HB II Poverty and Aging DB & Responses. Week 11

Social Work and Aging in Place: A Scoping Review of the Literature

Amanda J. Lehning, Emily Joy Nicklett, Joan Davitt, and Hilary Wiseman

Aging in place (AIP) has become a major focus of aging policies, programs, and scholarship in recent years. This article presents a scoping review of the social work literature on AIP. Based on predefined eligibility criteria, the authors identified 22 empirical articles published between 1980 and 2014. Many of these studies focused on settings that are particularly rele- vant to gerontological social work practice, including congregate housing alternatives to nursing homes, grassroots and volunteer-run organizations, and agency-based programs. The majority of the studies examined in this scoping review presented AIP as a rationale for the study, but very few examined AIP as a predictor or outcome of interest. As this body of research is still in its early stages, many of the articles are descriptive rather than analytical in nature. This is a necessary first step in the development of research to inform policies and programs to promote AIP. The authors conclude with recommendations for further advance- ment in this area of research, including the potential for social work scholars and practitioners to examine and address inequities in opportunities for older adults to age in place.

KEY WORDS: aging in place; gerontological social work; older adults

Aging in place (AIP), defined as the abilityof older adults to “live in their homes orcommunities as long as possible” (Yen & Anderson, 2012, p. 951), is a major focus of aging- related policies, programs, and scholarship. For exam- ple, the Older Americans Act Reauthorization Act of 2016 (P.L. 114-144) provides funding for a variety of community-based services that aim to promote AIP. In addition, federal and state governments have im- plemented promising programs and interventions, such as Money Follows the Person and the State Bal- ancing Incentive Program (both expanded through the Patient Protection and Affordable Care Act), to help older adults who need assistance to remain in or return to their community (Kane, 2012). Nonprofit organizations, including the increasingly popular Vil- lage model, offer supports and services to help their members age in place (Greenfield, Scharlach, Lehning, Davitt, & Graham, 2013). This proliferation of pro- grams is in response to a variety of factors, including the high costs of institutional care (Scharlach & Lehning, 2012), reduced access to informal supports (Szinovacz & Davey, 2008), the potential benefits of AIP for older adults’ independence and positive self- image (Rubinstein & Parmelee, 1992), and the pref- erence of the majority of older adults to remain in their own home or community and avoid relocation (Feldman, Oberlink, Simantov, & Gursen, 2004).

Concomitant with this increase in policies and programs are efforts by gerontological scholars to develop an evidence base on AIP (Vasunilashorn, Steinman, Liebig, & Pynoos, 2012). Although this scholarly literature has explored various lines of inquiry, critical gaps remain in our understanding of AIP. Conceptually, for example, there is a lack of consensus about terms (for example, AIP versus aging in community), the specific living arrange- ments that encompass AIP (for example, avoiding institutionalization, remaining in the same home, relocating to another home or community), and whether AIP is an end to itself, or more of a means to achieve health and well-being. Empirically, there is limited information regarding the causes and con- sequences of AIP, including whether these may vary among more vulnerable populations. Charac- terizing the literature is an important step toward a more consistent and systematic approach for study- ing this concept.

Social work practitioners are often involved in the development, implementation, and evaluation of policies and programs to promote AIP, and could particularly benefit from the advancement of an evidence base for these interventions. Further- more, reflecting the profession’s focus on social justice and serving vulnerable populations, social work scholars have the potential to add critical

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knowledge to this area of research, particularly in terms of ensuring that AIP policies and programs do not perpetuate or exacerbate inequities in health and well-being. The purpose of this review is to examine the contributions of social work to the scholarly literature on AIP and to identify op- portunities for further social work involvement that informs policy and practice.

BACKGROUND The concept of AIP has received increased atten- tion in light of the aging of the U.S. population. By the year 2030, one in five Americans are pro- jected to be age 65 or older, totaling 72 million people (Federal Interagency Forum on Aging- Related Statistics, 2012). In addition, the number of Americans age 85 or older, who are much more likely to require assistance due to health problems or disability, will triple between 2010 and 2050 (U.S. Census Bureau, 2010).

