He was. I am.

Formative Years
As I recall my childhood, I remember, very distinctly, a formative moment. My family was enjoying a day at our summer swimming spot near the town where my grandfather was raised. He brought everyone there a couple of times each year, and we would picnic and swim and explore all day long. It was pure heaven. For Pappy, it was more than heaven – it was who he was, and he took care of that place like he took care of himself.

While we played, he was cleaning the riverbank. Not only would he pick up the trash that people left behind at our spot, but he would pick up the driftwood and debris that the river left each time it rose, and fell, and dropped what it carried from upstream. We were always downstream, and he left each time with bottles, cans, bottle caps, and pull tabs.

I must have been four years old. I remember being given a piece of candy that was encased in a paper wrapper. I left with it, unwrapped it, and truly, carelessly dropped the wrapper towards the sandy edge of the river bank - Pappy’s river bank.

The candy never made it to my mouth. He was getting older, but he was fit, and really fast. The wrapper hadn’t even reached the ground. As I was moving my hand to my mouth, my arm was stopped just short of its goal. I felt a squeeze on my wrist, and turned into the largest finger tip I have ever seen in my life. It was like a cartoon finger with a massively skewed perspective between my startled face, and his angry mug. As the candy was taken away from me, I heard these passionate words ring through his lips: “Don’t you ever litter again!” I never did.

I was heartbroken. Not because I lost the candy, but because I had disappointed my grandfather. Even at that age, he was the world to me. He was the patriarch and I knew it. Like a wise and benevolent Pied Piper, he led my brothers, sisters and cousins to his favorite places, and we followed with glee. When we got where we were going, we would explore to our hearts content, knowing he was watching, protecting. He would teach us plant names, and impart his values about nature. We were fearless. He kept the monsters at bay. We always made it home safe. This was just how it was.

That day on the river determined who I was going to be. His presence in my life as a child, his admonishment at that moment, his impromptu lesson given to me as a matter of who he was, made me who I am. It led to a “Save the World” sticker on my pencil box when I was ten. I still have it. It determined my career when I chose a college major. I became a Landscape Architect, a steward of the environment.

As he was declining a few years ago, I watched my mother give up her freedom to care for him in my father’s home, a home that was located in the country, miles from town. In between jobs at the time, I spent time there with the three of them to regroup. I witnessed again, even in late stages of Alzheimer’s, life lessons given by a man who understood what it was all about. He could barely hear, he couldn’t see me, or remember my name, but each time I walked into the house, I asked him “How’re you doin’ today Pappy?” And each time, he would reply to no one in particular, “Anyone I can, and you’re next!” It always made me smile. He taught me to enjoy life right up to the end.

It was during this time that I began thinking about how we care for our elders. My parents are isolated. When it was time to care for my grandfather, my mother moved him away from his home, and into hers. It was a difficult time, but my mother chose to keep him out of a nursing care facility, which was his only other option. My father is battling an illness of his own, and it would take my mother 30 minutes to get them both packed in the car to go 5 minutes up the road to buy groceries. What he did for her, she now did for him. Mom worked hard and there was no respite. But pappy seemed happy. Seeing my parents work so hard, and seeing how content my grandfather was gave me mixed feelings. I started thinking about another option. Once again, my grandfather would determine who I would become.

Why bore you with this little recollection? Because it gives information to two very important issues that we are all dealing with today. The first is how important it is to have an elder in our lives, everyday, to teach the younger about life, and how to be valuable citizens to this planet. The second is how important it is to care for our elders, and for our caretakers. To this audience, this is all very obvious. But it is not always easy to accomplish, mostly because of the physical nature of our health care system, especially for those who may live in isolation.

For the first issue, I want to talk from my professional point of view, as a Landscape Architect and as a steward of the environment. In my career, we are fortunate to learn about a broad range of topics. We often look at these topics as systems. The more systems you study, the more apparent it is that systems often have patterns and act alike. They are interconnected and dependent on the other elements in the system. Think of environmental systems, highway systems, or the health care system.

