When it comes to culturally competent elder care, assimilation is not the goal, and everyone is not expected to be the same. Cultural differences are embraced, and fostered.

Vijay Bali, 70, was looking excitedly at his phone. "My India has won!" he crowed.

"Soccer?" I asked.

"No soccer," he said indignantly, explaining that he cared only for cricket. With Bangladesh defeated, India would play Pakistan next.

"My son is in finance, one of my daughters is a dress designer," said Bali, a retired Bollywood film producer with a master's degree in economics. "Now I am a senior, what do I do? Sitting at home is just boring."

We were standing in the lobby of an Indian adult day-care center operated by Boulevard Adult Day Care of Flushing, LLC, which runs several similar programs in the New York City borough of Queens. Unlike typical American nursing homes and adult day cares, Boulevard tailors almost every aspect of its centers to the cultures their clients grew up with.

A version of this story originally appeared in the November 2017 issue of Pacific Standard. Subscribe now and get eight issues/year or purchase a single copy of the magazine.

A version of this story originally appeared in the December/January 2018 issue of Pacific Standard. Subscribe now and get eight issues/year or purchase a single copy of the magazine.

"I went to other centers," said Bali, wearing a brown dress shirt and jeans. "And the best part of this center is, first, it is an Indian community." And second, he said, the center serves strictly vegetarian food, in keeping with his religious traditions. "This place gives me the knowledge of Indians residing in the U.S.A., a look into my people. Today I feel that I am at home."

Bali was expressing one of the fundamental ideas motivating Jeffrey Rosenfeld, a professor, consultant, and researcher in the field of environmental gerontology who studies the social and psychological aspects of where we age. He believes that the safest and most supportive places to grow old remind people of where they're from.

At the intersection of aging, immigration, and small business, culturally specific senior centers open and close frequently in New York City. This story recounts a moment in the lives of people and places in the spring of 2016. Since then, many things have changed, but the need expressed by Bali and the solutions offered by Rosenfeld represent a larger, global conversation about what it means to age in a plural society.

Rosenfeld's expertise is newly in demand, as a generation of immigrants reaches retirement age and middle-aged immigrants increasingly move their parents to the United States to be near them. According to Aging in the United States, a 2016 report by the Population Reference Bureau, the number of Americans older than 65 "is projected to more than double from 46 million today to over 98 million by 2060." Over the same period, that population is expected to become more diverse, dropping from 78.3 percent non-Hispanic white to 54.6 percent. In New York City, a 2013 study by the Department for the Aging found that more than half the population over 60 was foreign-born.

Neither the waves of elderly immigrants coming to the U.S., nor the millions already here, are interested in assimilating, Rosenfeld told me, and if the country's aging industry wants to successfully accommodate them, it must consider their cultures along with their health. The Western elder-care industry has a bad reputation, in part because it is based on a one-size-fits-all model.

If our environment helps to create who we are, then we also risk losing part of ourselves if we move to a place we don't recognize. The American idea of the melting pot asks individuals to fuse with a greater whole, but an elderly immigrant has lost enough of themselves already just by moving to an unfamiliar place late in life. Any more melting and they might dissolve entirely.

As a boy, Rosenfeld, now in his early seventies, lived in the same building as his Jewish grandparents, cousins, and uncles on New York City's Lower East Side. At the time, the young Rosenfeld wasn't really aware of culture. "You couldn't see it because you were living it," he said. Rosenfeld has spent his career studying, and helping others build, "the close connection I enjoyed growing up and could never really replicate."

On a rainy day in February, Rosenfeld was visiting Boulevard's Indian center, in part to research a book he is writing about "culturally competent care," the academic term for the feeling of home that Bali described to me. Inside the front door, a sculpture of the Hindu god Shiva and his family filled a heavy golden frame, greeting the seniors who spend their mornings and afternoons here. The face of a Sikh guru smiled from a book cover, and statues of other gods and goddesses lined the check-in desk.

