The photos in the brochures and on Web sites are all different yet somehow similar: A group or a pair of elegantly dressed older men and women sit or stand against a backdrop of flowers or greenery, their graying hair carefully coiffed, their faces clear-eyed and smiling, their teeth white and perfect. These are portrayals of the world of retirement homes or, as many prefer to call themselves, senior citizens' residences, in which - at least according to the pictures - happy seniors live out their autumn years playing bridge or billiards, strolling through gardens and sipping coffee in the company of vivacious friends.
Although old-age homes have always existed in Israel for those who cannot care of themselves, it is only in recent years that the American idea of retiring to a comfortable community of seniors has taken off here. Over the past 20 years, retirement homes have sprung up all over Israel, and each seems to be trying to outdo the next in the level of luxury, services and amenities on offer.
"There are now more people over 65 in Israel than there are under 25," says David Ditch, CEO of the Ad 120 chain. "The population is getting older, but physically they're still young because medicine has advanced so much. The standard of living has gone up, and the elderly population has a lot of free time and is looking for ways to fill it."
Official government figures bear this out. According to the Central Bureau of Statistics, there were 670,000 people aged 65 or over in Israel in 2003, comprising almost 10% of the population. This proportion was more than double the 4.8% in 1955 and is expected to reach 12.7%, or 1.2 million people, by 2025. Life expectancy in Israel has risen to 77.5 for men and 81.5 for women, more than five years higher than it was in 1980.
But with increasingly long lives come other challenges. Fully 25% of Israel's elderly live alone; and while their health may be good, loneliness and boredom can eat away at their days. Retirement homes promise a range of social and cultural activities in a supervised setting. But before rushing out to book a place for Grandma, there are some factors to take into consideration.
"When someone comes to us and says they want to put Dad in a home, the first question we ask is 'Why?' and the first thing we do is meet the person to see what they want," says David Danhai, who set up and runs Yad Lakashish, a free advisory service for the elderly. "If the children say Dad is lonely, we look at why he's lonely. He may already live in an apartment but shut himself off from his neighbors because that's his personality. A closed-off person will be just as closed off living in a home. Or he may be lonely because he doesn't know where to go to find activities and meet people his own age. We show such people how to use the resources they already have in their area, such as the local day center for the elderly, golden-age club or public gardens. It is no small matter for an elderly person to move out of the home where he has lived for most of his life. It's traumatic and drastic, and a step that shouldn't be taken lightly."
There are two types of retirement housing in Israel, and the differences between them are significant. First are old-age homes (batei avot), which are licensed and supervised by the Ministry of Social Affairs. While many people think these are only for the feeble and bed-ridden, in fact many of them are designed for the independent senior who wants to be taken care of. Ministry conditions dictate that these homes must provide three meals a day (and two snacks) in a dining room, have a certain ratio of staff to residents, clean residents' rooms daily, keep strict hygiene in the home's laundry, among other stipulations. An old-age home may have a greater or lesser range of activities for residents, and medical supervision is ever-present. Residents generally live in one- or two-room apartments, which may have an electric kettle but no cooking or laundry facilities. All apartments have emergency call buttons, and staff check in on residents if they do not show up for a meal. Residents pay an entry fee of NIS 130,000 to NIS 220,000, as well as monthly maintenance fees of NIS 5,000 to NIS 7,500. This entry fee depreciates to nothing within three to five years. The Ministry's Web site (www.molsa.gov.il) lists some 190 licensed old-age homes across Israel.
The second type of retirement housing is sheltered housing (diur mugan). This category is unlicensed and unregulated, but that does not mean it falls short. On the contrary, it is into this category that luxurious retirement residences such as Ad 120 fall. And it is this category that has grown so dramatically over the past two decades. Sheltered housing buildings are essentially private apartment buildings for seniors with some - or a lot of - extras. Residents live in one-, two- or three-room apartments which, unlike old-age homes, have a kitchenette and cooking facilities and in some cases space for a washing machine. Apartments are cleaned weekly and have emergency call buttons, but daily check-ups on residents are not necessarily made. Sheltered housing buildings usually have swimming pools, gymnasiums, game rooms and libraries and offer a wide variety of activities, including arts & crafts, exercise classes, concerts and lectures. In some homes, lunch in the dining room is included; in others it is extra. Some add coffee and cake in the afternoon. Residents pay a deposit of NIS 530,000 to NIS 1.8 million for their apartments, as well as a monthly maintenance fee that can range from NIS 3,000 to NIS 5,000. The deposit depreciates by 2% to 4% annually for 10 to 12 years, and what is left is given to the residents' heirs.
