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As Cynthia Leibrock writes in the Preface, "The power of a healing environment comes from the little things, the design details that empower patients to take responsibility for their own health." In Design Details for Health, she offers specific design details that can improve patient outcomes by returning authority to the patient, along with fascinating case studies and research demonstrating the positive role design details can play in reducing healthcare costs. Practical and inspiring, this innovative book is essential reading for architects, interior designers, facility managers, and healthcare professionals.
Attention to detail is the cornerstone of success in virtually every enterprise. This is especially true in the field of healthcare design, where design details can have a profound impact on the quality and efficacy of care.
In Design Details for Health, Cynthia Leibrock gives designers and other industry professionals specific examples showing how design details can offer patients greater comfort and independencewhile also giving healthcare facilities a competitive edge-saving staff time, cutting overhead costs, and reducing liability.
With the help of nearly 200 images, many in full color, she offers flexible, innovative design solutions in key areas such as lighting, acoustics, color, furnishings, and finishes. From acute carehospitals to specialized ambulatory care and home treatment settings, she addresses a variety of healthcare environments and includes inspiring case studies that reveal how effective design details work in the real world.
Throughout the book, Cynthia Leibrock presents findings from the cutting edge of design research-including results published here for the first time-reflecting the experience and expertise of hundreds of healthcare designers and architects in the United States and abroad. Covering topics ranging from acoustics to lighting, this valuable data includes citations for further reference.
When design empowers rather than disables, everybody wins. Sensitive to the needs of both patients and the providers that serve them, Design Details for Health is essential reading for today's architects, interior designers, facility managers, and healthcare professionals involved in commercial and residential healthcare facilities.
". . . this book is a reference standard with timeless value." -Wayne Ruga, Founder, The National Symposium on Healthcare Design
Assisted Living Apartments.
Caring for People with Dementia.
Home Health Care.
Subacute Care and Rehabilitation.
Day Care and Respite.
Inpatient Psychiatric Units.
Directory of Designers and Consultants.
Directory of Manufacturers.
The future of assisted living is lifetime care in one location. It is not the continuing care concept where residents (who are often treated like patients) are moved from independent living to assisted living to skilled care units. The best of assisted living provides the independence and dignity of a home, individual assistance with daily activities, and physical medical care for life in the same apartment.
Traditionally, assisted living has been defined as a housing model offering support for unscheduled needs, 1 including assistance with ADLs, personal care, and some health care. Skilled nursing has been defined as 24-hour medical intervention in a health care facility. But the line has blurred between the two; skilled nursing is trying to become a housing model and assisted living is providing more medical service.
Health care is now portable; many interventions can easily be brought to patients and their families with advancements in home health care. In addition, most assisted living complexes offer transportation to ambulatory care. Others have nurses on call, if not on the premises, 24 hours a day. Some complexes have two-tier call systems that let residents choose between minor assistance and emergency help. Prevention is a priority; nutrition, exercise, security, and safety are addressed (see Details on page 49).
The worst of assisted living is a skilled nursing facility decorated to look like home to ease the guilt of family members institutionalizing a loved one. These models are easy to identify; the exterior clearly reads facility, not housing complex. They are basically medical models inappropriately used as housing models.
In the United States, many older people are forced to live in health-care facilities. This is not true in much of Europe, where a distinct separation is maintained between housing and health-care facilities. Rehabilitation, emergency assistance, and 24-hour skilled nursing are available at home, but fewer Europeans actually live in healthcare facilities. The United States has the largest percentage of people living in nursing homes of all developed countries in the world.
ASSISTED LIVING IN EUROPE
In Rotterdam, Holland, 60 nursing home patients were moved into apartments at The Bergweg Project (see Figure 1-1). They will not be moved along the continuum of care from independent living to assisted living to skilled nursing. Bergweg residents can now live with their spouse of any age, have their children stay overnight in the apartment, and develop friendships with their neighbors without fear of being moved out of the neighborhood into a healthcare facility. This project has literally returned life to residents who were previously subsisting in semiprivate (which means almost public) rooms in nursing homes.
The complex consists of 180 lifetime apartments, each with two or three rooms totaling 660- 740 sq. ft. The apartments are not only accessible to people in wheelchairs; they are accessible to people in hospital beds as well (see Figure 1-2). Even bedridden residents can be bathed on a gurney in the privacy of their own bathroom (see the Research Abstract on page 101). A special shield can be used to keep the attendant dry (see Figure 1-3).
