Published previously in Environments for Aging Magazine, Fall 2016
Dating back to the 1960s, Skilled Nursing Facility (SNF) design re-created hospital settings with operational and residential models guided by a clinical mindset. Fifty years later, the legacy of that institutional approach can still be found in SNF interiors that feature long corridors, a preponderance of semiprivate bedrooms, and centralized dining rooms.
Design, more and more, is moving away from this approach. Starting in the 1980’s and 1990’s, individualized design and layout approaches were employed in special care units (SCUs) serving persons with dementia and other memory care needs. Protocols were personalized right down to how food was served-gone were the food trays and cellophane-wrapped slices of bread. The “aha” moment came with the realization that if person-centered environments could be offered in an SCU, they could be offered other long-term care environments.
“By 2004 to 2005, a number of excellent white papers, documents, and VA guidelines were coming out regarding person-centered-care,” says Maggie Calkins, behavior researcher, consultant, and executive director of The Mayer-Rothschild Foundation (Chicago), which focuses on quality-of-life Improvement for elders in long-term-care communities.
Today, skilled nursing design is steeped in person-centered care elements such as private rooms with private bathrooms, an absence of centralized nurses’ stations, smaller resident wings with dedicated kitchens, easily accessible and visible outdoor spaces, and common areas that integrate staff and resident activities.
Despite this progress being made, consumer preference remains with avoiding skilled nursing for as long as possible, which is influencing the resident populations that designs must support.
“People are living longer, medical care is improving, and less expensive alternatives such as adult day healthcare, home healthcare, assisted living, and supportive housing are growing,” says Tom Gears, principal with SWBR Architects (Rochester, NY.). “The typical resident entering a skilled nursing facility is now older and in need of more medical services.” Growth in the sub-acute, short-term stay market is also affecting SNFs, Gears says, requiring communities to support not only different diagnoses but traditionally younger residents, as well. To that end, highly flexible environments are preferred.
A household remedy
“Our clients are not focusing on an individual population. We’re designing for multiple populations and multiple acuity levels, says Rob Simonetti, Senior Associate and Design Director with SWBR. “When we focus less on medical diagnosis and more on the whole person, we see that there Is a narrower spectrum of differences between people. Environments that support all domains of wellness can serve the vast spectrum of needs and can be supplemented with specific care for the individual.
“One major design solution being implemented across the country to create appropriate environments for care is the household model. “The smaller household models offer providers the flexibility to address different populations, services, and diagnoses with specialized needs in controlled, intimate environments, “says Joseph Hassel, principal with Perkins Eastman (Chicago).””It also offers the provider the ability to expand or contract the program offerings based on market need.”
This often translates to “neighborhoods” broken down into 24 private rooms or fewer, says Susan Ryan, senior director with The Green House Project (Baltimore). In comparison, traditional models being renovated formerly offered 40-, 45-, or even 50-plus bed layouts, she adds. The Green House Project, founded in 2001, partners with organizations to realize the design and building of small-scale, community-based licensed SNFs, emphasizing a household model and person-directed care. Currently there are 208 Green House Homes in 49 communities across 30 states.
Examples of the household model in action Include The Terraces at San Joaquin Gardens, a community of the American Baptist Homes of the West (ABHOW) in Fresno, Calif., which features a replacement SNF that opened in 2014 and offers three separate households within a one-story building. The project was designed by Douglas Pancake Architects (Irvine, Calif.). The previous site had 88 beds, of which 80 percent were semiprivate; in contrast, the three households each now feature 15 units with 12 private bedrooms and three semi-private bedrooms with two beds.
A similar design sensibility is evident in The Living Center of Manhattan, a building initiative of The New Jewish Home in New York City. Groundbreaking for this 376,000-square foot SNF is set for summer 2017, with doors expected to open in winter 2020. The 20-story hi-rise, designed by Perkins Eastman, will have 11 floors with 22 Green House homes-two households per floor-to accommodate a total of 264 residents. In each home, 12 private bedrooms will surround a great room showcasing a living room, an open kitchen, and a dining room, the latter boasting a dining table large enough to seat all12 residents plus guests. Five other floors with a total of 150 beds-90 private and 60 semi-private-will be devoted to short-term rehabilitation.
When It comes to interior approaches for SNF households, the individual needs of residents come first, says Debbie Wiegand, a project guide with The Green House Project. “We ask ’would It belong In your home?’” regarding color, furnishings, and other design elements. If not, it’s excluded from the design mix. We want to get rid of Institutional cues; we just want to make sure we’re creating something residential.
Small houses In the Sarah Neuman campus of The New Jewish Home In Mamaroneck, N.Y., features a large, open kitchen/ dining room/living room area that includes a hearth. The combined space conveys “home, right down to each kitchen’s granite counter tops; refrigerators look like residential models, yet they’re commercial grade for durability. Perkins Eastman designed the small houses; three of which are open and a total of seven are planned as part of a phased renovation, from 2014 to 2017.