Each sheltered housing or old-age facility has a separately run Ministry of Health licensed nursing division for residents who need chronic care.
It is hard not to be impressed by Ad 120 in Hod Hasharon - especially by the seven-story glass-roofed lobby with greenery hanging from the balconies. Thoughtful design touches and careful finishes are everywhere, from the paintings and statues crafted by residents in all the public areas to the carpeting in the corridors - and the apartments themselves.
Few residents are generally seen in the public areas, and this is a source of pride for the staff who say, "All the residents are busy - they're all at activities or have gone shopping (at the adjoining Margalit Hasharon mall). No one sits around here with nothing to do."
Says Ditch, "The whole concept of private senior citizens' residences came from the US about 20 years ago. "Private entrepreneurs here started two or three companies. In the beginning it was very difficult because nobody knew what it was and what the customers wanted, or even who the customers were. We started 15 years ago and were one of the first. We had to make a market for the product, which took a few years. Today, it's thriving."
The Hod Hasharon complex, which opened six years ago, was the company's second home. It is constructing a third, even more luxurious, building in Ramat Hahayal, north of Tel Aviv. Ditch says they plan to build or to buy and renovate three more buildings within the next five years.
Ditch says Ad 120 is unique in several ways: It chooses sites for their proximity to shopping and entertainment centers rather than building on cheaper land far from activity centers; it is the only company with an assisted living division for those who need help if their health deteriorates but are not chronic nursing patients; and it is the only home that has an in-house doctor 24 hours a day.
"We have a very good name and we offer a very high standard of service. Private companies like us cannot afford not to give good service," he says.
In Herzliya, another sheltered housing building stands out. Beth Protea was set up by former South Africans in 1992 and is Israel's only English-speaking retirement home. Most residents are originally South Africans, but there are also some British and Americans.
"Ours is a real family home, small and intimate," says director Lynn Lochoff, a former social worker who has run Beth Protea for three years. "We pride ourselves on being a home away from home. The idea is that people can live out their advanced years in dignity. You don't feel that you are in a facility for the aged."
Walking around Beth Protea, one sees many residents people in the public areas. Some are chatting in the lobby; others are in the library, taking advantage of large-print English books. An arts class is full. Artwork and statues created by residents are everywhere, and coffee and cake is served in the afternoon. And here, lunch is included in the fees. Lochoff points out that the staff checks on residents if they do not come to the dining room for lunch. Strikingly, prominently placed in the library is a yizkor book with a page devoted to each person who has passed away.
"Residents like to look at this book," says Lochoff. "They remember their friends and they know that they too will be remembered in this way."
The home is adding an assisted living division, slated for completion in October. Another feature is Beth Protea's outreach service, Beth Protea Plus, which opened this year and provides a free advisory service to the elderly on any issue. [(09) 9595228].
"We were getting so many calls from South Africans, Americans, even Israelis, about all sorts of issues to do with the elderly that we decided to devote a full-time social worker to help people with their inquiries," says Lochoff.
In a quiet, green corner of Kfar Saba, Hamavri is an old-age home that has been in operation for 33 years. It is similar to Beth Protea in the standard of furnishings, but its status as a licensed old-age home means its emphasis is somewhat different. Director Riva Shtreifler has some harsh words to say about the sheltered housing concept. "We take care of every one of our residents," says Shtreifler, a qualified nurse who has run Hamavri for 15 years. "We check on residents if they don't come to the dining room for a meal, and we pay attention to what each one eats. We certainly don't force anyone to eat, but we keep a careful watch on their intake. In sheltered housing, nobody knows whether a resident has eaten or not. Elderly people often can't be bothered buying food or cooking, or they forget to eat or don't feel well enough to eat. Our residents put on an average of five to 15 kg in their first year here because in their own homes they were starving themselves," she says.
"Also, our residents who need regular medication are given it by a nurse. They can't forget to take their medicine or take too much of it by accident, as can happen at home or in sheltered housing. An old-age home pays attention to small details. By law we have to clean the rooms daily, so the cleaners come to know the residents well and look out for details that can indicate a problem. For example, a cleaner may notice that the shower hasn't been used for a few days, and tells us. People can become fearful of falling in the shower as they get older, so they stop washing themselves. We can arrange for someone to be there so the resident can wash in peace. In sheltered housing, nobody knows if a resident hasn't washed for days, and nobody is there to supervise them in the shower."
