Tackling the Caregiving Crisis by Design: Reducing Preventable Threats to Better Serve Older Clients and Support Their Heirs

By Esther Greenhouse, MS, CAPS

Your clients’ financial security and physical independence are at risk if housing is not included as a crucial component of and resource for retirement, legacy, and long-term care planning.

What if helping clients stay financially independent could also reduce care-related withdrawals, protect assets, and strengthen relationships with heirs? Long-term care and caregiving needs and costs are a known threat to your clients’ physical and financial independence with age. However, most financial plans are incomplete and unsustainable because they only consider future costs of care, and lack an accurate understanding of the role of the home environment in shaping a client’s physical and financial future. As a result, clients are left vulnerable to preventable physical and financial decline from a misunderstood threat: the design of where they live.

What is the Problem?

We’ve identified three major problems when housing is not included in retirement and long-term care planning:

• Clients are at risk of preventable forced frailty, increased dependency, eviction from their home of choice by poor design, and unnecessarily higher caregiving demands and costs due to where they live now, and where they will live when they receive care.
• Plans that fail to incorporate home as a major variable can increase the likelihood that clients and their heirs will incur unnecessary financial and human costs.
• Spouses and adult children face unnecessarily higher caregiving burdens and negative impacts on their own health and financial well-being in the present and in their own retirement.

Costly Misconceptions

We’ve seen two costly misconceptions when it comes to planning for clients’ housing needs as they age:

• Aging in Place as the Answer: Over the past 10 years, there has been increasing emphasis on helping older adults to age in place. This is not the right perspective, since over 90% of older adults already age in place. The issues are that they do so 1) by default without an informed plan and cost/benefit analyses, and 2) attempt to age in place in homes and communities with significant barriers to successful aging in place.¹   
  
  Aging in place is terrific if it is a realistic option. But few people know that only 5% of the U.S. housing stock has the key features necessary for successful aging in place. Sometimes, moving to senior housing or a Continuing Care Retirement Community (CCRC) is a wise choice. They are not all created equally in terms of design features, services, costs, and protocol of care (if/when needed). But exploring them with the goals of how they can enable clients to maintain their physical and financial independence with age should be an essential part of your planning services. 
   
• Home Mods if Needed: Many professionals I speak with on these issues say, “My clients could always make home modifications should they need them.” This is a crucial point to address. Again, only 5% of the housing stock has the key features necessary for successful aging in place, so chances are that your clients are living in housing that threatens their independence as they age.
  
  Yes, home modifications can make a significant positive difference in a client’s ability to remain in their home of choice. However, there are substantial issues regarding home modifications:
  
  
  • They come too late: Changes are often implemented after a person has already been disabled by design and health conditions.
  • Clients don’t want them: When incorporated after need, changes are typically piecemeal and institutional. They signal frailty and dependence.
  • It’s the worst time for renovations: When a person or loved one is in the hospital or rehab, or has just returned home, is not the time for finding a contractor and undertaking renovations.
  • Money: Many people may not have the funds, think they do not have the funds, or they or some family members are not willing to invest the money to make the necessary modifications.

A Better Way Forward

Clients can avoid these issues and take control of their futures by treating their home as a strategic asset and a prevention tool—a resource to preserve both physical and financial independence with age.

Just like healthy habits and financial planning, proactive decisions about where and how your clients live can dramatically reduce decline, care needs, and long-term costs. You can help them do this by incorporating the Enabling Design Approach (EDA) into your process.

The Enabling Design Approach 

The first pillar of the EDA is that of environmental fit: If the home they live in is not designed for the lifespan, it will push them to an artificially lower level of functioning and independence. This results in greater frailty, dependency, and caregiving needs and costs. It is crucial to recognize that like a healthy lifestyle, these negatives are preventable when they choose to live in homes that enable them to maintain as much physical independence with age as possible.  

The second pillar is the fact that the status quo of how we design and build is flawed. We do not design and build for the lifespan, age span, or ability span, so most people are trying to adapt to their environments. This is particularly an issue as we age, and most of our abilities move farther from the design norm.  

The third pillar is looking at policies, programs, plans, places, and economics through the lens of the first two pillars. What is being impacted by them? How can we leverage this knowledge to make informed choices that turn unnecessary deficits into advantages?

Your clients can turn the typical scenarios around when they view where they live as a resource to maintain their physical and financial independence with age. Whenever they are looking for a new home or renovating their existing home, they should be including enabling design features. These are not medical devices but rather design solutions that enable independence across the lifespan, size span, and ability span. Some great examples include:

• Zero-step entry to the home: This is crucial for an older person using a walker, an adult using a wheelchair, a parent pushing a stroller, or anyone bringing heavy items in or out of the residence. For a person with mobility needs, this can mean the difference between remaining at home, greater levels of care, and need for costly medical transport or independence.
• Microwave at counter height: The design and build trend is to place a microwave in line with upper cabinets or worse, above a cooktop. To put it bluntly, this is terrible design, not only for an older person who may have reduced reach range or balance, but absolutely no one should be bringing hot food and liquids down toward them.
• Zero-step shower: Stepping up and over a curb in a wet, slippery environment is a risk at any age but especially for older adults or anyone with balance or mobility issues. Without zero-step showers and grab bars, your clients are at greater risk of falls. With an enabling shower, they have the potential to save approximately $100 of aide costs with every shower, and to maintain the dignity, privacy, and agency of bathing themselves.

