Designing For The Aging Population In Acute Care Environments

We knew a major shift in healthcare design was afoot when a major provider asked us: “How is your design of this hospital senior-friendly?” As lines between models in the care continuum begin to disintegrate, designing for acute care means looking to the strategies used in post-acute environments.

There’s no doubt that aging is a hot topic. The elderly consume healthcare services at a disproportionate rate compared to other age groups. And as baby boomers begin to swell this patient segment, providers are focused on reducing readmission rates and efficiently managing care across the continuum, making design that’s sensitive to older generations a priority.

In post-acute environments, the patient stay is longer, so one goal is to create a living environment where they can have a high quality of life, staying socially connected and feeling in control. With acute care, on the other hand, the objective is to deliver high-quality care in an efficient manner and to discharge the patient as soon as possible.

Although there are major differences between acute and post-acute environments, the two settings can be compared when three main spaces are considered: corridors, the patient/resident room, and support spaces. While many of the strategies suggested on the following pages are specific to the elderly, ultimately these are design moves that benefit everyone, regardless of age. In times of illness or rehabilitation, every element that brings physical healing, mental stimulation, and emotional support contributes to holistic wellness.

Corridors
In post-acute environments, one of the goals is to get patients out of their rooms so they can participate in rehab and social activities. The corridor becomes more than just a space to move through; it’s an opportunity for spontaneous social interaction, a place to be. In post-acute corridors, seating or other destinations, spots of interest, etc., should be provided at short intervals (for resting, or as a place for conversation)and artwork and views to the outside should be included, to encourage patients to be up and out of their rooms.

The acute care corridor is more of a space for visitors and staff than for patients because patients are less likely to leave their rooms. It’s more of a movement space and less of a social space. Elderly visitors can benefit from some of the post-acute care strategies for designing corridors, specifically the inclusion of places to stop and rest spaced at short intervals and visual clarity for aging eyesight.

Both post-acute care and acute care corridors benefit from small-scale design moves to aid with visual impairments. For example, the base color on the walls is often designed to match the flooring, which can make it difficult for an elderly person to tell where the wall and floor meet. Contrast between the handrail and the wall is also important. High light levels from a variety of sources, not just overhead, benefit the aging eye. Additionally, flooring patterns that stay within similar tones will help lessen the appearance of holes in the ground. In both settings, elevators should be easily identifiable, have call buttons that accommodate assistive devices, and be large enough to include room for sitting.

Acute care corridors

• Bold floor patterns to highlight nurses’ stations are great for wayfinding, but the color contrast can cause the elderly to think it’s a step or hole.
• Floor and wall colors should be different to distinguish the two planes.
• Handrails need a contrasting color to be easily distinguishable and create a feeling of security. And often, equipment is parked in front of handrails.
• There’s a heavy reliance on signage for wayfinding since patient visits are shorter. To accommodate aging eyesight, the letters need to be large and easily readable, and at lower heights where possible.
• Corridors are typically double-loaded for efficiency, so there’s little to no natural light. This is not easily mitigated because acute care settings are designed for staff efficiency. Single-loaded corridors are an alternative in post-acute settings because mobility is encouraged and nursing is not as intensive.
• Hard-surface flooring such as linoleum, rubber, and vinyl makes glare more likely. Subtle patterns, gradient colors, darker tones, and wood-grained flooring create texture that softens the traditional institutional white floors with bold patterns. The paradigm shift is still a challenge for staff, administrators, and patients who need to be convinced that flooring does not have to be shiny and white to be clean.

• There are typically no places to stop and rest. Small built-in benches out of the exit path or at the end of the corridor by a window can be incorporated. Often, lighting comes from one source only—typically bright overhead fixtures. High light levels and a variety of sources are needed for the elderly eye.

Post-acute care corridors

• Handrails are easily identifiable, continuous, and smooth to the touch (to protect delicate skin).
• Natural light and windows are ideal in post-acute care to encourage mobility for rehab patients and movement/socialization for the elderly.
• There’s less dependence on signage and more on visual cues at walls and room entries for cueing and wayfinding. The signage that exists is placed lower because the elderly tend to look down.
• Flooring is generally carpet: softer, quieter, and less institutional. While this is not an appropriate material in acute care, a textural or wood-grained look in the floor in acute care is desirable.
• Corridors are designed for multiple functions such as socialization and rehabilitation. For example, distance markers can be applied through subtle floor or wall patterns to aid in rehabilitation;  interesting features on the wall (artwork, niches, displays, etc.) and lighting variations can encourage activity and movement. Clear floor space free of obstacles (such as equipment) and destinations at the ends with seating and views promote socialization. 

