Closing the circle: the evaluation of Brewster Village; Does a facility upgrade really work for everyone involved? The authors placed one such project under the scientific microscope.

Only one year after its demolition, the old Outagamie County Health Center, with its origins in the county poorhouse and poor farm, is already a fading memory in the minds of residents in Appleton, Wisconsin, and surrounding towns. Attention is now focused on Brewster Village, the new 204-bed, county-operated skilled nursing facility, which sits adjacent to the site of the old Health Center.

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The story of the creation of Brewster Village was featured in DESIGN 2003 (Alden AL, Weisman GD. "'Inmates' to 'Villagers': The Creation of Brewster Village," p. 22), published by Nursing Homes/Long Term Care Management. The planning, programming, and design process followed what we characterized as an "action research" approach, marked by a high level of communication, collaboration, and group decision making among four key organizations: Outagamie County Health Center (OCHC); Horty Elving, Architects, of Minneapolis; Oscar J. Boldt Construction of Appleton, Wisconsin; and the Institute on Aging and Environment (IAE) of the University of Wisconsin-Milwaukee. The DESIGN 2003 article described the "front end" tasks (analysis of comparables, preparation of preliminary program, review of schematic design alternatives) for which IAE took major responsibility. This article describes the evaluation study of Brewster Village, also carried out by IAE, based upon data gathered during a two-year period from residents, staff, and families before and after the move to the new facility.

As a cutting-edge environment, Brewster Village is clearly different in many ways--architecturally and organizationally--from the antiquated facility it replaced. Some of these critical differences, as displayed in table 1, are the shift from shared to private resident rooms, more than doubling the social space per resident, and the clustering of residents in "households" of 13 or 14 rather than units of 30 or more.

Although the benefits for residents and staff of some changes, such as a 15% reduction in maximum travel distance from resident rooms to common areas and a 27% reduction in the number of residents who need to be moved more than one floor, are relatively self-evident, other psychosocial consequences of the relocation required more detailed study.

The Evaluation

Consistent with "action research," our approach was aimed at evaluating the consequences of the residents' relocation from OCHC to Brewster Village. Unlike the classic scientific method, however, our approach did not enable us to randomly assign OCHC residents to "experimental" and "control" conditions, because all OCHC residents were relocated, either to Brewster Village or elsewhere. Also, unlike a more traditional experiment, our approach did not begin with formal hypotheses regarding the impact of Brewster Village on OCHC residents, staff, and families. Indeed, different theories of elderly/environment relationships actually suggested three quite different outcomes of relocation--ranging from negative to neutral to positive.

Predictable negative impact of relocation. The impact of relocation on the elderly, either from home to institution or from one institution to another, has been researched extensively. In many of these studies, relocation is associated with increases in mortality and morbidity. While such negative outcomes can be ameliorated to some extent by relocation-preparation programs, such as that undertaken by Brewster Village, relocation theory would suggest neutral to negative consequences of a move, particularly for physical and psychological functioning of residents with diminished competence.

The continuing consequences of aging must also be considered when one is evaluating the negative impact of relocating the elderly. The interval between our gathering the first premove resident data and the final postmove data was roughly two years. Thus, among a sample of study participants with an average age of 73 at the initiation of the study, one might reasonably predict some continuing drop in competence, both physical and psychological.

Predictable positive impact of a therapeutic environment. It seems reasonable to predict that a new $26 million facility, designed and built to be therapeutic--for example, with protected outdoor courtyards (figure 1) and living rooms, dining rooms, and kitchens for each household--would have some positive impact on residents, staff, and families.

Measuring Responses to Environmental Change

We believe the most effective and meaningful environmental evaluations include both quantitative measures (based on "hard" numbers) and qualitative measures (more perceptual or judgmental). The quantitative measures employed in our evaluation are detailed in table 2. In all cases, we endeavored to contrast insights from those individuals--staff and residents--who not only have daily contact with Brewster Village, but also can compare it to their experiences in the old county home.

Although we were particularly interested in the impact of relocation on residents (their physical and psychological functioning, agitation, and activity participation), data were also gathered from staff (their satisfaction, stress, and burnout), as well as from family members of residents (their perceptions and satisfaction). While our particular focus was on the change in physical environment, we endeavored, consistent with a systemic perspective, to look at the impact of Brewster Village in terms of its organizational and social environment, as well.

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Findings regarding residents. Residents' comments about the development of the new facility, which they watched intently during the nine months of construction, have been positive. According to one resident, "In a way there is no comparison between the old building and Brewster Village. This place is wonderful." Residents likewise indicated that they enjoy their new private rooms and bathrooms, and that the small household settings provide a sense of community not present in the larger, 30-person units of the old facility.

With respect to quantitative measures, table 2 presents a general picture of residents' physical and psychological functioning during the two-year evaluation period. The overall trend is "no change"; it is as though the three outcomes cited earlier--negative, neutral, and positive--"balanced out." The exceptions were the mood/depression subscale of the Multidimensional Observation Scale for Elderly Subjects (MOSES, a standardized measure of residents' physical, cognitive, and emotional functioning) and the mood/behavior subscale of the MDS. Both of these measurements indicated significant improvements, while the communication/hearing subscale of the MDS showed a significant decline.

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Findings regarding staff. Staff response to the new facility has been exceedingly positive. This finding is particularly important, given the fact that the model of care employed at Brewster Village is quite different from that of OCHC and that staff duties have changed as a consequence. To encourage development of staff/resident trust, the households typically have one dedicated CNA for every seven residents. Staff have willingly incorporated the additional tasks of household duties, such as cleaning the kitchen, serving meals, and doing laundry. Direct-care staff have commented to the effect that "it's not more work, just different work. Even though we have extra duties, we have more time to spend with residents."

