Design tends to be evolutionary, not revolutionary. Progress is typically made in incremental steps, tweaking what “is” to change what “will be.” Occasionally, a revolutionary idea comes along, one that makes us stop and reconsider what we thought we knew. So when I was asked to write about what I feel are the top 10 design innovations from the past decade, I let my mind wander over all the changes we've witnessed. There is now widespread recognition that things will be different as the Baby Boom generation moves, inexorably and generally unwillingly, into that category of citizenship we have, in the past, so easily called senior citizens. This is not a cohort that takes aging (or anything else for that matter) lightly. Many are already helping aging parents cope with later life changes, vowing that things will be different when they get to that stage. We are beginning to see that commitment in changes to nursing homes. It is heartening for those of us who have been in the industry for 25 or more years to see that people are increasingly unsatisfied with what we let nursing homes evolve into-staff-centric institutions that cared more for the body than the soul. I wouldn't yet call the culture change movement a tsunami, but it is certainly a significant groundswell, with enough traction to be more than a passing fad. Whether you refer to it as person-centered care, resident-directed care, or as I prefer, self-directed, relationship-based life, it is here to stay.
But there have been changes in other arenas as well. So let's explore the past decade. Some ideas are big-at the scale of the building or even the community-while other innovations appear in areas such as the small details of a handle grip. All make a difference.
INTENTIONAL ELDER-FRIENDLY COMMUNITIES
Unfortunately, the majority of new homes are still being built with multiple levels, steps at the threshold, and in cul-de-sac suburbs that require a car to go anywhere. Hopefully, in the next decade, we will see more development of intentional elder-friendly communities such as those being spearheaded by groups like the Village to Village Network (www.vtvnetwork.org) and Generations of Hope Communities (www.generationsofhope.org).
THE GREEN HOUSE® PROJECT
Who would have thought, 15 years ago, that you could have a house-a freestanding building-where 10 people lived and loved and laughed and cried, and received nursing level care? There were some smaller household examples, but they were almost always housed under a larger roof, usually with the typical organizational structure, a focus on operational efficiencies, and an institutional culture. There were exceptions-many of the Pioneer Network founders recognized that changing the physical environment was necessary but not sufficient; organizational change was needed to really change the culture from institution to home.
Some care providers thought that if they created a space that looks like a household, it would act and feel like a household. Not true. The Green House project (www.thegreenhouseproject.org) has demonstrated that not only is it possible to live in a home and receive skilled nursing services, the model can be financially viable. The model is spreading and several other organizations are now supporting the small house movement, including the National Alliance of Small Houses (www.smallhousealliance.org) and the Association of Households International (www.ahhi.org).
It's still a young model, and needs more years of experience to demonstrate continued success. A testimony to its radicalism is that a lot of professional caregivers and nursing home administrators still don't believe it can be done. And yet it is. Ask those who live or are employed in a Green House and they will tell you, in no uncertain terms, that it works.
CODIFYING PCC AND THE HOUSEHOLD MODEL
Household models started appearing in the late 1980s and throughout the 1990s, so it can't be called one of the design innovations of this decade. However, many care communities have found it difficult to achieve their desired design because various codes present barriers. The Centers for Medicare & Medicaid Services (CMS) has made considerable efforts to communicate that person-centered care (PCC) and the household model are consistent with its regulations. Ten years ago it was common to hear the argument that you can't “let” residents sleep in because it violates the rules on time allowed between meals. CMS has clarified that residents have the right to choose when to wake up (and go to bed, when to bathe, etc.).
In 2008, CMS, in conjunction with the Pioneer Network, held “Creating Home in the Nursing Home: A National Symposium on Culture Change.” This historic event brought together regulators, designers, and care providers to discuss the impact of supportive design on people living and working in nursing homes. The papers and presentations focused on both the research and the codes that support or hamper the development of livable nursing home design. By the end of the day, representatives from the National Fire Protection Association (NFPA) were saying, “We didn't realize how important these aspects of design are. Work with us so we can create codes that ensure safety within a household model.” And that is happening.
Four proposals were put to the NFPA Technical Committee on Health Care Occupancies, and after vigorous and lively debates, it appears that all four may be adopted in the NFPA 101 Life Safety Code 2012 edition (final decisions coming in June 2011). In acknowledging the importance of these topics, NFPA convened a separate, mid-cycle National Health Care Summit and committee meeting to specifically address issues of household models and culture change in the healthcare setting.
