e-09 households - eua · e-09 households: a discussion of history, design process, operations,...
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E-09 HOUSEHOLDS: A DISCUSSION OF HISTORY, DESIGN PROCESS, OPERATIONS, & ARCHITECTURE
Jeffrey Anderzhon, FAIASenior Planner / Design Architect
Andrew Alden, M.ArchSenior Planner / Designer
Lorraine G. Hiatt, Ph.D.Environmental Psychologist / Gerontologist
@AndrewA_EUA
/andrewalden1
Jeffrey Anderzhon, FAIASenior Planner / Design Architect
@JeffA_EUA
/jeffreyanderzhon/j
Andrew Alden, M.ArchSenior Planner / Designer
/lorraine-g-hiatt-ph-d-83569627
Lorraine G. Hiatt, Ph.D.Psychologist / Environmental Gerontologist
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• Identify specific elements of the physical
environment in older adult communities.
• Hear trends that are shaping the physical
environment, care program, and operations.
• Appraise contemporary designs, the operational
method assumed for the layouts, and how these
layouts may influence care.
• Obtain programming and design ideas geared
toward a collaborative process.
THE AGENDA
• History
• Architecture
• Lessons Learned:
Strengths, Room for Creative Initiative/Variations
• Operations
• Design Process
• Take Aways
THE EVOLUTION OF
SENIOR LIVING CARE
HISTORICAL
PERSPECTIVE ON
CARE SETTING
1890’s
STATE SOLDIERS HOME, Providence, RI circa 1890
CONNECTED SMALL HOUSE COTAGES and “NEIGHBORHOOD, “Familiar in RI!”
MULTI-STORY, COMMONS WHAT’s Old is New Again and it only took 216 years!
St. Simeon’s
13th Century
St. Simeon’s
13th Century
Civil War Hospital
Washington D.C. 1863
Civil War Hospital
Washington D.C. 1863
Origins : Double Loaded Corridor
1940’s
County Home
Wisconsin
County Home
Wisconsin
1955
County Home
Wisconsin 1955
Double Loaded Corridor
1980s
A LOOK BACK TO LOOK AHEAD: USER PREMISES
WHATS IN A ROOM 1960-1990
A LOOK BACK TO LOOK AHEAD: USER PREMISES
WHATS IN A ROOM 1960-1990
�User viewed as patient= ill.
Medication uses high.
�“Senility” “Incurable”
�Custodial, Safe?, Confining
�Design around furniture not
movements.
�HV complicated window use.
�Incontinence assumed.
�Infirm: Clothing non essential.
TODAY: COAX MOVEMENT, EXPECT MEMORY
ENHANCEMENT, CREATE “CONTINENCE”
Understanding the Aging Experience in a
Traditional Care Setting
Loss of privacy, choice, control, identity, incredible
monotony, odor and clutter. Note “previewer.”
Engineering Driven Design:
Plans for Nursing “Health” and
“Homes for Aged Similar
1960-1995
VESTIGES OF CUSTODIAL
BED BASED CARE• Staff/ Supplies Centralized.
• Residents out of View.
Immobility High.
• Shapes Complicate Time
GAME BOARD STAFFING
CHALLENGES CONVERGE: LARGER
“UNITS” “RACE TRACK” AROUND
STAFF UTILITIES
CHALLENGES CONVERGE: LARGER
“UNITS” “RACE TRACK” AROUND
STAFF UTILITIES
Failure to Integrate Flow of Care, Social Life and Supplies.
Staff walk more. Resident-requests are compromised by
linear halls and lack of short cuts. Residents Suffer
Exploded Corridor
Divided Floor Plan
1990s
WHAT IS THE CURRENT
DEFINITION OF A
HOUSEHOLD?
A small group of residents living within a physically-defined environment
that "feels like home" and that has a kitchen (with a wide variety of
food accessible to residents around the clock, including breakfast-to-
order and on demand), a dining room and a living room.
Staff is consistently assigned so they can develop meaningful
relationships with the residents, work in self-led teams and perform a
variety of tasks.