Elders and Children, the Human Ecotone
As an example, ecological systems can consist of mature forests or younger fields that may someday be a forest if natural succession is permitted to occur. The boundary between forest and field is called an ecotone. The forest has distinctive characteristics and species that make it different from the field. The field is also lively and diverse, but unique from the forest. The ecotone is the fuzzy and shrubby area in between that has life from both places. In this area, there is an enormous amount of life and activity because it shares characteristics of both the field and the forest – the new and the mature. The field will eventually become the forest because the seeds are already there. It only needs time to grow. Because it is in itself a different zone, the ecotone may contain life not found in either the forest or the field.

Looking at the natural human order in the manner that we look at forest succession provides a bit of insight into some of our societal problems. It seems logical that we should be providing a health care setting where children can interact with our elders. In the system described above, there exists a richness of the environment when two distinct groups meet. It is about the information that is passed between groups and the energy that can be created when they mingle. Kids and seniors are automatically drawn to each other. It seems like they are interested in each other, for their similarities and for their differences. A child reaching for that curious, glorious white hair! A grandmother amazed at the internet lesson her five year old grandson just delivered. The human system is dependent on this interaction.

A place that integrates the unique nature of these distinct human forms might be able to create a new kind of environment that does not readily exist today. Instead, we have created a system that separates our children from our elders. This is an opportunity lost, and one that is fairly new to human beings. We have always had our elders to teach us and provide guidance. It saddens me to think of the limited opportunities that exist today for children to talk to their grandparents. So many times kids are cooped inside while their grandparents wither hundreds of miles away, isolated in a care environment that is remote and bucolic on the outside and has wearisome age-precision on the inside. The term ‘being put out to pasture’ comes to mind. Visiting grandma is nearly impossible alone. The path is far too long and has many perilous distractions. The world is too full of big, bad wolves.

Just as a field will become a forest, a child will grow to be a senior. When a grandparent is in a child’s life, self actualization will occur and meaningful seeds will be planted. Formative moments will occur. The opportunity exists to learn where we came from and who we will become. For a child, this is the roadmap that provides a sense of well-being and confidence. It is an opportunity to learn how to be a productive member of society. For an elder, it gives a sense of purpose, an outlet for teaching years of experience and meaning from a life well-lived.

Care For the Caregivers
For the second issue, I also would like to speak as a Landscape Architect and as a person who designs human environments. When my mother cared for her dad, she was isolated and had no place for respite. She was only five miles from a town center, but there were no facilities appropriate for caring for a man with Alzheimer’s or for a man with MS. She never took a day off except for the rare day that my Aunt came to visit. However, my grandfather was happy. I think there were many reasons for this but the biggest was that he was at home, getting home-cooked meals, and he was with his child. My mother and father were there, and they all loved each other. For the record, my parents still do!

Other elders in my life have taught me life lessons and have guided my new philosophy of aging and care. I benefited from an elderly couple who was looking to leave their family farm and move to a small Pennsylvania farming town where their kids went to school. I remodeled their home to be more appropriate for them as they aged, and was entertained for hours with stories of local, almost forgotten history. There was no place for them to go that would permit them to age in place, and convenient healthcare was simply not available. Even home delivered care was limited. That has since changed for their town, but if trouble comes, they will be forced to leave their home. There had to be a different answer in town.

The PatinaCare Model
PatinaCare is a holistic look at elder housing and delivery of care. It looks at models such as the Green House that have successfully determined what a building can be. It also considers successful adult and child daycare centers where intergenerational contact can occur. But it goes further and looks to town centers to provide the physical framework to establish a different pattern of healthcare delivery. It revitalizes the town centers while providing health care and housing for the greater community. It permits people to remain members of their community and be comforted with familiar surroundings. Most importantly, it provides a convenient setting where children and elders can interact, and where caregivers can get some relief.

