To Grandma's house we go: a clustered living concept offers a more home-like environments.

FOR SEVERAL YEARS, MANY LONG TERM CARE DESIGN PUBLIcations have been touting the benefits of clustering new assisted living facilities and nursing homes. The clustering concept groups individuals with similar care needs into neighborhoods--within a larger facility. The neighborhoods are organized by the special care plans required for the specific needs of each population. The smaller scale of these neighborhoods offers a home-like living environment and an opportunity for residents to make and enjoy new friends who are at a similar stage in life. In many retirement homes, the population might include residents suffering from various levels of dementia, residents on short-term stays rehabilitating from a medical event, and a range of resident acuity from those who need only light personal care to total care.

To achieve effective clustering, each neighborhood must be independent of one another. Neighborhoods cannot serve as a circulation route to access other areas. Each cluster should contain the activity and service spaces a particular group of residents may need in their daily lives. Small clusters of residents with similar needs can certainly share some service and support spaces, but the overall scale of each area should be minimized to promote a home-like atmosphere. Resident living units can be grouped around activity spaces or family rooms to eliminate or reduce the number of corridors. Smaller staff areas can be designed similar to country kitchens, which can double as smaller-scale kitchens or activity spaces if properly equipped.

Forego the traditional locker-room-style bathing facilities. Instead, provide a central bathing space for each clustered household that would accommodate one resident at a time. This space can be easily designed for lifts and large equipment and still maintain a residential character. When considering other amenities think of "Grandma's house," and select traditional house features such as real or decorative fireplaces, six-panel doors, wood casing, crown moldings, chair rails, coffered ceilings, and porches accessible to secure gardens. Also, be sure to provide generous day lighting.

Dining in smaller groups will also greatly enhance the living environment. Serving kitchens close by can eliminate the need for tray transport and help to insure that food can be served hot or cold as appropriate. Resident preferences also can be more easily addressed. Transport carts can be limited to bulk food carts which are much more manageable than heavy tray carts, and negate the need for expensive hot food pellet systems.

Selection of cluster size and groupings of clusters should take into account staffing ratios of both aides and nurses and the type of care anticipated. Obviously, dementia and high acuity residents require higher staffing numbers than "intermediate care." Clusters must be staffed around the clock so night-shift ratios must be considered.

If a 100-bed nursing home is anticipated with a unit manager for each 50 residents, then two groups of clusters totaling 50 residents each may be appropriate. Within those groupings, staffing can be assigned to smaller clusters, or neighborhoods, of beds. If daytime direct-care staffing for 50 residents is 10 and nighttime direct care staffing is five, then two clusters of 10 beds each and two of 15 may be appropriate. Or, two clusters of 12 beds each and two of 13 each. With either of these options, one staff member is available to assist with transfers throughout the unit during the night. (Five clusters of 10 beds would likely not be appropriate.)

With this scenario, two dining rooms of 25, plus guests, may make sense. Or, dining in each cluster could be selected for an even more residential environment.

Whatever your staffing ratios are, crunch the numbers and come up with a scenario that works for you. Keep in mind that staffing ratios and regulations change, as do the needs of resident groups. So, try to come up with a solution that offers flexibility. Most of our clients are selecting cluster sizes between 10 and 17 beds in various groupings, although some have utilized clusters as low as seven for dementia care areas and as high as 25.

Regardless of the sizes selected, an effectively designed and operated nursing or assisted living home with a clustered concept offers superior care plans that cater to a specific resident group and offer a home more like "Grandma's."

RELATED ARTICLE: Money matters

No one likes to construct a quote over the phone for a hypothetical situation. Predicting the difference in cost between a clustered concept and a traditional medical model is just as murky, given the numerous variables such as labor costs and location that have to be figured into the final price tag. However, it is fair to say that a clustered concept costs more, due to the added square footage required.

