Senior living environments—and senior living design as an industry—have come a long way since Environments for Aging was launched 20 years ago. The magazine has, too (for more, see “Celebrating the 20th Anniversary of Environments for Aging.” This issue brings the addition of a new Editorial Advisory Board, composed of 19 senior-level professionals including architects, interior designers, owners/providers, and consultants. To help recognize the 20th anniversary of EFA, the group gathered recently via conference call, sharing stories and perspectives on the industry’s evolution over the past two decades.

When EFA’s previous incarnation, Design magazine, was first published in 1997, nursing homes (still the nomenclature at the time) remained the prevailing housing type. These highly regulated environments were institutional in nature, defined by double-loaded corridors, shared resident rooms, artificial light, and centralized nursing. But change was afoot.

Assisted living was emerging as a desirable new option, board members describe, largely because it didn’t come with the stringent codes the industry was so used to balancing. It allowed designers to begin playing with scale, breaking 60-resident platforms down into smaller households of eight, for example. “We could do the kinds of things we wanted to do: make it homelike, make it more hospitality-inspired, give residents choice. Then, we said, how do we do that in long-term care, because these residents are going to be moving through the continuum. That’s what we saw as the obstacle,” says Dan Cinelli, managing principal and board director at Perkins Eastman (Washington, D.C.).

An additional push came from the memory care solutions being brought to the table at the time—also small in scale and residential in nature. “We kept looking at the fact that if this model is good for a resident who is cognitively challenged, why wouldn’t it also be good for those who are dealing with more of a healthcare issue?” says Mitch Elliott, senior partner at RDG Planning & Design (Omaha, Neb.), on his early days working with owner/operator Vetter Health Services.

As this shift in mindset emerged, it came with some pushback on code officials by groups like SAGE (Society for the Advancement of Gerontological Environments). Cinelli says members challenged regulators to consider departures from requirements that were far more aligned with medical environments than residential ones, asking questions such as whether a nurses’ station was really needed. It was the start of the deinstitutionalization of senior living. “We were, as a field, moving away from institutionally designed settings, but on the whole, we hadn’t defined what we were moving to,” says Margaret Calkins, one of the founding members of SAGE and current executive director of The Mayer-Rothschild Foundation (Kirtland, Ohio).

While aesthetics were evolving and residential approaches were being introduced, under the surface, communities were still largely based on staff-centric operational models, which limited the effect of progress—still an underlying challenge today. “I think in the past 20 years that’s beginning to change. It’s not widespread, but it’s beginning to change,” Calkins says.

Supporting the model
The solution is person-centered care, and to identify how to achieve it, owners found themselves looking inward. “We realized we were providing really good medical care and very traditionally oriented care, but we weren’t creating an environment where people could live rich, full, meaningful lives, even though they need some assistance and care during the day,” says Steve Lindsey, CEO of Garden Spot Communities in New Holland, Pa. “That drove the journey of discovery around what kind of environment did we need to create to facilitate a life for the people who lived there that would be enriching, rewarding, and purposeful.”

Part of this process included a new effort to listen to those who knew best. For the first time, resident focus groups were more commonly held ahead of design projects, facilitating meaningful involvement in decision-making and engagement in operations. “It allowed us to start listening to the consumer, listening to the resident, and pushing back on the status quo that’s always been there,” Cinelli says.

This trend also brought the emergence of new efforts to support person-centered care through the built environment. Elements like access to nature and daylight became priorities. “Oftentimes in old institutional models, daylight wasn’t one of the driving factors. I think, for us, that’s what really began to change how we looked at spaces and the way we started to lay out these projects,” says Eric McRoberts, partner at RLPS Architects (Lancaster, Pa.). Additionally, ideas of resident dignity surfaced and resulted in private bedrooms and baths, as well as residential kitchens where food is prepared and served, and additional dining options.

More deeply, designers began asking questions of not only residents but staff about why earlier efforts to deinstitutionalize weren’t necessarily working. For example, outdoor spaces would be provided but no one would use them, says Jane Rohde, principal of JSR Associates Inc. (Catonsville, Md.). “You’d build a building on very little input and then didn’t understand why it wasn’t being operated efficiently or there was low staff satisfaction, residents couldn’t get in and out of the toilet room by themselves, or whatever the case may be. It didn’t take long to evaluate where the gap was,” Rohde says. “The harder part has been bridging the gap and getting information from people to get the operational side and the design side to understand this is a mutual benefit.”

