Intergenerational Housing: The Case of Humanitas Netherlands

Abstract

We analyze a case study of an innovative intergenerational housing arrangement in the Netherlands as an example of how a local long-term elderly care practice evolved in response to contemporary challenges. Identified elements of the established local practice relate to the characteristics and strategies of an institutional entrepreneur and elements of the new practice that comes into being, in which reciprocity and mutual learning have a central place. These elements might benefit future elderly housing initiatives as well.

Keywords:

• Intergenerational living
• social innovation
• system perspective
• institutional entrepreneur

Introduction

Due to changing circumstances in, among other things, demography and demands and perspectives on “good” health care, changes in health systems are inevitable for health care services to remain acceptable, accessible, affordable, of high quality, and trustworthy (e.g., Broerse & Bunders, 2010), including those in the field of elderly housing and care. Although this need for change is broadly recognized and accepted, the majority of initiatives, while different in dynamics, structures, and contexts, have not been successful in realizing their desired gains (Simmons, Fajans, & Ghiron, 2007; Stambolovic, 2003). In this article, we present a case study of an innovative intergenerational housing arrangement in the Netherlands, called Humanitas, as an example of how a local long-term elderly care practice evolved in response to contemporary challenges. Via observations, interviews, and inspection of artifacts, we analyze and reflect on this local practice. We especially zoom in on its transition of a predictable and controlled environment toward an intergenerational living environment that is lively and joyful with an unconventional approach that received both national and international attention (e.g., AFP, 2014; Turner, 2016). We identify elements that make this practice work and aim to give more insight in the role of both actors and their (systemic) environment in realizing the transition made. That way, we strive to inform further research, and the design, implementation, and management of approaches to health care reform, and elderly housing initiatives in particular.

Background

A growing body of literature is dealing with the analysis of transitions of sociotechnical systems and the system innovations these require (e.g., Geels & Schot, 2007; Raven, 2007). This literature provides relevant insights, understandings, and strategies for more effectively realizing health system reforms (Broerse & Bunders, 2010). At the same time, the importance of agency, that is, the critical role of actors in transforming a system, is also increasingly recognized in literature that focuses on actors that maintain, create, and disrupt institutions (de Savigny & Taghreed, 2009; Zietsma & Lawrence, 2010). Here the notion of institutional entrepreneurship has a central place, which refers to those actors or agents who initiate changes that contribute to transforming existing or to creating new institutions (e.g., Battilana, Leca, & Boxenbaum, 2009). In this article, we bring to bear approaches from this literature, most of which emerged in domains not related to health or elderly care, on our understanding of health system reforms. More specifically, we found the institutional entrepreneurship literature useful because it zooms in on actors, that is, institutional entrepreneurs, and their agency as being embedded in an institutional environment (Battilana, Leca, & Boxenbaum [2009] refer to this as the “paradox of embedded agency”). Indeed, we found much of what seems relevant to change in the Humanitas case to resonate with the description of institutional entrepreneurship, that is, an institutional entrepreneur who has carefully maneuvered her environment to produce change that would break away from the existing institutional order (we return to this point in more detail in the following).¹

We present the case as a historical case study that, hopefully, provides inspiration for pondering elements that may or may not explain the enabling factors for health system reforms at larger scale. That is, we use a single-case study to enable informed suppositions about the elements explaining its (apparent) success that can be exposed to more systematic research in the future.

Methodology

To gain in-depth insight into the elements that have been relevant for the transition of Humanitas toward an intergenerational living environment, we made several on-site visits and conducted interviews with the director, with two members of the works council, with three of the managers, with one employee whose assignment is the “normal life” within Humanitas, and with one of the resident students (n = 8). In addition, one of the authors (RK) visited Humanitas six times in the past 2 years. Each visit took 2 to 6 hours, and consisted of observations and walking interviews with staff—including the director—and people living and volunteering in Humanitas. Notes were taken of all interviews, meetings, and observations, and preliminary analysis of identified elements and strategies contributing to the new practice of Humanitas was discussed with the director, managers, and/or the employee of “normal life” and adjusted subsequently. In addition, news articles, policy documents referring to Humanitas, and external communications were analyzed to identify elements relevant for the transition toward an intergenerational living environment.

