neighborhood as a place to live
People have enough to eat	7. Percentage of people age 65+ who report cutting the size of or skipping meals due to lack of money
Assistance services are available and residents know how to access them	8. Percentage of people age 65+ who do not know whom to call if they need information about services in their community
	9. Percentage of people age 65+ who are aware/unaware of selected services in their community
	10. Percentage of people age 65+ with adequate assistance in activities of daily living (ADL) and/or instrumental activities of daily living (IADL)
It optimizes physical and mental health and well-being.
Community promotes and provides access to necessary and preventive health services	11. Rates of screening and vaccination for various conditions among people 65+
	12. Percentage of people age 65+ who felt depressed or anxious and have not seen a health care professional for those symptoms
	13. Percentage of people age 65+ whose physical or mental health interfered with their activities in the past month
	14. Percentage of people age 65+ who report being in good to excellent health
Opportunities for physical activity are available and used	15. Percentage of people age 65+ who participate in regular physical exercise
Obstacles to use of necessary medical care are minimized	16. Percentage of people age 65+ with a usual source of care
	17. Percentage of people age 65+ who failed to obtain needed medical care
	18. Percentage of people age 65+ who had problems paying for medical care
	19. Percentage of people age 65+ who had problems paying for prescription drugs
	20. Percentage of people age 65+ who had problems obtaining dental care or eyeglasses
Palliative care services are available and advertised	21. Percentage of people age 65+ who have used or know how to access palliative care services
It maximizes independence for the frail and persons with disabilities.
Transportation is accessible and affordable	22. Percentage of people age 65+ who have access to public transportation
The community service system enables people to live comfortably and safely at home	23. Percentage of people age 65+ with adequate assistance in ADL
	24. Percentage of people age 65+ with adequate assistance in IADL
Caregivers are mobilized to complement the formal service system	25. Percentage of people age 65+ who provide help to the frail or disabled
	26. Percentage of people age 65+ who get respite/relief from their caregiving activity
It promotes social and civic engagement.
Residents maintain connections with friends and neighbors	27. Percentage of people age 65+ who socialized with friends or neighbors in the past week
Civic, cultural, religious, and recreational activities include older residents	28. Percentage of people age 65+ who attended church, temple, or other in the past week
	29. Percentage of people age 65+ who attended movies, sports events, clubs, or group events in the past week
	30. Percentage of people age 65+ who engaged in at least one social, religious, or cultural activity in the past week
Opportunities for volunteer work are readily available	31. Percentage of people age 65+ who participate in volunteer work
Community residents help and trust each other	32. Percentage of people age 65+ who live in “helping communities”
Appropriate work is available to those who want it	33. Percentage of people age 65+ who would like to be working for pay

The AdvantAge Initiative framework and the four domains are consistent with ecological models used in the epidemiology of aging (15,16). Some components of ecological models of aging include age, gender, socioeconomic status, race and ethnicity; social capital (a characteristic of neighborhoods and communities such as levels of trust and social norms of reciprocity and mutual aid); the physical environment (including environmental pollutants, and characteristics of the built environment such as housing, transportation and patterns of land use, housing design elements such as the placement of stairs and lighting, walkability and proximity to goods and services); living arrangements; marital status; social support; and the patterning of health behaviors and exposures such as physical activity, tobacco, alcohol, and diet and nutrition (16).

The AdvantAge Initiative Survey Questionnaire

A cornerstone of the AdvantAge Initiative is a survey of community-residing older adults. This type of data is important because it complements the “top down” perspectives of institutions and professions, and may challenge organizational and individual assumptions about aging and older adults. It also enables stakeholders to hear a variety of community voices. The survey collects information on key indicators of what makes a community aging-friendly. The survey findings and specific indicators have been described as a “springboard for action” (2), basically serving as a starting point for the AFCI. The survey also includes open-ended questions where older adults can provide insight on what would make their communities better places to live. Some sample responses of respondents include: “In general my immediate neighborhood has become very upscale over time so that continuing to live here has become more and more expensive. In order to survive and afford food and goods, I must travel outside the area. When and if I move in the future it will be because the cost of living has increased beyond my means,” and “Pave the sidewalks and streets, which are full of crevices and potholes and other irregularities, which make walking hazardous” (17).