Older adults with a desire to age in place face a number of barriers to doing so. First, aging is often accompanied by declines in physical or cognitive functioning that can restrict health, quality of life, and independence. About one-third of Medicare recipients (the majority of whom are 65 and older) have a limitation in performing personal and house- hold care tasks, as measured by activities of daily living and instrumental activities of daily living, respectively (Federal Interagency Forum on Aging- Related Statistics, 2012). Approximately 80% of older adults have been diagnosed with at least one chronic illness, and half have at least two (Centers for Disease Control and Prevention, 2011). Second, in the United States, declines in fertility rates, high- er participation of women in the workforce, and increased longevity impose challenges on family and friends to continue to provide informal care (Spillman & Pezzin, 2000; Szinovacz & Davey, 2008). Third, despite increased availability of home- and community-based services, the U.S. long-term care system remains fragmented, expen- sive, and unable to meet the needs of many older adults (Scharlach & Lehning, 2012), particularly those seeking community-based alternatives to nurs- ing home care (Zarit, Shea, Berg, & Sundstrom, 1998). Finally, the physical and social infrastructure of many cities and towns in the United States do not support the needs of older adults. For example, zoning ordinances in many suburban communities limit legal occupancy to a single family, dictate

large minimum lot sizes, and restrict building addi- tional structures on properties (Byun, Waldorf, & Esparza, 2005), limiting the housing alternatives available to older adults who wish to remain in their community but have difficulty maintaining a larger single-family home.

In spite of these challenges to AIP, there are in- dicators that the proportion of older adults staying in their own home and community is increasing. The percentage of older Americans living in a long-term care facility has declined since the 1970s, particularly among those in the 85-and- older population, 26% of whom lived in a nurs- ing home in the 1970s compared with 14% by the mid-2000s (Hayutin, 2012). Furthermore, data suggest that more older adults are remaining in their communities rather than relocating to new ones. For example, 4.4% of those age 65 and older moved in 1999–2000 (U.S. Census Bureau, 2001) com- pared with only 3.2% in 2010–2011 (U.S. Census Bureau, 2012). These statistics support the prop- osition by scholars that older adults’ housing arrange- ments have become increasingly stable (Forrest & Kearns, 2001).

The benefits of AIP potentially emerge from the strong feelings of place attachment older adults develop if they have lived in their home or com- munity for many years. Furthermore, the home and neighborhood environment is thought to become increasingly important as people grow older and leave the workforce, develop health pro- blems and disabilities, or experience mobility chal- lenges (Burns, Lavoie, & Rose, 2012). Thus, older adults may also develop strong feelings of place attachment because they spend the majority of their time in their home and immediate neigh- borhood environment. Place attachment in turn may contribute to health and well-being in later life because it fosters physical insideness (that is, the ability to easily navigate familiar environments), social insideness (that is, feelings of belonging and confidence in accessing informal assistance), and autobiographical insideness (that is, deriving mean- ing and self-concept) (Rowles, 1983).

Along with the increasing number of policies and programs that aim to promote AIP, as well as a growing recognition of the barriers to doing so, there has been a rise in the number of scholarly publications examining AIP. In their analysis of peer- reviewed articles published in 11 leading gerontology journals from 1980 to 2010, Vasunilashorn and

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colleagues (2012) documented a dramatic increase in the number of AIP publications per year, particu- larly after 2000. For example, AIP was mentioned in fewer than five articles per year in the 1980s, but it was discussed in more than 60 in 2010. Although Vasunilashorn and colleagues (2012) provided an important overview of the AIP literature; they also raised concerns regarding the potential for this liter- ature to inform programs and policies that aim to help older adults age in place in a way that is safe and supports their quality of life. The authors re- ported that 70% of the publications mentioned AIP only indirectly, meaning that it was not the primary focus of the study. The lack of studies including AIP as a predictor or outcome suggests limited empirical support for the benefits of AIP. The authors noted that designing studies that can capture the variety of individual and environmental factors involved in AIP and subsequent outcomes is difficult because it is not a “one-size-fits-all” concept. In addition, the authors identified four topics typically addressed in the literature on AIP: environment, services, tech- nology, and health. It is likely that these topics do not encompass the numerous factors that influence, or are influenced by, AIP. Therefore, there is a need for additional assessments of the state of AIP litera- ture to complement and build on this prior work.

