June 2020, Volume XXXIV, Number 3

Architecture

Person-centered care environments

New trends in assisted living facilities

hysical or cognitive difficulties often make living at home impractical or unsafe for older adults. Multiple home care options provide support for those wishing to remain in the familiarity of their own home, but this can be an expensive proposition, and one that could limit the social interactions or the sense of community and belonging that are available in congregate long-term care settings.

Choosing the right facility can be overwhelming. Several long-term care communities stress their “chef-driven” menus and beautifully appointed entrance lobbies to prospective residents and their loved ones. Architecture clients often wish to present a “Wow” experience for those entering the facility. First impressions are important, but it is even more important to be sure that the same careful design and execution of the physical environment occurs throughout the long-term care facility.

Whether it is the availability of appropriate types of services, accepted payer sources, or cultural affinity groups, sorting through the various settings and organizations is a difficult task. Decisions can produce even more anxiety during the current pandemic. Some family members may contemplate “rescuing” loved ones from congregate living settings, believing this is the safest alternative—but very few loved ones have the training or ability to practice infection control as effectively as long-term care providers.

Guidance for consumers and physicians

Minnesota’s Assisted Living Report Card—now under development—may help consumers and physicians sort through a variety of quality measures for long-term care settings (see recent Minnesota Physician article at http://mppub.com/mp-s4-0320.html). Building on the experience of the state’s Nursing Home Report Card (http://nhreportcard.dhs.mn.gov/), planners have developed a list of nine quality domains based on national literature, reports, and experts. Among the nine domains, Quality of Life; Safety; and Physical and Social Environment most directly correlate to and can be impacted by the architecture and design of long-term care settings.Environment has a significant impact on well-being and quality of life.

Individuals who have lived within congregate settings rate the quality of the physical and social environment as being more important than those who have not done so, but a review of data from the Nursing Home Report Card shows a discrepancy in satisfaction ratings between residents and their family members. In one cohort of facilities, resident and family ratings on the quality of the environment correlate closely, but in a separate cohort, residents rate the environment much higher, often twice that of family members. This diversity of opinions points to the difficulty that people have in describing which physical attributes of the environment are important, or to a lack of understanding of how these attributes can affect residents, family, and staff.

Physical environment contributes to therapy

The late David Green, former CEO of the Evergreen Retirement Community in Oshkosh, always explained to visitors that the built environment was the most important therapeutic tool available to caregivers. Subsequent research confirms this observation, demonstrating that the environment has a significant impact on the well-being and quality of life experienced by its occupants.

These “person-environment” studies led to the development of new types of environments for aging after the passage of the Federal Nursing Home Reform Act, created under the 1987 Omnibus Budget Reconciliation Act. New regulations mandated that quality-of-life measures be integrated into the life of nursing home residents on an equal or greater footing to quality of care. Person-centered care that looked at each person as an individual became the new standard. The proliferation of assisted living centers as an alternative to traditional nursing homes pushed the concept of personalized, non-institutional care environments throughout the long-term care industry.

There are a wide variety of care setting typologies available, ranging from independent living, assisted living, memory care, and nursing homes. In many cases it is difficult to distinguish one type of setting from another. For example, assisted living may offer two-bedroom apartments with full-unit kitchens, while nursing home care suites may provide studio-like living quarters and tea kitchens with mini-bars. The service needs of each individual—and the license level of the operator—should determine the type of setting to be selected.

Focusing on the physical environment

A number of common attributes of the physical environment that should be considered by physicians and consumers appear in the Facilities Guidelines Institute (FGI)’s Guidelines for the Design and Construction of Residential Health, Care and Support Facilities (https://tinyurl.com/mp-select-care-2020). Part 4.1 of that document, “Specific Requirements for Assisted Living Facilities,” has been adopted as the governing standard for the design and licensure of assisted living facilities in Minnesota, beginning in August 2021.

These concepts and attributes have been integral to the work of architects across the nation as they strive to provide person-centered care environments focused on quality of life for all occupants. Two local Twin Cities examples of my firm’s work include the Shaller Family Sholom Home East Campus in Saint Paul and the Minnesota State Veterans Home Building 22 in Minneapolis. The Shaller campus includes affordable independent living, assisted living, memory care (assisted living), nursing home, and hospice care services, whereas the Veterans Home is a 100-resident nursing facility designed as the final phase of a 300-resident campus reconfiguration within a historic setting.

Key concepts

Major physical environmental contributors to quality of life appear below. Many of these person-centered care concepts are in place throughout the country, and Minnesota regulators have been at the forefront of encouraging movement toward person-centered care environments. With the recent concerns over COVID-19 transmission, greater attention has been given to protection of older and vulnerable populations. Based on early indications, person-centered design models have performed well in helping to control transmission of the disease, thanks in great part to the courageous efforts of direct care staff.

Private accommodations. An early and devastating COVID-19 outbreak in the Twin Cities occurred at a well-respected suburban campus where most residents lived in semi-private rooms with a toilet room shared by four residents from two adjoining rooms. Thousands of older U.S. nursing homes still fit this description. In the past 15 years, nearly all new and renovated resident rooms our firm has designed have been private rooms with individual bathrooms. In 2006, the FGI adopted private rooms as the standard for all new hospital construction, noting that it represents a best practice for infection control.