The apartments are built over an ambulatory healthcare facility (see Figure 1-4) offering skilled nursing to 60 patients and assistance to an additional 60 in the apartments. No one lives in the healthcare facility. Many apartment residents, however, spend a portion of each day there receiving therapy and rehabilitation.
Each apartment overlooks an atrium whose glass roof provides year-round protection from the elements. Atriums are appreciated by older people with concerns about safety and security (see Figure 1-5). Even though the Bergweg atrium is located on the second floor, a stream runs through it. Sculpture, trees, and plants are all bathed in daylight, a major contribution to a healing environment. Surrounding the atrium is a 20,000 sq. ft. shopping mall that is not just for the elderly --the entire community uses the shops, restaurants, hairdressers, kiosks, etc. Next to the elevator, an escalator from the street invites walk-in traffic and community interaction with the residents (see Figure 1-6).
In addition to serving 180 apartments, the ambulatory healthcare facility provides daycare for 20 community residents and is staffed with occupational therapists, physical therapists, a full-time general practitioner, a dentist, and a massage therapist. Its offices open to the street, encouraging community use. The entrance to the facility is also on the street level, well away from the apartment entrance. The Dutch want clear separation between housing and healthcare facilities.
Bergweg is a truly integrated complex offering shopping, dining, and health care to the entire community in a mode sensitive to the security and dignity of the older residents. This housing model is emerging in many countries in Northern Europe. Increasingly, Europeans are not required to move out of their homes into a healthcare facility. If a resident does not function well in an apartment, other housing choices are available (e. g., group homes for people with advanced stages of Alzheimer's; see Chapter 2). But most older people can receive services in their own apartments for life, even if they lose ambulatory ability and are confined to bed.
Apartments are frequently constructed over a geriatric rehabilitation clinic (see Chapter 5), but again, the separation between the place in which one lives and the place in which one receives health care is well defined. If necessary, one can receive treatment all day in the clinic and still have the dignity of returning to one's own apartment at night.
In many Scandinavian complexes, therapy equipment is displayed in visible public areas to encourage residents to exercise. Residents are actually expected to exercise to maintain ability and elevate self-esteem. They are expected to perform at their highest level to save staff time and maximize independence. These expectations are not in place in many U. S. complexes.
ASSISTED LIVING IN THE UNITED STATES
Much of U. S. assisted living design was built by former nursing home administrators and is still based on a nursing home model. This model is the result of the social programs of the 1960s and 1970s, when the federal government became the principal payer for care of elderly residents in nursing homes. Government reimbursement drives nursing home design and staffing, dictating such details as square footage per patient. Reimbursement is dependent on government approval through the certificate of need (CON) process and state inspections. There is little change in revenue when these inspections determine that quality of care exceeds the level required by regulations, and every incentive exists to maintain minimal care. Design improvements are discouraged by lengthy waiver, conditional-use permit, and variance processes.
On the other hand, the best designers are willing to jump through hoops to build innovative models, and theirs is the work that raises overall quality levels. Theirs is also the work that gets published and becomes the latest standards of good design. For example, when assisted living is combined with historic preservation, requirements can be modified to preserve the historic significance of the project (see Figure 1-7). One restoration was able to hide sprinkler heads in cornices and visual alarms under chair rails, retaining their function but eliminating the institutional appearance they convey.
Many licensure codes, however, would need to be changed to construct affordable Scandinavian lifetime models in the United States. 3 Scandinavian fire codes for long-term care are less stringent than those in the United States, allowing fireplaces in skilled nursing homes, reduced separation requirements, and natural (flammable) materials. Scandinavians are willing to take some risks to improve quality of life.
On the other hand, some U. S. health-care construction requirements are not stringent enough. For example, the minimum space required for dining rooms may be as little as 9 sq. ft. per person; for people using wheelchairs, walkers, or medical equipment, the minimum should be 25- 30 sq. ft. per person.
In the lifetime model, the separation between health care and housing may actually reduce code compliance requirements. For example, if the apartment is not considered part of a nursing home, there is no requirement to keep all rooms within 120 ft. of a nursing station. Apartments may not be required to be sprinkled (although it is a good idea to do so). But even lifetime apartments are overregulated in some areas. For example, the quantity of apartment parking required by code is not needed. Many older residents in a lifetime model no longer drive.
What are the program requirements of a lifetime model? In addition to transportation, the model must include optional assistance with the ADLs. These activities include housecleaning, daily bed making, linen service, personal assistance (e. g., bathing, dressing, and medication), meals, and health monitoring (e. g., pulse rate, blood pressure, and weight).
