Evaluating your facility's design: renovate or evacuate?

SCANDINAVIAN HOME, Cranston, RI. This cheerful LTC dining room occupies what was once a dingy and little-used basement. Windows beyond are outside the former foundation line, and provide view to a sunken courtyard created as part of the renovation project.

Have you noticed? Nursing facilities built as "state-of-the-art" as recently as 15 to 20 years ago are now seen as "hopelessly outmoded." This is a result of a growing elderly population; a more dependent population needing higher levels of care and demanding better environments; and the ever-present pressures of regulations. New health care standards and building codes, coupled with family expectations for a more "homelike" environment, are leaving many facility managers faced with the dilemma: Renovate the existing building? Or evacuate to new quarters? In making this important decision, a number of factors should be considered. These include: facility size, facility layout, life safety compliance, available renovation strategies, logistics and cost-effectiveness.

Facility Size

Existing gross floor area (GFA) for nursing care and support spaces is a useful indicator of renovation potential. A decade ago, a GFA of 350 to 400 sf per bed was satisfactory. Today, given the inherent inefficiency in plan layouts and new regulations like those of the Americans with Disabilities Act, 400 sf per bed is seen as minimal; 420 to 450 sf per bed is viewed as a better and more realistic departure point for renovation. However, even these "rules of thumb" apply best to larger facilities or new construction. For a small facility (50 to 80 beds) in an inefficient older structure, 500 sf per bed is often a better target for successful renovation.

Some existing facilities are so overcrowded, or contain so much wasted space in the wrong area, that arranging or renovating the facility is not possible. Take, for example, one Vermont facility, built in the 1960s, where the sf per bed was only 295. After an investigation, it was determined that no amount of clever rearrangement of partitions and doors could ever solve the facilty's severe overcrowding problems. As a result, this building was evacuated, and the LTC operations were relocated to new construction nearby.

At another facility, in Rhode Island, even 490 sf per bed was deemed inadequate because it included wasted space in the basement and too many single-occupancy resident rooms.

Generally, square footage is most usable for renovation on the entry and nursing care floors. Basement and attic square footage may sometimes be renovated to be more useful, but only when operations are carefully planned to either minimize or else facilitate trips between floors for related tasks. For instance, modern meal tray and cart service make it reasonable for kitchens to be located on one floor and dining on another.

Facility Layout

Even where floor area per bed seems adequate, structural configurations may impede successful renovation. Usable floor area may be spread among too many floors, such that a resident population of 90 is divided among three nursing units of about 30 persons -- a-unit size many operators regard as too small to staff cost-effectively.

Sometimes floor plates are large enough, but shaped wrong. Optimum width for a new nursing wing with patient bedrooms on each side of an 8-ft corridor is about 54 to 57 ft. Older facilities tend to be narrower in wing width (more like 45 ft), and therefore require room layout compromises if they are to be renovated.

Surprisingly, older facilities, built around the turn of the century, can be easier to renovate than "modern" ones. These old buildings often used both corridor and outside walls for structural bearing. This means that partitions perpendicular to the corridor are nonstructural and easily removed. Furthermore, old buildings usually have many small windows that occur at frequent intervals.

At one 80-bed facility in Montpelier, Vermont, it was found that despite wing widths of 42 ft, many new and useful room layouts were possible once the non-bearing partitions were gutted out. Windows at intervals of six to eight ft ensured that each new space got at least one window.

In contrast, a much newer 60-bed facility in Barre, Vermont, was found to be more spacious than the one in Montpelier. But with windows and concrete columns on a rigid 13-ft grid, there was no way to obtain resident bedroom modules other than 13 ft, and significant improvements to the room plans were not feasible.

Many of today's older facilities are composites of an original structure built early to mid-century, plus one or more additions built in subsequent decades. Unfortunately, these facilities were often designed (at least in part) as "rest homes" for the ambulatory elderly, and are thus afflicted with small floor level differences between one area and another. Really short interior ramps -- those ascending less than two ft or so -- can sometimes be retrofitted at the code-compliant maximum slope of one ft rise in 12ft. With height differentials over two ft, however, we've found that slopes of one in 14 or one in 16 work better for residents and staff. Either way, a small level change is a big nuisance that cannot be corrected, and finding a place to install 25 to 50 ft of interior ramp can be difficult.

Life Safety Compliance

Life safety code standards have gone through substantial upgrades in the last 25 years. Old facilities typically operate on waivers, but most states are increasingly intolerant of "grandfathered" conditions that are not up to code. Two of the major areas are means of egress and inadequate building structures.

One commonly encountered deficiency is the inadequate means of egress in multi-story buildings: stairs which are too far apart, or which discharge back into the building instead of outdoors, or which cannot be accessed directly from the corridor. Often such deficiencies can be remedied by a new stair lower appended to the the building exterior.

Deficiencies resulting from the wrong construction type are other major concerns. For instance, wood frame (house type) construction is no longer legal for multi-story nursing homes in most states. Until recently, code enforcement officials have been willing to consider sprinkler systems as acceptable protection for wood buildings. But this kind of leniency is in decline, and state officials are now pressuring LTC operators to evacuate their wooden structures.

Renovation Strategies

In some facilities, successful renovations can be accomplished simply by moving certain walls and doors, and implementing mechanical and electrical system upgrades.