Size of dining and social groups. Household model facilities are designed as small family-sized settings of 8–20 residents. Each household is envisioned as a self-contained living environment, with all of the normal spaces found in a home alongside required care support areas for staff. Compared to institutional model nursing homes, smaller living groups provide a family-sized social group and dedicated direct care staff, who gain an intimate understanding of the care needs and desires of residents. This model can limit contact with outside groups if necessary, creating what some call a “COVID Bubble.” Similar household designs are often used in memory care environments. In other settings, activity lounges make it possible to create small groups, using social distancing for dining and activities.

Variety of activities and experiences. Psychologist Mihaly Csikszentmihalyi’s “Flow” concept states that life entails what we like to do, how we feel about it, and whom we do it with. He stressed that quality of life can be found in everyday experiences. The challenge is to increase the time we spend doing activities that maximize the experience of Flow—a difficulty for caregivers, since these activities and experiences are unique to each individual. Physicians and family members should look for settings that provide opportunities to fulfill these desires, and then communicate this information to future caregivers.

Access to the outdoors. Spending time outdoors benefits both psychological and physical health—activating all of our senses, boosting vitamin D through sunlight, and improving circadian cycles. Ease of access to the outdoors is particularly important for those with limited mobility. In multi-story structures, exterior roof terraces and balconies on each floor can help. These smaller outdoor features can allow community members to interact while maintaining social distance.

Minnesota regulators have been at the forefront of encouraging movement toward person-centered care environments.

Changing design aesthetics. Many recent retirement housing units and long-term care developments, particularly within urban locations, are being designed with contemporary European-style interior design elements that feature easier maintenance and sanitation, as well as antimicrobial surfaces. The challenge in designing for infection control will be to retain a residential look and feel without reverting back to institutional patterns.

Accessibility standards. While the Americans with Disabilities Act (ADA) includes requirements for accessibility, these standards were not developed with older, frailer individuals receiving assistance from caregivers in mind. Many facility designers go beyond the ADA to provide additional space to accommodate assisted transfers. In assisted living facilities, the Fair Housing Act—with less stringent requirements and smaller spaces—is allowed as the minimum standard. Look for bathroom arrangements that go beyond minimum standards and support aging-in-place, allowing the environment to adapt as a resident’s needs change.

Hand-washing stations. A hands-free sink, cleaning agents, and towel-free hand drying can limit the spread of disease. Soap and water are more effective than the ubiquitous alcohol-based hand sanitation dispensers. We have designed hand-washing stations within or near dining areas for both ceremonial and hygiene purposes. In higher acuity environments, additional hand-washing stations should be provided within—or just outside of—resident rooms, to eliminate staff use of bathroom facilities for hand-washing. Bedpan sprayers in resident rooms and toilets without seat covers should no longer be allowed due to their potential to aerosolize pathogens.

Ventilation systems. Centralized fresh air and continuous exhaust systems are critical to limit exposure to the coronavirus. The main concept is to maintain a negative pressure within resident rooms to avoid spread of contamination. Proper filtration of room air is also key. Typical recirculating ventilation equipment, often found in older nursing homes and assisted living units, has little capacity to filter contaminants, especially those as small as a virus. HEPA filters are the suggested means for capturing these types of pathogens. The Association of Healthcare Engineers (ASHE) has developed white papers and standards regarding the creation of settings for COVID-positive patients, although most of their efforts have centered on COVID-19 wards for patients with confirmed cases.

Multi-level campuses or care systems. One key factor in selecting an assisted living setting for a family member is the desire to make a single move to a setting where future needs could be accommodated. My family selected a single campus containing a full, interconnected continuum of care for our loved one. Other options may include the selection of a care network, or a health care system that offers a variety of settings from which to choose, all managed by an umbrella organization. Changes in health and cognitive capabilities can occur quickly, so planning for the future is a valuable exercise.

Conclusion

The physical environment is an important part of the long-term care milieu that is often overlooked in choosing suitable long-term care settings for patients or family members. The current Nursing Home Report Card provides little specific information in this area beyond a broad measure of the proportion of private rooms available, and the domains evaluated for inclusion in the upcoming Assisted Living Report Card appear to downplay the direct effect of the environment on resident well-being and quality of life. Physicians and family members can help to ensure a successful transition by understanding the aspects of life—whether physical, emotional, intellectual, or spiritual—that are most important to the patient or loved one, and then comparing potential settings against the concepts discussed above to see if there is a congruence between the desired quality of life and the physical environment.

Gaius Nelson, MA, is president of Nelson Tremain Partnership, a nationally recognized architecture firm in the field of Design for Aging. He earned a Master of Science degree in Architectural Studies from the Massachusetts Institute of Technology, focusing on person-environment research in long-term care settings. Mr. Nelson has been instrumental in working toward change in Building and Design Codes & Regulations as they are applied to facilities for older adults.

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Gaius Nelson, MA, is president of Nelson Tremain Partnership, a nationally recognized architecture firm in the field of Design for Aging. He earned a Master of Science degree in Architectural Studies from the Massachusetts Institute of Technology, focusing on person-environment research in long-term care settings. Mr. Nelson has been instrumental in working toward change in Building and Design Codes & Regulations as they are applied to facilities for older adults.