Stakeholder Engagement Process and Technical Assistance

Following the survey data collection, communities then begin a community-wide collaborative process to “make meaning” from the data. The AdvantAge Initiative survey provides a “data snapshot” of how well older adults are faring in their communities. These survey data may also be presented alongside secondary data, such as information collected from other sources, such as local parks departments and transportation authorities on the availability and accessibility of transportation and recreational facilities. In the AdvantAge Initiative, data are considered numbers only until they are turned into “information” when community stakeholders get together to interpret the numbers and apply their own knowledge, experiences and perceptions to the discussion about the data. Many of the communities that have implemented the AdvantAge Initiative process have convened wide-scale summits with press coverage and attempts to engage with audiences and organizations that may not have identified aging as a key issue or concern (14). This type of participation is key to community building (18). A definition of participation that grounds the AdvantAge Initiative community planning approach is as follows, “Participation ... provides a collaborative process by which community inhabitants reach common goals, engage in collective decision making, and create places, and these places, in turn, serve as material expressions of their collective efforts” (19).

The ultimate purpose of the AdvantAge Initiative is to use the consumer-derived information to help community stakeholders develop and implement an agenda (“Action”) to make the community a better place to live for older adults and their families.

The VNSNY provides tailored technical assistance to guide stakeholder engagement and action planning. Such activities may include the preparation of reports, the writing of press releases, developing tailored marketing messages, giving interviews to local media, building and sustaining relationships with diverse audiences, and organizing and facilitating stakeholder engagement events. In addition, technical assistance may include aiding communities in developing sustainable aging-friendly initiatives, such as working to secure sustainable funding streams and advance aging-friendly public policies and legislation.

Research Design and Methods

We present case studies from three AdvantAge Initiative projects: Memphis and Shelby County, Tennessee (2012); New York City’s Chinatown neighborhood (2006); and the state of Indiana (2008). We present the results of this inquiry to demonstrate the unique and varied ways that different communities have used the AdvantAge Initiative to make their communities more aging-friendly.

One coauthor (L.E.) began by interviewing one of the developers of VNSNY’s AdvantAge Initiative (M.O.) who has led over 60 AdvantAge Initiative projects over the past two decades, and asking her to identify projects that differed in terms of their size and scope and geographic location that were successful in making meaningful changes to support the functioning and well-being of older adults in their communities over time. A second objective in the selection of projects to present in the current paper was to include projects that had different initiators and funders of the AdvantAge Initiative (e.g., local philanthropies familiar with their community, local health care organizations, Naturally Occurring Retirement Community programs, and state/regional and municipal planners).

The three communities that we describe in this case study were begun at different time points, and are very diverse in terms of their geographic location and community demographics. In addition, the funding sources and initiators of each project were very different, as are the outcomes of each of the projects. Yet, despite these differences, each of these projects was able to engage diverse stakeholders, involve older adults in the planning and implementation process, and make meaningful changes to create environments that are supportive of the health and functioning of older adults.

After identifying the three candidate AdvantAge Initiative projects, key personnel from each of the communities were invited to participate. An approximately 1-hour structured interview was conducted with a key staff member from each of the communities by one of the study authors (L.E.). A guide was developed consisting of 12 open-ended questions to elicit relevant information about the AdvantAge Initiative projects.

Key personnel from each of the sites were also asked to provide any other information that may be useful in better understanding their initiatives. Materials that were provided included reports prepared by grant awardees, copies of local press coverage, copies of annual reports and internal reports, journal articles and book chapters describing their initiatives, and copies of meeting minutes. In addition, one study author (L.E.) conducted internet searches for local press coverage, and reviewed other information available on partner websites.

Notes from the interviews and materials from the communities were summarized, and were used in writing the case studies and in preparing the table summarizing the key features and outcomes of each of the AdvantAge Initiative projects described in greater detail in the sections that follow.

Case Studies from AdvantAge Initiative Projects in Three U.S. Communities

In this section, we describe the three case studies in greater detail. The communities in the three case studies are different in terms of their geography and size, yet they all share common resources such as community-based nonprofit organizations, financial resources, and volunteers. They also share a vision for improving their community’s aging friendliness that involves short-, medium-, and long-term outcomes. We present a logic model that illustrates the collaborative process that moves the AdvantAge Initiative process from data to action in Figure 2, and we present a table summarizing the key features of each project in Table 2.

Figure 2.

Logic model illustrating the inputs, outputs, and outcomes of the AdvantAge Initiative projects.

Table 2.