Courtesy of : www.pioneernetwork.net
HOW SMALL? BILOXI
VA a “Community
Living Center (CLC)” 12
PERSONS DAYS; 24
NIGHTS
• VA Cap of 613 NSF/Vet in 2008
• Houses have Neighborhood Social Option.
• Night Staffing at 2 per vet possible at 3.8 – 4.0 hppd
• Opened central cook chill food and capacity for neighborhood prep.
Biloxi VA, First Generation Veterans’ “Community Living Center” Blitch+Knevel, Early diagonal bathroom 2008.
Courtesy of ARI : www.ari.org
Courtesy of ARI : www.ari.org
Household: Household:
Short Corridor Style Hearth Style
Combination / Hybrid Household Styles
Household / Neighborhood
ARCHITECTURE /
LESSONS LEARNED
ARE WE DESIGNING HOUSES
THAT PRODUCE
CAPABILITIES?
• Inspiring Walking Even a
Few Steps
• Incorporating Movement
and Equipment in Entire
House Configuration
• And tucking away
equipment, but keeping
it at hand.
TRANSFORMING
“CUSTODIAL” CARE TO
FAMILIAR LIFESTYLES
GETTING OUT OF ONE’S ROOM =
GETTING INTO/OUT OF BATHROOMS!
50% BATHROOMS MET ADA BUT DEFIED
SAFE HANDLING 1990-2004+
GETTING OUT OF ONE’S ROOM =
GETTING INTO/OUT OF BATHROOMS!
50% BATHROOMS MET ADA BUT DEFIED
SAFE HANDLING 1990-2004+
• 1970’s-today: Studying self-
propulsion, discovering elbow,
feet and care partner
movement gymnastics.
• New bathrooms shapes
emerged. 5.5’ vs. 5’ turning
(before staff assistance) per FGI
Guidelines 2008, 2016.
• Dialogues: ceiling lifts or ceiling
“transport assists” for all or…
teach people skills of movement
and self toileting. Apply for
Equivalent Facilitation! www.fgiguidelines.org check link for 2016
REDESIGNING TIME;
RESHAPING SHOWERS
• 9 user/care patterns
studied.
• Redesign resident and
staff time.
• Flushing rather
than managing
waste
• Showering with
dry floors
HOW MUCH TIME CREATED?
1.5 HR-2 HRS per 8 RESIDENTS
in ONE DAYTIME SHIFT! Case
Study Follow-up in 2016
(Case Example Francis Parker at Monroe© Spiezle Group Architects/LG Hiatt, Used by permission.
ADA Compliant
But….
LESSONS: ROOMS DRIVE TIME
USE. 1998 GOAL SHORTEN HALLS
(Better Rooms, Less Gross Area)
� VISUAL and ACTUAL PRIVACY, BATHROOM
ACCESS yet to “COST CAPS:” 590/GS Per
Person. Focus capital not operating $.
� CLUSTERS MIRRORING STAFFING RATIOS (7,
10-11, 14) rather than 1:10 MANDATED
� LOCALIZED STAFF and SUPPLIES
� SHORTEN DISTANCE to SOCIAL (AT 15
NSF/PERSON REQ. and CENTRALIZE)
� POE’s INITIATED; STAFF TIME REDESIGNED;
STATES LIKE NY, MD, WI took note….
� BEGINNING OUTCOMES OF SHARED vs.
PRIVATE ROOM DUE TO BATHROOM ACCESS
BUT WHERE’S THE SUN????
NY State Veterans Home Batavia;
Similar Weinberg Buffalo, Peter Drucker Award on Innovative Elder-Staffing Design.
A LOOK FOR GREAT ROOMS, LIGHT and
EFFECTIVE CARE 12-21 Person Clusters
and Inspiring Walking
CLUSTERING VILLAGE SHOLOM 2001
• 2 Individual Living Suites of 12,
Distinctive Day Staff, Social + Supplies
• Paired 12’s for Social/Dining and Night
Staffing.
