Nursing homes: now healing from the outside in; Strategic site design is giving traditional nursing homes enhanced resident appeal.

From independent living facilities to hospice care, assisted living, skilled nursing facilities, and continuing care retirement communities, seniors today have many housing options. Above all, they are looking for facilities that will provide optimal care, treating them with dignity and respect and allowing them to maintain, as much as possible, the independence and quality of life with which they are accustomed.

Although certain senior housing types, like assisted living, have long offered apartment-style living and other quality amenities, nursing homes are becoming more competitive in the senior housing arena--upgrading from the typical institutional-style twin-bedded rooms with shared bathroom facilities to single-bedded rooms with private baths and other amenities. As a natural next step, nursing homes are taking it outside, extending upgrades to the outdoors by giving these campuses a more residential feel and adding amenities like courtyards and rehabilitation gardens.

Steve Levin, president of Continental Wingate Development in Massachusetts, developer of more than 20 senior care facilities, knows the importance of good landscape design for senior housing sites, noting that it is "critical" to the development's overall program. "It is the first thing you see," says Levin, "and it creates a certain image and sets the stage for the nursing home site."

Another factor driving the trend in nursing home site design upgrades is the increasing number of younger, more mobile short-term rehabilitation residents in these facilities. Levin says that Continental Wingate has observed an increase in these types of residents and, as a result, has added short-term care wings to many of its nursing home sites. As younger, often more a mbulatory residents come to nursing communities, more accessible campuses with amenities, such as scenic walking trails and gardens, will be more in demand.

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A Home Away From Home

Nursing homes have traditionally projected an institutional feel, typically with minimal landscape design. Now, for the reasons described above, nursing homes are renovating their sites to appear more residential. This effect can be achieved by adding:

* warm outdoor, residential-scale lighting, such as wooden post lights and ornamental lighting at building entries

* plant materials traditionally found on single-family home sites, including flowering shrubs and material that attracts birds and other wildlife

* materials such as stone walls and brick or stone paving versus concrete

* residential site furniture, such as movable tables and chairs and comfortable outdoor rocking chairs

* fencing and screening made of wood or other warm materials

Through these site additions and strategic material selection, nursing homes can create a landscape that reminds residents of home and makes them comfortable with their new surroundings.

The Great Outdoors

In an attempt to connect nursing home residents with the outdoors, facilities are upgrading sites with amenities such as easily accessible outdoor terraces and walking paths. These outdoor spaces are designed to have a very natural look and feature plant materials and other elements, such as birdhouses, that attract wildlife.

In Dedham, Massachusetts, Hebrew SeniorLife's NewBridge on the Charles, a 159-acre senior campus community (offering all levels of care), is planning to include more than three miles of interconnected trails weaving through a sylvan site. Because this development will be part of an intergenerational community, sharing a campus with a K-8 school and early childhood education program, the accessible walking trails will also connect such elements of the campus as the school's playing fields and recreation areas, thus encouraging intergenerational interaction.

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Other outdoor amenities being considered for nursing home facilities include therapeutic outdoor spaces, such as "rehab gardens." Rehabilitation gardens feature all the amenities of a typical indoor physical therapy room and can be part of an overall wellness program. These gardens feature elements such as sets of stairs and railings, as well as walking trails, with assisted seating areas for residents to practice sitting down, standing up, and performing other daily life activities.

More nursing homes are also installing dementia gardens, a feature traditionally found on assisted living sites. An increase in dementia patients or the addition of dementia programs to nursing home facilities may be the cause of this trend. At Riverdale Gardens Rehabilitation and Nursing Center in West Springfield, Massachusetts, the facility owners added a garden specifically focused on the needs of dementia residents. These gardens feature creative elements to jog users' memories and remind them of experiences in their lives. Some gardens include basketball hoops and balls, or perhaps a car that residents can sit in. Dementia gardens also feature looping sidewalks and a fence or otherwise enclosed space to prevent residents from losing their way. They may also include cues, such as colored doors, architectural treatments, or special paving patterns, to help residents get their bearings within the garden.

In addition to specialized gardens, nursing home facilities are adding courtyards and other senior-friendly outdoor spaces for residents and visiting family members to use. At the Continental Wingate facility in East Longmeadow, Massachusetts, the site designers are creating an interior courtyard that will give residents secure access to the outdoors. A similar courtyard was also designed for the Meadowood Nursing Home in South Hadley, Massachusetts. Because the courtyard is located in the building's interior, and thus surrounded by walls, residents feel safer and can go outside without being constantly shadowed by a staff member. Spaces like this provide residents a quiet area for reflection or meditation, with comfortable seating areas and plenty of plant materials, including planters at wheelchair height. They also are pleasant outdoor settings for families to visit, thereby providing a pleasant visiting experience and, hopefully, encouraging them to come back often.

Safety First

With the addition of usable outdoor space on nursing home campuses, facility owners must pay increased attention to the accessibility of these areas. To provide a safe, accessible environment for residents, the following elements should be considered:

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* amount and placement of ramping and railways

* reduction of grading and keeping stairs to a minimum

* adding pigmented paving to reduce glare

* using bright-colored landscape elements that are more visible to aging eyes

Improving accessibility on campus and taking these precautions will help ensure a safe environment for ambulatory residents.

Siting of Buildings

To further improve nursing home residents' experiences, facility owners should consider the siting of buildings on campus. For instance, long-term care, which often houses less ambulatory residents, can be sited near gardens, fountains, and other landscape amenities to provide an enjoyable view for residents who may not be able to go outdoors. Landscape views are an important part of the healing and wellness philosophy at NewBridge on the Charles, for example, where long-term care rooms will be sited next to recreation fields and early childhood play areas.

Nursing homes should also consider the relationship between different levels of care on campus. At NewBridge on the Charles, each type of senior housing will be interconnected by an enclosed building structure, surface trails, and covered walkways through a subsurface parking garage. For instance, residents in the senior-supportive manor houses on the west side of campus will be able to interact with the other residents by walking a short distance via a covered walkway or through an underground connection in the garage. This arrangement will give the senior programs enough separation for an autonomous identity while still making interaction available when desired.

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Not only does upgrading a nursing home's landscape and site design help to maintain a competitive edge in the senior housing arena, it also makes these facilities feel like a "home away from home." From interior courtyards, rehabilitation gardens, and walking trails, to adding residential character through strategic material selection, nursing homes can raise the level of care for residents while treating them with the dignity and respect they deserve.

Joseph T. Geller, ASLA, is the founding partner of Geller DeVellis, Inc., with offices in Boston and Wellesley, Massachusetts. Geller DeVellis provides landscape architecture, site planning, and civil engineering services to real estate developers, corporate and commercial building owners, municipalities, educational institutions, and construction management, engineering, and architecture firms. For further information, phone [phone] or visit www.gellerdevellis.com. To send your comments to the author and editors, please e-mail [e-mail].

BY JOSEPH T. GELLER, ASLA