Best-practice design for the bathing facility: ADA guidelines need to be re-examined. (Feature Article).

For many a nursing home operator, the Americans with Disabilities Act (ADA) seems like enough to worry about when it comes to creating a handicapped-accessible facility. Once you and your designer have created or renovated a space that the local building department finds to be ADA-compliant, your work, so far as that goes, is done. Correct?

In fact, there is a growing movement among healthcare designers that says that ADA compliance really isn't "correct" when it comes to designing for the disabled elderly who typically reside in nursing homes and, increasingly, assisted living. "ADA accommodations tend to focus on the younger disabled," notes architect Cornelia C. Hodgson, partner, Dorsky Hodgson + Partners, Inc., Cleveland, Ohio, "who often have lower limb disability but good upper body strength facilitating independent transfer--not the description of the typical frail elderly person." Several studies have found that, as a result, ADA recommendations have little to do with meeting the specific needs of elderly residents and in some cases can aggravate them.

This issue came to a head with the recent publication of a report by the United States Access Board, an ADA-specific federal government study group, that focused on bathroom design in geriatric facilities. The Access Board is charged with examining ADA recommendations in line with their impact on specific population groups. The Board's report, issued in November, indicated among other things that ADA-compliant standard bathing facilities don't work for increasingly frail populations. For instance, grab bars installed according to ADA guidelines facilitate moving oneself about within a tub or shower but not an assisted transfer. Also, a fixed seating arrangement in a tub can be more of a hazard than a help to a frail older person, and climbing in and out of a tub becomes less and less a possibility.

According to Hodgson, an advisor to the Access Board, this led the Board to propose several options: Roll-in showers with seating that is adjustable and even removable altogether, if the resident so wishes; vertical grab bars located outside the shower or tub, allowing residents to stabilize themselves while being dried or dressed by a caregiver; room for the caregiver to provide bathing assistance; and protective half-walls for the caregiver to stand behind to avoid getting wet.

The Board also makes specific mention of walk-in tubs. Their advantages for access are obvious, although the Board notes that a possible drawback is the need for a bathing resident to wait in the tub as it is being drained; also, because of their height, these tubs do not permit installation of all ADA-recommended grab bars (whether they're relevant or not).

Hodgson offered a few further thoughts on optimal design for bathing in assisted living facilities. "A big issue is to make the tubs less medical-looking. Tub controls, for example, might be concealed behind a curtain or towel. Decorator colors are a good idea--one doesn't always need white or hospital green. The tub shouldn't look odd or strange; it should look like something you'd want to take a bath in. I would also suggest that an assisted living tub be six feet long, rather than five feet, and that they provide seats that straddle the tub wall so that a seated person can swing her legs in and out of the tub safely and comfortably."

What about addressing the "sales appeal" of an oversized assisted living bathroom located in a unit that is supposed to look "homelike"? Hodgson offers an unusual suggestion: "When I'm traveling, I'll often visit a Ritz-Carlton or Four Seasons or some other high-end hotel and ask to visit their handicapped suite in order to see how to provide barrier-free access with an upscale appearance. I find that the room doesn't have to be huge or intimidating if it is carefully designed. You can do beautiful barrier-free."

Right now, though, the struggle is on just to get local building departments to go along with any handicapped accommodations other than those strictly defined in ADA guidelines. "They have no reason to stick out their necks," says Hodgson. "The Access Board report is one step in a process toward publishing revised guidelines. In the meantime, these are options that facility operators and designers can push for, and hope for the best."