Some of the most important aspects of senior housing and health care service delivery are the location and placement of the housing and care services. They determine two very important aspects of community; 1) social inclusion, and 2) efficient delivery. In rural areas, where services are more difficult to provide, it is important to consider the fact that people who are part of a broad community, geographically speaking, more often than not, consider themselves a member of a single, localized core community, or rural town. This is often due to church or school association. In other words, a twenty mile radius often has a single town center. That town center is the focus and the draw to the members of the greater community.

If elder care services modeled after Continuing Care Retirement Facilities or a new kind of satellite office of existing home care agencies were placed in that town center, then they could provide for the broader geographical boundary by attracting those citizens into the town at the critical time, or by providing a more efficient tele-health system or monitoring component that would permit rural residents to stay in their home. The town center is the key to efficient health care delivery.

In urban areas, this is much simpler. Even cities have definable neighborhood centers. These are the core communities. Once determined, the PatinaCare model can make health care delivery accessible at a much different scale by utilizing existing population centers. Imagine walking to a senior health care facility to get your morning coffee. While you were there, you could drop off your child and visit your grandmother.

Currently, the options for elder health care are 1) staying at home with home care support- the most desirable for the majority of elders and baby boomers, 2) moving in with relatives or moving into an ECHO cottage that is attached or detached to a family member’s home, 3) moving in to an elder-ready independent cottage with or without support service, 4) moving directly into personal care or assisted living, usually outside of the community, and 5) moving into full time nursing care, also outside of the community and an option that is more and more pre-designated to existing situations. More options are being developed by the day, mostly because the boomers are not going to deal with the kind of facilities where they placed their parents. Most health care providers I speak with do not want to live in the places in which they work.

Staying at home would require the help of local Area Agencies on Aging. With additional help from occupational and physical therapists, local home care agencies, and certified aging in place specialists (NAHB, AARP), home modifications necessary to stay in the home could be determined and completed. Technology could be placed in the home that permits monitoring from the newly placed town-center health-service (Smart Spaces).

When the choice is made to leave home, assisted living and independent cottages would be found in the town center. In this manner, the elderly are still members of the community of which they associate themselves. Kids can interact with elders on a daily basis because the new facilities would be mixed-use, complete with coffee shops and fitness centers, and combined adult and child day care centers. After all, many adults needing care often have the same needs as children. Care is local and autonomous, and assurances are made that care will be available to all existing residents giving members of the community a healthy sense of well-being and association. Graduated care is available directly in their town.

This scenario relies on the placement of new facilities. Currently, facilities are placed where the developers decide and the markets determine they should be placed. It is based on an errant zoning history, one that separates institutional, residential and commercial uses. Zoning has become a bad habit for both developers and financiers. Fortunately, strides are being made to roll back some of these development policies as city officials and planners recognize the problems that they cause.

Future policy may give greater incentives to place elder facilities in existing town centers. There is already a LEED (Leadership in Energy and Environmental Design) for Neighborhood Development certification system being tested that rewards new buildings for their use of vacant sites and existing infrastructure. Especially in PA, where there is a disproportionate amount of new, suburban development in regards to population growth in the state, it does not make sense to place new health care facilities and elder housing apart from our existing core communities. In fact, it could be a state-wide policy to place new facilities and housing within our core communities in order to promote social inclusion and efficient delivery of health care service – even to rural residents.

Ideally, facilities-based providers could begin to rethink the manner that they provide care. Imagine a CCRC and its components. It has independent cottages, assisted living, and nursing care available. It often has other services that mimic downtown streets. In the campus environment, these are usually separated building types. Often, even the assisted living branch and the nursing branch are in different units, or at least bridged with a common area. Now imagine how this might look in an existing town, especially one with many vacant lots and underutilized buildings. Sprinkled in the downtown would be the assisted living and nursing portions, adjacent to, and sometimes in combination with a coffee store, a bagel shop, a flower shop, a beauty salon, and other ‘active’ places that reach out to Main Street. One block behind Main Street, imagine an active Elm Street, with independent cottages that blend with other homes in the existing residential neighborhood.