Residential cues guide interactions at The Cottages at Garden Grove, a SNF in Cicero, NY, as well. SWBR designed The Cottages, 12 8,400-square-foot units, each having 13 private bedrooms and all containing private bathrooms with showers. Front doors feature a doorbell, providing a simple residential association right from the start. “The exterior door is locked in the household model,” Simonetti says. By comparison, in a traditional facility, particularly a larger one, “people walk in and walk the halls; everything is public.” That sort of visitation, he explains, conveys a sense of entitlement. Instead, in a household model, “the whole home becomes the residents,” he says. “Visitor’s act differently: You wait In the foyer until you are acknowledged. That’s perfect”
The up-and-coming residential emphasis in skilled nursing facilities includes public space filled with natural light and windows offering strong visual connections to outdoor settings. But a more obvious example of the model’s person-centered features is an all-private bedroom layout that includes a private bathroom. “In all of my experience over the past decade or more, even in the medical model, the bathrooms are being put in the bedroom, says Douglas Pancake, president of Douglas Pancake Architects. It’s terribly undignified to be wheeled down the halls.
“Where semi-private bedroom allocation occurs, half-walls should be used to define respective sleeping spaces, wlth each bed having a resident-dedicated area and direct window access, Pancake says. In some scenarios, two residents may express a desire to have a shared bedroom-spouses, partners, siblings, good friends. Even so, a patient-centered shared space in this arrangement consists of two areas: either two designated bedrooms or one bedroom and a living room space, with each configuration divided by a solid partition wall with a door that closes. “From an ideal perspective, everybody deserves the option of a private room unless you want to share,” Catkins says.
Striking a balance
Still, a natural tension exists between creating a residential environment and supporting the inherent clinical nature of skilled nursing. “You have to design for both, “says Martin Siefering, principal with Perkins Eastman (Pittsburgh). State requirements introduce necessary features that are institutional in aesthetic: mounted boxes to dispense latex gloves or soap, for example. Alarm systems, charting technology, vitals monitoring, and exam lighting are all required elements.
“We always have to have 4-foot-wide doors and 8-foot-wide corridors. We do have emergency call systems. We will always have a med room,” Pancake says. “There are critical medical components that will never go away, but we are disguising them. They are readily available to staff, but not in the faces.
“In place of traditional higher-walled nurses‘ stations are now small charting tables or telephone tables with wood cabinetry and milling that blends in with other common area, living room, and den furnishings. And with electronic charting and the use of other paperless technology, documentation can be done via a tablet in resident rooms or in a hallway charting nook. Where nurses’ stations do exist, they’re being significantly scaled back with “a single sided grouping of cabinets and a counter that promotes staff and residents to occupy the same areas” says Russell Mauk, ABHOW’s vice president of design and construction (Pleasanton, Calif).
“We have initiated the use of charting alcoves or cabinets along one side of the corridor where the nurses can perform their recording tasks,” Mauk says. “This eliminates the institutional feel of a traditional nurses’ station while keeping the nurses visibly available to the residents.
Cultivating a residential environment further includes resident-specific medication drawers and customized sterile supply drawers. “A storage cabinet is located inside each resident bedroom, which contains the key care-giving medications and supplies so that mad and supply carts are not parked in the corridors, creating an institutional ambiance,” Siefering says. Other bedroom cabinet systems can store a resident’s wheelchair or walker, If desired, but with easy accessibility when needed. “The design of skilled nursing facilities will continue the evolution into friendlier environments where technology allows the systems required for that high level of care; however’, it will also allow (that technology) to be hidden to the residents, Mauk says.
The goal, however, is not to eliminate all medical aesthetics from view. Bed levels are visibly low where risk of falling Is a concern-that responsive adjustment Is observable and assuring. “This is an example of when healthcare takes precedence, says Audrey Weiner, president and CEO of The New Jewish Home. “It’s functional; there’s no hiding of the equipment. Some medical elements belong In full sight and are a welcomed fixture of the resident’s routine. “I’m not sure how I would disguise an oxygen canister, Weiner says. “I’m not sure of the value of that. There’s nothing derogatory about . If I were at home and needed oxygen, it wouldn’t be wrapped up and disguised.
The future profile
Despite a prevalent desire by many to age at home, skilled nursing will remain a practical and needed solution that comes with its own benefits-especially for those who eventually require 24/7 care. “While home is the preferred location for most, the delivery of essential support services can be cost prohibitive, and the elder is often socially isolated if they stay at home,” Ryan says.
Projecting demand for the market, Siefering says that “short-term rehab lengths of stay will probably continue to shorten, but many seniors will have recurring visits to short-term rehab. There’s always likely to be a demand for long-term care, but it will become more medically intense with residents who have multiple chronic conditions.
How the industry responds with appropriate design solutions will be key. “The innovation, Calkins says, “is the continuation of moving toward smaller groups of residents mingling in a setting that is much more residential in character-living in a house, not an institution.”