City living and aging well aren’t opposites. But staying independent in a dense urban environment takes a different kind of planning than aging in a suburban ranch house or a rural community. Row houses have stairs. Grocery stores are blocks away. Neighbours are close but often strangers. A real long-term care plan for urban seniors has to account for all of it.

Almost 77 percent of adults age 50 and older want to stay in their homes and communities as long as possible (AARP). That’s not a niche preference. It’s the default wish for most older adults, and cities present a specific set of obstacles standing between that wish and reality. Below are seven pillars that address those obstacles directly, rather than treating urban seniors like they live in the same conditions as everyone else.

Pillar 1: Account for the physical realities of city housing

Urban housing stock wasn’t built with aging bodies in mind. Many row houses in the city comprise three or four stories that are linked through narrow staircases. Prewar buildings containing apartments have restricted doorways, small bathrooms, and tubs that are inaccessible to people with mobility issues. Walk-up apartments without the provision of elevators imply that aged residents are exposed to daily risk.

It is important that necessary home modifications are carried out before a fall occurs rather than waiting for it to happen. Modifications include fitting grab bars in bathrooms, installing stairlifts or ramps in areas where stairs cannot be avoided, and replacing high-sided tubs with walk-in showers. For some buildings, it would be prudent to move the bedroom to the ground floor. Since landlords of older buildings are often unwilling to make changes, it is advisable to provide a written request for modifications in advance and be informed of what is permissible according to local housing regulations. Post-injury, one would be required to make arrangements for the contractor and procure the necessary permits during an emergency as opposed to doing it at one’s own pace.

Pillar 2: Build a financial strategy with multiple layers

Long-term care is expensive no matter where you live, but urban costs tend to be higher. The best financial plan typically combines personal savings, long-term care insurance, and public assistance, rather than counting on one alone. Long-term care insurance must be purchased well before any diagnosis or decline, since health qualifications get stricter and premiums rise with age. For families with no LTCI in place, Medicaid is the default, but that often requires a Medicaid spend-down: systematically shedding countable assets to the program eligibility threshold, without leaving an elder destitute. The spend-down has rules and lookback periods that change by state, so it helps to have an elder law attorney or financial planner who knows the lay of the land close by. Guessing at this part of the plan is one of the most costly mistakes families make.

Pillar 3: Build a coordinated, local care team

A broken care team is your biggest danger for long-term care planning in the city. Your primary care doc, a geriatric specialist, family, and any in-home caregivers should all be working from the same info, not stuck in silos.

Hire someone. Seriously. A geriatric care manager (sometimes called an Aging Life Care Professional) isn’t cheap, but they’re worth it. These certified pros help families with paperwork, set up appointments, and act as a tiebreaker when you’re arguing over next steps. For the nitty-gritty of daily life, many metro families find it easiest to work with a quality Philadelphia home care provider to coordinate in-house support, deal with challenging mobility issues involving stairs and public transit, and just have a consistent friendly face around. Seniors really do thrive better with familiar caregivers.

Family should have defined duties as well. One person does appointments, another handles finances, another does daily check-ins via phone. If you don’t divvy things up that way, things slip through the cracks, and everyone gets exhausted.

Pillar 4: Solve transportation before it becomes a crisis

Driving can become unsafe for older adults long before they’re willing to give up their car keys. But in many cities, older people can more easily make the switch to driving less if they’ve planned for a new mobility network. Paratransit, the door-to-door transport service for people with mobility problems, is offered in some form in nearly every metro area, but the length of its waiting lists and the size of its scheduling windows can vary dramatically. Many nonemergency medical transportation services operate ride-share programs specifically for older adults, tapping volunteer drivers through aging agencies and other non-profits. Others pay for seniors’ rides in taxis or through app-based services. And many elders still feel comfortable relying on traditional public transit as long as it’s properly configured. Elevators and low-floor buses have made it easier for wheelchair users, and system maps can aid in planning escalator-free routes. The trick with any of these options is to test them before the first big required trip, such as a visit to the emergency room or doctor.

Pillar 5: Address social isolation directly, not as an afterthought

Cities are densely peopled, but urban seniors frequently say they feel isolated. A person can live in a 300-unit building and not have a single real conversation in a week. And isolation isn’t just a bad feeling. It’s a known health risk that correlates with cognitive decline, depression, and even death.