Summary of the AdvantAge Initiative Process, as Implemented in Three U.S. Communities

How community is defined	Initiators of the AdvantAge Initiative process	AdvantAge Initiative survey tool	Key dissemination and planning activities undertaken	Priority areas identified	Sample outcomes resulting from participation in the AdvantAge Initiative process
Memphis and the surrounding Shelby County, Tennessee	The Plough Foundation partnered with VNSNY Center for Home Care Policy and Research	Telephone survey is conducted by a survey research firm, reaching a random sample of n = 551 residents in 2012	Report is prepared summarizing the AdvantAge Initiative survey results and it is disseminated to relevant stakeholders in the community Group meetings are held to identify opportunities for action, conducted by skilled facilitators A three-part speaker series is convened	Many older adults reside in housing in need of repairs to address water damage, problems with insulation and heating/cooling, accessibility and safety modifications Food insecurity is experienced by many residents There is a need for greater community involvement in the problem of elder abuse Many older adults do not know where to access services for older adults	Plough Foundation provides philanthropic support to sustainable initiatives to address some of these areas, and volunteers also contribute time and resources:• Habitat for Humanity and college students volunteering through Service Over Self work to improve housing conditions (safety in home, modifications to reduce utility costs)• No Hungry Senior initiative is undertaken to improve food security of older adults with lead agency MIFA Meals on Wheels• Coordinated Response to Elder Abuse—a new set of policies, procedures and framework for changing the way care teams respond to victims and passage of new legislation
Chinatown neighborhood of New York City	Chinatown Neighborhood Naturally Occurring Retirement Community (NNORC)partnered with VNSNY Center for Home Care Policy and Research	Survey is conducted via telephone reaching n = 201 residents in 2006; later surveys conducted by volunteers in face-to-face interviews	Report is prepared summarizing the AdvantAge Initiative survey results A coalition and partnership is formed with numerous legal assistance, health delivery, and other organizations participating	Many older Chinatown residents lack health care proxies Many older Chinatown residents have not had colon cancer screening	A large building near the Chinatown NNORC donates space for community activities and meetings Sustainable partnerships and coalitions are formed Outreach efforts are undertaken to encourage colon cancer screening and advance care planning (e.g., pamphlets, radio messages on Chinese language programs) Organizations use online tracking tools to monitor their progress in improving colon cancer screening rates and the execution of health care proxies
State of Indiana	State of Indiana partnered with VNSNY Center for Home Care Policy and Research	AdvantAge Initiative survey is conducted in a random digit dial survey reaching 5,000 older residents, providing information at both the state and smaller local level	Community building activities are conducted throughout the state using tools such as• Collages• Mapmaking• CharrettesArchitecture students assist residents in rethinking the built infrastructure of the community, envisioning new retail businesses, sidewalks, housing types, and landscaping to make the community aging-friendly	Need for reengineering the built environment so that it meets the needs of people throughout the life span Need for more consistent and clear planning methods across the group of area agencies on aging in Indiana	Local area agencies on aging organize local planning activities, and planning workshops are held around the state, followed by participatory planning workshops to assist community members in understanding data and its implications and moving toward action Local area agencies on aging use data from the AdvantAge Initiative survey and process to prioritize long-term planning objectives

Note. VNSNY = Visiting Nurse Service of New York. NNORC = Neighborhood Naturally Occurring Retirement Community.

In each of the case studies below, we describe the AdvantAge Initiative survey process and some indicators from the list of essential elements of an aging-friendly community that the partners decided to target. It should be noted that the starting time of these projects—2006 (New York City, Chinatown), 2008 (state of Indiana), and 2012 (Memphis and Shelby County), reflect only the initial steps of the AdvantAge Initiative process, which was the beginning of a longer process of making these communities more aging-friendly. Each of the communities described in this paper continues their efforts to this day.

Because of the impracticalities and limited resources to resurvey older adults, the three communities chose process measures to evaluate the effectiveness of their programming activities, focusing on the products and deliverables produced by their activities (20). These measures were relevant to their programming efforts, as highlighted in the case studies below.

Case Study 1: AdvantAge Shelby County

This AdvantAge Initiative project (begun in 2012) was supported by funding from the Plough Foundation, a philanthropic organization that aims to address social and economic needs in a sustainable way in the Memphis and Shelby County, Tennessee area (21). Following the completion of the AdvantAge survey and a report summarizing key findings, Plough Foundation staff made a coordinated effort to send the report to relevant state and local stakeholders, including elected officials, local media, and college presidents. They also spoke to local newspaper editorial boards and gave presentations to community groups. A staff member of the Plough Foundation gave many presentations to local community groups such as AARP and Rotary Club chapters, the Board of Directors of the Metropolitan Inter-Faith Association, the Professional Network on Aging, local planning department meetings, among others. In the words of a staff member affiliated with this initiative, they “Put information that matters in the hands of people who can make a difference.” They also hosted a three-part “Aging in Place” seminar series with skilled facilitators and guest speakers. They termed this series, “An Aging Society: Meeting the Challenges,” where the audience profile differed for each of the seminars. The first seminar addressed how to improve health and address health aspects of aging, as well as rethinking community resources for aging in place, with the audience consisting of various practitioners in the Memphis area and members of the Aging in Place taskforce; the second addressed community responses to elder maltreatment and victimization with local and state leaders and members of the Plough Foundation Elder Maltreatment Workforce; and the third addressed a new vision for 21st century aging and how to prepare for the coming “age wave” and potential solutions, where the audience consisted of key media personnel, elected officials, and other community leaders.

