The residential assisted living model, or RAL, has been gaining traction over the last few years, with approximately 30,000 RALs in the U.S. These small residences house eight to 30 seniors, are staffed around the clock, and deliver meals and noninstitutional-based services such as hair and nail care and social activities. But what makes RALs unique in the genre of assisted living is their location—within residential neighborhoods. Many RALs are situated in existing homes that include some level of retrofitting to accommodate elders, and others are purpose built.
RALs are staffed according to their licensure, which varies depending upon state and local requirements, but typically include an administrator and/or registered nurse. Additionally, there may be a licensed practical nurse and personal care workers along with a chef and activities’ staff.
Overall, the model answers the desire of a growing number of families seeking environments that provide seniors the services they require but within the communities they already know and love. Plus, the scale is another proven benefit. “Smaller environments provide an opportunity for residents to have better quality-of-life outcomes because they have more choice, shorter walking distances, and better control of their environments,” says Jane Rohde, founder and principal of JSR Associates Inc. (Catonsville, Md.), which provides senior living care modeling and design consulting.
Yet, despite their growing popularity, RALs face difficulties with building codes and zoning officials, Rohde says. “There’s a lack of understanding that an RAL is a home where services are provided. Building officials try to place RALs into an institutional occupancy, and it is not an institution or facility; it’s a home.”
Clarifying matters
To help remedy points of confusion tied to RALs and other assisted living models, the Residential Document Group, a subset of the Facility Guidelines Institute’s Health Guidelines Revision Committee, is working to update and revise language in the “Assisted Living Facility” chapter of the Guidelines for Design and Construction of Residential Health, Care, and Support Facilities. The goal is to better define assisted living models. Rohde, one of the chairs for the group, says changes to the document are currently out for public comment, with hope that the revised typologies will be part of the 2022 edition. (The public comment period closes on Sept. 30.)
In the existing language of the 2018 Guidelines, assisted living models are designated by size—small, medium, and large, based on the number of residents. The proposed changes recharacterize care models as typologies: residential, household, and apartment-style communities. The residential typology is used to define an RAL setting as:
• Single-family homes in residential neighborhoods.
• Includes the character of a single-family home.
• Includes dining and living spaces that are often combined with an open residential kitchen to create a great room.
• Can be purpose built but often remodeled.
• Amenities and care provided.
• Occasionally other staff members are included (activity person, chef, etc.).
• Variety of private and shared bedroom and bathroom spaces to support residents’ personal choice; as a result, there may not be a 1:1 ratio of bathrooms to bedrooms.
• Direct visual and physical access to natural areas or landscaped outdoor spaces for residents and staff.
Rohde says the inclusion of RAL in the updated guidelines is to support the segment of the industry that comes from a residential perspective in terms of providing care within a home setting versus other types of assisted living. The goal, she adds, is to not institutionalize elders based upon diagnosis but to allow them to continue living in a home with normal daily activities coupled with the care needed, to support as much independence and choice as possible.
Case study: Evermore Senior Living of Lake Ridge
Rohde says that often her clients pursue the RAL setting when looking for places for their own parents. That was the case for Dave Risi, an industrial hygienist and safety professional who also invests in real estate and rental properties. He and his wife were looking for a place for her then 88-year-old father, who lived with his wife in New Jersey. “He had always lived in a house,” Risi says, “and wanted to continue living in a house.”
When the couple couldn’t find the setting they wanted in Northern Virginia, Risi decided to build his own. He spent six months researching and connecting with organizations like Residential Assisted Living National Association (RALNA), which provides support services and information on owning and operating an RAL.
Risi found two lots zoned residential in a subdivision in Woodbridge, Va., and worked to get approval from neighborhood homeowners to change the language in their covenants to allow the RAL. “My wife and I bought a lot of coffee and cake and assured the neighbors that we’d be building the quietest homes in the neighborhood,” Risi says. In April 2018, Risi and JSR Associates began designing what would become Evermore Senior Living of Lake Ridge in Woodbridge, Va. The project includes two 5,500 square-foot ranch homes, each housing eight bedrooms with en suite bathrooms, for memory care and assisted living residents. The first home was finished in July and received its certificate of occupancy in August. Design plans for the second home are in the works, with construction expected to begin in early 2021.
The final design for Evermore features a single-story house with an open floor plan, including a large central kitchen, dining area with a table that seats up to 10 people, and a living room with a stone hearth and fireplace. Where skilled nursing communities’ hallways are 6 feet wide, Evermore’s hallways are 5 feet wide “so it doesn’t look institutional,” Risi says.
With safety and health concerns front and center, Rohde made sure that the house has a pathway to allow clean materials, including food deliveries and packages, to come through an exterior door on the side of the house and directly into the kitchen. Throughout the house, all soiled materials and trash get collected and go out a side door to the outside, removing the need for waste to be carried through the home. Another important design feature is the HVAC system, which is made up of three large heat pumps with HEPA filters and UV-C filtration units. “HEPA blocks bacteria and dust, but that doesn’t do enough for viruses, so the air is disinfected with ultraviolet,” Risi says. The home has three zones, and each bedroom has its own heating controls as well as a radiant heat panel in the ceiling to provide comfort without a more expensive overall system, Rohde says.
These safety and health features have taken on added importance during the COVID-19 pandemic. And, in general, RALs and other small-house models have proven beneficial for residents, with less traffic through the community and less square footage to clean and disinfect. “There’s recognition that smaller homes with dedicated staff lower the potential of exposure, and residents can be monitored for early detection of any illnesses or changes in behavior,” Rohde says.
Risi’s ultimate goal is to have four homes in Virginia “to optimize the business, since by law one executive director can operate up to four homes in the state,” he says. Although Risi’s father-in-law passed away last year and was never able to reside at Evermore, Risi is happy that others will have the opportunity to live in a place he inspired. “Our seniors should have the option to live in an environment that resembles how they lived their lives up to that point—in a residential home with a group that resembles a family,” he says.
Stacey Freed is a freelance writer based in Pittsford, N.Y. She can be reached at [email protected].
