Coming: design to minimize resident moves; Interview with Susan Mack, OTR/L, CAPS, president, homes for easy living--universal design consultants.

People just want to stay home. That simple statement underlies what many are calling the future of long-term care: the surge by many states toward Medicaid-financed home- and community-based services; the Bush administration's encouragement of same (see "Gazing Into a Crystal Ball" by Alan E. Schabes, Esq., October 2004, p. 92); and the ongoing census troubles of nursing homes and even assisted living facilities. And yet an essential component of this trend--the use of universal design to accommodate aging in place--has implications for assisted living and nursing homes for a couple of reasons: (1) Most residents, once having moved in, would rather not leave those facilities either, and (2) it's always good to know what your independent living colleagues are up to. Recently a leading proponent of universal design for senior living, consultant Susan Mack, OTR/L, CAPS, surveyed the long-term care horizon with Nursing Homes/Long Term Care Management Editor-in-Chief Richard L. Peck.

Peck: I understand that you come at this from an occupational therapy back-ground.

Mack: That's true. Occupational therapy, as you know, involves modifying the environment to facilitate a person's ability to function. As an OT, though, I was frustrated. You prepare clients for home and then find out that the home is fraught with architectural barriers they had never thought of as potential obstacles to their returning home. Everything we had accomplished in our facility's supportive environment was lost. And people themselves didn't want to spend the money on making the necessary modifications to their homes. Today's elderly, in particular, came out of the Depression era and are fiscally conservative. They just say, "Don't worry, honey," and go home and substitute sponge baths for bathing, resulting in skin breakdown, and stop cooking, resulting in nutritional status deterioration. They become socially isolated because of their inability to navigate stairs.

[ILLUSTRATION OMITTED]

We did what we could. From when I was a student in the 1960s, I used to make adaptive equipment by hand, like the built-up spoon handles that the OXO company has made mainstream today. It took about 20 years for the light to come on for me that this sort of environmental and product design could be beneficial to everyone, that these modifications have universal benefits--hence the name universal design.

Peck: Universal design has taken the knock in some quarters that building in accommodations for later-life disability makes a residence look like an old person's home before its time. Your thoughts?

Mack: Universal design, when it is done well, is beautiful. In my work on universally designed homes, I'd say 80% of my buyers are able-bodied adults who are not at all frail. As long as the design is not obtrusive and institutional-looking, clients love the open, spacious, and user-friendly floor plans and see the ergonomic benefits, as well as the future aging-in-place benefits, and are appreciative. Universal design is something, by the way, that can benefit institutions. Assisted living is designed for caregiving, not necessarily for enhancing independence, but universal design can do both. And when you step into a nursing facility, as I have, and see bathrooms too small for the caregiver to provide assistance, you know that there is still a lot of need for better education in universal design.

Peck: Just what is universal design, in your view?

Mack: Universal design is not just an accessible bathroom. It is a supportive community designed to accommodate diversity and ongoing changes in human function. Universal design has five basic components:

1. It has enhanced safety built-in with, for example, convenient and sturdy grab bars, enhanced lighting for aging eyes, and reduced trip hazards, such as no-step entries and walkways, and close attention to transitions from carpet to hard surface flooring.

2. It is ergonomic: For example, providing raised, front-loading washers and dryers will benefit not only the elderly but everyone with a bad back.

3. It is work-simplifying; universally designed kitchens, for example, make meal preparation safer and easier, with minimal distances to traverse.

4. It is inclusive, offering options for everyone from granny to the XXL football player down the street; that means it is adaptable and flexible to meet the needs of diverse ages, sizes, and abilities.

5. It affords the ability to age in place in family neighborhoods, as well as retirement communities.

Peck: What interesting innovations are you seeing in this field?

Mack: You see some vendors now trying to mainstream universal design into private housing. Kohler is an example: It now offers a selection of "comfort-height" toilets. We're seeing better shower products: better designed grab bars, and molded seats, and thresholds that are low, flexible, or even removable; Comfort Design, Best Bath, and LASCO are putting out nice products here. Moen is marketing grab bars that match the designs of its high-end faucets in overall finish. In kitchen design, Frigidaire is marketing side-opening ovens for ease of use. Whirlpool came out with its front-loading, front-controls, raised-pedestal Duet washers and dryers to reduce stress on the back. So vendors are most definitely responding.