The AdvantAge Initiative survey in this community involved a random telephone survey of n = 551 participants, representing 92,472 adults aged 65 years and older in Shelby County, Tennessee. Some of the most salient indicators in this community involved housing needs, which falls in the domain of Basic Needs in the AdvantAge Initiative framework. The survey revealed that many residents did not feel that they could remain in their own homes for as long as they would like due to concerns about maintenance issues. Among lower-income respondents who reported needing home modifications, the needs identified included minor or cosmetic repairs, such as painting or floor refinishing (76%); major structural repairs, such as a new roof or new plumbing (64%); bathroom modifications, such as grab bars, handrails, elevated toilets, or nonslip floors (60%); help dealing with insects or rodents (45%); better cooling in the summer (43%); better heating in the winter (35%); and better access into and within the home, such as stair rails, ramps, and wider doorways (9%). Another concern identified through the survey findings were issues involving food security, where in the lower-income range, 10% experienced food insecurity, 20% reported that there are not convenient places nearby to buy fresh fruits and vegetables, and 13% reported difficulty affording fresh fruits and vegetables.

Prior to the start of the AdvantAge Initiative process, the Foundation decided to develop a strategic funding initiative around aging and older adult housing. While the Foundation had traditionally funded many programs that benefitted older adults, they decided that strategic investment was needed to make a meaningful and sustainable impact in this area. The Plough Foundation used the AdvantAge survey findings as part of their research to help them develop funding strategies for aging programs. Following the speaker series, the Plough Foundation issued their first request for proposals to the community in which they invited collaborative ideas. They decided to fund three major initiatives: Aging in Place Home Modifications for Low Income Seniors (Lead Agency—Habitat for Humanity of Greater Memphis); No Hungry Senior—an effort to feed those most food-insecure (Lead Agency—Metropolitan Inter-Faith Association); and The Coordinated Community Response to Elder Abuse (CREA) (numerous grantees throughout Shelby County, where the present-day lead agency is the Family Safety Center of Memphis and Shelby County). Other initiatives funded by the Foundation included a community-based eye clinic with free glasses, the training of certified aging-in-place specialists, the creation of episodes of “The Best of Times” aimed at adults aged 55 years and older which aired on local public television stations, and the implementation of the National Council on Aging’s Aging Mastery Program in senior centers (22). Many of these awardees also leveraged significant resources from their volunteers, including organizations such as Service Over Self, a subgrantee of Habitat for Humanity, which trains high school and college students to provide home repair services and conducts other summer volunteer opportunities and leadership development programs (23).

Those who received home repair services and accessibility modifications through the Habitat for Humanity project reported positive outcomes, such as good customer service, improved safety in the home, lower utility costs, and greater satisfaction with socialization in the home. As one recipient said, “I had no income to spend on fixing these things even though they were costing me money and making me sick. If I made more income, then I would have fixed these things myself but I don’t. I wanted to fix them, but I couldn’t physically do it and I didn’t have the money. So I just dealt with it and it got worse.” Another described her experience with the program, “Now that I have all of these repairs, I’m saving money, I use the grab bars in the bathroom so I can feel safe, my floors aren’t falling in so I can walk around without falling in a hole! And all of the repairs are very easy on the eyes! From the street and from the inside, it just looks so much better too.” From 2015 through mid-summer 2019, the Plough Foundation has contributed nearly four million dollars for accessibility modifications such as bathroom grab bars and ramps, critical repairs, and energy efficiency modifications to help older adults remain in their homes. The sustainability of these efforts can be seen in the fact that Aging in Place is now a core piece of Habitat for Humanity of Greater Memphis’ mission, and Habitat for Humanity of Greater Memphis now leads more than a dozen Habitat for Humanity affiliates throughout the state of Tennessee in an Aging in Place program called the “Elder Trust/Senior Trust Program” to provide these types of repairs and home modifications in multiple counties across the state.

In 2014, there were approximately 3,000 people on the waiting list for Meals on Wheels, and the Plough Foundation’s grant helped to reduce this number by approximately 50% (24). The lead agency for No Hungry Senior was Metropolitan Inter-Faith Association, and it partnered with the Aging Commission of the Mid-South, Baptist Memorial Health Care, Catholic Charities of West Tennessee, CoactionNet.org, Memphis Jewish Federation, Methodist LeBonheur Healthcare, Mid-South Food Bank, and University of Memphis School of Public Health to offer No Hungry Senior. The program provides older adults who are homebound or lack access to food a hot meal each weekday or a weekly box of shelf-stable items, and partnerships and volunteers have helped keep the program costs down. Between May 2015 and July 2019, No Hungry Senior has provided almost 650,000 meals to seniors, and as of mid-summer 2019, 1,785 older adults were enrolled in this program.

