December 2019, Volume XXXIII, No 9

Senior and Long-Term Care

Trends in older adult residence design

Emphasizing quality of life

he past 30 years have seen a significant shift in both the populations and the designs of long-term care facilities. A once-homogenous cohort of older adults with a limited range of personal care and chronic medical needs has evolved into a diverse group of patients and residents in multiple settings: short-stay, post-acute, and rehabilitation. Assisted living has become a residence of choice for those seeking help with activities of daily living such as dressing and eating, as well as what gerontologist and environmental psychologist Lorraine G. Hiatt, PhD, terms “bio-care”:  personal attention to the body related to toileting, bathing, grooming, and hygiene. And with an increasing population of elders with cognitive difficulties such as Alzheimer’s disease and other dementias, safe, secure living environments where exit seeking and agitation can be redirected have been well received.

Careful planning and design of environments for each population group can greatly improve the quality of life for patients and residents, while also improving the efficiency and satisfaction of care providers. Understanding the differences and the similarities among the variety of users within any environment can help determine design strategies for both new and remodeled facilities.

Older misconceptions

During a 2018 segment of the PBS NewsHour, 95-year-old Hazel Cross said that moving into a nursing home “would be the end—of my life!” This is a common response from seniors. Many others have no desire to even visit a nursing home, which still retains the stigma of being a place of sickness and dependency, or simply a place to die—a reputation similar to that of hospitals in years past. This reputation is perpetuated in large part by the design of the physical environment. When Medicare and Medicaid became dominant payment methods for long-term care, the regulatory agencies charged with implementing these programs, unfortunately, adopted an institutional model based upon hospital care and design concepts.

Minnesota was at the forefront in the development of assisted living settings.

That model typically included a hub-and-spoke design focused on a centralized staff station, with direct observation of long, double-loaded corridors lined with rows of patient rooms. The rooms offered limited privacy and forced occupants to share all aspects of their intimate lives with strangers. This design was an efficient method for staff to oversee large numbers of patients that either stayed in their room (often in bed), or were gathered together into large centralized dining or activity rooms. Patient/resident satisfaction was not the prime directive in this scenario.

New conceptions

Over the past 30 years, however, there has been a slow but steady shift in the methods and locations for providing long-term care services. Beginning with the passage of the Omnibus Budget Reconciliation Act of 1987 (OBRA ‘87) and the Nursing Home Reform Act, the focus has changed from quality of care to quality of life. Long-term care residents are now entitled to a set of rights that include privacy, individuality, and dignity, in addition to medical care. Self-determination and resident-focused or resident-directed care are key concepts.

At the same time, rising costs of care and the desire for alternatives to nursing homes led to what were, at the time, innovative care settings unhindered by strict state and federal regulations. Minnesota was at the forefront in the development of assisted living settings with projects such as the Elder Homestead of Minnetonka. Using homecare services to provide personal care and nursing assistance meant that residents could live in the setting of their choice, whether that be in their traditional family home or a purpose-built elder community. By bypassing the constraints of an institutional building code classification and restrictive health department rules, living arrangements and provision of care were no longer linked.

Interestingly, the State of Minnesota maintained a light touch in regulating these evolving models of care. In many ways, Minnesota encouraged the evolution of alternative care settings with policies that incentivized the transition of residents to less restrictive (home or assisted living) environments. This led to the reduction in the number of low-acuity residents within traditional nursing home settings. Additional policies led to a significant reduction in the number of Minnesota nursing home beds. Nursing homes have become the dwelling place for individuals with significant medical and nursing needs, either on a long- or short-term basis.

Responding to market demands

Ten thousand baby boomers reach retirement age each day, according to a 2012 Pew Research Center report. Life experiences and expectations of today’s retirees are much different than those of older generations, and these consumer expectations have helped fuel major trends in design and construction.

The uncoupling of care services from the physical environment now allows a wide range of choices. Universal Design concepts—which stress design that meets the needs of all users, despite age or disability—proliferate in new housing construction, providing an increasing stock of accessible housing options with broad appeal. Larger scale age-limited independent living settings provide similarly accessible accommodations, with or without the opportunity to procure home-delivered services. Independent living is often available on campuses with a full range of activities and services, up to and including long-term and end-of-life care. Many of these Life Plan Communities provide resort-style amenities, with activities and food service options.

As designers plan out apartment design and detailing comparable to market rate housing, they should also organize activity locations in a manner that helps to support a sense of community. Proximity to activities is one of the prime determinates in frequency of use by residents. Low scale, spread-out community campuses must provide opportunities for socialization and participation within manageable walking distance to resident apartments. Taller, denser structures with smaller footprints are often more successful in providing access to community spaces, as elevators provide excellent and dependable transportation to otherwise remote locations.