Some of these services can be provided by family members, reducing costs as much as 40 percent and encouraging family participation with the resident. 5 Residents should also be encouraged to help one another to bolster self-esteem, reduce dependence on staff, and reduce costs. A case manager must track volunteer involvement and ensure that all needs are being met.
Cost is the issue that reduces demand for the lifetime model in the United States. Existing models are expensive, and assisted living has never been a high-end market. Wealthy people generally receive their care at home, seldom moving into assisted living complexes that do not offer life care. The wealthy also avoid the CCRC model which moves residents from level to level. They do consider a condominium model that provides healthcare security for life with most medical care at home. The Stratford is one such project.
This ten-story condominium complex is located in San Mateo, California. It offers 65 condominiums that can all be converted to assisted living. This is one of the few complexes in the United States licensed for both independent living and assisted living in each residence. Amenities include hotel services; a concierge keeps treats on hand for the many pets. Design details include an electronically controlled entrance, a maple-paneled library (see Figure 1-8), and an enclosed swimming pool. The first-class restaurant is nothing like the congregate dining halls frequently found in assisted living. It offers several choices in dining: an elegant restaurant, two private dining rooms, and a chef's bar for a quick meal (see Figure 1-9).
The Stratford plan includes a lifetime medical program, including an on-site physician for consistency of care (see Figure 1-10) and a full-time registered nurse. Transportation is provided to all medical and dental appointments, and medical insurance forms are processed by the staff. The wellness program includes health education (in the penthouse lecture room overlooking the bay), fitness classes, and nutritional consultation.
An alternate model for lifetime care is been offered on many college campuses --Cornell, Iowa State, Indiana University, University of Connecticut, Dartmouth, Duke, University of Washington, Stanford, Princeton, and Lehigh, to name a few. Assisted living apartments are provided on campus, offering all of the perks of college life with none of the course requirements. Residents can attend classes, parties, free concerts, and collegiate games. Sophisticated medical care is often available on these campuses and there is a strong emphasis on rehabilitation. Although skilled nursing is not generally offered in the apartments, most schools have a fine record of getting residents out of nursing homes and back on their own.
PLANNING PUBLIC SPACES
The best of assisted living apartments provide environmental layers to allow residents to gradually enter social situations. A deck overlooking the entry permits residents to screen visitors without making a social commitment. The deck can also be used as a place for residents to smoke away from the entry. The first impression at many complexes is an entry littered with cigarette butts and a group of smokers as the official greeters.
Entry landscaping must be carefully planned with no place for an intruder to hide. Even in safe locations, older people may perceive danger lurking in a highly landscaped entry. Night lighting contributes to the perception of safety and empowers the many older people who have trouble with night vision.
Landscaping should offer distinctive layouts for each entry. Courtyards assist residents with orientation by spacially differentiating exterior landscaping. Parking lots should also be small and clearly differentiated (see Details on page 49). To maintain a residential environment, delivery vehicles should not use the main entrance. They should deliver close to the staff kitchen, perhaps through a residential garage.
As in any apartment building, the public spaces of assisted living complexes should be homelike and inviting (see Figure 1-11), but not at the expense of clear spacial definition. Forty percent of assisted living residents have some degree of dementia, and they may become confused in unfamiliar spaces like large congregate dining halls.
Interior spaces should be small, intimate, and clearly defined (see Research Abstract on page 21). Interior social layers can be created by half walls, balconies, window seats, greenhouse enclosures, and atriums. Glassed-in porches can provide the dual benefit of a social layer as well as access to nature in a safe environment for socialization. Exterior views of nature keep residents alert to the weather and to seasonal changes.
An exterior swimming pool offers an opportunity to exercise, spend time outdoors, and socialize. Tables with umbrellas can define personal space in the pool area and create another social layer (see Details on page 54). A swimming pool also offers an excellent opportunity to invite the community into the complex for exercise classes or an afternoon of family fun.
Water aerobics (followed by a sauna or spa) can provide significant pain relief. Swimming pools must be planned for users in wheelchairs as well as those with reduced hearing and vision (see Chapter 8). An interior pool may be a good place to increase sensory stimulation by adding live butterflies and the relaxing sound of falling water. If the pool is located in the basement, provide access to daylight and extra attention to acoustics. The concrete surfaces may reflect sound, making therapy and instruction difficult. Consider an instruction pit, a sunken area next to the pool that keeps the instructor dry and at the same level as the swimmers. Instruction and treatment areas should be acoustically isolated from the rest of the complex to prevent sound transition.