Through the coming together of community members and stakeholders, an additional key area to target was identified—the need for more planning and response to address the problem of elder abuse. More than 25 partner organizations, including legal organizations, health care organizations, law enforcement, and victim services were involved in this initiative, and a new set of policies, procedures, and a framework were developed for changing the way care teams work to respond to victims of elder abuse, neglect, and exploitation. The name of this community initiative is the Coordinated Response to Elder Abuse, or CREA. An important outcome of these efforts was the passage of legislation to protect older adults. CREA works alongside the District Attorney General’s Vulnerable Adult Protective Investigative Team (VAPIT), a statewide legislative initiative designed to protect vulnerable adults (25). As of mid-summer 2019, more than 750 older adults have been helped by CREA, and in 2018, VAPIT referred 600 cases locally, 49% of them related to neglect. Another important outcome is the raising of community awareness of issues surrounding elder abuse through efforts such as a countywide multimedia campaign begun in June 2019 called Speak Out Memphis, which encourages the public to join the fight against elder abuse.

Taken together, the process indicators that are being used to evaluate the effectiveness of the varied efforts include the number of homes restored, television episodes produced and viewed, the number of meals delivered and clients served, client satisfaction with the home improvements, the number of eye exams conducted and eyeglasses distributed and follow-up care provided, the number of certified aging-in-place specialists trained, and the passage of elder abuse legislation.

Case Study 2: AdvantAge Chinatown NNORC

This AdvantAge Initiative project (begun in 2006) was supported by state funding from the New York State Office for the Aging through the Chinatown NNORC program as a means of assessing the health and social needs of older residents in the Chinatown neighborhood. The NNORC initiative involved several formal partners, including the Visiting Nurse Service of New York, the Chinese Consolidated Benevolent Association (an umbrella group of business, social service, and community organizations in Chinatown), the Chinese American Planning Council, which was founded in 1965 as a social service agency to meet the needs of the Chinese American community, and University Settlement, a multiservice agency that has served many residents in New York City (26). The Chinatown neighborhood consists of 24 of New York City’s densest city blocks, with a large proportion of foreign-born residents with very limited English proficiency (26).

The Chinatown AdvantAge telephone survey of Chinatown residents aged 60 years and older was conducted in Chinese by a professional survey research company using a random digit dial, list-assisted design that produced 201 completed interviews, representing 3,043 people aged 60 years and older in the four block groups containing the Chinatown NNORC. Some of the most salient indicators in this community involved health screenings, which fall in the domain of Optimizing Physical and Mental Health in the AdvantAge Initiative framework. The survey findings showed that two health areas that needed improvement were the low colon cancer screening rates among Chinatown older adults and low rates of advance care planning. The American Cancer Society recommends colon cancer screening to begin at age 45 for people at average risk, with screening to continue for people in good health with a life expectancy of more than 10 years through the age of 75, and for people ages 76 through 85 the decision to be screened should be based on a person’s preferences, life expectancy, overall health, and prior screening history (27,28). Appointing a health care proxy ensures that an individual has a person who can speak for him or her to make health care decisions in the event of a medical emergency or if the individual cannot make medical decisions on his or her own.

To tackle the issue of improving colon cancer screening, a coalition was formed, with participation by the American Cancer Society, Beth Israel Medical Center, Charles B. Wang Community Health Center, Confucius Pharmacy and Surgical Supplies, New York City Department of Health and Mental Hygiene, New York Downtown Hospital, University Settlement, and the Visiting Nurse Service of New York. The coalition partners met periodically, outreach materials were tailored to the residents in the Chinatown community, and radio, television and local newspaper advertisement campaigns were initiated. In addition, a large residential building (Confucius Plaza) hosted events to promote this campaign. As of the writing of this paper, the coalition is still active, and colon cancer awareness events are still held each year in March during National Colorectal Cancer Awareness Month.

Partnerships were also formed around the issue of advance care planning, with numerous legal assistance and other organizations participating. A process has been established so that a person who wants an appointment to discuss advance care planning is able to schedule one with one of the participating partners. This effort has been very successful over the years, and continues to be active to this day, with partners continuing to track the number of health care proxies executed.