To have a specific analytical focus on the critical role of actors in transitions, we used the theoretical framework of Battilana et al. (2009), in particular the two categories of interrelated enabling conditions for the emergence of institutional entrepreneurship: field and actor characteristics. According to Battilana and colleagues, relevant field characteristics are jolts and crises; acute field-level problems that might precipitate crises; problems related to scarcity of resources; and the degree of heterogeneity and institutionalization. Social position and individual actor characteristics such as demographic and psychological factors are considered relevant actor characteristics. Analyzing the presence of these enabling conditions in the Humanitas case provided understanding of the transition Humanitas made so the relevant elements contributing to the realization of the new local practice could be identified. In addition, we also analyzed activities undertaken in support of the implementation of the changes. Building on management literature of change, Battilana and colleagues summarize three sets of activities relevant in implementing change that we applied in analyzing the Humanitas case. These activities relate to (a) developing a vision, (b) mobilizing people behind that vision, and (c) motivating others to achieve and sustain the vision.

Results

The remainder of this article is structured as follows: We start with describing the relevant field and actor characteristics in the Humanitas case. Then we elaborate on the actual (tactical and operational) process of implementing changes and on the new practice that emerged, including its new institutional logics. Finally, we describe the relevant elements we identified from this case in realizing an innovative intergenerational living environment.

Field characteristics

The trends of an aging population, increasing numbers of chronically ill elderly people, a required increase of labor force to fulfill all future care tasks, and less financial means for health and care services influenced the stability of, among other things, the regime of long-term care. When the Dutch government decided in 2012 to stop funding care costs for citizens over the age of 80 without an urgent care need (Bijvank, 2016), the elderly care sector faced a situation in which fewer people applied for a place in retirement homes, resulting in less financial means and empty rooms. In other words, trends at the macro level caused crises and problems related to scarcity of resources at the meso level. The government’s’ decision to stop funding led to acute field-level problems of how to stay in business. Combined, these trends resulted in an environment in which changes in long-term health care delivery for elderly people were needed in order for such care delivery to survive.

In addition, two other relevant dynamics were present at the level of regimes that fueled the transition of the Humanitas home for the elderly. First, managerial developments in the professional care environment over the past decades led to a situation such that people living in elderly care facilities were taken care of in a more or less “mechanistic” approach (e.g., Bone, 2002; Pfaff et al., 2010). Frequently, people became “objectified” and (merely) received minimal, efficient, and cost-effective assistance in daily life. Most of them had limited interaction with the world outside the care facility. As a result, many people living in long-term care facilities were lonely, isolated, focused on their limitations, and unhappy, which is associated with increased mortality (Steptoe, Shankar, Demakakos, & Wardle, 2013). At the same time, student housing in the Netherlands was and still is expensive, cramped, and limited, and many students had troubles finding a room.

Actor characteristics

Humanitas faced these trends and challenges when its new director started in 2012. The director saw these field-level conditions as opportunities to change the current way of health care delivery. In other words, the limitations and negative side effects of current dynamics of the sociotechnical system around Humanitas, combined with trends at the macro level, resulted in an environment in which the director felt a need to and could start acting. Driven by the belief that elderly care homes could be organized in a different, more personal, and “better” way, it was her passion and firm conviction to realize this change. She acted from a holistic perspective, being convinced that the current mechanistic approach in health care in which care was provided to people in order for them to stay alive could be changed toward an approach in which assistance and care were provided for people with a focus on individuals: their needs, desires, demands, and, specifically, their abilities and happiness. She was also aware of the student housing problem and envisioned a profitable situation for both groups. As she aimed for a warm and comfortable home (not a house), having young people living inside Humanitas could make this happen, according to her. At the same time, students would have to borrow less money because they could rent a room for free at Humanitas in exchange for being a “good neighbor.”

Process of implementing divergent changes

The process of implementing the envisioned changes resulted in several challenges. First, the director needed to convince the board that her vision was going to result in a “better” Humanitas, both socially and financially. After several meetings, the board agreed to a pilot project in which one student would live in Humanitas for 1 month. The director shared her vision with an interested student and explained that, besides being a “good neighbor,” no other rules applied. Apart from organizing one evening meal a week, he was mainly expected to spend time with the residents. Nobody was keeping track of time: The relationship with the student was based on trust.