Patient rooms
Storage, display, and personal control are central themes in the post-acute care patient room. Since the patient may be there long-term, a significant amount of storage in the room and bathroom is desirable. The ability to adjust the lighting, shades, television, acoustics, and personalization of display provide control over one’s own environment. Difficulty sleeping is a common problem for the elderly, so night-time control is especially important.

There’s very little patient storage space in the acute care room; typically, the storage is there for the staff. There’s an opportunity to hide equipment that may look scary with attractive casework.

In post-acute spaces, there are common areas in which to socialize with visitors. This is not the case in acute care: Socialization occurs in the patient room. A designated space for visitors with furniture that’s senior-friendly (easy to get in and out of, not too low, sturdy arms) is important.

In both post-acute and acute care rooms, there’s an opportunity to encourage bedside wellness. Space should be provided for the patient to get up, use an assistive device that’s adjacent to the bed, and move around. Elderly people lose strength faster than younger people, so being in bed for long periods of time is especially detrimental to their health.

In both settings, high-contrast furniture can help a patient identify his or her bed, bedside table, and other furniture against the floor to reduce fall risk. Other strategies to reduce fall risk in both settings include a night-light that can be controlled from the bed and a handrail from the bed to the bathroom to help guide the patient.

The patient bathroom is another area where acute and post-acute care design has differed, but that’s beginning to change. In post-acute settings, the focus is on fold-down grab bars for independent or assisted toileting. Acute care spaces are now incorporating those features, as well, since the majority of patients are older and it can be too labor-intensive to rely on the nursing staff to assist.

Acute care patient rooms

• The room is often designed for a range of acuities and includes lots of equipment that may be frightening for the elderly, even if not being used. Hiding this behind casework so that it can be visible only when needed can lessen an institutional feel. 
• Patients are less independent and less mobile, so the room is focused on bedside care. Typically, the rooms are tight and difficult to maneuver with mobility devices.
• There’s little patient storage and minimal personalization because patients may be there only for a short amount of time. Even small opportunities for personalization, such as shelving opposite the bed, can help make the room feel more residential. 
• Visitor interaction occurs inside the room, so there should be a dedicated zone for family and visitors.

Post-acute patient rooms

• Stays are longer, so space for personalization and storage in the room are incorporated.
• Finishes provide a residential feel. A wood-grain flooring look is preferred, although carpet is also appropriate to make the room feel residential.
• Independent toileting is emphasized with direct visual access and fold-down grab bars. 
• Larger rooms allow for patients to be out of bed.
• Barn doors with door pulls create wider access into the rooms so patients with mobility devices can easily maneuver on their own.

Nurses’ stations
Support spaces in post-acute settings have long been the key to creating a residential environment. Current trends decentralize nurses’ stations into small-scale work areas, often no more than a desk in a common space, such as a living room or family-style kitchen. Other support spaces are designed to be part of the background—doors are virtually hidden from view. An on-stage/off-stage approach is taken so that patients see as little equipment as possible (while it’s beneficial for patients to see staff, seeing equipment isn’t desirable).

Acute care nurses’ stations

• Nurses’ stations that are highlighted with bold floor patterns can be too confusing for the elderly. Nurses’ stations can be highlighted with lighting and vertical materials instead of flooring. 
• Generally, nurses’ stations are highly active and noisy, and can be unwelcoming to elderly visitors seeking information about their loved ones. A concierge-style nurses’ station can be more welcoming.
• There’s more equipment out in the station. Putting equipment away when not in use can make station feel more approachable. 

Post-acute care nurses’ stations

• The nurses’ station is designed to look like a concierge desk so that it’s welcoming for patients and visitors.
• Equipment is hidden in rooms or within casework when not in use. Nursing functions are incorporated into residential features such as kitchens near the dining area, through small-scale workstations that blend into the residential environment.

Joyce Polhamus, AIA, EDAC, LEED AP BD+C, is vice president of SmithGroupJJR (San Francisco) and leads the firm’s senior living and healthcare interiors practices. She can be reached at [email protected]. Alexis Denton, AIA, LEED AP BD+C, is an associate with
SmithGroupJJR (San Francisco) and holds graduate degrees in architecture and gerontology from the University of Southern California. She can be reached at [email protected].