Key personnel who worked on the Chinatown initiative offered advice for other communities wishing to implement such an initiative. They recommend always having peer educators or some other type of peer-to-peer component as part of health promotion initiatives and to maintain good relationships with the media. It is also essential that all promotional materials and media activities and other events be culturally appropriate for the target audience. Program staff recommend that outreach and other efforts also target the adult children of the older adults who may have influence on the health care decisions of their parents. They also recommend keeping track of long-term outcomes and process measures by using web-based data collection tools that all partners can use.

The process indicators chosen to evaluate these efforts were the sustainability of the partnerships and coalition that were formed, and the number of events held to promote advance care planning and colon cancer screening, as well as the number of health care proxies executed and the number of colon cancer screenings conducted.

Case Study 3: AdvantAge Indiana

The final case study that we present in this paper is much larger in scope than the other two case studies presented. This project began when the state of Indiana received a U.S. Administration on Aging Planning Demonstration grant in 2006 to use the AdvantAge Initiative process for statewide planning. Additional funding was provided by 15 Area Agencies on Aging (AAAs), the Division of Aging, and the Daniels Fund of Denver, Colorado. In addition, Lilly Endowment funded a small grant program to supply resources for community participation activities.

The long-term goals of this project were to: (1) use the AdvantAge Initiative survey and planning process to help the state’s Area Agencies on Aging create required 3-year plans for the U.S. Administration on Aging (now part of the U.S. Administration for Community Living), and (2) help make Indiana an aging-friendly state. The first 2 years of the project were developmental, followed by a 5-month long survey period conducted by a national survey research company, and then followed by a 7-month participatory planning approach (2). During this participatory phase, several AAAs organized local planning initiatives, ranging in scale from small neighborhood committees fostered by the University of Indianapolis, to area-wide planning workshops.

A random telephone survey of 5,000 older adults was conducted. The survey was designed so that it could provide reliable estimates at the local planning area level. Two features that define the Indiana AdvantAge initiatives were the focus on citizen or community participation and an emphasis on planning for changes to the built environment.

In the participatory workshops that were held, numerous participation methods or tools were employed to increase people’s involvement and create consensus. Many of these methods were used in Indiana under the direction of Philip Stafford of the Indiana Institute on Disability at the time. These participatory approaches implemented in Indiana are described in greater detail in Elderburbia: Aging with a Sense of Place in America, and in Table 3 (18).

Table 3.

Examples of Participatory Approaches for Community Engagement Used in Indiana

• Guided visualization. Guided visualization or guided imagery is a low-cost method that a single facilitator can use with small or large groups. The process involves inviting participants to relax, close their eyes, and “travel” with a guide for a brief period where they might imagine they are an aging-friendly community (18). After the exercise, the facilitator hosts a discussion with the group asking people to share key elements of their vision for the aging-friendly community and how the dreams can be realized in the community (18).

• A “graffiti” wall. This involves the placement of a blank mural in a public venue with a simple set of instructions and markers. It is an engaging way for participants to express themselves about an issue or create a vision for the future, and responses can be transcribed to an alternate format when it is time for the mural to be removed (18).

• Personal collages. This involves creating a personal collage of what makes an aging-friendly community and then using the results for a group discussion. Participants can use newspaper clippings, magazine images, photos, or hand-drawn pictures to make a collage of what makes an aging-friendly community and facilitators can then use the collages in group discussion (18).

• Intergenerational mapmaking and the community walkabout. Children can become involved in an exploration and critical examination of their neighborhood (18). Activities may include mapping the neighborhood, going on a chaperoned walk around the neighborhood, and reconvening to discuss what would make the community a good neighborhood in which to live in (18).

• The “charrette.” A charrette is a “multiday planning process during which an interdisciplinary professional design team creates a complete and feasible plan that reflects the input of all interested parties by engaging them in a series of feedback loops. The term ‘charrette’ is derived from a French word meaning ‘cart’ and refers to the final intense work effort expended by architecture students to meet a project deadline” (18,29). In 2007, students and faculty of the College of Architecture and Planning, Ball State University assisted residents in rethinking the built infrastructure of the community, envisioning new retail businesses, sidewalks, housing types and landscaping to make the community aging-friendly.