PURPOSE OF THE REVIEW In this scoping review we aimed to characterize the contributions of social work to the existing lit- erature on AIP. There are several reasons why it is valuable to assess the state of the literature, specifi- cally within the field of social work. First, social work scholars are well positioned to increase our empirical understanding of the complex interplay of individual and contextual factors that help or hinder older adults’ ability to remain in their own home and community. This focus on the person and his or her surrounding environment has been described as “the unique contribution of the social work profession” (Silverstone, 2005, p. 309), and in recent decades there has been a call for social work researchers to incorporate more environ- mental characteristics into their work (Holland, Burgess, Grogan-Kaylor, & Delva, 2011). Second, social work’s concern for vulnerable populations highlights social work scholars’ potential to call attention to AIP inequities in terms of who bene- fits from different policies and programs, as well as who is aging in place compared with who is stuck in

place in a way that is detrimental to safety, health, and well-being. One of the first publications to discuss this concept of being stuck in place, for example, was coauthored by a social work scholar (Torres-Gil & Hofland, 2012). Finally, social work scholarship on AIP can inform the practice of clinical and macro social workers in the field. For example, because more than 80% of older adults indicated that they want to remain in their current homes and com- munities as long as possible (Feldman et al., 2004), promoting AIP aligns with strengths-based and empowerment-oriented social work practice (Chapin & Cox, 2001). Furthermore, social work practitioners are key implementers, both indepen- dently and as members of interdisciplinary teams, of policies and programs that aim to help older adults age in place. Given social work’s focus on the environment and complex social systems, geron- tological social work scholars are well positioned to contribute to translational and interdisciplinary research on AIP (Burnette, Morrow-Howell, & Chen, 2003).

In this scoping review we aimed to map the AIP literature in the social work field, and therefore ad- dressed two questions: (1) What topics are ad- dressed by the social work literature on AIP? and (2) What empirical evidence from this social work literature can inform programs and policies focused on AIP?

METHOD We conducted a scoping review to examine social work contributions to the literature on AIP. A systematic review synthesizes the research literature on a particular question and typically excludes studies due to sample size, study design, or quality; however, a scoping study can be used to summarize an area of research more broadly (Arksey & O’Malley, 2005). We searched for ar- ticles published between January 1, 1979, and December 31, 2014, in the following databases: Family and Society Studies Worldwide, Social Services Abstracts, PsychINFO, PubMed, Sco- pus, Cochrane Central Register of Controlled Trials, Social Sciences Citation Index, Ageline, and Proquest Research Library. We used the fol- lowing search terms: “age in place,” “age-in-place,” “aging in place,” “aging-in-place,” “ageing in place,” “aging in community,” and “ageing in community.” For each of these terms, we also limited our search by combining those terms

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with the following terms: “social work,” “social worker,” and “social welfare.”

A summary of our abstraction process and eligi- bility criteria is presented in Figure 1. We excluded any articles not written in English or published before 1979. We also excluded publications that were not peer reviewed, such as reports and other products from the gray literature. Our eligibility criteria specified that the article is part of the social work literature, which we defined as (a) first author is a current faculty member, researcher, or student in a school of social work; (b) first author holds a graduate degree from a school of social work; or (c) article was published in a social work journal. We then assessed whether the article’s population of interest is older adults, which we defined broadly as at least 50 years old in light of the wide variation of age ranges included in gerontological studies. We then conducted a more in-depth review to determine whether the article examined AIP, which we based on the extent to which AIP and relevant synonyms appeared in the text, as well

as whether the findings and conclusions of the arti- cle could inform policies, programs, and research on AIP. We excluded a number of articles, for example, that referred to AIP briefly in the Intro- duction or Discussion sections without attempting to connect study findings to this concept. Finally, we limited the review to articles reporting empiri- cal findings.