Access to natural elements may also be provided by large windows that open onto protected interior gardens and invite exploration. Double-loaded corridors (with rooms off both sides) offer few opportunities for window placement. A corridor that circles an atrium or patio tends to have shorter horizontal stretches and offer more articulation. When this design is not possible, the corridor can be deconstructed with jogs or curves. Corridors can be planned to encourage chance encounters and excuses to meet people. Resting places should be provided and supportive handrails visually integrated (see Details on page 254).
Details define a residential environment. Seating breaks up long walks; kiosks offer snacks and drinks. Conversely, the design formula for an institutional environment is uniformity and lack of detail. Shiny beige composition floor tile and unfamiliar spaces like dayrooms are institutional clichés (see Details on page 181).
Rooms should be planned with clarity of purpose. Keep spaces understandable, with public spaces very public and private spaces very private. Residents do not understand a living room with 50 chairs in it. Spaces and finishes should anticipate behavior, particularly dementia and incontinence (see Research Abstract on page 23).
Most assisted living residents experience some degree of memory loss. Familiar details like a fireplace, a case filled with books, and a china cabinet can trigger long-term memory and serve as important wayfinding cues (see Details on pages 251 and 252). Fragrances like baking bread and morning coffee are also important cues. Music can be used to bring back long-term memories and cue the start of daily events, maintaining a sense of order.
Public space in assisted living can and should retain familiar, home-like qualities. Residents can be offered supervised options, like participating in laundry and cooking. A vegetable garden, aviary, greenhouse, aquarium, and liberal pet policy also allows the residents to express personal interests. Secure displays of personal collections offer important wayfinding and orientation cues. Abstract art can be problematic for some; choose realistic themes, perhaps including relationships with children and pets. Residents feel more in control when designers humanize interiors with such elements as bay windows, mullions, balconies, and carpeting (see Details on page 24). Human scale should be maintained, especially in areas frequented by residents. Entries, porches, and transition spaces may include windows with small panes and doors with details on a traditional residential scale.
Public space should also encourage social activity. Lobbies become hospitality centers, with the receptionist sitting close to the guests to provide information. Reception may include serving beverages. Sometimes a bar may be provided to serve cocktails. Small, intimate dining areas may be planned to encourage socialization. Soft table cloths, fitted to prevent sliding, and fresh flowers maintain the ambience. Plan one of the smaller dining areas for those who have difficulty with eating and may be embarrassed to dine with others.
To improve visual acuity in dining rooms, it is important to provide contrast between the chairs and the floor covering and between the plates and the table. Specify 80 percent light reflectance from the wall and uniform levels of glare-free light at approximately 50 footcandles (fc) 7 (see Details on page 80).
Areas of decision like entries, reception lobbies, and elevators require increased lighting levels, up to 100 fc for close work like reading instructions or signs 11 (see Details on page 83). Redundant cueing should also be provided in the elevator, and an emergency elevator phone should be connected directly to the building manager and receptionist (see Details on page 130). This phone cannot replace the elevator alarm system required by the Americans with Disabilities Act (ADA).
Lighting can also be used to reinforce the change from public to private space. Increased lighting levels at apartment entrances offer control, security, and clarity. Differences in detail, materials, and size can accentuate the transition, providing a unique apartment entrance as part of the wayfinding plan. The entrance can also serve as an important place to people-watch from a wheelchair or to charge a power wheelchair. For this purpose, plan a special outlet and ventilation from the odors caused by recharging. For ambulatory residents, provide a place to sit down to remove boots and overshoes before entering the apartment.
A NOTE ON APARTMENTS
Apartments are private; facilities are not. When people are shuffled from level to level, possessions must be eliminated and physical territory is reduced. The value of privacy and independence increases dramatically.
The apartment represents a place to maintain independence when, through aging, all forces seem to lead to less control. An individual's home allows that person to stay in touch with "the person they were in the past." It provides a place to accumulate memories.
As we age, each change can represent a loss of territory and possessions. Symbols of life like a flower box, a mailbox, a doorbell, a clothes-line, and holiday displays become increasingly important. Residents need to remain connected with others, but through windows, doorways, and porches that permit the choice of privacy.
Chapter 3 is filled with universal design detail that should be integrated into apartments. As a closing thought to this chapter, please consider that social spaces and bedroom spaces are culturally incompatible. At a minimum, apartments should offer separation between sleeping areas and living areas.