The Interpretive Guidelines that accompany the Guidance to Surveyors have also been significantly revised to specifically incorporate language that supports the self-directed, relationship-based lifestyle. Nursing home surveyors now have clear directions that resident choices and preferences are to be honored.
Another key example of codifying the household model comes from a recent revision to Florida's building code. The new codes specifically allow the inclusion of various household design elements including resident rooms clustered around their living spaces (which may include a kitchen), a limit in shared rooms to two residents, direct access to a window in each resident's space, and the spaces shall be separated by a solid wall (not a curtain).
ELIMINATING THE NURSING STATION
For a long time, the traditional nursing station was a space nurses felt was indispensible. But often it became the barrier that separated staff from the very residents in their care. This past decade, there have been many examples of households (no longer “units”) that have eliminated this institutional icon. Work spaces may be decentralized to a number of smaller desks or alcoves throughout the household or incorporated into kitchen areas. Often there is a separate enclosed office or mini-conference room for private conversations. This shift to smaller workspaces is supported by the growing use of computer-based charting. When relevant and up-to-date resident data is available to staff on any computer terminal, and call systems can page staff wherever they are, there is no need to be tied to a single charting location. It is important, however, to recognize that the nursing station also served to support staff interactions-both work and personal-which impact the culture of the organization. Some communities have found that if all shared work spaces are eliminated, staff can feel alienated from each other. The revised Interpretive Guidelines also specifically indicate that a “nursing station” is not a requirement.
ELIMINATING THE MED CART
Like the nursing station, the large, plastic med cart sitting in the hallway or dining room is an institutional icon that should be retired. Alternatives such as medication storage systems are designed to look like furniture. There are also other alternatives such as storing medications in locked cabinets in resident rooms, which puts medications in close proximity to the residents. Nurses who have not used this system often argue that the residents are not always in their rooms when it's time to distribute meds. However, nurses that have used this system, particularly in small households that have consistent staff assignments, say it's not hard to know when and where residents want their medications, and the walking distances are so short that it is easy to distribute them.
SMALLER IS BETTER
While there is no single definitive study on the ideal household size, virtually every study that has looked at resident/staff outcomes related to the size of resident groupings (units or households) concludes that outcomes are more positive with smaller groupings. The outcomes range from less disruptive or anxious behaviors; greater socialization between residents; less use of psychoactive medications; greater resident, family, and staff satisfaction; and less staff stress. Much of this research was conducted in the 1990s, but it is just beginning to be more widely adopted. While fewer care communities are building 60-bed units, which were once considered the best size from a management/staffing perspective, there are still some being designed and built today.
On the other end of the scale, households are now being built with as few as eight or nine residents, although 12 to 18 is more common. One proposal to the NFPA Life Safety Code mentioned in this article uses 24 as the maximum number of residents who can be served by a kitchen with residential kitchen equipment located in the household and not having to be separated by a two-hour firewall.
In older buildings (built before the Americans with Disabilities Act [ADA]), bathrooms are often small, with barely room for the toilet and sink, and certainly no space for an assistive mobility device. They often were shared between two resident rooms. Lighting was almost universally poor, sometimes as low as 1 foot-candle (50 fc is usually recommended). The passage of the ADA in 1990 dramatically increased the size of bathrooms (at least some) requiring a 5′ turning radius. However, the ADA Accessibility Guidelines recommended designers put the toilet with the center line 18″ from a side wall. The goal was to make sure the grab bar was in reach of the person using the commode. However, many residents require a one- or two-person assisted transfer, and only having 18″ significantly increases the risk of musculoskeletal injuries as staff try to twist and bend in such cramped space.
Some states will now allow a variance that permits the use of fold-down grab bars adjacent to the toilet. This puts grab bars within easy reach on both sides of the toilet, a better option for someone with 1-side neglect or weakness. It also allows placing the toilet further from the wall to create more room for staff to provide assistance without injury.
Another change we are seeing is the inclusion of bathing or, more often, showering right in the resident's bathroom. Ohio is the first state to require that all new nursing home resident rooms include a shower or tub in the bathroom. Increasingly, we are seeing en-suite showers (also referred to as European showers)-where the whole room acts as the wet room. Although slightly less familiar, this is generally much easier for both staff and residents because it provides more room for maneuvering-both while taking a shower and at other times because the floor space is more open.
LIGHTED GRAB BARS
One of the most interesting products to recently appear is the lighted grab bar. It is well documented that most falls occur at night, as residents get up to go to the bathroom. When a light is turned on at night, the sudden change of light levels can be physically painful, and the contraction of the pupil is not immediate. If the bathroom light is on, then turning it off before heading back to bed can cause momentary blindness. Both situations put people at high risk for falling. A lighted grab bar provides enough light to find the toilet without having to turn on additional lighting. It also highlights the bar so it is easier to see and use.