The first author then reviewed all 22 eligible ar- ticles, with each coauthor reviewing a subsample, so that each publication was reviewed by two authors. For each article, we examined the specific aims (including the context of AIP), methods, findings, and implications. For the majority of arti- cles, interpretation of these characteristics was simi- lar between the two reviewers, and we resolved any inconsistencies through discussion before cate- gorizing and summarizing the publications.

RESULTS We identified 22 articles from the social work liter- ature that focus on AIP. Details about the articles,

Figure 1: Literature Search Strategy and Exclusion Criteria (Articles Published January 1, 1979–December 31, 2014)

211 articles

128 articles

34 articles

145 articles

22 articles

66 excluded: duplicates, not published in English, and/or appeared before 1979

17 excluded: not peer reviewed

94 excluded: • 36 not in social work literature • 4 not focused on older adults • 54 not substantive enough focus on aging in place

12 excluded: not reporting empirical findings

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including specific aims, data collection, sample, and findings, are presented in Table 1. Although publication dates ranged from 1991 to 2014, the overwhelming majority of studies were published within the last decade. Reflecting the diversity of topics addressed, which we detail later, the sample sizes and inclusion criteria varied widely, ranging from large representative samples of all older adults living in a geographic area (for example, Tang & Lee, 2010) to small purposive samples of vulnera- ble elders (for example, Witso, Vik, & Ytterhus, 2012). Most of the articles examined individual or organizational outcomes, with only one study (Silverstein, Johns, & Griffin, 2008) focusing on the community as the unit of analysis.

Topics Addressed by the Social Work Literature For our first research question, we identified six to- pics within the social work literature on AIP. Four articles (Bryant, 2003; Chapin & Dobbs-Kepper, 2001; Janicki, McCallion, & Dalton, 2002; Sheehan & Wisensale, 1991) examined AIP in alternative resi- dential settings, such as age-segregated housing. We categorized four articles (Carpenter et al., 2007; Tang & Lee, 2010, 2011; Tang & Pickard, 2008) as addressing anticipatory relocation (that is, not AIP) or the expectation to age in place, particularly the role of formal and informal supports in predictions about future living arrangements. Another three ar- ticles (Soderberg, Stahl, & Melin Emilsson, 2013; Wiles, Leibing, Guberman, Reeve, & Allen, 2012; Witso et al., 2012) explored older adults’ perspec- tives on AIP, including the experience of remaining in the same home and community. Two articles (Norstrand & Chan, 2014; Smith, Lehning, & Dunkle, 2013) examined characteristics of the phys- ical or social environment that may support AIP, such as aging-friendly communities. The largest category was composed of studies, primarily descriptive, of community-based interventions to support AIP, such as Villages or Naturally Occurring Retirement Community supportive service programs (NORC SSPs). This category included seven articles (Black, 2008; Bronstein, Gellis, & Kenaley, 2011; Gonyea & Burnes, 2013; Greenfield, 2014; Greenfield et al., 2013; Osterkamp & Chapin, 1995; Scharlach, Graham, & Lehning, 2012). Finally, two articles (Marken, Moxley, & Fraley, 2011; Silverstein et al., 2008) presented an evaluation of a service learning or train- ing program related to AIP.

Empirical Evidence to Inform Policies and Programs To address our second research question, we first reviewed each study to determine how the authors conceptualized and measured AIP. Although the conceptualization of AIP differed between articles, the majority took a more inclusive view of this term, aligning with our own definition of living in one’s home or community. Several articles also emphasized that AIP reflects personal choice, not simply living arrangement (for example, Scharlach et al., 2012; Wiles et al., 2012). Among the quanti- tative studies, only one of the 22 articles in this review operationalized AIP as either a predictor or outcome variable. Specifically, Bryant (2003) mea- sured AIP as the length of time the respondent re- ported living in his or her current community and found that AIP can contribute to better self-reported health and well-being outcomes. The three qualita- tive studies on older adults’ perspectives asked partici- pants directly about their experience with AIP. Two of these studies identified the role of AIP in elders’ feelings of autonomy, independence, and dignity (Wiles et al., 2012; Witso et al., 2012), while the third raised concerns about the ways an overem- phasis on AIP may discourage older adults from seeking needed assistance (Soderberg et al., 2013).