• Multi-tasking Personal Laundry in
Cluster. Diversified Night Staff
• Planned for Movement; Flexible for
Memory Care
SIMILAR
• Weinberg Buffalo and Syracuse, NY
1998, Rosenfield NBBJ
• Peabody, Manchester, IN 2000-1, RLPS
• Waveny Care, Memory Suites, RLPS,
New Canaan 1999-2001
INNOVATORS: “RIGHT
SIZING,” “DISTINCT HOUSE”
CONNECTIONS and
DAYLIGHT
2000: Francis E. Parker Home
Added “EVERGREEN WAY”
Small House
12-Elders Staffing 5.2 HPP
Evergreen Way, Francis E Parker, Piscataway NJ©2016: Replicated in Monroe, NJ:
More Thoughtful Connections from Care Homes-
Neighborhood-Commons
2000
2014: Upsized to 16 Elders to Optimize staffing 4.0 HPPD. 2014
SPONSOR CRAFTED vs. PROTOCOL MODELS
• Sponsor Inspired
• Choices
• “Protocol” Models
• Small House, Greenhouse™ , “Intentional Design”
Perkins Eastman Architects
Spiezle Group Architects
Small-House/
Neighborhoods
Short Corridor
Household
Hearth
Household
Hybrid
Household
Renovation
Household
Household Layout Comparison
Eppstein Uhen Architects, 2016
Physical Environment Comparisons Between Models of Care
TRADITIONAL
LONG TERM CARE MODEL
CONTEMPORARY HOUSEHOLD
RESIDENT CENTERED CARE MODEL
Large Centralized Activity Space Small Decentralized Activity Spaces
Large Centralized Dining Space Small Decentralized Dining Spaces
Centralized Staff Space (Nursing Station) Small Decentralized Staffing Spaces
Centralized Care & Service Spaces Decentralized Care & Service Spaces
Institutional Style Finishes & Furnishings Residential Interior Finishes & Furnishings
Lack of Natural Light & Exterior Views Natural Light & Options for Exterior Views
Majority of Multiple Occupant Rooms
(2, 3, or 4 people) Shared 2 Piece
Bathrooms. Limited Private Rooms
Private Rooms with Private 3 Piece
Bathrooms. Limited Number of Companion
Rooms, “Smart Doubles”
Monochromatic Interior Colors &
Lack of Textures
Variety of Interior Colors &
Mixture of Textures
Limited Outdoor Access and Garden Outdoor Access with a Variety of Spaces
OPERATIONS
INTUITIVE CAREGIVING
• See, Hear
• Touch Downs and “Home
Inspired” Work Areas
• Share Care Partners
Assistance on Request
Supplies clean and soiled
where needed available less
visible
• In Room Clean/Soiled
• Reach-In Equipment Alcoves
• Linen/Supplies in Residential
“Built-ins
• Planned with Game boards
STEALTH SERVICES: Single
and Multi-Story Examples
DESIGNING TO STREAMLINE SUPPORT
AND GET BACK TO RESIDENTS
Examples: Rhode Island Veterans Home SFCS, Inc. Mease Manor Memory Care, Dunedin, FL, Slator Group Architects PC
and Parker at Monroe, Spiezle Group Architects.
MULTI-STORY
CONNECTED FOR SERVICE ONLY
Right Above: Sponsor Driven Design.
Levindale Hebrew Home, Hord|Coplan|Mach,
Baltimore, MD
Above: Leonard Florence Center for Living Greenhouse™ DiMella Shaffer, “Design for Aging-International Case
Studies of Building and Program,” 2012, Wiley, also in VA CLC DESIGN GUIDE 2012,www.clcdesignguide.gov
• SEPARATE HOMES OR
PAIRED
“NEIGHBORHOODS”
• BOTH CONNECT Service
• HOUSES NOT
SOCIALLY CONNECTED
• EACH Connected to
Community Life
14 14
10 10
DESIGNING SERVICES ARE
INTEGRATED INTO RESIDENTIAL
HOUSEHOLD (12-16 Each) and
NEIGHBORHOOD (24-32 Each) Ea
ch
HO
US
EH
OLD
(
Ne
igh
bo
rho
od
Neighborhood Services: “Hub Staff”* √
Home Office, Team Care, “Touch
Downs,” Medications
√
Launderette √
Clean Linen; Soiled Linen, Lift Storage √
Neighborhood Prep Kitchen √
Home Style, Kitchens, Plating, Aromas √
“Stealth” Service “Alley” Exits, Janitor,
Mech’l , Wheelchair Wash/Charge
√ √
HOUSEHOLD Porch Entries √
Activities/Project Room / Therapy
and Storage
√
Brenda: is this okay?
