Let's stop tweaking a flawed modeling.

Although she doesn't see herself as a "contrarian," interior designer Cynthia Leibrock admits to a fondness for controversy. And she is prepared to stir one up with her unorthodox views on that recent ideal of long-term care design, the "homelike" environment. In her view, although designers have swung away--and rightfully so--from the purely institutional model, they have gone too far. It is time to see healthcare design in a new light. Leibrock is qualified to criticize, having been a notable interior designer in the field for 30 years, author of three award-winning books, an instructor at Harvard University for more than a decade, and proprietor of the Easy Access to Health, LLC, consulting firm and the AgingBeautifully.org Web site. She recently explained her views in an interview with Nursing Homes/Long Term Care Management Editor-in-ChiefRichard L. Peck.

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Peck: There seems to be a trend to make healthcare environments more "homelike," but you seem to be going on the premise that homelike isn't enough.

Leibrock: It's not that homelike isn't enough. "Homelike" healthcare environments erode confidence in the professionalism of what is essentially a healthcare facility. I, for one, would question the competency of a provider working out of an office or a facility that looks like a tacky home, with cute wallpaper borders, artificial plants, and wood paneling--not to mention design touches that pose potential infection-control problems, such as flounces that collect dust, wall textures that provide a growth environment for microbes, and other homelike but possibly hazardous materials. A qualified healthcare designer finds the line between a stark, institutional environment and a "homelike" environment cliche. Look at some of the long-term care projects designed by Susan DiMotta with Perkins Eastman. She does a great job of finding this line.

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What we really want is not a homelike environment, but a healing environment--an environment with soft colors, warm finishes, music, healing gardens, and the like that support health. We also need a more rehab-centered long-term care model oriented to helping people to become more independent and more interested in doing for themselves.

Peck: What factors should LTC designers take into account to be more rehab-oriented?

Leibrock: The psychological impact of the environment is often overlooked. We have design research available documenting that the built environment can reduce stress and depression. In my latest book, Design Details for Health, I cite research correlating the soothing sounds of moving water with relaxation, linking sunlight exposure to enhanced well-being and reduced length of stay, and documenting the therapeutic benefit of healing gardens. Pleasant aromas have been shown by research to reduce the levels of blood pressure, respiration, and pain perception. Unpleasant odors, such as those of urine and ammonia, can trigger feelings offear and anxiety, but appealing fragrances, such as spiced apple and strawberry, have been shown to reduce stress. Research has shown that hospital patients assigned to rooms with window views had shorter postoperative stays, had fewer negative evaluations by nurses, and required less medication. Research also proves that window access improves memory, orientation, and sleep, and reduces hallucinations and visual disturbances.

Peck: How might facilities be designed to motivate older people to adopt healthy habits and positive attitudes?

Leibrock: Design can make it fun to stay positive and healthy. For example, I remember one patient who resisted bathing. We thought we could solve the problem by offering a large shower with controls that were easy to use, but the patient still had no motivation to bathe ... until he discovered the hot tub. This made getting cleaned up fun--and, because he had to take a shower before he could use the hot tub, the bathing problem went away.

Peck: In viewing the facility as a place providing healthcare, what design concepts would help patients develop confidence in the facility's healthcare orientation?

Leibrock: Some of the ideas supporting professional healthcare provision are obvious--for example, reduce clutter in the common areas and make sure that the waiting areas are not littered with old magazines covered with dried food--in other words, look professional. You would be surprised at how often I see these abuses. Other ideas are more subtle: Avoid environmental stressors such as poor air quality, noise, inadequate lighting, unpleasant odors, and lack of privacy. Provide patients with control over their environment, perhaps in choice of music, lamps for additional task lighting, and accessibility features that keep them caring for themselves to the extent possible. All of these are steps toward promoting good health.

Interior designer Jain Malkin offers some of the best ideas for professional healing environments in her book Hospital Interior Architecture: Creating Healing Environments for Special Patient Populations. Much of what she writes is quite relevant to LTC settings. My three-day course at Harvard on universal design offers further suggestions for keeping patients interested in and responsible for their own health [see www.AgingBeautifully.org/Harvard.html], as does the article I authored recently for DESIGN 2004 ["Practical Applications of Design Research on Aging," p. 20].

Peck: How would design for post-acute care relate to residential design in a particular facility? Should there be separate areas of the facility for these two approaches? Or should homelike concepts be worked into the post-acute design and, if so, how?

Leibrock: Design for post-acute care should not relate to residential design. In my opinion, it's not okay for people to "reside" in healthcare facilities. The best long-term care facilities provide geriatric rehabilitation and have a great track record of returning patients to their homes. We can learn much about this from European long-term care providers.

Peck: What are some lessons we can take from overseas?

Leibrock: The Dutch build apartments in which residents are guaranteed that they will never have to live in a healthcare facility or be moved from housing to assisted living to skilled nursing. Imagine a network of friends and services that remains in place for a lifetime, with medical records in-house and an outpatient geriatric rehabilitation center on-site, together with Alzheimer's daycare. Healthcare is provided in each apartment--every 15 minutes if necessary.

In our country we offer the continuing care retirement community (CCRC), which threatens to punish the resident if he or she becomes seriously ill ("we'll move you"). This threat of relocation hangs over the resident, even if the move might be just to another wing or building on the same campus. Moreover, this model leads to segregation and discrimination. When residents are segregated by acuity level, we find that independent living residents begin to resist dining with skilled nursing residents. They won't even visit friends in a place that they might end up having to occupy. This is discrimination.

We have spent too much time tweaking the residential model. Basically, we need to stop delivering the patient to the healthcare and start delivering the healthcare to the patient.

For further information, send e-mail to [e-mail]. For information on Cynthia Leibrock's two Harvard University courses, visit www.AgingBeautifully.org/Harvard.html. To comment on this article, please send e-mail to [e-mail]. For reprints in quantities of 100 or more, call [phone].

Interview with Cynthia Leibrock, MA, ASID, Hon. IIDA