Several articles measured closely related con- cepts that can inform policies and practices to pro- mote AIP. Specifically, the articles by Chapin and Dobbs-Kepper (2001), Janicki and colleagues (2002), and Sheehan and Wisensale (1991) indicated a need for housing providers to develop clear strategies and policies to support higher-need residents to age in place. The four articles on anticipatory relocation or expectation to age in place suggest that a significant proportion of older adults are concerned about whether they will be able to remain in their own home, and raise questions about whether those who are at a higher risk for unwanted relocation are plan- ning for future service needs. Furthermore, these studies indicate that older adults have only limited knowledge about the community supports avail- able to help them age in place.

Approximately half of the articles (12 of 22) did not measure AIP or a closely related concept, but instead described the need to promote AIP as a rationale for conducting their study or discussed the implications of study findings on AIP. Some of these studies reported significant associations between various community characteristics (for example,

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Table 1: Characteristics of Social Work Studies on Aging in Place (AIP)

Study Specific Aims Data Source Sample Findings

AIP in Alternative Residential Settings Bryant (2003) Relationship between AIP in a

religious community and variety of health and social outcomes

Standardized self- administered survey

72 African American nuns (ages 30 to 84 years) living in religious communities

AIP was associated with better perceptions of health status, stress, and depression as well as greater satisfaction with community and relationships.

Chapin & Dobbs- Kepper (2001)

Admission and retention policies in assisted living that could support or create barriers to AIP

Standardized self- administered survey

141 administrators from assisted- living/residential health care facilities in Kansas

Admissions and discharge criteria were less supportive of AIP for residents with severe cognitive impairment, behavioral problems, or health conditions they cannot self-manage.

Janicki, McCallion, & Dalton (2002)

Strategies of group homes to support the AIP of residents with intellectual disability (ID) and dementia

Unstructured self- administered survey

Representatives from 54 group homes in the United States, United Kingdom, Ireland with at least one resident with an ID and dementia

Identified three strategies for individuals with both an ID and dementia: (1) continuing provision of AIP supports, (2) developing in-place progression options (for example, creating a specialized dementia unit), and (3) referring out to long-term care.

Sheehan & Wisensale (1991)

Discharge policies in senior housing for frail residents

Standardized self- administered survey and unstructured in-person interviews

98 administrators from senior housing in Connecticut

Few housing providers have written discharge policies to guide decisions about relocation to higher level of care, despite growing concern about the ability of residents to age in place.

Anticipatory Relocation or Expectation to Age in Place Carpenter et al. (2007) Contributors to concerns about

future relocation Standardized in-person interviews

324 adults age 65 and older living in a suburban area of St. Louis with a high percentage of older adults

Concerns about future relocation were most often due to health and financial limitations, barriers to safely moving around the home, household maintenance, and keeping social connections.

Tang & Lee (2010) Older adults’ perceptions about services needs to age in place

Secondary analysis of standardized self- administered survey

4,501 adults age 50 and older living in 13 U.S. communities participating in Community Partnerships for Older Adults (CPFOA) program

Those older, in poorer health, female, less educated, and with lower income were less likely to perceive future service needs to age in place. Previous use of in-home personal services was associated with greater perceived need for services to age in place.

Tang & Lee (2011) Relationship between social support and expectations to age in place

Secondary analysis of standardized self- administered survey

4,501 adults age 50 and older living in 13 U.S. communities participating in CPFOA program

Formal support was associated with longer perceived ability to age in place, while informal support was not associated with expectations about AIP.

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Table 1: Characteristics of Social Work Studies on AIP (Continued)

Study Specific Aims Data Source Sample Findings

Tang & Pickard (2008) Older adults’ awareness of services to facilitate AIP

Secondary analysis of standardized self- administered survey

4,611 adults age 50 and older living in 13 U.S. communities participating in CPFOA program

Found low awareness of long-term services and supports available in their community. Respondents who reported that services were not available in their community were more likely to anticipate needing regular help to age in place or having to relocate at a younger age.

