Adapting the facility to a tumultuous future; significant design decisions confront the nursing home as long-term care evolves.

Let's face it, this nursing home looks like an institution, and whatever color you paint the walls, we are still faced with an environment that is not suited to our long-term care needs."

So explained a nursing home administrator as I toured her facility. Despite all the care, love and devotion of the staff, they were faced with a daily battle against a built environment that just did not work.

Unfortunately, this was not an isolated case. The United States is littered with similar examples of nursing home environments that cut against the grain of what management and staff attempt to do in terms of their programs of care and support for the people they serve.

Is the problem just bad design? Do architects fail to create the right solutions? No. The problem of nursing home design goes far deeper. It's a fundamental issue: The concept of the licensed nursing home has become out of sync with the needs and expectations of our elderly population who require long-term care.

The root cause of the problem is that nursing homes were originally conceived out of a hospital model of care -- an environment best suited to short-term medical treatment. It is only recently that we have begun to distinguish old age from illness. Becoming old does not necessarily imply that one will become ill or need constant medical supervision.

Yet when the Medicare legislation was drafted in the 1960's, it automatically assumed that long-term care would take place in an environment best suited to the treatment of illness rather than the promotion of wellness and the right of individuals to privacy, dignity and independence. While increasingly ill elderly are indeed being found in nursing homes these days, long-term care is still the primary mission.

The nursing home environment today is driven by a plethora of codes and regulations that are written in a language of the past. Most nursing home administrators I have had the pleasure to interview consider the regulations a hinderance to the type of environments and care programs they would like to see.

The codes rightly protect and enforce certain Life Safety issues, but beyond that there is little mention in the codes of the quality of life that a resident can expect within a code-dominated environment.

It's time for the codes in their present form to go -- they no longer have any relevance to our long-term care needs. Furthermore, I would suggest that there would be few who mourn their passing.

To create a vision for the future, that is, how nursing homes could look in the next decade, it's important that we return to basics. Let us just for a moment sweep away the regulations, the reimbursement procedures, even the word "nursing home," and imagine what type of environment we could create that would best serve a human being in need of support during the final years of life.

It would perhaps be a place of contemplation and companionship, a place of light and warmth, a place of love and hope, a place of peace and yet also of activities, of music, of memories and laughter. But it would also be a place to cry, to be alone, to do as one chooses.

What a contrast these simple, yet fundamental, basic human requirements seem from the reality of the nursing home environment, from the double loaded corridors, the shared bedrooms, the fluorescent lights and those unsightly nursing stations.

Even beyond improved residential standards, the nursing home of the future will be radically different from our current models. Indeed the question is no longer whether the nursing home should change, but rather how quickly it can change to keep pace with the changing market.

Some would argue that an aging population would secure an increasing demand for nursing beds well into the next century. However, available research suggests that the "age wave" may indeed beach the nursing home in its current state, while the market moves up shore.

In terms of consumer demand and new models of care, plus the revised financial reimbursement packages of mixed case assessment, the nursing home must stand as the most vulnerable component of long-term care. As within any evolutionary cycle, the key to survival will be to adapt or die. That is the challenge each nursing home administrator and their board faces in taking an outmoded building type into the next century.

The writing is already on the wall. In June this year the U.S. Census Bureau showed a slower than expected increase in the nation's nursing home population during the 1980's, providing evidence that growing old need not lead inevitably to life in a nursing home.

Researchers have indicated that these numbers underscore other studies in the United States that fewer elderly Americans are suffering from the kinds of disabilities that have historically confined them to nursing homes. This improvement also stems from healthier lifestyles and medical technological advances that aid recovery from strokes, broken hips, and traumas of aging. More importantly, during the past decade there has been expansion of services that allows seniors to stay out of nursing homes, including the advent and growth of home health care and the European model of residential long-term care which we call Assisted Living. These options have been eagerly welcomed by the elderly population who consistently say in consumer surveys that they would rather die, literally, than live out their last years in a nursing home.

So how can nursing home boards prepare for the inevitability of future change?

Despite the many negative aspects of existing nursing home environments, there are, in fact, many opportunities which are waiting to be explored. Essentially there are four options which need to be considered:

* Do nothing

* Convert to Assisted Living

* Integrate as a community resource

* Implement programs for sub-acute care.

Let's take a brief look at each option and then consider some of the specific issues that must be addressed in making a decision.