Case Study: Prevention Pays

Of course it would be great if you and your clients were to incorporate this approach simply for its potential to positively impact their health and independence and reduce caregiving burdens on loved ones. However, there are also significant financial reasons.

• Delay or Prevent Move to a Care Facility: Every month that a move to a care facility is delayed represents a cost savings. Applying the EDA for my own mom, we were able to delay her move to a facility by seven years, saving the family an estimated $500,000 to $1.5 million. And although she needed to live in an assisted living facility for seven months at a cost of about $100,000, she was able to leave a sizable inheritance to her children and grandchildren.
• Reduce Caregiving Costs: What if you could help your clients’ heirs not need to bathe or toilet their loved ones? How would your clients feel if they could avoid or reduce having a stranger or a family member bathe them or help them toilet?
  
  What if helping them do so could save them $100 a week or up to $5,000 a year—and if their overall home environment enabled them to successfully age in place, what would the cost savings be? Potential savings on facility rates² should be considered when exploring a renovation or move to senior housing:  
  • Independent living rates: $3,065/month
  • Assisted living rates: $5,350/month
  • SNF rates: $10,646/month (private room)
  • Memory care rates: 25% more than assisted living

You may know from experience that these are national averages and vary significantly based on location, amenities, and quality of services and the environment.

• ROI: What if you could provide your client with an investment with an ROI of 45%? How about 3,000%? Here are some real examples:
  
  Bidet seat:
  $1,000 total investment ($500 for the bidet seat, $500 installation by a licensed electrician)
  Potential savings if used regularly, reduced aide visits for bathing:
  One less aide visit/week: $75-$140
  Potential savings over one year: $3,750–$7,000

In my mother’s case, she saved approximately $31,000 in reduced paid care over the seven years she needed assistance at home.

Additional benefits include:
Reduced UTIs
Reduced caregiving demands on heirs
Increased dignity, agency, and independence

This is also a practical issue because our nation has a rapidly expanding shortage of paid caregivers. Your clients may have the funds for care, but who will provide it?

Solutions: Integrate the Enabling Design Approach (EDA)

You can amplify the value you deliver by integrating the EDA into your firm’s planning philosophy. This holistic, practical approach complements your expertise in financial, retirement, estate, and extended care planning—and positions you to serve both aging clients and their heirs more effectively. While Silver To Gold provides the services listed below, this is also a template for you to incorporate it yourself into your work with your clients, with overall actions that include:

• Create a paradigm shift among your team and clients
• Train your staff
• Offer client engagement events for older clients and adult children
• Incorporate EDA into your intake process, planning conversations, and resources
• Use strategy sessions to explore living environment as a financial and care variable

Leverage Existing Programs and Resources

Share these resources with your team, your clients, and their heirs; use them to inform the action steps:

– AARP’s Home Fit Guide is a valuable tool for people to assess their own homes and their parents’ homes and is a vehicle for working with builders 

– NAHB’s Certified Aging in Place Specialist (CAPS) program, created with AARP, has trained thousands of builders, developers, designers, occupational therapists, physical therapists, and realtors throughout the nation. Do you know all of the CAPS professionals in your community? Enlist them, and similar practitioners, as a resource.

– Use the Guiding Principles for Creating Enabling + Equitable Housing + Multigenerational Communities: Based on my EDA and the concept of equity, these principles were developed to help built environment sector practitioners and related professionals positively shift the environments they are creating to address the real and preventable problems the design of our communities have created.

– Use content from (while attributing credit) Silver To Gold’s blog: https://silvertogoldstrategies.com/aging-in-place-essentials-to-thrive/.

Conduct a Cost-Benefit Analysis and Practical Assessment that Includes Housing that Enables Independence  

There is excitement over the use of predictive analytics to complement professional expertise and inform financial and long-term care plans. However, they fail to take into account the features of where the client currently lives and where they will live should they need care.

In addition to asking questions like:

• What is your ideal plan for the next 15–40 years of your life?
• Who will provide care or assistance if you or your spouse need it?

Also ask:

• Does the design of your current home support your plan?
• If you plan to move, do you know what home features will enable you to live your ideal plan?
• If you or your spouse should have changes to your abilities and need assistance, what types of services might you need? Are these available in your current community? Are they available in the community to which you plan to move?

By understanding and addressing the reality of the impact of where your clients live on their physical and financial well-being, and incorporating it into your current services, you can offer truly comprehensive planning with a sustainable plan that can help reduce preventable long-term care needs and costs for your older clients and their heirs.

¹https://www.jchs.harvard.edu/research-areas/reports/projections-and-implications-housing-growing-population-older-households

²From Genworth’s Cost of Care Survey 2024, https://investor.genworth.com/news-events/press-releases/detail/982/genworth-and-carescout-release-cost-of-care-survey-results?utm_source=chatgpt.com

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Esther Greenhouse is an environmental gerontologist, longevity strategist, and CEO of Silver to Gold Strategic Consulting. Her firm helps financial planners and LTC insurance companies reduce preventable care needs and costs to preserve assets, delay claims, and retain heirs through staff trainings, client engagement, and advising. Its unique approach has shaped projects including the nation’s first elder-focused ER and AARP International’s Equity by Design initiative.

image credit:  nelyninnell