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Closing the Circle: The Evaluation of Brewster Village

June 1, 2004
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Resident- and staff-friendly design concepts are put to the scientific test by Andrew L. Alden, MArch, and Gerald D. Weisman, PhD
Closing the circle

The evaluation of Brewster Village

Does a facility upgrade really work for everyone involved? The authors placed one such project under the scientific microscope

BY ANDREW L. ALDEN, MARCH, AND GERALD D. WEISMAN, PHD Only one year after its demolition, the old Outagamie County Health Center, with its origins in the county poorhouse and poor farm, is already a fading memory in the minds of residents in Appleton, Wisconsin, and surrounding towns. Attention is now focused on Brewster Village, the new 204-bed, county-operated skilled nursing facility, which sits adjacent to the site of the old Health Center.

The story of the creation of Brewster Village was featured in DESIGN 2003 (Alden AL, Weisman GD. "'Inmates' to 'Villagers': The Creation of Brewster Village," p. 22), published by Nursing Homes/Long Term Care Management. The planning, programming, and design process followed what we characterized as an "action research" approach, marked by a high level of communication, collaboration, and group decision making among four key organizations: Outagamie County Health Center (OCHC); Horty Elving, Architects, of Minneapolis; Oscar J. Boldt Construction of Appleton, Wisconsin; and the Institute on Aging and Environment (IAE) of the University of Wisconsin'Milwaukee. The DESIGN 2003 article described the "front end" tasks (analysis of comparables, preparation of preliminary program, review of schematic design alternatives) for which IAE took major responsibility. This article describes the evaluation study of Brewster Village, also carried out by IAE, based upon data gathered during a two-year period from residents, staff, and families before and after the move to the new facility.

As a cutting-edge environment, Brewster Village is clearly different in many ways-architecturally and organizationally-from the antiquated facility it replaced. Some of these critical differences, as displayed in table 1, are the shift from shared to private resident rooms, more than doubling the social space per resident, and the clustering of residents in "households" of 13 or 14 rather than units of 30 or more.

Although the benefits for residents and staff of some changes, such as a 15% reduction in maximum travel distance from resident rooms to common areas and a 27% reduction in the number of residents who need to be moved more than one floor, are relatively self-evident, other psychosocial consequences of the relocation required more detailed study. Table 1. Comparing the Outagamie County Health Center With Brewster Village Outagamie County Health Center Brewster Village Maximum distance to main activity area 325 feet 275 feet Vertical distance to main activity area 67% of facility needs to move at least one floor (required daily) 40% of facility moves one floor (not required daily) Social space per resident 30 sq. ft./resident in unit 70 sq. ft./resident in household Resident room Double occupancy (125 sq. ft./resident) Private rooms (255 sq. ft./resident) Location of activities and services Centralized activities & services: long travel distances Decentralized activities & services: reduced travel distances The Evaluation
Consistent with "action research," our approach was aimed at evaluating the consequences of the residents' relocation from OCHC to Brewster Village. Unlike the classic scientific method, however, our approach did not enable us to randomly assign OCHC residents to "experimental" and "control" conditions, because all OCHC residents were relocated, either to Brewster Village or elsewhere. Also, unlike a more traditional experiment, our approach did not begin with formal hypotheses regarding the impact of Brewster Village on OCHC residents, staff, and families. Indeed, different theories of elderly/environment relationships actually suggested three quite different outcomes of relocation-ranging from negative to neutral to positive.

Predictable negative impact of relocation. The impact of relocation on the elderly, either from home to institution or from one institution to another, has been researched extensively. In many of these studies, relocation is associated with increases in mortality and morbidity. While such negative outcomes can be ameliorated to some extent by relocation-preparation programs, such as that undertaken by Brewster Village, relocation theory would suggest neutral to negative consequences of a move, particularly for physical and psychological functioning of residents with diminished competence.

The continuing consequences of aging must also be considered when one is evaluating the negative impact of relocating the elderly. The interval between our gathering the first premove resident data and the final postmove data was roughly two years. Thus, among a sample of study participants with an average age of 73 at the initiation of the study, one might reasonably predict some continuing drop in competence, both physical and psychological.

Predictable positive impact of a therapeutic environment. It seems reasonable to predict that a new $26 million facility, designed and built to be therapeutic-for example, with protected outdoor courtyards (figure 1) and living rooms, dining rooms, and kitchens for each household-would have some positive impact on residents, staff, and families. Measuring Responses to Environmental Change