Example with
Brenda Landis, AIA SFCS NNVH CLC
CASE STUDY: PARKER AT
MONROE SMALL HOME
LIVING
INTEGRATING
CARE
SOCIAL CHOICES
MOVEMENT
and
“STEALTH”
SERVICES
Images with permission, Parker at Monroe©, Spiezle Group Architects, LG Hiatt, Environmental Gerontologist, 2016
Operational Comparisons Between Models of Care
TRADITIONAL
LONG TERM CARE MODEL
CONTEMPORARY
RESIDENT CENTERED CARE MODEL
Ailment/Disability Focus Resident as Individual Focus
Staff Control of Daily RoutinesResident Choice and Control of Daily
Routines
Maximization of Staff EfficiencyOptimize Resident Quality of Life &
Independence
Rotated Staff Assignments Permanent Staff Assignments
Specialized Job Tasks (Hierarchical) Wide Range of Tasks (Team Oriented)
Quality of Care Emphasis Quality of Care & Quality of Life Emphasis
Majority of Food Preparation &
Plating of Food Behind Closed Door
Majority of Food Preparation & Serving of
Food at Decentralized Dining Spaces In
View of Residents
THE PROCESS
INNOVATIONS TAKE NEW TOOLS:
VISIONING, PRICING and APPROVALS;
EQUIVALENT FACILITATION
Experiential Design
Experiential Design
CONCLUSION
BENEFITS OF CONTINUING TO IMPROVE HOUSEHOLDS
Residents
• Freedom, Dignity
• Exercise Choices
• Easier Bathroom Use
• Agitation Reduction
• Improved Memory Retention for Many
• Improved Way Finding
• Energy Improved
Caregivers
• Streamline Assistance
• Safety for All
• Eases Personal/ Bathroom Care
• Redesigns Time for Person-Focused Roles
• It’s Rewarding!
Sponsors
• Layouts supporting ADL’s/Memory are Consistent with MDS values and $ per day
• Images Improve: Living Rather than Sedentary Social
• Important to Stakeholders: Families, Residents, Staff and Reviewers
Key Take-Aways
• The physical environment can elevate or hinder the
experience of place from the perspective of
residents, family, and staff members.
• When effective, environments are a 24 hour a day
partner in vitality and memory enhancement… when
falling short, they render the elder a “patient” and
divert precious care- and service partner time to the
short-comings of design rather than elders’ potential.
• There are lessons in the history of design and present
progress suggesting that it is to soon to fix one plan,
size or feature as the icon of healthy aging.
TAKE-AWAYS: Find Time for Meaningful Interactions with Elders in
Small Homes/Neighborhood Layouts
1. Secure Exits Or Staff Bear This Job.
2. Less Noise Or More Agitation.
3. Fewer Distractions Or Confusion. Fragmentation.
5. Streamlined ADL Or Less Time for Intervention
4. Mobility Encouraged Or Staff Must Assist.
6. Needed Items Near Or Staff Run. Hunt. Chaos.
7. Rhythms Supported Or Delivery, Imposes.
8. Activity Designed In Or Mischief. Inactivity...
9. Easy to See, Listen Or Rush. Wait. Worry.
10. Sense of Accomplishment OR Staff Turnover, Absences
Legacy of Missed Opportunities and Small House Design
Jeffrey Anderzhon, FAIA
@JeffA_EUA
Mobile: 402.598.3167
Andrew Alden, M.Arch.
@AndrewA_EUA
Mobile: 414.687.7403
Mobile: 917.297.8239
Contact Information