Older Adults’ Perspectives on AIP Soderberg, Stahl, & Melin Emilsson (2013)

Older adults’ decision-making process about relocating and AIP

Unstructured in-person interviews, field notes, and observations

Purposive sample of 21 older adults ages 73 to 94 living in Sweden

Identified two approaches: (1) justifying remaining in their own home, and (2) making excuses for the need to relocate to a residential home. Interview findings indicated that (a) older people push limits, (b) older people lay modest claims to assistance as long as possible, (c) older people feel bad for not meeting expectations.

Wiles, Leibing, Guberman, Reeve, & Allen (2012)

Views of older adults about AIP

Unstructured in-person interviews and focus groups

Snowball sample of 121 older adults ages 56 to 92 living in two communities in New Zealand

Older adults reported wanting choices about where they live. AIP was described as not only related to staying in a particular house, but remaining a part of a neighborhood and community. AIP was identified as an advantage representing independence, autonomy, and identity.

Witso, Vik, & Ytterhus (2012)

Experiences of older adults AIP with support of in-home services

Unstructured in-person interviews

Purposive sample of 10 older adults ages 72 to 89 with health impairments in Norway

Main theme was importance of older adults maintaining their dignity and pride by actively participating as long as possible. Older adults described “getting oneself going” by organizing their life in a way that they could still participate. They also discussed “keeping one’s place at home, in the neighborhood, and in the family” even with their reduced capacity.

Characteristics of the Physical or Social Environment That May Support AIP Norstrand & Chan (2014)

Changes in social capital, and its relationship to health, with age

Secondary analysis of standardized self- administered survey

2,344 adults age 65 and older living in five counties in Pennsylvania

High levels of social capital were generally associated with better health and functioning. Unexpectedly, among the oldest-old higher neighborhood trust was associated with more instrumental activities of daily living limitations.

Smith, Lehning, & Dunkle (2013)

Measures of aging-friendly community characteristics

Secondary analysis of standardized self- administered survey and administrative data

1,376 adults age 60 and older living in Detroit

Identified six factors for future measurement of aging-friendly communities: access to business and leisure, social interaction, access to health care, neighborhood problems, social support, and community engagement.

(Continued)

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Table 1: Characteristics of Social Work Studies on AIP (Continued)

Study Specific Aims Data Source Sample Findings

Community-Based Interventions to Support AIP Black (2008) Health needs of residents in a

naturally occurring retirement community (NORC)

Standardized in-person needs assessments

Purposive sample of 114 adults age 60 and older living in a NORC in southwest Florida

Those age 80 and older reported lower levels of physical, psychological, and social well-being.

Bronstein, Gellis, & Kenaley (2011)

Evaluation of a neighborhood NORC program

Unstructured in-person interviews

Five directors of partner organizations and four members of the Resident Council of NORC program in Albany

Identified four themes: (1) AIP is preferable and NORCs can support AIP, (2) there is a need to develop informal support systems, (3) concrete support (for example, home maintenance) is needed, and (4) collaboration with community services agencies is critical.

Gonyea & Burnes (2013)

Evaluation of program combining aspects of Village model, NORC supportive service program (SSP) model, and program in Israel

Standardized in-person interviews and standardized follow-up telephone interviews

33 older adults ages 69 to 95 participating in Aging Well At Home program in Boston

Program participation was associated with a decrease in perceived stress, but no significant change in loneliness or depression.

Greenfield (2014) Develop a conceptual framework examining the social–relational activities of NORC SSPs and initial and long-term outcomes for participants

Secondary analysis of unstructured in-person interviews

Representatives from all 10 (representing 15 programs) lead agencies of NORC SSPs in New Jersey

NORC SSPs facilitated social capital by forming relationships between staff and residents, creating partnerships with professionals in the community, and facilitating relationships among residents.

