A home away from home: it's the dominant trend in long-term care design: making the facility more like home.

Some of the field's top design specialists agree that the move from an institutional model to more of a residential and hospitality model is what's on everybody's lips. But to what extent facilities are able to make this switch is dependent on the market--and the bottom line.

The move toward a more residential model for nursing home care presents some significant design challenges.

The savviest designers are already starting to look beyond the obvious--you can dress up a room with nice drapes, colorful walls, and carefully placed personal belongings, but at the end of the day, does it really feel like home?

"People haven't really sat down and thought, 'What makes a house a house?'" says Michael Allen Hall, AIA, principal in charge of long-term care for Noelker & Hull Associates in Chambersburg, PA. "It goes beyond the finishes. We've been doing house-wrap interiors where we just touch the finishes and the surfaces. You have to look at how you organize spaces."

About 70% of the projects at Noelker & Hull, he says, are long-term care related--15 in total as of p resstime, with Hall working on 12 of those.

What it really comes down to, Hall and his associates have found, is that a place-based model of care depends on creating a sequence of architectural spaces to reflect the adjacencies of a home.

In an older nursing home, there are resident rooms, and other areas such as lounges and medical stations are placed in the leftover spaces outside of the rooms. By planning the rooms first and then "plugging everything rise into leftovers," as Hall describes it, you're not linking areas such as they are in a home.

Richard Rosen, AIA, LEED, principal of the New York office of Perkins Eastman, agrees.

The traditional model, he says, is to have the nurse's station in the center of everything, looking down residential corridors. "We're looking to deinstitutionalize that and open it up a bit more, even providing satellite nursing stations on the floors to have the caregivers on the floor with the residents," Rosen explains.

The satellite stations create "neighborhoods"--the nurses are on the same floor in the same location as the residents for whom they care.

Residential v. hospitality-based

Although the new model is alternately described as one that is both residential and hospitality-based, Hall believes the two terms mean different things.

"When you go to a nice hotel, you know you're in a nice hotel. You know it's definitely not your home," he explains. "A home-based model--a residential model--has more privacy. It's more primary. Domestic activities are more emphasized, and staff are in street clothes instead of a uniform. In a hospitality model, they wouldn't be in street clothes, they would be in a maitre d'uniform, colorful and a little more stylish."

Residential models, he says, tend to be designed to hold more of the residents' personal belongings.

"Some facilities want to place everything in the right place and make everything perfect. But that isn't your house," he emphasizes. "Some people need that kind of residential clutter. In a hospitality model, everything is in place."

A residential model isn't necessarily better or worse than a more hospitality-driven model, but either way, it affects the psyche of the residents riving there. "When you deriver your care to your resident, you have to philosophically step in with whatever approach you're taking," Hall advises.

The privacy factor

"A lot of places have semi-private rooms, but the trend is private rooms," says Rosen. Most new projects his office examines are demanding 95%-100% private rooms, he adds. It's what the market demands; any new skilled nursing facilities built or converted in the future will need to have all private rooms.

"Double rooms were driven by efficiency and state Medicaid reimbursement," he explains. "Some states limited construction dollars per bed, which limited you to more economic arrangements--the semi-private rooms."

Obviously, you'll still have to keep all of the equipment needed to treat residents, Rosen says. But in terms of furnishings, decor, and window treatments, the trend is to make rooms single and more visitor-friendly. Window seats have become a popular accoutrement, Rosen adds.

Another emerging factor is wireless Internet, which is provided in some new designs, so visitors can spend more time at the facility, bringing laptops and work.

"There's no one formula for this," Rosen cautions. "Try to make it more homelike, less institutional-private rooms and fewer beds."

Consider repositioning 

One of the words facility designers have heard often in the past year or so is "repositioning," Hall says.

"More and more, the phone is ringing with people who built buildings years ago to evaluate whether or not the building would meet a higher standard of care," adds Dan Morris, AIA, president of MorrisSwitzer Environments for Health, Inc.

Repositioning refers to taking an old, usually medical- model-based facility and turning it into a homier place, Hall explains. "But from a buildings systems standpoint, it's difficult to do that," he says.

What can happen when widespread teardowns begin, Hall says, is the old adage about throwing the baby out with the bathwater. Older facilities typically have rooms that are stacked end to end in a tight, rhythmic order, according to an institutional model of design.

"If you try to open it up, what you're faced with in most cases is taking the bed count down. Then you start to play with the revenue issue," he adds.

A better way to reposition is to look within each room and make the room space itself more habitable. By adding a bay window, for example, you don't increase the floor space, but you increase the light in the room, says Hall.

"More light, more air, better rooms, more private rooms, and an overall nicer facility," Rosen suggests. Those things, once thought of as luxuries, are now the rules instead of the exceptions, and the market demands them.

Get the mission right first

Overall, the best long-term care facility designers are the ones who figure out exactly what theft customers want early on. "If you're attempting to change, what is it you're thinking of changing to?" Hall asks. "And do your staff have the emotional ability to change with [your vision]? In some cases staff embrace it, and in other cases they don't. They think, 'We've always done it this way, and there is no need to change that.'"

Additionally, changing your facility to a more residential or hospitality-based model isn't getting any easier from a financial standpoint.

"There is a price tag associated with [change]," Morris says. "It's common to see a 15%-20% price premium to accommodate some of those changes. I think for some organizations that's feasible, and for others it's beyond their reach."

RELATED ARTICLE: The aging-in-place model.

In order to remain economically viable, many nursing homes are adding other components, including those that trend toward the model of continuing care retirement communities (CCRC). By offering all models of senior care at your facility, Rosen argues, the organization can guarantee care across the continuum for potential residents.

"In the public eye, the words 'nursing home' and 'skilled nursing' imply a less than optimal existence," Rosen notes. "I think what a lot [of places] are trying to do is offer skilled nursing as just one of several services for aging in place. The nursing becomes a guarantee of life care as you move through the continuum. You are living well as a senior adult."

You can hold on to residents by offering long-term flexibility to accommodate people whose health status changes over time, says Morris. "People don't want to have to physically move into an alternative location when their health diminishes or deteriorates," he emphasizes.

Offering a short-term rehabilitation option at a CCRC continues to be popular, Rosen adds. Short-term therapy can appeal to a younger clientele--those who don't need 24-hour-a-day care but need two weeks to a month to recover from injuries or surgery.--Chad Berndtson

BY ADRIENNE TRIVERS, ASSOC. EDITOR & CHAD BERNDSTON, EDITOR