IT BEGAN WITH A PROMISE.

HOW COMMITMENT TO A GOAL GUIDED ALL DESIGN DECISIONS FOR THIS NEW ALZHEIMER'S UNIT

Founded in 1949 and located on the west Side of Madison, Wisconsin, Oakwood Village now provides independent and assisted living apartments and skilled nursing care for more than 400 residents. By 1998 though, it had become apparent that the needs of otherwise healthy residents suffering from early stages of Alzheimer's disease and related dementias were not being adequately addressed. An environment was needed that would support their independence within secure surroundings. When Oakwood Village's Executive Director John Noreika spoke at the dedication of their new Covenant Oaks dementia care, assisted living facility this year, he reminded those in attendance of Oakwood's promise to serve older persons by responding to their "physical, social, emotional, intellectual and spiritual needs..."

This is the story of how that gap was filled through a design and construction process that reaffirmed the promise made to the community.

The process involved family members, residents and staff working together as a team with Oakwood's board, OWP&P Architects, and I. H. Findorff & Son Construction. Specific goals were established early in the design phase, providing a foundation on the basis of which all decisions were made--from conceptual planning through the development of construction details. The twelve goals were posted at every meeting throughout the design effort and remained the focus throughout. These goals included:

Let the physical environment be a living metaphor of the Oakwood mission.

Overall Goal

As evidenced by the responses to the following goals, the entire program for this facility, as embodied in the completed construction, is designed to meet the "physical, social, emotional, intellectual and spiritual needs" of the residents who will call this place home.

Responding to Residents' Physical Needs

* Provide secure shelter, warmth and food. This most basic and obvious of goals proved nonetheless challenging with this project, given the desire to create a homelike environment. The balance between safety and residential character is key to the success of the new unit. The entire floor is accessible to the residents, allowing them to experience alternative indoor and outdoor spaces that are secure and supervised. Access to staff areas, on the other hand, is discouraged via low light levels, less pronounced signage, unobtrusive doorways and the absence of dead-end corridors.

* Ensure an appropriate range of environmental and sensory stimulation and information. Positive stimuli are emphasized, while potentially deleterious sources are carefully controlled. Thus, there are music programs, but no paging systems. Because exit doors are unobtrusive and the unit is inherently appealing, instances of alarms set off by elopement attempts have been rare. Vinyl-backed carpeting provides aesthetic, acoustic and safety benefits, while minimizing potential odors caused by incontinence. Aromas created by serving meals within each household enhance resident appetites and, as a result, help control weight loss often associated with dementia.

* Provide opportunities that support programs for wandering. Corridors are kept to a minimum and are frequently punctuated with open areas and views to both external and internal spaces, yet a variety of continuous circuits is available for residents to explore. Programming and activity centers encountered along each route encourage engagement rather than aimless wandering.

Addressing Social and Emotional Challenges

* Break the scale of the total environment into smaller groups of neighborhoods. This was achieved early in the planning process by creating four distinct households.

* Maintain an individual's right to privacy, choice and control. A hierarchy of spaces occurs in each household and along "Main Street" for varying levels of privacy and community. In addition the interconnected house-holds and secure gardens provide an unprecedented freedom of movement for residents.

* Create unobtrusive opportunities for social interaction. Interior and exterior spaces are arranged to continually redirect residents' attention toward inviting common areas. In this way, opportunities are created for spontaneous interaction, thereby encouraging meaningful relationships with other residents and staff.

* Allow space within the program for family and volunteer support. As with any such facility, programming cannot be adequately supported by staff working alone. By virtue of the warmth, scale and comfort of the environment, family members and volunteers are encouraged to make this unit their "home away from home," thereby motivating them to visit often.

Supporting Intellectual and Spiritual Well-Being 

* Emphasize links with the past and with the familiar. Early focus groups, including residents, staff and family members, established the interior image of the households. Each house-hold has its own unique decor, furniture and detailing to both assist in wayfinding and allow the family to decide which environment is most reminiscent of home for the particular resident.

* Support those abilities not totally impaired by dementia. Multiple cueing devices assist residents as well as family members and staff in orienting themselves. These include memory boxes, artwork themes, landmarks (grandfather clock, quilts, aviary, etc.), color, pattern and signage. Residents are encouraged to engage in activities such as doing laundry, setting tables for dining, assisting in meal preparation and washing their own dishes.

* Support and reinforce each resident's understanding of where he or she is in time and space. The strong relationship to the outdoors, both visual and physical, provides the most effective reinforcement for remaining cognizant of the time of day, the season and the location of each space relative to other parts of the facility.

Looking Ahead: Allow for Change and Changing Needs

Alzheimer's research is proceeding at an ever-quickening pace, and there are indications that effective treatment, and perhaps even a cure, could be on the horizon. Moreover, care delivery philosophies and methodologies are themselves continuously evolving. Thus, to tailor a facility too specifically to the treatment of a particular pathology can result in premature obsolescence. Covenant Oak has therefore been planned in a manner that would allow it to be readily converted to conventional assisted living, should market conditions so dictate. Brief descriptions of key design components will help explain how these goals and strategies were implemented.

The basic plan arrangement consists of four households connected by a "Main Street" circulation "spine" containing common functions. Each household consists of eight private rooms and one semiprivate suite and houses up to ten residents. Two such households combine to form one neighborhood around a shared secure garden. Each neighborhood has its own spa for assisted living or independent bathing, a garden room and an activity room. Both the garden room and the activity room provide direct access to the internal courtyard. The connecting link provides shared amenities, including a business center, salon and library, along with staff support offices and workrooms.

Each of the four households centers around a "country kitchen" that encourages resident participation while serving as the central point of observation for staff. The kitchen opens into a dining/activity room with direct access to a secure courtyard. A small working nook allows staff to perform administrative tasks while maintaining visual supervision. A "fireside lounge" within each household provides residents and family members with a quieter place to visit. In addition, each household contains a laundry/activity area where residents can engage in familiar "chores," by doing their washing and ironing.

The resident rooms are furnished by the residents and their families. Each room features a small foyer, which acts as a buffer between the public and private zones. The European-style bathrooms--which are entirely waterproof, including light fixtures--feature a toilet and sink, as well as a removable shower wand that transforms the entire room into a private shower. This solution allows for assisted showering within the privacy of each resident's room and facilitates cleanups necessitated by incontinence, while occupying less space than a shower stall. The toilet is visible from the resident bed to serve as a constant cue.

The story ends where the process began: with the residents themselves. The design process was informed from the start and, at the end, finally demonstrated that this place would not only be homelike, but would in fact be the residents' home. That focus expedited all decisions.

Margaret J. Cervantes, AIA, IIDA, and Robert C. Pfauth, AIA, NCARB, are with OWP&P Architects, Inc., a full-service design firm based in Chicago, with a dedicated LifeCare group specializing in environments for the older adult.