The new environment has also impacted the indirect-care staff, especially those involved with food service. The decentralization of the dining spaces into small-scale dining spaces in each of the 15 households was initially a daunting prospect for those involved. One-fourth of each meal (soup, vegetables, bread, rolls, and cookies) is now prepared in the household kitchen (figure 2). Brewster Village has also instituted a "Food Host" program, in which dietary staff spend 60% of their time in the household serving meals, cleaning/stocking the kitchen, and talking with residents about menu selections for the next day. What staff had perceived at the outset to be an impossible task, they now embrace. One staff member commented, "I was worried about having to deliver meals and spend time on the households, but now I love getting out of the kitchen and spending time with residents."

The data analysis of staff stress and satisfaction indicates, as with residents, a pattern of consistency, with few notable changes. Statistically significant improvements were noted in the Maas and Buckwalter Satisfaction Inventory subscales concerning satisfaction with working conditions and with the emotional climate (table 2). Premove data suggested that staff had been attempting to compensate for the OCHC's poor physical environment by transporting the 30 or more residents in their units to the relatively distant common areas and outdoor spaces, and had been dealing with behavioral problems caused by the inadequacy of those spaces, thus increasing their burden. The subsequent improvement in working conditions and emotional climate suggests that Brewster Village has had a positive impact on the staff.

Findings regarding families. Family members have also expressed enthusiasm about the new therapeutic environment. They expressed appreciation for the higher quality of life that the new environment provides for the residents, as well as the improved visiting atmosphere. "It's less like a hospital and more like a home," commented one family member. "The quality of care has always been high, and now the environment matches that high standard," observed another. Family visitation has developed into an important part of the residents' routine; rough estimates suggest that the amount of visitation might have more than doubled. In addition, visitations are now geared more toward extended families, including younger children.

Quantitative measures of family members' satisfaction indicated no change, principally because premove scores were already very high (a "ceiling effect"). Closer examination of the family satisfaction data indicates that, even with this ceiling, questions that dealt specifically with the physical environment showed a statistically significant improvement.

Conclusion

Brewster Village and its "villagers" reflect the dramatic changes in how our society now defines and provides care for the elderly, the developmentally disabled, and the chronically mentally ill. Traditional institutional models of care are increasingly being replaced by smaller-scale, resident-centered environments. Our goal was one of unfreezing societal understanding of what a long-term care facility was "supposed" to be. Everyone involved in this project was committed to making Brewster Village a national model for geriatric and dementia care, especially for a publicly financed facility.

The ongoing effects of Brewster Village are well-captured by the comments of one staff member: "I was giving a tour to family members and the wife of a resident broke down in tears. She indicated that we had given dignity back to her husband. It sent chills through me; I realized that we were only starting to discover what we had accomplished."

Administrator David Rothman, who initiated the Brewster Village project, describes what he has learned: "We knew that a well-designed environment could have positive effects on resident outcomes--but we learned that residents become more independent and quickly become more empowered in expressing their needs and wants, that families are more comfortable with visiting and participating in facility functions, that staff work more closely as a team, and that residents adapt more easily when they have a private space that is truly their own."

Table 1. Comparing the Outagamie County Health Center With Brewster
Village

                        Outagamie County          Brewster Village
                        Health Center

Maximum distance to     325 feet                  275 feet
  main activity area
Vertical distance to    67% of facility needs     40% of facility moves
  main activity area      to move at least one      one floor (not
                        floor (required daily)    required daily)
Social space per        30 sq. ft./resident in    70 sq. ft./resident in
  resident                unit                      household
Resident room           Double occupancy (125     Private rooms (255 sq.
                        sq. ft./resident)         ft./resident)
Location of activities  Centralized activities &  Decentralized
  and services            services: long travel     activities &
                          distances                 services: reduced
                                                    travel distances

Table 2. Results From Quantitative Instruments Used to Gather Data From
Residents, Staff, and Family Members

Instrument                           Significant  No Change  Significant
                                     Positive                Negative
                                     Change                  Change

RESIDENT
Cohen-Mansfield Agitation Inventory                   X
Activity Participation Scale                          X
Multidimensional Observational
  Scale for Elderly Subjects
  (MOSES)
  Self-Care Functioning                               X
  Disoriented Behavior                                X
  Depressed/Anxious Mood                 X
  Irritable Behavior                                  X
  Withdrawn Behavior                                  X
Minimum Data Set (MDS)
  Physical Functioning                                X
  Mood & Behavior Patterns               X
  Communication & Hearing Patterns                               X
  Cognitive Patterns                                  X
STAFF
Maas & Buckwalter Satisfaction
  Inventory
  Working Conditions                     X
  Emotional Climate                      X
  General Feelings                                    X
  Client Care                                         X
Maas & Buckwalter Stress Inventory                    X
Aiken Satisfaction Survey                             X
FAMILY
Family Caregiver's Instrument                         X

BY ANDREW L. ALDEN, MARCH, AND GERALD D. WEISMAN, PHD

Andrew L. Alden, MArch, is on the staff of Engberg Anderson Design Partnership, Inc., Milwaukee, and Gerald D. Weisman, PhD, is Professor of Architecture and Codirector, Institute on Aging and Environment, School of Architecture and Urban Planning, University of Wisconsin-Milwaukee. For further information, send e-mail to [e-mail] or [e-mail]. To comment on this article, e-mail [e-mail]. For reprints in quantities of 100 or more, call [phone].