One of the participatory tools used was guided visualization or guided imagery, a low-cost method that a single facilitator can use with small or large groups, where the process involves inviting participants to relax, close their eyes, and “travel” with a guide for a brief period where they imagine an aging-friendly community (18). After the exercise, the facilitator hosts a discussion with the group asking people to share key elements of their vision for the aging-friendly community and how the dreams can be realized in the community (18). Another tool used in some of these participatory workshops was a “graffiti” wall, which involves the placement of a blank mural in a public venue with a simple set of instructions and markers. It is an engaging way for participants to express themselves about an issue or create a vision for the future, and responses can be transcribed to an alternate format when it is time for the mural to be removed (18). In Bloomington, Indiana, a mural was posted in conjunction with a multimedia display on aging at a local community arts center (18). Another tool that was used involved asking participants to create a personal collage representing their view of an aging-friendly community and then using the results for a group discussion. Participants can use newspaper clippings, magazine images, photos, or hand-drawn pictures in the making of the collages. In this project, many of the collages emphasized social and family connections, spiritual themes, community services and infrastructure, and recreation and leisure (18). This collage-making activity was also used in the older adult focus groups that were held to develop the AdvantAge Initiative framework.

An example of a participatory method that focuses on intergenerational involvement is the use of mapmaking and the community walkabout. For example, the Crestmont Discovery Project in Bloomington, Indiana was conducted in 2004 and involved an intergenerational focus. The goal was to engage children in an exploration and critical examination of their neighborhood (18). Activities in this multiday project included mapping the neighborhood on the first day using a GIS map obtained from the city utilities department that is cut into transparencies that can be projected onto a large blank mural that is constructed using a roll of newsprint obtained from the local newspaper office. Children used colored markers on the blank mural to mark streets, house footprints, and other structures of significance, such as parks and schools (18). On the second day, students were paired on a chaperoned walk around the neighborhood and given different tasks such as identifying water features, and on the third day students reconvened to discuss what would make the community a good neighborhood in which to live in (18).

Each of these and other participatory methods may be used in the right context, but facilitators must pay attention to practical aspects of implementation, such as whether the tools require simultaneous participation by all participants, and whether the method is more appropriate for small groups or large audiences. In Bloomington, Indiana, for example, Stafford organized two aging-friendly community charrettes in partnership with Ball State University School of Architecture and Planning. A charrette is a “multiday planning process during which an interdisciplinary professional design team creates a complete and feasible plan that reflects the input of all interested parties by engaging them in a series of feedback loops. The term ‘charrette’ is derived from a French word meaning ‘cart’ and refers to the final intense work effort expended by architecture students to meet a project deadline” (18,29). These charrettes focused on the prospect of senior housing in an intergenerational, downtown neighborhood and in the district surrounding the hospital. This work continues to this day with the relocation of that hospital and its replacement by a “lifetime community district.”

Numerous communities and organizations throughout the state used the survey data and the participatory methods to plan for the needs of their residents. The St. Joe Community Foundation of South Bend, Indiana, for example, used its own data sources, prior to the statewide survey, to identify aging-friendly funding priorities and after the AdvantAge survey data were analyzed, provided substantial funding for a home modification program. AdvantAge Initiative data were used in other proposals for local projects funded under the state’s “Communities for a Lifetime Initiative,” which was a collaborative effort among state agencies, educational institutions, and nonprofit organizations to encourage cities and towns to support the meaningful participation of people of all ages and abilities across the entire life span (30,31). Three communities using AdvantAge Initiative data received Lifetime Community grants from the Indiana Housing and Community Development Authority: (1) Linton, Indiana created a senior-governed home modification initiative to identify and implement home modifications in 19 homes, as well as install a wheelchair lift in the public swimming pool; (2) Portage, Indiana created a downtown senior-friendly outdoor fitness park; and (3) Huntington, Indiana developed a unique paired housing project for adults with developmental disabilities near the downtown. The promotion of senior housing in downtown areas is promising for a number of reasons, especially in cases where housing is located within walking distance of retail establishments, churches and other places of worship, libraries, and community centers and recreational facilities (32).

Thus, in AdvantAge Initiative Indiana, the process measures varied depending on the community. The direct outputs or deliverables included changes to the built environment, such as home modifications and larger community modifications to make the communities more accessible to older people and people with disabilities.

Discussion and Implications

As shown in the case studies presented in this paper, the three communities are very different in terms of their size and geographic location. In one case study, community was defined as the city of Memphis and the surrounding Shelby County; in another, it involved the densely populated Chinatown neighborhood in New York City; and in the third, numerous communities throughout the state of Indiana were involved. Yet all three projects share a number of common features. The projects began with the desire to improve aging-friendliness in a sustainable manner, and they all used data to inform the process. In these projects, consumer-derived information from the AdvantAge Initiative surveys was used to get a sense of older adults’ experiences in and perceptions of their communities and complemented data from other sources.