* Strategic Addition

At most old facilities, a strategically placed addition -- even a very small one -- can open up a world of renovation possibilities. At one facility, an effective addition was accomplished by simply enclosing some outdoor porches; building up the porch floors 7 inches, and removing the former exterior wall, made it possible to join the porches to adjacent interior space. These enclosed porches added very little square footage, but obtaining new usable floor space at exactly the right spot resolved circulation problems and allowed for a new, more functional nursing core.

At another project, a large multistory combustible structure (vintage 1890) had been enlarged by a smaller concrete frame addition (vintage 1920). Modern codes prohibit nursing home patients from living above the first floor in combustible construction, and thus the 1890 building remained occupied as LTC due only to a fat file folder full of waivers. The entire property was made code-legal by supplementing the concrete frame addition with a new steel frame addition -- thereby assembling enough non-combustible construction to create functional, code-compliant nursing units. The combustible structure of 1890 was re-occupied for a different use.

Are additions realistic on tight sites? For most facilities, the answer is yes. Most new facilities occupy around four to six acres of land (even without septic fields). However, one recently completed addition/renovation project fit a 60-bed operation into less than two-thirds of an acre (part of a small city block). Although this project required some height and parking relief from the local zoning board -- and also forced the adoption of relatively small 21-bed nursing units -- the addition was effective. So even small additions can support major transformation -- if they are properly integrated, physically and functionally, with the pre-existing building. Rarely is a site so meager that it can not accommodate a small addition.

* Strategic Demolition

Sometimes the right answer is tearing out rather than adding on. One old building we dealt with had three fire stairs within 120 ft of each other. We demolished the center stair, filled in the voids with floor structure, and liberated sizable areas on several floors for a new lobby and bedrooms.

* Adaptive Use

In several projects, even though existing structures make poor LTC facilities, they can be used for other purposes, such as another form of elderly housing, e.g., retirement apartments or congregate care units. A typical adaptive use project consists, first, of constructing a LTC addition next to the occupied facility, then renovating the old building for new uses once residents are moved to the replacement construction. Often, when the "addition" substitutes for the existing building, it is larger than what it replaces.

Old wood frame buildings that are found non-compliant for nursing occupancies may be deemed fully code compliant for other types of residences because life safety codes are usually more lenient for other forms of elderly housing than for nursing care.

Other Critical Considerations

Even when the drawings show an interesting renovation scheme, considerations other than floor plans and codes will affect the renovation decision. For instance, consider the logistics of getting work done. While nursing home residents often find construction to be interesting, working in occupied space is a major challenge for both contractor and staff. Moving beds, desks, and construction activity back and forth inside an operating facility can become a nuisance. This was the case on a recent project where the contractor had to set floor tile in 4-ft widths -- first on one side, then the other, of an 8-ft corridor.

When doing renovation work, it's worth considering reducing the facility census by 25% to 30% for the construction timeframe. This is especially advisable where construction is taking place in resident bedrooms. Often, though, relocating residents for the short term is not practical. In these instances, a project can be successful when residents exit their bedrooms in the early morning and return at night to a new and improved space, with a new sink, fresh paint and ceiling tiles, and improved lighting. Needless to say, this kind of success requires excellent cooperation between the facility's staff and the work crew. This might be motivated by remembering that reducing patient census during construction impacts revenue and could be considered a construction cost, in itself.

Cost effectiveness. Basic gut rehabilitation eliminates all nonstructural elements within the building shell and provides new spaces, with new finishes and utilities. This kind of construction -- which must also include demolition and hazardous waste disposal costs -- will often carry a price tag per square ft of about two-thirds that of new construction.

However, many rehabilitation projects, by choice or necessity, continue on to include new windows, roofing, structural modifications and even new elevators. When construction scope expands like this, costs can approach 80% to 90% of new construction. At this point, one must stop and ask: Is it really worth it? Will the renovated building be a splendid facility -- or will it have so many compromises and shortcomings built in that spending a little more for a new facility becomes the wiser choice? Many proposed renovation projects become abandoned -- and properly so -- when studies disclose that the finished project would cost almost as much as new, but still contain important deficiencies.

Epilogue: Get It Right the First Time

When building projects go off track, it's not so much because the project team does its job wrong, but rather because the team does the wrong job. They renovate when they should evacuate, or vice versa. Unfortunately, there are no simple, unequivocal rules for making the decision. The choice between renovation and evacuation depends on the careful weighing and balancing of many factors. We suggest:

* Giving renovation every possible chance. Before reaching a premature conclusion, make sure you have fully considered all the options for conserving and upgrading your existing facility. A good renovation architect should be able to show you possibilities you would never imagine on your own. A well-thought-out renovation project may help conserve an historic structure, forestall abandonment of a potentially valuable asset, and let you continue operations in your traditional community setting. All this comes on top of possible savings in construction costs.

* Avoid reality denial. Don't feel an obligation to stick with the renovation option just because you've done a lot of work thinking about it. If the best renovation proposals still don't solve key problems or provide an environment you will like, it's probably time to start looking for a new site and structure. At all costs, make no piecemeal improvements (the new elevator, the air conditioning upgrade) which are not plainly part of a long-term strategy for maintaining and enhancing the building.

* Take the long view. Don't base your choices solely on what seems most expedient or least expensive for the next two or three years. Amortization of building costs are usually only 12% to 18% of your facility's annual operating budget, and whatever you choose to do now will probably have a life span of 25 years or more. Prior to arriving at a decision, think first about how the intended project will benefit and serve residents, staff and the surrounding community -- not just for today, but for many years after its completion.