Second, having a student living in an elderly home was new for everyone, both staff and residents, and resulted in unpredictable and new situations: for example, the smell of alcohol in the elevator late at night when the student came back home, or the alarm that went off when one of the girls he brought back to his apartment was searching for a toilet. Initially, these new situations resulted in complaints, primarily from worried staff members. However, the director stuck to her vision and decided that as long as the residents did not experience strong negative consequences of these actions, the student could stay. Again, her vision was not to manage a sterile, controlled house without risks and romances, but to enable a home environment where real people live real lives. And, as one of the staff members explained, “a certain degree of friction is what makes life lively.”

Third, starting the new intergenerational way of living resulted in the articulation of many opinions and questions from others, including board and family members. The main questions related to the balance between happiness and safety. Board and family members argued from a risk avoidance perspective that, for example, racing on mobility scooters as competition between students and residents was not safe. After all, residents could fall and break something, or worse. In response to these questions, the director articulated from her vision that residents are experienced adults, able to make their own decisions. If they decided to take a risk, it would be their own decision. Why should she, or other staff members, protect people from joy?

New practice: lively, joyful, inclusive living environment

Currently, the intergenerational living environment of Humanitas consists of six students and 160 elderly residents. It is a place where people love to come and live. Although, for example, the living of a student in Humanitas first seemed to result in new situations with undesirable consequences, such as alarms that went off late at night, a situation arose in which Humanitas’s residents love to keep track of which student is bringing someone back to the home. Instead of having no new conversation subjects except different medications and doctors’ appointments, the love lives of the students are the subject of the day and reconnect the residents with their own romantic selves and remembering their own youth, including pick-up lines. The students share their experiences when coming home from class, a concert, or a party and form a connection to the outside world for the elderly residents. They also help residents with their computers, tablets, and telephones, which, for example, resulted in online connections between residents and students via Facebook and Instagram, and other digital connections of residents with family and friends. Together the residents and students play games, both traditional Dutch games and college drinking games, go to the shopping mall, go to restaurants, and so on. But also nonresidents are welcome at Humanitas. A group of children with autism, for example, has built a train set in the basement, which is regularly visited by them, a local photographer uses the digital screens in the home to exhibit recent work, there is billiards club, and the garden is open for everyone. In other words, Humanitas is part of, and perhaps a central place in, the community.

The appreciation of all efforts made and changes realized by staff members, residents, students, volunteers, or others is central to the vision that drives Humanitas’s living environment. All ideas proposed are answered with “yes.” This “yes-culture” (Van Marrewijk & Becker, 2004) is a central element in all Humanitas organizations and stimulates all those involved to articulate their ideas and solutions and to undertake a variety of activities, and ensures that all ideas are considered. Furthermore, there is, for example, a program developed for Humanitas staff in which employees can choose how they further want to develop themselves. This program is based on the intake procedure that is also used for future residents and has three central questions: Who were you, who are you now, and who do you want to be? Also, gift vouchers are frequently provided to show appreciation for the efforts made. In addition, knowledge or expertise that is not (yet) present within the organization but considered of added value to realize a proposed idea, for example, is acknowledged and acquired via external resources, in terms of training of current staff or employing people.

Currently, there are no intentions to increase the number of student inhabitants, but the director took her dream one step further. She strives to turn her intergenerational home into an (even more) inclusive home. Therefore she recently introduced the “Adelbold project.” In the direct environment of the Humanitas home, a neighborhood called Adelbold, several people live who are in need of some sort of social or practical support and/or assistance in daily life, that is, people with a disability, a chronic illness, and/or other limitations. Many of them are unemployed and have an above-average care demand, resulting in high costs for both local authorities and insurance companies. Actively outreaching, Humanitas welcomes each of them to their facility, providing attention and free structural, temporary, and emergency support. Furthermore, Humanitas emphasizes the value, options, and possibilities of these people, instead of their limitations, disabilities, chronic conditions, and related cure and care needs. As a result, Humanitas is able to provide an environment for these people in which they live as independently as possible and are stimulated to contribute in line with their possibilities. The result is an even more inclusive place, where neighbors love to come and spend time with each other and with the Humanitas residents, and where several assist freely with gardening and technical support for instance. Humanitas’s residents and people participating in the Adelbold project indicate that their quality of life is improved and care costs consequently most likely drop. In sum, Humanitas is profitable and inspires and connects elderly residents, students, people in need of support, and many others, including staff, family, local community members, municipalities, educational facilities, and foreign programs.

