Considerations toward a conversion.

Renovating and adapting older facilities for assisted living and subacute care will pose challenges. A case in point.

To convert a traditional 204-bed nursing home into a combined 172-bed SNF/68-unit assisted living facility is no easy feat. As of last December, though, our firm completed the $6 million renovation, conversion, and new construction for Harwich Road Realty Trust of Brewster, MA. It is called Brewster Place, and all of us involved view it as a learning experience.

We reviewed the market analysis (required for HUD financing) that was conducted by the owner. It disclosed that the existing facility had too many of the wrong kind of beds. Though the conversion would meet a strong need for skilled nursing beds, the market survey also revealed that Brewster's assisted living-qualified population was not being served.

We realized that we needed to create two separate entities for the two different populations. That meant designing separate entrances, so that those entering the assisted living building won't sense the proximity of the adjoined skilled nursing facility. The assisted living entrance was located at the rear of the skilled nursing facility. The two populations never cross paths when entering the manor.

Meanwhile, the nursing facility looked dated, and we did some cosmetic work to make it look compatible with the assisted living structure. The assisted living exterior uses similar materials and colors to make a connection with the skilled nursing facility. Though the building is designed with a variety of elements that distinguish it from the nursing home, the nursing home was modified to break up a very long, monotonous facade - essentially by taking elements from the new construction, such as covered porches and mansard roofs, and applying them to the nursing home.

Interior design of a combined facility presents its own challenges because the two types of facilities are governed by different requirements. The interior design of all skilled nursing facilities in our state is somewhat constrained by Department of Health regulations. Dimensions have to fall within certain measurements and programming space has to be separated from living space. Assisted living has no such regulations, and allows more flexibility in terms of arranging spaces.

However, having both areas feel more residential, both on the exterior and the interior, was a design priority. Also, the administrative offices and reception areas, which previously had been extremely institutional, were completely reorganized. A residential setting was recreated in the main public spaces using a combination of correct lighting, appropriate furnishings, wood trim moldings and attractive color choices.

The commercial kitchen, built originally for the traditional facility, is the only component that the two programs share. Kitchens are very expensive, but with some minor design work, we made it more efficient to accommodate the increased output for the assisted living units. The office was moved to an under-utilized storage closet, allowing for more food preparation space. By adding doors and rearranging the dishroom, we were able to better serve traffic circulation needs. Some kitchen equipment was upgraded and additional equipment purchased. A remote existing kitchen was converted into a remote production and warming kitchen, located adjacent to the new assisted living dining room.

The assisted living section is actually a combination of new construction and renovation of existing structures. This modified the cost of the conversion - much of the plumbing was already in, the windows and roof appeared adequate, and the existing plumbing stacks could be reused. In all, new construction amounted to 36,000 square feet, and was devoted mostly to common spaces, such as living rooms and libraries, as well as the reception areas. The rehab for the assisted living portion encompassed 8,000 square feet.

The assisted living units are studio apartments built for single occupancy. They have a private bathroom with a shower, and a small kitchenette. Studios were chosen for this particular market based on affordability. There is little to no financial assistance for those elderly who choose assisted living.

Conversion of the nursing home to a skilled nursing facility acknowledged residents' higher acuity levels. For example, there is less need for a single large dining room and more for on-unit or in-room dining. We therefore converted the large dining area into a multi-use space for common usage: one third of the room was kept as a small dining room and two thirds converted to an activity room for SNF residents.

A practical consideration in converting any occupied building is where to put the residents while this is going on. How do you do a renovation and build a new construction without displacing people? To the extent you can, you figure out the movement of people in context with the construction - a logistical puzzle and difficult to predict. A formula needs to be worked out before the new construction is undertaken. When it is done in phases, for example, nursing home residents who are assisted living-appropriate can be moved into the assisted living facility.

I'd like to claim that we figured it all out, but things happened that were unanticipated, including an outbreak of the flu on the nursing unit which stopped construction for a week.

"Aging in place" is a new trend, as illustrated at Brewster Place, which is developing in long-term care facilities. It is almost always a big decision for people considering moving out of their homes into a facility, and it helps if people feel some assurance that their needs will be met over the next 10-15 years. To accomplish this, facilities have to be able to accommodate the movement of seniors from independent and assisted living to skilled nursing, smoothly and with little disruption. This is a challenge that all of us connected with long-term care must face.

Michael Liu is principal and Gary Kane is project manager at The Architectural Team, Inc., Chelsea, MA. For further information, call 617-889-4402.