This isn’t something you solve with a general “structured social calendar.” You need to get into the weeds. Senior centers are often open daily and offer programs, meals, and fitness. Adult day programs put on activities and send a bus to haul people in, giving a reason to get out and an opportunity to socialize with other attendees. Some volunteer networks (a few of which are actually within NORCs) arrange for regular visitors or helpers for check-ins. NORCs are apartment buildings or neighborhoods that aren’t built for seniors but happen to have a huge number of them, often in cities that have aged in place. If you happen to live in one, solve transportation and you solve isolation as well.

Pillar 6: Get legal protections in place early

Legal paperwork is the task families procrastinate on most; and the one that costs the most when overlooked. Do you have a Durable Power of Attorney (POA)? You can’t access a loved one’s finances or make decisions on his or her behalf without it, even in a crisis. What about a healthcare proxy or living will? Those decisions can get tied up in court or side-tracked while doctors wait for the lawyers if you don’t.

These documents are state-specific, and the requirements aren’t the same from place to place. A document that meets the letter of the law in one state may not be enough in another. That’s important for snowbird seniors, who divide their time between two states, and for seniors who moved and made their documents in one state. Get them signed now, while there’s no question that the senior was of sound mind. It will only get harder later.

Pillar 7: Use technology to close the safety gap

Smart home devices have gotten a lot better at solving specific urban problems: apartment living without a family member nearby, buildings with poor cell reception, seniors who live alone and can’t call for help if they fall.

Personal emergency response systems (PERS) let an elderly person call for help with the push of a button, and many now come with fall detection that triggers the call automatically. Smart home sensors can alert to out-of-the-ordinary patterns, like a door that hasn’t opened by mid-morning, or the stove left on. Medication management apps can send alerts, and notify a caregiver if a dose is skipped. None of this is a substitute for human interaction, but it can give long-distance family members real peace of mind and buy time in situations where minutes matter.

Planning for emergencies unique to city living

Senior citizens living in urban areas face unique emergency situations that are not covered by general emergency planning manuals. For instance, during a power outage, a senior living on the 15th floor may no longer have a working elevator. In a non-airconditioned building, extreme heat takes very little time to become life-threatening. Typically, evacuation routes don’t take people who can’t use stairs into account.

In order to be effective, an actual emergency plan must include the name of someone specific who will be able to check on them during a citywide event, list a backup power source for any necessary medical devices, and identify an evacuation route that doesn’t assume a working elevator. Other critical details to include are a list of medications and medical history that do not require a phone or Internet connection – which often go down first during significant emergencies.

Knowing when it’s time to move to a higher level of care

Each plan must establish specific and objective triggers indicating the end of safe independent living, without assuming it’s the proverbial big event that makes the decision for you. These signals can be masked by love and routine until a sudden change rips that all away, perhaps irreparably. More than likely, they involve the older adult’s capacity for the Activities of Daily Living (ADLs) such as bathing, dressing, and eating, and the Instrumental Activities of Daily Living (IADLs) such as money management, shopping, and transit usage.

ADL and IADL assessments are great tools for a dispassionate evaluation of this capacity. In general, when a senior begins to lose autonomy in two or more ADLs or IADLs, non-medical home care or clinical home health services will be necessary. When the older adult’s needs exceed what can be safely and wholly provided at home, the next stop is assisted living. This is also when respite care should be considered. Respite care gives the family caregiver a planned escape before they force themselves to a crisis decision due to burnout. This requires very little guesswork or guilt if these parameters have been established early, while cooler heads prevail.

The plan is the point

All these pillars must function together. For example, installing a stairlift will be ineffective unless there is a transportation strategy in place to take the senior to the doctor’s office. Having a power of attorney is irrelevant if no one is aware of where the document is located. The long-term care plan for urban seniors has greater significance when the city is viewed as part of the equation and not as something to be considered later, and when each component is developed based on the daily life of that urban senior.

Robert Haynes, a psychology graduate from the University of Hertfordshire, has a keen interest in the fields of mental health, wellness, and lifestyle.