The center's clients sat around long tables while a man recited poetry in Urdu. The group, around 20 Indian men and women in their seventies, had just finished a breakfast of dalia, a warm, sweet, oatmeal-like dish. The women mostly wore saris. Men wore Western-style shirts and pants. Several wore turbans.

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As Rosenfeld and I were escorted to a table and given bowls of dalia, he put his hands together and bowed to each person we passed. They smiled and bowed back. Megha Mehta, a slim 29-year-old Indian woman in black slacks and a bright purple shirt, came in as we were finishing. She created and directed the Indian program.

Mehta moved to New York from Mumbai to pursue a master's degree in social work at Columbia University. She met Rosenfeld shortly after she graduated in 2011. Mehta's grandparents still live in India. "I don't get to see them every day, but in my heart I feel like I have 50 more grandparents to take care of," she said. In traditional Indian homes, a daughter-in-law cares for her in-laws, and as a young female program director, Mehta easily fills this role. She calls her clients "uncle" and "auntie."

Boulevard is owned by Michael Marx, who also runs programs for Hispanic seniors and seniors who are Bukharan Jews, an isolated group from Central Asia. The first time Mehta met him, at an open house for the then-prospective Indian program, she said: "I introduced him and said, 'This is uncle so-and-so, and aunt so-and-so,' and he said to them, 'Your niece, she's so nice.'" Later he asked, "How can everybody be your uncle or aunt?" In India, Mehta explained, it's disrespectful to call elders by their names.

For Marx, 29, culture is about accepting that different people have needs that can't always be rationally explained. "There are things about my own religion that I don't understand," he told me. (Marx is Orthodox Jewish.) "If I would tell you some of the things that I do, you would look at me like I'm crazy." His culturally specific centers succeed because Marx knows that each facility must be customized to meet each group's needs. The Bukharan singers he hires would be incomprehensible to the Indians, and the meat-heavy Central Asian food would be sacrilegious for some Hindus.

"I would like to have a place where I could bring in every kind of person," he said. "It's more money for me, but what kind of food am I serving? My entertainment? My staff?" He is resigned to spend more to keep the populations separate but happy.

In 2015, when Marx moved the Bukharans to other quarters, he gave their old building to Mehta's Indian program. She and her staff immediately started redecorating. "We brightened this place up," she said. "Indian culture is all about colors," and that meant gold, silver, and red.

Every room got colored balloons, streamers, and crepe paper. Mehta hung traditional spinning-top-like gumbads from the lights. One staff member brought the Shiva sculpture back from a visit to India. Above the security alarm Mehta hung a wooden peacock, the national bird of India. The three-story building has rooms for exercise, a quiet room with huge, comfortable chairs, and a music room with a karaoke machine and instruments including a dholak, a traditional Indian drum.

If her clients were still in India, they would be cared for by their daughters-in-law, Mehta said, but here in the U.S. their children are at work, and adult day cares like hers have become necessary. If a man were running the program, it wouldn't work as well. He wouldn't get as much love and affection from the clients. "It's just a cultural bias," she said. "They're from a different era," and this isn't the time or place to challenge their biases.

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In a way, culturally competent care is a movement against the melting-pot idea of America. Assimilation is not the goal, and everyone is not expected to be the same: Cultural differences are embraced and fostered. I remember the nursing home where my German great-grandmother died, on the plains of Western Minnesota. Was there a culture to that place? Yes, but it was so bland that little comfort could be drawn from it. When it comes time, if my maternal grandmother could move into a Catholic-Italian, theater-savvy, gourmet-cuisine-serving assisted-living situation, I have no doubt that she would be happier—and what little research there is on this topic agrees.

According to "Diverse Communities, Common Concerns: Assessing Health Care Quality for Minority Americans," a 2001 paper from the Commonwealth Fund, "Fifteen percent of African Americans, 13 percent of Hispanics, and 11 percent of Asian Americans said there had been a time when they felt they would have received better care if they had been of a different race or ethnicity," and "Asian Americans were least likely to feel that their doctor understood their background and values and were most likely to report that their doctor looked down on them."

