_victor regnier

Assisted living

Assisted living represents a model of residential long-term care. It is a housing alternative based on the concept of outfitting a residential environment with professionally delivered personal care-services in a way that avoids institutionalization and keep older frail individuals independent for as long as possible. (1)

‘A special combination of housing and personalized health care designed to respond to the needs of those who need help with activities of daily living. Care is provided in a way that promotes maximum independence and dignity for each resident and involves the resident’s family, neighbors and friends.’ (2) (def. ALFAA)

should :

• appear residential in character
• be perceived as small in scale and size
• provide residential privacy and completeness
• recognize the uniqueness of each resident
• foster independence, interdependence and individuality
• focus on health maintenance, physical movement and mental stimulation
• support family involvement
• maintain connections with the surrounding community
• serve the frail

Typical resident:

Typical resident of an assisted living environment is often a frail female in her mid-eighties. Typically, she is in danger of institutionalization because of decline in competency and an inability to organize the necessary network of services to live independently. Two typical profiles:

• older, cognitively alert, physically frail individual
• physically able but mentally frail individual experiencing the first stages of dementia (3)

Concepts :

• create a place of One owns
• serve the unique individual
• share responsibility among caretaker, family members and resident
• allow residents choice and control (6)

How and with assisted living has evolved:

• increased number of older frail (over 85 : 3.3 M in 1990 to 23.5 in 2040 in US)
• availability of community-based long-term care
• increasing cost of nursing home care
• questioning the inevitability of institutionalization
• evolution of new alternatives between congregate housing and skilled nursing
• phasing out of immediate care
• relaxation of state regulation
• greater consumer demand for alternatives to institutionalization
• increased corporate interest in creative housing alternatives for older frail people (ex. Brighton Gardens Marriott, corporations see assisted living as similar to other high-service hospitality arrangements they are familiar with, assisted living becomes a logical model for innovation and investment) (14)

Assisted living has developed two models of care, medical and residential. The residential model physically separates assisted living and skilled nursing care units. In the residential model assisted living often involves separate residential pavilions having self-contained services or tethered to congregate housing. More intensive health services such as physical and occupational therapy, are brought in when needed. The medical model views assisted living as a health care environment attaching it to or locating it within a nursing home. (16)

Precedents :

-US continuing care retirement communities

-North European sheltered care housing arrangements (smaller than American equivalents, designed and constructed as housing rather than as institutional environments)

-Traditional board-and-care homes (19)

Environment and behavior issues :

• privacy (sense of seclusion, free of unauthorized intrusion ex. door lock)
• social interaction
• control + choice + autonomy
• orientation + way finding (reduce confusion)
• safety + security
• accessibility + functioning (ability to manipulate fixtures + controls)
• stimulation + challenge
• sensory aspects (visual + auditory + olfactory)
• familiarity (historical references + solutions influenced by tradition)
• aesthetics + appearances (non institutional environments)
• personalization (mark the environment as the property of one individual)
• adaptability (to fit changing personal characteristics) (25)

The term assisted living refers to both a philosophy of care and an idea about the character and appearance of the environment. In general, most providers have sought to create buildings that house the smaller number of units that meet reasonable tests of service economy. In general, the smallest professionally managed and economically viable ‘stand-alone’ models range from 20 to 30 units. A facility of more than 80 units takes on the appearance of an apartment building or hotel…

Another important factor is whether the building was originally designed as an assisted living facility or was remodeled from another use. Adaptive reuse projects have included former elementary schools, hospitals, hotels, nursing homes and congregate / independent housing. One current trend involves the remodeling of wings or floors of congregate housing into assisted living. Older houses in particular make interesting projects for adaptive re-use. The building should appear related to housing and should not create ambiguity about its character. (30)

Spatial zones:

• peripheral outdoor spaces
• shared and private outdoor places
• common shared spaces
• service facilities
• resident units (33)

Planning and design directives:

• residential character + image (establish behavioral expectations based on the character, image and appearance of a setting)
• function, behavioral purpose and variety
• outdoor areas defined as rooms (relationship + access to landscape)
• support for family interactions (building should provide places that invite and support a range of family interactions)
• adaptive environments (building and service program designed to change as residents age in the facility + environment should be ‘prosthetic’ and ‘therapeutic’, working toward the maintenance of existing competencies and the restoration of lost abilities.)
• public to private continuum of spaces (spaces within the facility should reflect a homelike environment that balances the desire for social interactions with that for privacy)
• sensory simulation
• indoor / outdoor connections
• community exchange (seeking new forms of integration within the community, make the facility a community service provider rather than a static single purpose institution)
• activity generators that instill vitality (33)