Each of these communities brought together a range of partners at each stage of their projects, including older adults, social service providers, health care providers, law enforcement officials, political officials, religious and volunteer organizations, local media, and city planning departments, among others. The project leaders understood that it is important to get community buy-in before proceeding. This was the case regardless of the scale of the projects. For example, the Chinatown project, though smallest in scope, held numerous events in shared community meeting spaces, and older adults residing in the community always participated and played a key role. Despite the smaller scale of the project, they were nevertheless able to achieve meaningful outcomes in terms of promoting the execution of health care proxies and the receipt of colon cancer screening in the age groups at risk. They also formed a sustainable coalition of stakeholders that continues to coordinate efforts and activities to this day. The state of Indiana’s project was much larger in scope, and involved many different communities and planning regions throughout the state. They used the AdvantAge Initiative process to engage community members of all ages to think about aging and the built environment. And in Memphis, the Plough Foundation also brought many stakeholders to the table and even included Aging in Place seminars to help educate those who were new to the aging-friendliness concept and to invite as many differing points of view as possible. This mobilization of stakeholders and community members was necessary for the success of the projects, and for meeting their identified short-term and long-term goals. The activities and outcomes of these AdvantAge Initiative projects together touched upon all four domains of an aging-friendly community.

Another common feature of the three communities is that they all had “champions” in the community who were able to help move the projects forward. These champions can be politicians, business leaders, nonprofit leaders, and others who can inspire community residents and stakeholders to participate. The Plough Foundation in Memphis, for example, took a lead role in bringing together representatives from many different sectors that may not have traditionally collaborated with one another and opened the door to the possibility that disparate stakeholders can work together to make their community a better place for older adults to live. Many of the efforts and successes of the Plough Foundation’s multiyear investment were highlighted at the 2018 Grantmakers in Aging Conference. The Plough Foundation sets an example for other philanthropic organizations to get involved in learning about the needs and contributions of older people in their communities and supporting aging-friendly initiatives.

Our primary objective in presenting these case studies was to demonstrate that communities that differ in terms of their size, geographic location, demographics, and resources can successfully implement aging-friendly community initiatives. We further sought to demonstrate the varied outcomes that are possible with aging-friendly community initiatives to support the health, functioning, and well-being of older adults, consistent with public health and ecological approaches to aging. However, our presentation of the three illustrative case studies has several limitations that should be noted. First, we did not attempt to gather information about other community activities that may have been undertaken at the same time as the AdvantAge Initative in these communities. It is possible that other community organizing or advocacy activities took place independently of the AdvantAge Initiative projects and thus contributed to the long-term outcomes that were observed. Second, in interviewing key persons involved in the AdvantAge Initiative projects, we did not ask them to reflect on any perceived limitations of their approach or to reflect on outcomes that they may have been unsuccessful in achieving. Future research efforts may benefit from inquiring about less-successful case examples and efforts in order to better understand the factors needed to achieve short- and long-term objectives. Third, for this relatively brief case study format, we limited our selection of case studies to only a few AdvantAge Initiative projects. Regrettably, for the purpose of this brief paper, we were unable to present information on other AdvantAge Initiative projects that had other long-term outcomes, such as the Actors Fund project in New York City (17), which led to several worthwhile community initiatives, such as changing the traffic patterns in one neighborhood to make crossing the street safer for residents, or an AdvantAge Initative project in the East Harlem neighborhood of New York City which implemented a variety of fall prevention activities, including a photo essay created by seniors who attend a senior center in the neighborhood which raised awareness about the role that cracked, uneven sidewalks play in the high percentage of older community residents that have fallen outdoors and led to the repair of at least one East Harlem street.

It is important to bear in mind that working toward a more aging-friendly community sometimes means asking organizations and partners to change their usual way of doing things, which may be a challenge for organizations that are not used to coalition and consensus building. Another important point is that it can take a long time to reach desired outcomes, and that it takes continuing efforts to bring stakeholders together and sustain their engagement throughout the very long process of improving community-wide aging friendliness. While some activities and goals may be met in a very short time frame, other goals may involve a timeline of 5 years or longer. It should also be noted that financial resources played a key role in the three AFCIs that are presented in this case study report. Without the funding that the lead organizations were able to raise and use, their initiatives would not have come to fruition. Other resources, including the time contributed by partnering organizations and volunteers, as well as staff and consultant time, and the donation of shared community spaces to host events and community engagement activities also played an important role.

Taken together, these three case studies demonstrate innovative approaches that different communities have taken to improve their aging-friendliness. Every community is different and as a result each community needs to find its own way to implement an aging-friendly community initiative, taking into account the community culture, political climate, and available resources. But the AdvantAge Initiative has shown that certain actions, if implemented, can increase the likelihood that community initiated aging-friendly projects will come to fruition, as demonstrated by these three case studies.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: L.E. was supported by National Institute of Mental Health of the National Institutes of Health under Award Number T32MH073553. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.