Greenfield, Scharlach, Lehning, Davitt, & Graham (2013)

Organizational characteristics of NORC SSPs and Villages

Standardized self- administered survey and unstructured follow-up telephone interviews

Organizational leaders from 62 NORC programs and 69 Villages in operation in 2012

Village members were more likely to be younger, less functionally impaired, more economically secure, and live in communities with higher socioeconomic status. NORC SSPs offered more traditional health and social services, have more paid staff, and receive more government funding.

Osterkamp & Chapin (1995)

Adequacy and effectiveness of volunteer home repair and maintenance programs

Semistructured telephone interviews

Program coordinators or administrators from 80 programs using volunteers in home repair programs

Ongoing handyman services were effective in affecting health and well-being of older adults, but also most difficult to provide and coordinate. Emergency repairs were often difficult for volunteer services to provide due to cost and skill level needed.

Scharlach, Graham, & Lehning (2012)

Organizational characteristics of Villages

Self-administered surveys including standardized and unstructured questions

Representatives from 30 Villages in operation in 2010

Villages differed from other service models that promote AIP by (a) combining formal services with peer support and consumer engagement, (b) members being the main source of financial and human resources, and (c) maintaining autonomous control of the organization.

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social capital) or community-based interventions (for example, NORC SSPs) and outcomes that may in turn facilitate AIP, such as less stress (for example, Gonyea & Burnes, 2013). Others sought to clarify interventions or organizational charac- teristics, which is presented as a necessary first step toward more rigorous evaluations (for example, Greenfield et al., 2013).

DISCUSSION The findings from this scoping review of social work’s contributions to the empirical literature on AIP indicate that social work scholars are engaged in research that enhances our understanding of this topic, while pointing to critical areas for future research. Furthermore, many of the challenges to conducting rigorous research on AIP that have been observed in other disciplines (for example, Vasunilashorn et al., 2012) are also evident within the examined social work literature.

In line with social workers’ roles in the provi- sion of supports and services to promote AIP, many of the articles focused on settings for geron- tological social work practice, including congregate housing alternatives to nursing homes, grassroots or volunteer-run organizations, and agency-based pro- grams. In addition, several articles explored older adults’ perspectives on AIP, including those experienc- ing declines in capacity. The information gathered through these qualitative inquiries suggests the need for empowerment-oriented interventions that take into account elders’ preferences around AIP and relo- cation. Many of the articles provide a foundation for future research that has the potential to inform AIP policies and programs. The articles focused on NORC SSPs and Villages illustrate how this is a necessary first step—because these are relatively new models that have received limited attention by researchers, little is known about their inter- vention strategies or the ways they may differ from other service models that promote AIP. Greenfield (2014), for example, used data collected from organizational leaders to identify potential path- ways through which NORC programs’ enhance- ment of social relationships can improve access to community services and supports, which ultimately will promote AIP. The next step would be to empiri- cally test these relationships, and future studies should build on the work of the articles in our review. As one example, preliminary findings from evaluations of a single program that use a convenience sample

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and focus on a specific geographic region could inform research drawing from more representative samples and using more rigorous designs.

One important gap identified from this review relates to social work scholarship’s capability to advance our understanding of some of the poten- tial negative consequences of AIP for older adults, their families, and their communities. Among these 22 articles, only Soderberg and colleagues (2013) ad- dressed this topic in depth, and their findings that older adults living in Sweden may experience guilt and negative self-perceptions if they are unable to age in place should continue to be explored with other cohorts and cultures. The broader literature on AIP has noted that segments of the older adult population may be at a higher risk for detrimental outcomes if they age in place, including loneli- ness, social isolation, restricted mobility, and lim- ited access to supports and services (Phillipson, 2007; Sixsmith & Sixsmith, 2008). Although the over- whelming majority of older adults report that they want to age in place as long as possible (Feldman et al., 2004), a significant minority, such as those who are Latino or African American or have low incomes, may be stuck in place because they lack the resources to change their living situation (Torres- Gil & Hofland, 2012). Furthermore, questions have been raised regarding the proposition that AIP with community-based supports is a less-expensive alter- native to moving into a long-term care institution (Golant, 2008). However, none of the studies in this review analyzed the costs of AIP. Social work schol- ars have the opportunity to conduct research that questions the assumption that AIP is an optimal out- come for everyone, while also ensuring that policies and programs take into consideration older adults’ self-determination and do not perpetuate or exacer- bate existing inequities.