How much more? Well, the final price tag would of course depend on the actual location, construction crew, the weather and other variables out of our control. But, for comparison's sake, let's price a 100-bed home of 40,000 square feet, which is approximately the minimum requirement to meet the guidelines of the Americans with Disabilities Act. Construction costs for a traditional model would total approximately $3.6 million at the low end. The same-size facility built with a cluster arrangement would require 15 to 20 percent more in square footage and costs.

What about Medicaid reimbursement rates? Most of the cluster-designed facilities meet Medicaid reimbursement rates for their areas. The strength of the provider makes a difference in the final outcome. The more financially solid, not-for-profit providers are awarded more competitive interest rates. Some providers may have to cut back on some of the amenities, but the basic concept is still affordable.

Designing for a pest-free facility

While pests are not welcome anywhere, they are particularly unwanted in long term care facilities where they pose a potentially serious health threat to residents who may not be healthy enough to fight off diseases horn by mosquitoes, ants, rodents, and other pests.

A facility's design features can either attract or discourage pests, according to Frank Meek, BCE, national pest control technical manager at Orkin Pest Control, Inc. Meek isolates four potential trouble areas that, when addressed properly, will lessen your facility's vulnerability to pests.

Water

Pests thrive in water, especially still water. "Eliminating outdoor water sources is the most crucial issue in pest control," says Meek. "You want to eliminate a breeding ground for potentially, disease-carrying mosquitoes as well as ants and other pests." Water sources include standing water in gutters and on flat roofs and condensation from air conditioning.

Architecturally, pitched roofs are better than flat ones because they allow water to run off. "Institutional-style, flat gravel roofs accumulate water, "says Meek, "even with a draining system built in." Pitched roofs can also remove the attractiveness of the roof to birds, who can cause a health risk as well as structural damage."

To keep an air conditioning system's condensation from becoming a problem, keep the condensation pipe buried in the soil. This will keep moisture away from the building, and it can also serve in watering the grass and trees.

Entrances

Even if you take away the water and adjust the lighting, insects will still search for ways to get in. "The structure must be as tight as possible," says Meek. "Use good seals and weather stripping on the doors and windows. If it's a brick facility it will have weep holes for proper ventilation. The holes should be fitted with screens to prevent insects from using the weep hole as entranceways."

Landscaping

The placement of trees and plants around the building can also introduce vulnerabilities. You don't want trees that overhang and touch the building, providing a walkway for rodents, ants, and other pests. Also, certain plants should not be placed against the side of the building, especially those that are conducive to having aphids, which are small, soft-bodied insects that produce a honeydew substance that becomes a food source for ants. Aphids are attracted to plants such as roses, apple trees, and holly bushes.

Lighting

Another area of vulnerability is lighting. Meek advises facilities to use indirect lighting. Most facilities use direct lighting, which is attached to the side of the building. "When the lights are mounted on posts shining back on the building, the insects are drawn to the post rather than to the building," says Meek.

The type of lighting is important as well. "I want to stress the use of sodium vapor lighting over mercury vapor lighting," says Meek. "They have different wave-lengths that stretch above the light, and sodium vapor is more attractive than mercury vapor. Most facilities utilize a lighting contractor so it's a matter of specifying the use of indirect lighting with sodium vapor as much as possible."

A note about West Nile virus 

Much media attention has been given recently to the West Nile virus, which is carried by mosquitoes and has caused several deaths. According to Meek, the mosquito that carries this virus is a container-breeding mosquito. "It lives around structures and breeds in flower pots, bird baths, puddles of water, and gutters that back up and stagnate." Protecting a facility from West Nile virus is a matter of taking away stagnant water.

MARIANNE COTTER 

A winner of 15 national design awards, James Michael Milligan has been designing long term care facilities since 1978. He has worked on more than 400 projects for both not-for-profit and for-profit providers. Milligan currently serves as the president and founder of JMM Architects Inc., of Columbus, Ohio. He can be reached at 614-326-5565 or [e-mail]