Analysis: new practice with new institutional logics

In realizing an inclusive living environment, Humanitas’s institutional logics changed (e.g., Rao, Monin, & Durand, 2003), that is, the underlying values and beliefs that shape the cognition and actions in practice. In Table 1 we summarize this change. Humanitas’s health care delivery changed from care provided to people to care provided for people. With this, the purpose of the health care service is no longer to assist people to avoid risks, survive, and stay alive, but to enable people to live a life that matches their needs, desires, and happiness, based on their abilities. The tasks and responsibilities of staff members are no longer primarily based on standardized procedures and efficient and tight schedules. Realizing health care delivery in Humanitas has become a shared effort and responsibility of both staff members and residents. Besides the professional qualities of staff members, their interpersonal qualities and mutual learning have a central place in realizing such bespoke care. In other words, the elderly home made a transition from a predictable and controlled environment in which elderly people were objectified and received minimal, cost-effective, and efficient assistance in daily life to a surprising and anticipating intergenerational, enabling environment in which elderly people live; they do the things they can and enjoy doing and receive assistance accordingly. Furthermore, these experienced adults themselves contribute to their environment, and assist and inspire staff, students, and neighbors with their stories and experiences, and by slowing them down. In sum, reciprocity is key in Humanitas. It is no longer a house with facilities and services in which elderly people are permanent guests and conversations focus on losses and doctors’ appointments, but a home in which elderly people and students are the residents and staff and visitors are guests and conversations focus on the everyday things of life of the residents. Moreover, it is not only an environment in which elderly people live, but a central place in the community where elderly people, students, and others in need of support live together and the broader community enjoys spending time as well. As a result, the quality of life and health care has a different dimension: It is experienced and not “just” measured.

Table 1. Humanitas’s institutional logics before and after the transition toward an inclusive living environment.

Dimension/element/principles	Before transition	After transition
Guiding principles health care service	Elderly care’s raison d'être is to take care of an increasing group that is becoming older and, because of this, increasingly fragile and vulnerable and who should be protected from further decline; care is provided to people.	Elderly care’s raison d'être is to celebrate life, and to enable individuals to express and collaboratively make use of their unique qualities—reciprocity is key; care is provided for people.
	Focus on safety and risk avoidance	Focus on autonomy and happiness
Purpose health care service	Generic assistance to deal with age-related decline in functionality and limitations, and coping with decline	Tailored assistance to enable an individual’s options, qualities, interests, and possibilities, and combinations with other residents, staff, and visitors
Living and working environment	Predictable and controlled environment in which people receive assistance in daily life	Surprising, anticipating, and enabling environment in which people “really live,” i.e., do the things they can do and that they enjoy doing and receive tailored assistance accordingly
	House with facilities and services—residents are treated as permanent guests or clients	Home—staff and visitors see themselves as guests
	Conversational topics mainly revolve around family visits, loss of friends, loss of functionalities, and doctors’ appointments	Conversational topics include the lightness that youth can bring, about their study, their holidays, and their romances, and bring back memories of residents’ own youth and romances
	Quality is measured	Quality is experienced
	Detached from outside world	Central place in the community
Role of staff members	Each staff member has his or her own tasks and responsibilities based on his or her job profile, i.e., standardized procedures, efficient, tight schedules to realize health care service.	Shared efforts and responsibility of staff members and residents to realize health care service. This demands interpersonal qualities of individual staff members, besides professional qualities. Mutual learning has a central place.
	Focus on what a (future) resident can and can no longer do	Focus on who a (future) resident was, who she or he is and wants to be
	Workflow organized around target/client/patient groups	One cannot love a patient group, but one can love a person. This is the starting point for group processes and organizing the workflow.

Elements contributing to the realization of Humanitas’s intergenerational living environment

Based on the analysis just described, a number of elements can be identified that were important in realizing Humanitas’s transition. Although the elements described in the following are interrelated and can therefore not be viewed separately, for analytical purposes it is useful to elaborate upon them separately.

