When is an ALF more than just an ALF?

Can assisted living adapt to meet the inherent medical challenges of aging residents?

It sounds ideal: build into senior living facilities the necessities and amenities that might keep ill or increasingly frail residents in those spaces a bit longer. But when residents exceed two weeks of required nursing care within an assisted living facility (AID, it is likely that some regulation (building codes, reimbursements, or licensure) will force them out--even temporarily--until health is regained. (See "The numbers are in," below.) So where does design come in?

"The implications to me as an architect are technology and building codes," says David Hoglund, principal of Perkins Eastman Architects P.C., Pittsburgh, and a specialist in long term care facility design. "We have to respond to codes that [govern design when] people can't egress the building. Our tendency is to build to higher code; we can look just as residential. For those who say, 'It's medical versus residential,' I don't think it's versus anything. We can make a beautiful environment and still meet the medical needs of residents;" he claims.

Plan for emergencies

Evacuation in an emergency takes precedence over other planning issues: the safety of residents must be priority. Rather than look at mobility alone, Hoglund questions dementia and cognitive impairment (which affects more than one-third of assisted living residents, according to U.S. government estimates) as key factors in emergency egress situations and plans accordingly. "I wouldn't want the building to be the reason somebody has to move," he says.

Beyond ensuring buildings meet or exceed codes, architects and designers must consider the changing model of assisted living caretaking.

"Freestanding assisted living is one of the more challenging models that has sprung up in the past 20 years," says Diane Y. Carstens, vice president of Gerontological Services Inc., Santa Monica, Calif., a firm specializing in market research, design review, and strategic planning for housing and services for older adults. "We're in the early stages of under-performing assisted living projects; [many] were built without a very good understanding of assisted living," explains Carstens.

She consults with providers planning new facilities who often project just one or two daily assists per resident. But with the aging, service needs change quickly, Carstens explains. "CCRCs are adding light-care assisted living in a more independent living unit and competing for market share. That leaves the higher-acuity resident for assisted living. They get them frail."

According to Hoglund, "The problem is that the issue of accessibility has changed dramatically over the years. Buildings weren't designed for frailty. Assisted living has to accept and understand the fact that people will become more and more frail. That will continue to be the case."

Design for the frail

As a result, several questions loom large for planners: how to design to accommodate that increasingly frail population and how to create living units that meet a wide range of medical requirements but still look residential. And then there are the specifics: where to park and recharge residents' personal electric mobility carts, for example.

Carstens sets out by evaluating the most time-consuming, costly part of providing adequate care: what happens in the living unit. "The old-model corridor was very time consuming; clustering makes sense," she says, because it provides a residential-style layout and allows staff to meet residents' sporadic needs more efficiently. Staff members are simply closer at hand.

According to Atlanta-based designer Linda C. Watson, ASID, "You've got to make sure the environment is conducive to care," she says. By making linens and supplies accessible, staff members may spend less time fetching and more time working with residents. (See "Ideal bathing and toileting design," page 20)

Homespeak

Hoglund's architectural approach to personal space allows for medical requirements but ultimately mimics home. "We use words residents would use when talking about their house. They wouldn't call a living room a lounge; we take that and keep moving. We conceptualize it the way we would our house."

Gone is the hospital-style emphasis on the head wall and--depending on state regulations--the linear fluorescent light behind the bed, replaced by a minimum of 20 foot-candles of ambient light throughout the room. His design take on the window wall emphasizes natural light and incorporates a long window seat (with bonus storage for seasonal clothing) and space for plants.

Hoglund watches operators varying their approaches to necessary medical interventions in keeping with homelike surroundings. "We've seen people be very creative, using wicker baskets instead of medicine carts," he says.

Carstens' approach to the living unit involves thinking big: building larger resident quarters and smaller public spaces. "People value privacy; if you don't provide privacy, people will actually retreat," explains Carstens. It's a pragmatic, win-win idea: "The larger the unit, the more independent resident you're going to attract. As that resident ages, you can use the extra personal space for medical services, equipment, staff, wheelchairs, and walkers," she says.