A provider could give care in the same manner as usual, possibly in an even more compact location. At the same time, the provider could reach out to its new neighbors, providing care and a promise for graduated care right in the homes of the people that already live there. All the while, the town has new business life and human participation, which is likely to draw even more human activity. Efficient delivery is given at the point source of population density.

Developers will build a proven model. To get them into the mix, proven models need to be researched, considered, and tweaked. Many facilities that are healthy lifestyle-centered are making a lot of money. So are facilities that are day-care based, or those that combine different uses. If a plan were developed that utilized profitable, proven models in new ways, then steps can be taken to implement newer versions of previous solutions. For instance, the Green House model is doing well and is being replicated all over America. And coffee shops tend to make money. Instead of building a Green House on a campus, place it in the town center, add a coffee shop, place a fitness center on it, add a day care center, and call it a day. Four different uses in the same building that all make money, but they also cause social interaction. One can feed the other. Better yet, adaptively reuse an existing, vacant building or fill-in that ‘green ghetto,’ the one that is sprouting wild sumacs and fire-thorn cherries. It can preserve the town’s heritage, and provide distinctive architecture.

PatinaCare In Action
Just like any grass roots effort, PatinaCare relies on the talents of various professionals and concerned citizens. This is what is happening in Kennett Square, PA. No less than 22 different people and organizations, including town planners, developers, public health nurses, adult day care operators, facilities-based providers, politicians, designers, and resident citizens are moving forward with plans to revitalize their town by integrating affordable housing, senior health care, and intergenerational opportunities. PatinaCare offers a framework and a vision to help rally and organize the local troops to realize elder-friendly communities.

While still early in the process, the players are at the table and significant decisions are being made that will enable this entire town to age gracefully in place with efficient delivery of health services. A needs assessment will begin in the next few months that is being jointly funded by a facilities-based provider and pursuit of a “special project” grant from the county planning commission. This assessment will be an interactive process to determine the ‘elder-friendliness’ of the town. Local and state governments will contribute revitalization money to elder housing and care projects. I repeat. They provide money that is not allocated to health care services that will directly pay for a health care environment.

Kennett started with a vision of creating a place where children can interact with elders. The kids wanted it. The seniors wanted it. And oh yeah, the adults in between are seeing the logic of the human ecotone. It has blossomed into a grass-roots effort to provide all aspects of well-being and dignity to the resident-citizens of the Kennett region.

Conclusion
With caregiver numbers shrinking, the cost of healthcare soaring, and the funds of Social Security disappearing before our eyes, I see this as the inevitable outcome for healthcare and housing for the elderly in all of our existing communities. Everything else that we do is unsustainable and our children will pay the consequences. The system is crashing because of these inefficiencies, the physical nature of our health care system and the fact that the normal human order is not being considered or served. When we utilize a model that is holistic and integrates all the components of the system, then we will be able to care for everyone. We should create more opportunities for the human ecotone. We need to change the physical layout of the continuing care spectrum and nurture our towns to nurture our people.

When Pappy died, we automatically went to the river. We buried him late that afternoon, and as night fell, we descended to his ‘spot,’ the same spot where I lost my candy. We became children again. Before long, in the dark of the night, we were all in the river, playing and splashing, and as always, he was watching us and keeping the monsters at bay. We lit candles and watched as they followed the gentle current and spun on the slow eddies, until they finally rounded the bend just down the river. It was one of the best days of my life, and a memory that I will never forget. Being there, that night, we celebrated who he was. As we climbed out of the water, my aunt asked if we were all healed. It was something my grandmother always said that the river would do, something relating to sulfur from an old, upstream coal mine. I was healed. So was my family. Pappy was delivered, and we were healed. What an impact he had on us. I know who I am.