Peck: Do you see signs that the home-based and institution-based sides of long-term care are coming together on this?

Mack: It was interesting that, at a recent national Seniors Commission hearing in San Diego, one member of the commission, a top person in assisted living, kept referring to aging in place--but, in this case, his place. And yet many in housing take it to mean aging in a private home, not a facility. Yet the sides are coming together--because they have to.

Recently, for example, Malcolm [Mac] Kennedy, an assisted living developer and former president of the National Association of HomeBuilders' Seniors Housing Council, opened an independent living community in Newark, Ohio, that uses many universal design features. These for-sale duplex condos designed for aging in place are real property assets that will appreciate in value over the years.

Mr. Kennedy didn't see my concepts as a threat but as an opportunity. His campus has an established assisted living facility across the street and has arranged it so that its very attractive dining facility is open to the independent housing residents. This relieves them of having to cook from time to time, and introduces them to the facility and allows them to feel comfortable there. When the homeowners need to move to a higher level of care, this preexisting relationship will make moving into assisted living much less traumatic for the residents. I must say that, in general, this CCRC concept is something that I like a lot.

Peck: Any final reflections?

Mack: Well, I just had my 55th birthday this summer and, frankly, I can't wait to move into some of the more forward-looking, age-restricted communities I've seen. But we have a way to go. Some very famous senior communities are not universally designed. Yet, as we know, "active adults," as we call them, are forever wearing out their joints by skiing and playing tennis and golf. Unfortunately, with the development of any serious mobility problem, they're on their way to a nursing home for recuperation.

There is an effort being made throughout the country to adopt incentive programs that will give developers points, and therefore better access to funding, for projects that incorporate universal design features. But moving the idea along can be difficult at times.

The demographics make it obvious that we, as a society, need to create a comprehensive program to meet the huge current and future tidal wave of housing and long-term care needs of our seniors. Using universal design to extend independence and support caregiving in the home is only one of many solutions that we need to implement as soon as possible. Collaboration between housing and senior care professionals will be essential to effective community and program design.

For more information, visit www.homesforeasyliving.com. To comment on this article, e-mail [e-mail]. To order reprints in quantities of 100 or more, call [phone].

RELATED ARTICLE: A Long-Term Care Opportunity

As Susan Mack notes in the accompanying interview, developer Mac Kennedy does not see universal design posing a threat to the assisted living facilities he's helped create throughout Ohio. Quite the opposite: "There will always be a need for assisted living," says Kennedy, "even when we help people stay in their independent environments longer. The way this works out, this can be a feeder system."

"This" is a community of 26 condominium units that The Jerry McClain Company of Newark, Ohio, built adjacent to a 91-unit, 63,000-sq.-ft. assisted living facility in nearby Heath. The campus is called Chapel Grove Inn & Cottages. One of the selling points of the units has been their incorporation of design features that allow occupants to function gracefully as they age: exteriors that allow easy access by eliminating steps at entryways and reducing walking distances along sidewalks; kitchens featuring low-rise work areas and side-opening ovens; bathrooms with no-step showers and blocking built-in behind walls around toilets to support future installation of grab bars when needed; wider-than-usual corridors and doorways--in sum, homes that remain attractive for active adults while offering capabilities for aging in place.

Kennedy, a vice-president of The Jerry McClain Company, notes that the condos and assisted living are intended to function as a campus. He has taken positive steps toward familiarizing the condo occupants with their assisted living neighbors by offering vouchers for meals in the assisted living dining room and use of its exercise classes. "About half are using the dining room at least once a week," he says, noting that this frees them from the hassles of cooking every day and, in the process, gives them more of a feeling of familiarity with the facility and its staff. This should reduce the trauma when the day comes when a move to assisted living is inevitable.

For more information, contact Mac Kennedy at [phone].