The Transformation To A Person—Centered Model Is Well Underway
Credit for beginning the transformation of senior care from an institutional setting to an integrated, person-centered model is generally given to William Thomas, MD, and his Eden Alternative. For Timothy J. Mueller, Vice President of SFCS Inc. in Charlotte, North Carolina, an architect and designer who worked on a project with Dr. Thomas several years ago, the “culture change” movement in long-term care is all about “creating engagement.” And for architects charged with designing the physical backdrop for senior living facilities, it’s about truly creating an environment in which staff can provide a fulfilling and healthful living experience for residents.

“We’re completely redoing existing environments,” Mueller explained. “We’re destroying the broad, single corridor as best we can. And we’re trying to create small ‘households’ within even the larger skilled nursing and assisted living environments. When residents walk out of their individual quarters, they should feel as if they’re walking into the living room of their own home.”

The old nursing home model was based on efficiency—a clinical model, where staff members could easily move patients from one place to another. That has little relevance to a long-term care environment, where residents are encouraged to think of the facility as “home” and where they’re encouraged to support themselves as much as possible—but also to get support when needed.

Creating a holistic environment, therefore, involves redefining experiences—and redesigning facilities—to promote good health and a sense of wellbeing and, just as importantly, to be non-institutional. It means creating small households built around a “town square,” whether indoor or outdoor, where residents and a dedicated team of caregivers can replicate family life. Simply shortening the travel distance between the bedrooms and the dining and activity rooms to 30-45 feet, so residents can easily move from one location to another on their own, promotes good health and wellbeing. The environment then becomes more integrated, the atmosphere more free, and the experiences considerably more fulfilling for residents and staff alike.

The infusion of culture change into the small-house model, where households are linked together in a way that allows them to share staff more effectively yet still provide a wonderful living experience for the residents, is happening all across the country. Among the innovative architectural designs:

• Vertically stacked. Three households of 14-18 residents each are stacked, one pod on each floor of a building, and share staff within the footprint.

• Linked pods. Separate one-story pods housing 10-12 residents each are linked together by a central courtyard or perhaps an enclosed community center, where residents can share amenities and experiences with individuals from the other households and perhaps the general public.

• Flexible spaces. Residents in small cottages (households) have more personal space—a small suite with a sitting area rather than simply a bedroom—yet they retain connectivity to the common living room, dining room, activity room, and kitchen.

Better is better
Bigger used to be better in terms of senior living communities, and the focus was on creating a luxury experience that pampered seniors. Today, better is better—meaning more effective planning and efficiency of use. “Big doesn’t cut it anymore,” said Mueller. “Seniors have always been cost-conscious. Now, for obvious reasons, they’re more cost-conscious than ever.”

Providers built a lot of independent living when times were good but many, at the same time, neglected their health care side. Now, providers are ramping up their assisted living and skilled nursing environments to ensure a quality living experience from the day a resident moves in until the day he or she “moves on.” Mueller estimates that 50% of the work being done in his office right now involves repositioning facilities on the health-care side. “In three or four years, after the financial markets have turned around, the focus may go back to building more independent living,” he said, “but without good health care, seniors won’t move in.”

Even in this economy—or perhaps because of it—there’s also a growing interest in environmental design when repositioning or modifying existing facilities. “Sustainable design is a big focus,” Mueller agreed, “and ‘green design’ is not being pushed just by architects. Despite the reticence of some providers, residents are changing the paradigm. They see the importance of creating a sustainable environment for their grandchildren.”

So Mueller is seeing a heightened awareness among providers. They’re embracing or at least taking incremental steps toward sustainable design by incorporating “green” (sod) roofs, solar photovoltaics, high-efficiency heat pumps, and so forth. Some providers are installing CO2 sensors in buildings so they don’t have to run HVAC constantly (which builds up CO2); the fresh-air system kicks in when the monitor reaches a certain level. “There are tons of things we can do—and are doing—to reduce waste and save money,” he said.

The social aspect of design
Still another transformation that’s happening in facility design is based on the understanding that residents who move into independent living units are very much interested in the social aspect of living in a CCRC. Despite any limitations in their ability to get around as they once did, seniors opting for the retirement community lifestyle want friends and activities. They understand that having interests and keeping active helps promote a longer, healthier life. Providers are adding wellness centers to their community redesigns to help invigorate residents, get them involved in healthy activities, and help them stay lively.

In The Eden Alternative, Dr. Thomas identified three plagues of nursing homes—loneliness, helplessness, and boredom—that need to be eliminated. “Those three plagues need to be replaced with capability, excitement, and community,” Mueller suggested. “They certainly can be diminished, even in a nursing home setting, if the environment is fulfilling, interactive, and—yes—fun. The focus today is on the capabilities of the resident, not the difficulties. And if we can do that at every level of care, even as their abilities decline, that’s a huge transformation.” Integrating culture change has been a subtle evolution, but it’s definitely happening—at least the architects and planners are pushing for that integration.