Do Nothing

Despite all the demographic data and consumer surveys, there will be those Boards who will choose to carry on doing what they have always done. This may have been an acceptable option ten or even five years ago. However, the pace of change in long-term care is such that a reluctance to invest now into exploring alternatives for the future will prove costly and could put at risk the very viability of any nursing home operation.

Convert to Assisted Living

Many nursing home operators are aware of the advantages of Assisted Living and are considering converting their environments and programs to a more residential model of long-term care. However, to simply repaint the walls and lay a carpet will not automatically imply that Assisted Living can work within an existing nursing home building shell. Assisted Living in its purest sense is based upon an apartment-style of environment with self-contained studios or one-bedroom residential units, clustered around smaller scale neighborhood services and social opportunities. A nursing home environment, without radical structural change, can not easily or cost effectively disguise itself as a residential/apartment building.

"We have looked into the option of converting to Assisted Living by upgrading our interiors, but we realize this would be no more that papering over the cracks."

Nursing Home Administrator North Carolina 

However, it remains an option depending on the local market, although it may need to compete with purpose-built environments which may look more attractive having the benefit of creating a residential character from scratch.

Integrate as a Community Resource

Looking at what you already have, and what existing markets you can tap into, may be a more rewarding and less risky option. Nursing homes do have the capability of becoming a hub of services: providing adult day care, vision clinics, rehabilitation programs and health promotion centers, thus supplementing the residential program they now offer.

The President's impending health care reform package will almost certainly imply moving the focus of health care delivery away from hospitals and toward community-based, satellite health care facilities. Those nursing homes already located close to their local communities will be well-positioned to take on and develop this role. Of course there will still be a need for Skilled Residential Care, but the center will offer the home the opportunity to diversify its services. The typical nursing home layout would lend itself to simple conversion for these additional programs, with perhaps additions for day care and parking.

Implement Programs for Sub-Acute Care

Perhaps one of the most important and exciting opportunities for nursing homes are the opportunities they will present in the future for the delivery of sub-acute care. Patients whose medical conditions still require twenty-four hour monitoring and perhaps some medical intervention, but are no longer in a critical condition, are generally referred to as sub-acute. Sub-acute care is perhaps going back full circle where the nursing home began with the medical model.

However, as hospitals are becoming centers of high-tech, short-term, acute intervention, so there is a growing need for that longer second stage of recovery to take place out of the expensive environment of the hospital and closer within the fabric of the community. The nursing home could be an ideal candidate to take up this role.

It would, of course, be difficult and certainly not desirable to implement an entire sub-acute program overnight. The market, however, is there. Initially one could consider converting a wing of a nursing home for sub-acute services. As opposed to converting to Assisted Living, the typical nursing home layout, based already on the medical model, would be more compatible with the space requirements for sub-acute programs. Engineering services would need to be upgraded, but this could generally be accommodated within the existing shell, with perhaps a few alterations and additions.

Specific Considerations

In any option appraisal, it is sometimes helpful to prepare a checklist of the criteria that those options will be appraised against. Below are just some of the key issues that could form a checklist:

* What is the current occupancy level at the home -- has there been a shift in demand? If so, where?

* How many residents actually require twenty-four hour nursing care as opposed to more personal care programs?

* How well-located is the nursing home in comparison with other community services?

* What percentage of the residents are private pay, and what seems to be the trend?

* What is the physical condition of the home -- would it require upgrading in any case to simply improve existing programs?

* Is the building capable of being adapted (structurally)?

* Is there land to expand upon?

* What will the impact of case mix assessments be on your facility?

* What is the local competition up to?

* What relations does the home have with local hospitals?

It is also helpful when appraising options to look at the bigger picture and to consider long-term planning. It would be helpful at this stage for the Board to review its original mission for the home and to decide whether or not that mission requires any revision in the light of changing circumstances. The Board may find it helpful to prepare two lists: a list of things that work and a list of things that don't work. Although this may seem to be a very simplistic and somewhat pedestrian exercise to undertake, it often does bring into focus problems which are sometimes tolerated, but not always declared or stated to the Board.

In conclusion, one thing is for certain: The days of the nursing home as the preferred model for long-term care are numbered. Change is inevitable, and nursing home administrators and their Boards should begin now to strategically plan and chart the adaptability of their facilities to meet the future.

Martin Valins is an architect and author who has specialized in the programming and design of long-term care. He is Director of Research with Reese, Lower, Patrick & Scott in Lancaster, PA