Transitioning to extra services

As personal care needs increase, individuals often transition to some form of assisted living. Although some choose to bring private care directly into their independent living apartments, care can be managed more cost effectively in an environment designed as a service-enriched setting.

Private living spaces are often slightly smaller than independent living units—allowing residents to manage them more easily—but market demand for larger accommodations has increased. Service packages in assisted living facilities normally provide three daily meals. Unit kitchens are typically small in size, often limiting cooking appliances to a microwave oven. Additional safety features typically include emergency call systems, safety shut-off devices for appliances, and, in some cases, specialized motion sensing or video systems that are capable of interfacing with artificial intelligence-driven software that can detect changes in behavioral patterns, alerting family or doctors of possible health changes. It is not unusual for apartments to be outfitted with various assistive devices to maximize independence.

A wide variety of social and wellness-based areas become the focus of activity for residents outside of their private spaces. A lively activity program should be included to encourage participation and a sense of community and connection. Acoustics and lighting quality become important considerations in designing comfortable spaces.

Nursing homes: new models

While independent living and assisted living settings have focused on incremental changes to service-enriched residential apartment living, the nursing home industry has undergone a revolutionary transformation in the delivery of care. Driven by the rejection of the traditional institution as a viable model to ensure resident quality of life, a culture change movement focused on person-centered care developed.

Electronic charting eliminates the need for traditional nursing stations.

The physical environment is integral to this reconceptualization of what a nursing home should be. For those requiring long-term care, designers and elder care advocates now stress “home and household” models. Small-scale living environments—ideally with 10 to 12 resident rooms, at times up to 20—are clustered around open, sun-filled living, dining, and kitchen spaces, creating a living space for a family-sized group. Single bedrooms with bathroom suites provide a private retreat, while group activity areas offer opportunities for social interaction. Independence is encouraged through the design of spaces that are safe and easily negotiated, using wide door openings and adaptive accommodations where appropriate. Bio-care spaces are designed to enhance ease of use (reducing staff time) and to foster dignity. Supplies and equipment are close at hand for staff providing resident assistance in daily activities. Walking distances for staff and residents are reduced to manageable distances.

Some advocates promote the “Household Model,” which incorporates familiar settings for the care of those with dementia or other cognitive impairments. Paired with activity-enriched Town Center activity areas, including multiple positive distractions, provides a helpful combination of familiar and life-enriching environments.

Technology

Today the nursing and care staff no longer need to be tied to a physical location to receive calls for assistance. Wireless call systems allow calls for assistance to be received anywhere. And sophisticated programming allows transferring of calls to alternative staff should additional attention be required. Electronic charting eliminates the need for traditional nursing stations. Resident personal care is delegated to the direct care providers, freeing licensed nursing professionals to manage medical care within multiple household locations.

Minnesota also encouraged innovation by developing new rules for food preparation within residential household kitchens and through preference for Household Model nursing home construction under the Nursing Home Moratorium Exception Process. These initiatives have been adapted and used as exemplars within other jurisdictions.

While long-term care settings focused on a home-style congregate living model, short-term, post-acute, and rehabilitation care looked to the hospitality and medical markets to provide high-tech, high-touch environments where patients feel they are receiving the best, leading edge services. The goal for this population is to achieve independent functioning and return to the comfort of their own home as soon as possible. Small-scale groupings of patient rooms, similar to the Household Model, is also an appropriate organization of space for short-term settings and provides the flexibility to shift populations based upon market demands.

Rehabilitation suites with state-of-the-art equipment and warm water aquatic therapy pools with underwater treadmills are therapeutic amenities within many settings. Catered services are becoming standard options, offering room service and customized care.

The main distinction is that long-term settings are based upon the concept of creating a household environment for residents, while short-term patients are in transition back to their personal home and are working to be discharged as soon as possible.

Meeting individual needs

While it is possible to provide long-term care services within any physical setting, a variety of building typologies have evolved to serve distinct population groups. It is important to evaluate the specific needs of each population group to determine the most appropriate organization of spaces and elements to provide within each setting.

Building construction is an expensive and time-consuming endeavor. Understanding the common conceptual elements among various design approaches has the potential to provide flexibility for future changes in demographic or market considerations.

Gaius G. Nelson, MA, president of Nelson Tremain Partnership, PA: Architecture and Design for Aging, has over 35 years of experience as an architect and frequent presenter of innovative design concepts for elder living and care environments. He created and implemented the first Household/Neighborhood model nursing home in the country while working with Evergreen Retirement Community in Oshkosh, Wisconsin. 

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Gaius G. Nelson, MA, president of Nelson Tremain Partnership, PA: Architecture and Design for Aging, has over 35 years of experience as an architect and frequent presenter of innovative design concepts for elder living and care environments. He created and implemented the first Household/Neighborhood model nursing home in the country while working with Evergreen Retirement Community in Oshkosh, Wisconsin.