BETTER CEILING LIFTS
Healthcare workers, particularly in nursing homes, suffer very high rates of back injuries. According to the U.S. Bureau of Labor Statistics, sprains and strains are the leading cause of injuries in nursing homes. The Occupational Safety and Health Administration has recommended (but not yet required) that healthcare providers implement no-lift policies. Many nursing homes offer a variety of transportable lift and transfer devices. However, the lifts never seem to be where needed, when staff need them. While not the most “residential” of elements, ceiling lifts are catching on.
Attached to a ceiling track, most systems are designed so that the actual lift device only needs to be installed in rooms where it is required. The most comprehensive research on ceiling lifts, which has been conducted in Canadian hospitals, suggests that compensation costs for lift and transfer injuries were reduced by 82% and total claims costs by 40%. The time to recoup installation costs varies but appears to range between 0.8 and 4 years (depending on many factors, including what costs are included in the analysis). This is great news, not only for the staff and residents using the lifts, but also for the financial health of the facility.
UNIVERSALLY DESIGNED IMPLEMENTS
At the small end of the scale, there is now a wealth of small kitchen utensils, garden tools, and other products that follow Universal Design (UD) principles. Large, ergonomically correct, padded handles make them easy to grasp and use, even with significant arthritis. Larger display numbers with higher contrast are increasingly being found on timers, weather gauges, thermostats-even the occasional cell phone and TV remote. Unfortunately, very few electronic device manufacturers seem to understand this principle, as devices get smaller and smaller and more monochromatic for a sleeker look. Hopefully, this will change soon.
Unfortunately, there is a lack of widespread adoption of UD principles in building design. Despite having been around for several decades, and making such conceptual sense that it's hard to argue against, it has yet to be widely adopted.
Innovations for our older citizens over the past decade cover the full gamut. Even the language has changed. In the 1990s we moved from “caretakers” to “caregivers” and (some of us) from case managers (who wants to be a “case” to be “managed”) to care coordinators. In 2011, as Boomers start turning 65, there's been a revolt against being called “seniors” or “senior citizens.” Terms such as “elder,” “older adult,” and “seasoned” abound, and new terms appear weekly (e.g., “merryatrics,” “seniority,” and “geezers on the go”). Some of these terms are likely to be a fad, fading quickly, while others reflect deep epistemological shifts in our culture.
As youngsters, Boomers didn't “trust anyone over 30.” Then they turned 30, and didn't trust anyone over 40. As they hit 50 (gasp!), the search for eternal youth took hold, because everyone knows “younger is better than older” in so many ways. Plastic surgery grew at epidemic proportions. Now that they are reaching 65, and in the coming decade 75, my hope is that they will spur even more revolutionary design ideas. Let's really stretch and see what positive design looks like for people in their 3rd and even 4th quarter-century of life. LTL
Elder-Friendly Communities Sourcebook. School of Social Work, College of Health & Public Affairs, University of Central Florida. Orlando. Available at: www.cohpa.ucf.edu/documents/Elder-FriendlyCommunitiesSourcebook.pdf
The Green House® Replication Project: www.ncbcapitalimpact.org/default.aspx?id=146
Creating Home in the Nursing Home. Conference summary and copies of all papers, including the pre-conference code analysis written by Carmen Bowman, are available at: www.pioneernetwork.net/Events/CreatingHomeI
CMS Interpretive Guidelines for Long-Term Care Facilities. Appendix PP -“Interpretive Guidelines for Long-Term Care Facilities,” www.cms.gov/transmittals/downloads/R55SOMA.pdf
Ceiling lift research available at: www.prismmedicalltd.com/PDFs/MR_OHSAH_Ceiling_Lift_Project_at_StJ_Hospital.pdf
National Association of Home Builders' section on Universal Design. Available at: www.toolbase.org/toolbaseresources/level3aspx?bucketid=2&categoryid=22
Another Web site with good resources is www.makoa.org/accessable-design.htm
Margaret P. Calkins, PhD, CAPS, EDAC, is President of I.D.E.A.S., Inc., and Board Chair of IDEAS Institute. She currently serves on the Boards for Pioneer Network, and the American Society on Aging. Contact her at
MCalkins@IDEASConsultingInc.com. Long-Term Living 2011 March;60(3):40-45