"The more frail residents are, the smaller their world will become," says Carstens. She looks at design from the resident's perspective: "Is the front door really the front door?" she asks. "There's a residential unit, then there's this grand space where they all mush around. We have to provide transition." As part of that transition Carstens advises carving out niches to serve special needs. "A small, private dining room made out of an alcove may serve people who've had a stroke and are embarrassed to eat in the dining room," she says.

Make room for technology

If delivering higher levels of medical care depends on outside agencies and home health providers, facilities demand space for both the technology and administration that allows that to happen. "One of the design issues relates to technology: the only way to coordinate medical records is through technology systems. We're seeing facilities putting in very large computer rooms," says Carstens.

In the age of wireless personal safety devices, residents can signal emergencies or call for staff assists via remote smart systems that "talk" to each other potentially replacing the need for pull cords. Technological devices free staff from call monitoring, allowing them to tend to residents. Hoglund plans accordingly: "We don't want staff members sitting waiting for that call."

Carstens recommends another step: installing technology for use of magnetically encoded swipe cards that record residents' medical and dietary needs, particularly those of diabetics. "People would be amazed at how many diabetics go into nursing care," she says.

Staving off the SNF 

Postponing that trip to nursing care becomes the goal, which hinges on planning for wellness. "We're seeing in assisted living, coming soon, the whole concept of understanding health and wellness," says Carstens. "It used to be, 'You're either well or sick,' Older people are much more aware of wellness. A comprehensive program of healthy aging--rather than healthcare services--affects planning. If we continue to isolate health services, it will be the thing that no one wants [to go into]."

Her wellness concept includes exercise and fitness facilities, a clinic offering medical and educational services, and activity of daily living training. (See "CLTC Editorial Advisory Board member Robert P. Volzer, IIDA, on creative ideas for the AL market," page 22.) The ideal, according to Carstens, is a spa center incorporating a therapy pool, bathing room, barber and beauty amenities, and medical services such as routine blood pressure checks. "It's a completely different way of looking at things, reducing fear and negative images," she explains.

But can every freestanding assisted living facility successfully provide all this? No, admits Carstens. "It will be increasingly difficult for the single facility to remain competitive and provide what the market will need and demand. People have to network and affiliate; the smaller facilities will collaborate with other providers."

Florida-based freelancer Rachel Long is a regular contributor to CLTC.

The numbers are in

In its National Study of Assisted Living for the Frail Elderly conducted last year, the U.S. Department of Health and Human Services Assistant Secretary for Planning and Evaluation Office of Disability, Aging, and Long-Term Care Policy contacted via telephone 2,945 centers identified as assisted living facilities (ALFs), qualified 1,251 such facilities for eligibility, and interviewed their administrators extensively.

Among the findings of the National Survey of Facilities: 71 percent of ALFs reported a willingness to admit residents needing wheelchairs; 62 percent of ALFs would admit those needing assistance with walking, wheelchairs, or carts. Just 44 percent of ALFs would admit residents who needed assistance with transfers.

Regarding discharges, 72 percent of ALFs would not retain residents needing nursing care for more than 14 days. However, ALFs on multi-level-care campuses were more likely to admit and retain residents who needed nursing care or required wheelchairs. Across all assisted living types, 31 percent of administrators reported they would not retain a resident who required a wheelchair; 38 percent would discharge a resident who needed personal assistance with locomotion. In cases involving cognitive impairment, 55 percent of ALFs would not keep residents with moderate to severe cognitive impairment; 76 percent would not retain residents with behavioral symptoms such as wandering.

Ideal bathing and toileting design

Seemingly simple daily rituals can become extraordinarily difficult, even frightening, for the elderly as their medical needs increase. In recent years, designers have experimented with the bathroom (eliminating doors, for example, to cue residents with dementia or improving faucets for optimum control by arthritic hands). Linda C. Watson, ASID, principal of Watson Ltd. Planning & Design (Atlanta), is among those designers who work to create bathing environments that ease strain for seniors and caretakers alike.