Objective : promote an independent life-style

Design innovation + exploration :

1.Dwelling unit feature :

• kitchen (highly beneficial)
• storage
• grasp + manipulation (fixtures/arthritic hands, level style door hardware, pulls for cabinetry, looped storage spaces, window hardware easy to unlock and windows simple to open, oversized environment controls…)
• bathrooms (2 trends : large accessible room or small that can be navigated by leaning on edges of counters, grasping doorknobs or using towels racks for support)
• unit size (actual trend are larger units with more amenities; studios and one bedroom, 300-500 s.f.)

2. Neighborhood unit clusters :

• 6-10 units
• shared lounge / shared room in middle

Building clusters

3. Creative use of natural light

• windows with lower sills (wheelchair / seated residents)
• skylights

4. Use of spatial hierarchy

• atriums
• lobby
• open grand staircase
• overlook and preview spaces

5. Site design consideration

• courtyard buildings
• site design for exercise and therapy; site should support and encourage walking for exercise, possibly incorporating an extended nature walk when the size of the property is generous; having two paths from a resident’s room to the dining room encourages choice; sensory garden with accessible raised planter beds; birds, mammals and small amphibians provide a reason for a trip outside; wandering garden in Alzheimer facilities
• landscape elements; views of attractive outdoor landscaping from inside a building should be carefully considered
• landscape concepts that support activity; seats, entry, life style orientation toward the environment

6. Therapy and architectural design

• stress restorative health, exercise, fitness and social interactions
• encouraging socialization
• exercise therapy, gym, swimming pool expensive (shared used with community)
• animal assisted therapy (ex. shared dogs moving freely within the facility during the day)

7. Residential surfaces, materials and finishes

• nothing is more destructive to the overall character of a building than materials that give residents and visitors the impression that it is not a residential environment
• Residential image; sloped roof rather than flat roof
• Reduction of noise
• residential construction details and materials; a solution that solves an important functional problem may have negative psychological side effects. Nowhere it is more evident than in the design of environments for the handicapped. Solutions that resolve functional problems often do so by creating a stigma. The universal design movement seeks to employ solutions that enhance safety and manipulation for all populations while de stigmatizing these modifications.
• Environmental meanings
• Applications; developing residential references from the features and qualities of older housing stocks can avoid an institutional look while reflecting the history of housing in that region.

8. Exterior design considerations

• residential scale, structure of less than 3 stories, sloping roofs and fireplace chimneys are elements children often abstract to represent their concept of a house
• front porches, dormers and balconies
• residential stylistic expressions; because many of these buildings (adaptive reuses) are as old as the resident population they serve, they offer a familiar, attractive character that may have special meaning.

9. Visitation for the family

• unit design that support families (ex. a guest house unit of 650 s.f.)
• hospitality areas (ex. social lounge with opening beds and galley kitchen)
• family-care provisions

10. Codes and regulations

• regulations often restrict design expression
• local officials are less sophisticated
• regulatory reform and exceptions

11. Common, recreational and social spaces

• strive for uniqueness of purpose : give each space a clear purpose
• furnishing items and scales (extra residents’ pieces of furniture to be used in common spaces)
• alcoves, fireplaces and furnishing; attach alcoves spaces to larger rooms
• antique furniture selected to reflect the regional history of the surrounding area can stimulate positive past recollections while adding variety and interest.

12. Corridors and connecting spaces

• personalization at the entry; unit entry can be made more personal by decorating it to resemble the front door of a single family home
• Dutch doors and windows
• Natural light and unit clusters

13. Linking to the community

• Residents who move to assisted living often fear their move will begin a gradual disengagement from the broader community. Connections with the surrounding community that increase resident engagement can diminish this fear.
• A popular approach is to share the kitchen as a preparation site for community meals-on-wheels programs.
• Land use strategies + mixed facilities : include a child day care, a senior center, a market, an art gallery (free exhibition space with the gift of an art piece to the assisted living community) and art therapy program…

Extracts from REGNIER, Victor, Assisted living for the aged and frail, Columbia University Press, New York, 1995.