One approach that’s emerged is recognizing there’s no one-size-fits-all response and that simply incorporating daylight and a household model isn’t enough to achieve person-centeredness. “If you give someone a household model and they’re trying to operate it on a centralized system, the physical environment doesn’t support what they’re trying to do operationally,” Rohde says.
Designers discovered over time the critical importance of staff training and maintaining message, especially across leadership changes. Cinelli recalls designing a project where the owner encouraged a deconstruction of the traditional nursing home model, but by the time the community opened, a new administrator and director of nursing who hadn’t been involved in early planning stages defaulted to using it the way they knew how. “What was missing was that we didn’t give them an owner’s manual of what we recorded early on to make sure they understood why we made all these changes, what operations drove it. Because all of a sudden, the concierge desk was being used as a nurses’ station,” he says.

Look and feel
Beyond supporting a person-centered model of care, communities have transformed to answer higher expectations for the overall look and feel of a property—specifically, saying goodbye to Queen Anne and hello to a modern, contemporary approach. Board members say the introduction of HGTV, Food Network, and even Oprah into our culture has ingrained a new sense of self and possibility that’s thrown past practices of demographic segmentation out the window. “[Residents] are looking not just at what’s for ‘old people,’ but what’s for people. They want to be engaged in what’s going on in the world around them,” Lindsey says.

And, “it’s where the money is,” says Vassar Byrd, CEO of Rose Villa in Portland, Ore. “My customers don’t want to move into an institution of any kind. They’re looking for a neighborhood that supports their needs. The more it feels like a nice neighborhood, the more likely I am to attract them. There are so many options for them to not move anywhere, so many services available … it’s a lot to get them to say, ‘This other place is nicer than my home.’” Additionally, isolationism of years’ past is being replaced by senior living properties that better connect to their surrounding communities and encourage visitors with retail and dining options open to all. “Any time you do that, the aesthetic needs to fit in the context and not feel like an alien environment, so I think that’s also impacted aesthetics,” says Alexis Denton, principal at SmithGroupJJR (San Francisco).

Simultaneous trends skewed toward homelike and hospitality design have emerged, as well, with the former primarily occurring in higher-acuity care settings (skilled nursing, memory care) and the latter in independent living, active adult, or short-term rehab, with overlap between the two—think hospitality-inspired centralized services like dining but in a small house community, says Rob Pfauth, director of senior living planning at Erdman (Madison, Wis.). “They’re both responses to different segments of the marketplace, and each has its own place,” he says. “It’s an interesting dichotomy where they’re complementary but still divergent.”

Product manufacturers have taken note of the demand for change, too, with offerings evolving dramatically from the five patterns and three colorways an interior designer might have found available 20 years ago, says Laura Busalacchi, senior director of interior services for Brookdale Senior Living (Milwaukee). There’s been a surge in technology that allows the creation of materials that are suitable for senior living (cleanable, durable, etc.) but are also stylish, while furniture manufacturers simultaneously have explored options that are safe and supportive without simply being a plain, square chair. “There’s a lot of change just within that that allows the interiors to look and feel different because of the options designers now have,” she says. This movement has gone a long way toward improving more acute environments, too. “We can specify an independent living project that meets all the requirements of skilled nursing now, so there’s no step down in design from one level of care to another, which is critical,” says Dean Maddalena, founder and president of StudioSix5 (Austin, Texas).

Product selection isn’t the only thing that’s grown. More and more designers are entering senior living design, attracted to the progress taking place and bringing ideas from other sectors like hospitality and corporate interiors with them. “You’re getting a lot more designers in the field, and any time that happens there’s going to be more variety and more innovation,” Denton says.

Working together
The relationships between owners and the design community have in many cases progressed greatly since those conversations 20 years ago, when architects began pressing the status quo. For starters, some providers are coming to the table better informed. “Back in the day, we would call the architect and expect them to create a design, bring it to us, and we would put our stamp of approval on it and it would be built,” Lindsey says. “Now we’re starting to realize the importance of our involvement in the dialogue. We have a good sense of the experience we want people to have when they come into a space and how we want it to perform and function, well before we even meet with the architects.”

In fact, it’s the owners who may be doing the pushing back these days. “We have to communicate [our vision] clearly and be willing to say what elements are non-negotiable, are critical for the people I expect to live here, and really understand what is important,” Rose Villa’s Byrd says. “It’s definitely a partnership. I can’t imagine just handing it over. It’s a very intense back and forth, and a very rewarding experience.”