Another study of low-income African-American and Latina women in New York City and Los Angeles found that playing "culturally sensitive health-education videos" in the waiting rooms of medical clinics in patients' preferred languages resulted in an increase in cancer-screening tests.

"Instead of the term melting pot, meaning everyone is expected to blend, many believe the term salad bowl is more appropriate because people can stand out and be seen as individuals," wrote Larry D. Purnell in the fourth edition (from 2013) of his book Transcultural Health Care: A Culturally Competent Approach. "Health ideology and health-care providers have learned that it is just as important to understand the patient's culture as it is to understand the physiological responses in illness, disease, and injury. The health-care provider may be very knowledgeable about laboratory values and standard treatments and interventions ... but if the recommendations are not compatible with the patient's own health beliefs, dietary practices, and views toward wellness, the treatment plan is less likely to be followed."

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"When I came here as an immigrant, I felt like I was getting absorbed in a nation that had no culture at all," Mehta said to me later, over tea in her office. "I came from cultural practices of waking up and praying to the sun." As someone apart from the American mainstream, Mehta said, "You become overly sensitive to the needs of other cultures. Maybe you can feel how they feel."

Queens is perhaps the best place to test Rosenfeld's theories. According to the City of New York, 1.1 million people in Queens identified themselves as foreign-born in 2010, and at least 160 different languages are spoken, the most of any county in the nation. As a result, Mehta and Marx were interested in expanding the Boulevard concept. They considered Afghan and Hispanic programs, and they briefly collaborated with the Himalayan Elders Project, a volunteer-run adult day program in the Elmhurst neighborhood of Queens.

The Himalayan program meets three times a week in an old church that is now the headquarters of the United Sherpa Association in the U.S. Below a symbol of the Christian Trinity—carved into the church's facade when it was built—the headquarters is decorated inside and out like a Buddhist monastery. When I visited in the spring of 2016, through the ornate doorway and past the vestibule (filled with politely removed shoes), about 40 elderly Himalayans sat on rugs, cushions, and low benches along the wall. They chanted om mani padme hum in rhythm, thumbed prayer beads, and spun metal wheels filled with long scrolls of paper inscribed with prayers. They believe that the invocations are released as rapidly as the wheel can be spun, explained Thupten Sherab, the project's co-founder. The elders faced an altar where golden Buddhas and Bodhisattvas sat encased in ornate shrines. Religious instruments sat ready for service, incense burned in a tray, and tapestries hung around the room. Every decoration was painted or dyed red, green, yellow, blue, or white.

"The Tibetan population, they just like to pray the entire day," Mehta said. "It's very soothing, even though I'm a Hindu myself."

In the basement of the former church, sitting at a plastic table under fluorescent lights, Sherab, 46, explained that, as Tibetans, Sherpa, Nepalese, and Bhutanese people of his generation have become citizens and established themselves in New York, they've brought their parents to the U.S. to be near them. In 1998 he came to New York from a Tibetan settlement in India. Sixteen years later he helped his mother move to Queens too.

In her village in Nepal she had relatives nearby and Buddhist talks to attend, but in New York, he said, "She felt lonely and homesick." Every day she would watch him leave the house and go to work. She didn't speak English, so she was intimidated by the subway and the street signs. She spent all day at home.

Sherab, who also works as a housekeeper at a hotel, created the Himalayan Elders Project so people like his mother would have a place to gather and feel connected to their homeland, and their past. "They like to remember the old days, the old songs," said Mehta, who sat across the table. "They still feel like they're attached to that culture."

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Today the Himalayan program has more than 120 members, and Sherab said that his mother, who is 81, no longer tells him he's not taking care of her. "It's our time to appreciate what they've done for us,” he said. They should be able to "live feeling free until nirvana."

A volunteer brought me a cup of salty Tibetan buttered tea with milk. Mehta sat at the table to my left, talking on the phone with a health-care provider. She was trying to schedule a check-up for the old man sitting across from her. The check-up would begin to qualify him for a health insurance plan, which could then pay for his care in an adult day facility like this.