The prevailing assumption that AIP is a positive outcome, and what Golant (2008) referred to as “irrational exuberance” for the concept, may in part stem from the methodological barriers to con- ducting rigorous research in this area. Similar to a previously published review of articles on AIP in the gerontology literature (Vasunilashorn et al., 2012), the majority of the articles in our scoping review did not directly examine AIP. In part this reflects the difficulty of operationalizing AIP in a way that reflects staying in the home or commu- nity. Much of the prior work that could be relevant to understanding AIP examines living situations that

are too broad (for example, avoiding nursing home placement [Bharucha, Pandav, Shen, Dodge, & Ganguli, 2004; Gaugler, Duval, Anderson, & Kane, 2007]) or too narrow (for example, remaining in the same home from earlier in life [Sixsmith & Sixsmith, 2008]). For example, does AIP also encompass when an older adult relocates within the same community, such as downsizing from a single-family home to an apartment? What about when an older adult chooses to move in with other family members? To what extent should AIP reflect elders’ self-determination?

Due to a combination of this conceptual confu- sion, the underlying assumption that AIP is often an optimal outcome, and the challenges to con- ducting rigorous studies on this topic, the existing empirical literature on AIP is more descriptive than analytic. To improve the state of the science on AIP, there is a need for a more consistent defini- tion and operationalization of AIP as well as greater attention to potential inequities in AIP among vul- nerable groups. Further research is needed that uses rigorous quantitative and qualitative methodolo- gies, with clear implications for policy and practice. For example, for quantitative approaches using either primary or secondary data collection, addi- tional research is needed using prospective, longitu- dinal data on representative samples. Furthermore, given the wide range of individual and environmen- tal characteristics integral to understanding the expe- rience of AIP, more studies are needed that collect and analyze data on both older adults and their com- munities. As a final example, research on interven- tions and organizational practices often occurs too late in the process to fully capture individual, organi- zation, and community change. Future social work research should address these limitations.

To our knowledge this review is the first to examine the social work scholarship on AIP in a systematic way, but we acknowledge several lim- itations of our approach. First, we limited our search to peer-reviewed articles, thereby excluding chapters, reports, and other publications that have been coauthored by social workers. Our search strategy likely excluded articles that address the concept of AIP without using the specific termi- nology specified in our search criteria. By restrict- ing our review to social work scholarship, we are unable to compare the contributions of social work with those of other disciplines and fields. Finally, reflecting the state of the literature, the

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studies we reviewed included a variety of research designs, measures, and analytic approaches; there- fore, we were unable to conduct a formal meta- analysis.

Nevertheless, our review critically analyzes the social work scholarship on AIP to date and identi- fies directions for future work, such as conducting more rigorous studies that build on and move beyond descriptive findings, bringing a more criti- cal perspective to the underlying assumptions of AIP, and collecting and analyzing primary and sec- ondary data sources that address the complex inter- play of individual and contextual factors over time. Social work practitioners play a critical role in the development, implementation, and evaluation of AIP policies and programs; therefore, social work scholars should also play a key role in advancing our understanding of AIP. SWR

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Amanda J. Lehning, PhD, is assistant professor, School of Social Work, University of Maryland, 525 West Redwood Street, Baltimore, MD 21201; e-mail: [email protected]. Emily Joy Nicklett, PhD, MSW, is associate professor, School of Social Work, University of Michigan, Ann Arbor. Joan Davitt, PhD, is associate professor, School of Social Work, University of Maryland, Baltimore. Hilary Wiseman, MSW, MPH, is emergency department social worker, Veterans Health Administration, University of Maryland Medical Center, Baltimore.

Original manuscript received May 31, 2016 Final revision received October 28, 2016 Editorial decision November 7, 2016 Accepted August 21, 2017 Advance Access Publication October 31, 2017

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