"Keep environments simple so staff members don't have to deal with anything extraneous to clean," she advises. Simple, two-fixture bathrooms (toilet and sink) allow staff members to handle residents' bathing routines in larger, spa-style shower and bathing rooms. At issue are resident safety and the harsh realities of wasted space. Watson recalls seeing residents' bathtubs become urinals and storage places for outdoor furniture, "Why spend your money on a 3-by-3-foot shower in which staff members can't give assistance?"

Problems arise when residents see a monochromatic tile-and-fixture combination since color contrast becomes critical to the aging for depth perception and differentiation. "I've seen the units for roll-in showers; if the seat's molded into the unit and is the same color, residents will never know it's there," Watson explains. "We need to educate the adult child that color contrast will look a little bit strong to them, but it will make sense to their parents," says Watson. who-believes that proper variation in color and plenty of light can keep elderly "a lot more cognitively alert."

By design, empower able residents to stay independent yet create spaces conducive to staff assists when they become necessary. To increase safety and make surroundings more comfortable (and comforting), Watson employs these elements in bathing areas:

* color contrast between floors and walls

* specially angled grab bars in colors that differ from adjacent wall colors

* a row of color at eye-level to aid residents' spatial perception ("It grounds them so they understand how big that space is," explains Watson.)

* marked color contrast between shower seats and walls

* easily accessible towel hooks and storage compartments

* minimum 60 foot-candles of light for toileting and grooming functions

* appropriate lighting for spa bathing (see recommendations, below).

Watson looks to design a sturdy, comfortable shower chair that will work with two hand-held shower devices--one for the resident and one for the assistant. What's more, she's working with carpet manufacturers to develop a water-resistant, bleachable carpet for shower rooms to help reduce noise and increase comfort and safety.

"With bathing, your biggest fear is that you're going to fall, break a hip, get pneumonia, and die," says Watson of the elderly. She is counting on design to lessen the risk.

The Iluminating Engineering Society of North America publishes guidelines for minimum maintained average illuminance, interior and exterior, ambient and task light.

CLTC Editorial Advisory Board member Robert P. Volzer, IIDA, on creative ideas for the AL market

In today's senior living environments, architects and designers are helping providers respond to market demands with innovative new ideas for assisted living amenities:

"Beyond the fireside lounges, gardens, health clubs, and Internet cafes appearing in many assisted living communities, social spaces that mirror mainstream community life and engage residents should also be considered," advises Rob Volzer of Clark Patterson Associates in Rochester, N.Y. A space with "social-task" opportunities often proves to be a greater draw than static spaces that do not.

A "residential scale" kitchen area provided to allow staff, residents, and family members to visit while baking a tray of warm cookies, combines socializing and daily living skills. Likewise, a "laundromat" provides a dynamic social environment where residents can chat while folding a few clothes with friends or family--just imagine a college student sharing a load of wash and some laughter with a grandparent!

"Destination" social spaces such as an ice cream parlor with vintage 1950s decor offers residents and family members a social space with a "cognitive experience" as rich as their double chocolate malt.

"Assignable hobby space" addresses the needs of residents with intensive pastimes. From playing the piano to quilting to woodworking, many of today's seniors need dedicated, independent "creative space," staffed with someone to occasionally facilitate. "My father always said he would sign over his retirement to the first community that would give him a workbench and a 4-by-10-foot table for model railroading," says Volzer.

Indeed, the magic of music as therapy that can take place in such an assignable hobby space has been well documented. For instance, Harry Reid (D-Nev.), is quoted as saying, "Music therapy is much more complicated than playing records in nursing homes ... music helps all types of people remain forever young." [1]

Reference:

(1.) American Music Therapy Association Inc. Website: http://www.musictherapy.org/quotes.html. 1999.