Looking at the man's cards laid out on the table in front of her—social security, benefits, ID—she spoke English on the phone, then Hindi to a volunteer, who replied in Hindi and then asked the old man questions in Tibetan. He pulled out a flip-phone and handed it to Mehta. His number was written on a piece of paper taped to the back. She read it over the phone in English.

All of Boulevard's Indian and Bukharan clients are signed up for managed long-term care insurance plans. These plans take complete responsibility for an individual's care. Once a senior has qualified and chosen a licensed long-term care provider, that provider gets a monthly "bundled" payment from Medicare and Medicaid. Ideally, this money then goes to pay for a package of services, which might include adult day care, transportation, meals, and home visits. At the adult day programs I visited, no one paid out of pocket for anything. Of course, Boulevard is a for-profit business that administers these services in exchange for a portion of each client's Medicaid and Medicare allotment, but the seniors seemed happy to exchange that allotment for services they often didn't know they had access to.

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According to Rosenfeld, the future of culturally competent care resembles a 250-bed facility in Perth Amboy, New Jersey, called Aristacare at Alameda Center. At one time, the center had programs for four different cultures running simultaneously. It was created by Michael Neiman, an Orthodox Jew who has worked at or owned adult day-care and assisted-living programs for Hispanic, Indian, Korean, Jewish, Russian, and Anglo- and African-American communities.

In 2004 Neiman and a partner bought the Perth Amboy residence. The exiting Anglo-American and long-term programs were losing money, and one of the building's floors was empty. An Indian staff member suggested setting up an Indian program. Neiman decided to try it. With the help of his Indian staff, he figured out what aspects of the culture to offer: They set up a shrine to Hindu gods, played Indian music, burned incense, and served vegetarian food. They paid for advertisements on local Indian-language television and met with community leaders. The beds started to fill and the center began turning a profit.

Neiman told me about a typical case: They would get a potential resident's paperwork from a hospital. The paperwork would say the patient was combative, losing weight, and threatening suicide. His director of nursing would say, "We can't take this patient—look at all the psych issues." Neiman, knowing many Indian Hindus are vegetarian, would reply: "Of course they're losing weight—they're being forced to eat tuna fish. Their whole life, they've never eaten this kind of food."

"They would come to us and they would thrive," Neiman said. "They would be able to communicate, have the food that they want, have the social life that they needed."

Though the Indian program was a success, there still wasn't enough demand in the community to fill all five floors of the 250-bed building. To attract more business, Neiman decided to set up a unit to serve the local Hispanic population. He hired Hispanic consultants, who recommended lots of tropical plants and even a bird to give the floor a South American feeling. Neiman took their advice, and the program opened for business.

Neiman sold the Perth Amboy residence in 2015, but he said its new owners haven't altered the multi-cultural model. He later operated a nursing home in Cherry Hill, New Jersey, where one section was Korean and one was Anglo-American, each with a separate kitchen and chef. Now he owns a nursing home in Newark that has Indian, Hispanic, and African-American programs.

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The next time I visited Boulevard's Indian day care, on a sunny May afternoon, Vijay Bali was sitting at a table beside a small man with a long fringe of dark hair around a bald crown. The two friends had just seen a well-known guru speak on TV, and tears were rolling down the other man's face. The guru had uttered words that he was sure he himself had said in another life. "That was me, but who was me?" he said. "I'm not born, I'm not going to die. Soul is energy." He seemed to be speaking about things that had happened hundreds of years ago as if they had happened to him. Bali explained that his friend was confusing mythology with reality, and that Hindus believe events have happened before and will happen again. This man had studied in Germany and been an engineer, Bali said, and he showed me a black-and-white picture of his friend shaking the hand of an Indian prime minister.

Several other clients sat around the table with the two men and Mehta. They dozed, or half listened, but no one said that Bali's friend was crazy or wrong. They understood his frame of reference. They were familiar with reincarnation, colonial India, yogis, and gurus. In this shared world he was at home, and Mehta handed him a napkin to dry his tears.

A version of this story originally appeared in the December/January 2018 issue of Pacific Standard. Subscribe now and get eight issues/year or purchase a single copy of the magazine.

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