Shtreifler is also disparaging of sheltered housing's emphasis on activities. Hamavri does offer some activities, such as Yiddish and English classes, music and crafts, but the range is clearly less than in sheltered housing, and there is no swimming pool. Many more people sit in the lobby, some sipping tea or coffee, others reading newspapers or doing crosswords, others simply lost in thought.
"Elderly people don't always want to be doing so many things," says Shtreifler. "Sometimes they just want to sit and think. They don't necessarily want to be rushing around all the time feeling they must do something."
Official figures back her up. According to the Central Bureau of Statistics, some 91% of elderly people took prescription medications and 25% were hospitalized in the year before the survey. And 13%, or about 90,000 people, needed assistance with daily activities such as getting out of bed, dressing or washing.
Danhai, who has been running the Yad Lakashish free advisory service for the past five years and recently set up its Web site (www.yad-lakashish.co.il) chooses his words carefully.
"I would say that sheltered housing suits the 'young elderly.' That is, people who are under 75 or 80, in good health, who are looking for things to do, probably after losing their spouse. They want to move away from their old home and all the memories, and make a fresh start in a nice place. In such cases, sheltered housing could be good. But the sad truth is that most people don't stay healthy forever, and if their health starts to deteriorate and they start to need some help with things like washing or dressing, there is no one who can look after them in sheltered housing until they become so frail that they have to go into the nursing unit. Many sheltered housing facilities don't allow Filipino carergivers, or if they do, the carergivers are not allowed in the public areas and must stay in the resident's room. This is terrible, both for the Filipino and for the elderly person. Old-age homes are more care-oriented and have different divisions for people who require different levels of care."
Danhai points out that elderly people living at home can take caregivers in at will, and financial help for this is available from the government for those who need it. "My position is first and foremost to investigate all the options an elderly person has at home," he says. "Then, if staying at home is not an option, then we can think about what is the best option. People often think that if they pay more they will get more. But that's not always the case."
Three options, at a glance
Ad 120, Hod Hasharon
Category: Sheltered housing. Private company.
Set-up for independent residents: 240 apartments, mostly of two rooms.
Cost: $250,000 to $280,000 for average two-room apartment, plus monthly maintenance fee of $1,000 to $1,200.
Apartments contain: Emergency call system, central heating and air-conditioning, kitchenette, fixtures for washing machine and cable TV.
Services included in price: 24-hour security, medical supervision and central medical clinic with onsite doctor and nurse 24 hours, weekly cleaning of apartment, hot water, electricity, internal telephone, daily activities, swimming pool, gymnasium, games room, afternoon coffee and cake in lounge.
Extras for a fee: Lunch in dining room, external phone line, laundry service, excursions, onsite hairdresser, cosmetician and physiotherapist.
Other facilities: Assisted living unit for those who temporarily need help, with 20-25 beds.
Nursing division: 30-35 beds.
Beth Protea, Herzliya
Category: Sheltered housing. Nonprofit organization.
Set-up for independent residents: 105 apartments, mostly of two rooms.
Cost: NIS 700,000 for two-room apartment, plus monthly maintenance fee of NIS 6,300; NIS 1.2 million for three-room apartment, plus monthly maintenance fee of up to NIS 13,000.
Apartments contain: Emergency call system, central heating and air-conditioning, kitchenette, fixtures for cable TV.
Services included: Medical supervision with onsite nurse 24 hours and doctor on call, lunch in dining room, afternoon coffee & cake, weekly house cleaning, hot water, electricity, internal phone, daily activities, swimming pool, gymnasium, English library.
Extras for a fee: external phone line, laundry service, onsite hairdresser, cosmetician and physiotherapist.
Other facilities: Assisted living unit (to be completed in October) - 20 beds.
Nursing unit: 36 beds.
Hamavri, Kfar Saba
Category: Beit avot.
Set-up for independent residents: 120 units, mostly one-room studio apartments.
Cost: NIS 169,000 entry fee for one-room apartments, NIS 320,000 entry fee for two-room apartments, plus monthly maintenance fee of NIS 7,500.
Apartments contain: Emergency call system, central heating and air-conditioning, fixtures for cable TV, electric kettle.
Services included: Active medical supervision and care including daily allocation of prescription medicines, onsite nurses and doctor by day, doctor on call by night, three meals per day plus two snacks, daily room cleaning, weekly changes of bedding and towels or more often if required, laundry service, daily activities.
Additional facilities: 'Slightly feeble' division for those who temporarily need some help (after surgery, for example) - 32 beds; 'severely feeble' division for those who require more help - 32 beds; two chronic nursing units with 36 beds each - total 72 beds.
These three retirement homes do not represent a cross-section of options.