First, field characteristics were present that resulted in a window of opportunity to initialize and implement changes. Here the relevant element is the development of an innovation that addresses the experienced problems at all levels of relevant field conditions, that is, at both macro level and meso level. In the Humanitas case this implied that the intergenerational living concept addressed both the undesirable “mechanistic” approach in which elderly people are “objectified” and receive minimal, efficient, and cost-effective assistance in daily life, and the problem of less financial means and available staff to provide care for elderly people seeking for long-term care facilities in an aging society.

Second is the enabling role of actors. In this case, the director of Humanitas can be identified as an institutional entrepreneur. First, she had a personal belief and conviction that (health) care could be organized and provided in a different way—away from monocultural total institutions, toward mixed and personalized homes. That is, she was interested in divergent change, knowingly or unknowingly, that would break with the existing institutional logic. In addition, she was willing and able to realize and initialize the changes needed. With “willing” we refer to an intrinsic motivation to realize a “better” practice. “Able” refers to the social position an actor has (see also Battilana, 2006), including the access to relevant resources. In other words, the director of Humanitas had the personal characteristics and social position to start acting on the opportunities that the field-level conditions posed. Subsequently, she developed a vision that motivated and mobilized people and resources to make her vision a reality. The Humanitas case shows that a vision that guides actions in practice is crucial. Our analysis shows that the new director of Humanitas was able to mobilize and motivate people based on a (guiding) vision. Although she initially developed the vision herself, she disseminated the vision so that it became a shared one that motivates and guides the people working and living in Humanitas to realize, sustain, and optimize the established living environment. In other words, the vision makes the underlying reasons for change clear and provides a road map how to act accordingly. Another identified element is persistence: the ability to keep acting in line with the guiding vision, including the continuous stimulation of others to sustain the vision and acquiring knowledge and expertise that are not present but of added value in implementing changes. As the Humanitas case shows, innovations create new problems as well. Anticipating new, often unforeseen, situations requires the ability to let go, including acceptance of the risk of failure. By letting the new situation take its course, new cultures, structures, and practice have time and space to develop. This includes the acceptance that things might fail. The director of Humanitas showed she was able to take distance and embraced what came into being. A final identified factor is value and appreciation, visible in the appreciation of all people living in and contributing to Humanitas.

Discussion and conclusions

By analyzing the case of the Humanitas home for the elderly that resulted in a local new practice of inclusive long-term elderly care, we were able to identify factors relevant in the evolution of this practice. In line with previous research in the field of innovation studies (e.g., Geels, 2002), we show that an enabling environment for initializing divergent changes comes into being when trends at field level implicate a need for change of established institutional logics and when the perceived undesirable consequences of these established logics have manifested itself locally. In this case, an actor had the personal belief and conviction that the envisioned innovation would address the problems at both levels, thereby resulting in improvements of the current situation, and was willing and able to implement this innovation. This research shows the importance of the formulation of a vision by the actor who initializes and drives the transition, that is, the institutional entrepreneur. This vision functions as an explanation of the relevance of the intended changes and motivates and mobilizes others to realize the intended transition, including the provision of a common language that guides actions in practice and interactions between different actors (e.g., Grunwald, 2004; Mambrey & Tepper, 2000). Furthermore, we show that an institutional entrepreneur should be persistent, able to not give in, and able to keep acting in line with the vision, including the continuous stimulation of others to act according to the vision, while at the same time having the ability to let go and embrace what comes into being, including the acceptance of potential failure. This specifically applies during the first phases of implementing changes. Unexpected and unforeseen consequences and situations should be embraced instead of diminished or taken care of in order to let a new practice come into being. To realize this, the focus should be to realize reciprocity, responsibility and efforts made should be shared, and actors should continuously be involved in a mutual learning process and adjust their actions and structures accordingly.

We hypothesize that the identified factors relevant to Humanitas’s transition are also applicable, at least to some extent, to other initiatives aiming to establish changes in health care services and practice. Further research is needed to explore whether the informed suppositions about enabling factors for health system reform resulting from this research are relevant to realizing health system reform at a larger scale.

Disclosure statement

The authors report no conflict of interest.

Notes

1 Battilana et al. (2009) define institutional entrepreneurs as actors that initiate and subsequently participate in the implementation of divergent change (pp. 68–69). Institutional entrepreneurs do not necessarily have to be aware that they are engaged in institutional change, and they do not have to be entrepreneurs in the traditional sense (i.e., interested in launching a new venture).