For internal designers working for owners and operators, a new interest has emerged in not only basing designs on internal community feedback but of looking to the greater market to best position a property for the future. “The expectation for a while now is you need to go out and see the competition, check out what else is going on within that community to make sure we’re servicing and moving that property forward for the next 10-15 years,” Brookdale’s Busalacchi says. Likewise, at Sunrise Senior Living, Andy Coelho, senior vice president of facilities, design, and development (McLean, Va.), says, “We’re trying to do a lot more of bringing in our sales, marketing, and operation groups into the design process,” with insight delivered at the start and end of each construction project on what could be done better, what the competition is doing, and what customers are seeking.

Competition has become a significant factor in how the role of designers has evolved over time, as well, with speed to market driving the project schedule. “Where before we’d have nine months to go through the typical design process, to have a good set of drawings … we now sometimes shrink to two months. Time is money, and [clients] have to get the shovels in the ground and get to market before the person down the street,” Maddalena says.

And thanks to the shift in expectations on the resident side, Maddalena adds that he’s found conversations with clients referencing hotels, resorts, multifamily, retail, and other design genres that more holistically represent the lifestyles people live today and expect to have in senior housing. To that end, projects frequently must address the wants of all generations, including the children who will be the next to move in and the grandchildren who will be visiting. “You’re really designing multigenerational spaces, no matter what the level of care,” he says.

Overall, though, these trends capture a progressive sector of the industry, with many organizations still relying on institutional approaches. Causes for this include a lack of frontline staff exposure to new models of care via education or site visits as well as leadership’s inability at times to move past roadblocks such as existing building and financial constraints in order to enact change, says Rob Simonetti, senior associate and design director for SWBR (Rochester, N.Y.). “Although we’ve made great strides with person-centered care and implementation across the country, there are still so many folks who aren’t there. I find myself needing to come to the table as an advocate for change,” he says.

Horizon line
Despite the ongoing evolution from institutional to person-centered care, trends indicate more change to come. For starters, concepts of walkable, urban communities are gaining a lot of traction. Aside from the appeal the model has with baby boomers, there’s also a very conventional reason to pursue it: existing infrastructure. “The restaurants, the bistros, the cafés—that’s already in downtowns and it’s done as well as it can possibly be done. Theaters are there, art galleries are there,” McRoberts says. “Many CCRCs try to recreate that, but are you going to be able to do it as well? Probably not. …Those are the things you may no longer need to build in a community. I think that makes it a lot more manageable from a financial standpoint.”

Additional indicators point toward current practices of segregating individuals by age going to the wayside, replaced by more progressive approaches like multigenerational housing. “Clustering people by age or general care needs alone has been a convenience that will no longer be acceptable by the coming consumer,” says CC Andrews, president and chief strategist at Quantum Age Collaborative (Cleveland), adding that she anticipates even more emerging models, such as senior living around affinity groups (alma maters, professions, special interests). “Affordability, too, is going to be a huge issue going forward. The boomers, for example, have saved less than any generation before them, so new, less costly models will emerge just out of necessity.”

David Banta, director of senior living for WDG Architecture PLLC (Washington, D.C.), adds that residents today are living longer and are remaining actively engaged in their professions, volunteering in communities, sitting on boards, and consulting. “How do we allow them to get out and go to work or work from home?” he says. At the same time, there’s a larger population of individuals living longer with chronic illness, and the senior living industry will be “continually challenged to focus not just on care and safety, but to provide progressive supports that empower individuals to live self-directed, enriching lives,” Andrews adds.

EFA’s board members say it will be critical to better support seniors in the greater community, as well, from elder-friendly healthcare spaces in clinics and hospitals to neighborhoods that support the growing population of individuals aging with dementia. “We still have some fairly significant ageism, prejudice against older adults in our society, and how we as a culture go about trying to change that so that we recognize the gifts and benefits that come with aging, and not just the deficits, is something people don’t want to face,” Calkins says.

But with millions of aging boomers and intergenerational and urban models emerging, the silos society has grown accustomed to may be absent from the next wave of senior living design. “It’s breaking down all the barriers we’ve previously had and cleaning the slate,” Rohde says.

Jennifer Kovacs Silvis is editor-in-chief of Environments for Aging. She can be reached at