Environments for Aging: What do you think have been barriers to innovation in long-term care (LTC) design and how is the industry starting to break free from those barriers?
Lorraine G. Hiatt: Barriers are inherent in our early notions of “the aged,” in levels of care and in ideas of a right size or one protocol for healthcare. People are all aging and changing, even in LTC design. In fact, LTC is morphing to a series of lengths of stay and a fountainhead of services offered, not only for those who experience long versus short stays but also for those who obtain virtual services.
Instead of a building for a group of people of like needs or at one price point, we’re beginning to think of settings that accommodate more varieties of people who are developing, changing, and aging at different rates. Veterans Affairs’ adoption of community living center design guidelines—not standards—is a great example of one large sponsor’s efforts to provide a context for multiple levels of care, shifting patterns of need, and variations in assistance and technology.
When planning communities that are immersed in the local fabric of a community, who do you think should be involved in the process and how do you manage competing interests when there’s a diverse group of stakeholders?
Competing insights are healthy; imagine a dynamic group with members who view things in different ways (cost, speed of completion, acquisition versus new construction, etc.). What if the design process embraced a series of participants with different appetites for knowledge? Cross-sections of input and creation of a climate of different points of view are essential to evolving a locally fitting solution.
I have traveled a couple hundred days a year for 44 years or so. I use examples for each meeting and each project: visuals, stories, data, benchmarks, and question lists. It’s my sense that serving physical data and visual design solutions along with ethereal/visceral examples, evidence, and outcomes goes a long way in facilitating group growth.
I’ve also completed several projects knowing that there is sufficient flexibility in the site, building, and service plan to grow into or phase changes as experience grows with time.
For communities that will support aging in place over a long term, what’s the baseline of what should be planned?
LTC is built on a foundation of hospital design and yet a product quite different from what a hospital needs to be. Aging in one place forever? That’s an option. While I’ve seen a few individuals live such choices, I wonder whether the terminology isn’t crimping imagination. We’re seeking evolutions and choices for more dimensions or platforms for both aging in place and LTC. We may start by thinking of aging within the community, of people who live and function as part of the fabric of a community.
I believe we will reframe the definition of aging in place to choices of aging in many places with people of many ages, and come to a new understanding of the tipping points that drive us to ponder aging and its contexts. The geography of where a third of life is spent is likely to expand beyond dwellings and sponsored age-specific settings to enclaves in everyday communities, drawing on newer technologies and better physical as well as social design. Variations will emerge across markets and local climates.
Imagine if LTC providers were inspiring the articulation of a family or small group covenant of interdependence, to achieve a vision of aging in place addressing physical, social, and personal values. The idea that aging involves a separation from the rest of society in “special” environments—an iceberg philosophy of cutting loose the old—is not viable. Just as LTC emerged as a better solution for aging than hospitals, we need that expertise to help define the next evolutions of care.
How does the medical component come into play to support residents where they live, as opposed to an eventual move into skilled nursing, etc.?
Aging in place or design for lifetimes is a community concept; no one profession can possibly wish to define or manage it in totality. When the discussion table is set, the participants need to be broadly based, widely experienced, and of many ages and skills. If we don’t begin to have thoughtful conversations on our own, we may be impelled soon by the vacancies of the traditional nursing homes.
Instead of working among each other, professionals, developers, sponsors of hospitals, and nursing homes of long-term care in small house and long-hall configurations need to come together with larger communities to explore opportunities for mutual benefit of those aging, those providing care, and those skilled at design and motivated to finance innovations.
We need examples, not only of the design but of the roles and skills involved.
Innovation is one thing and wholesale adoption is another. What will be necessary for this type of cultural shift in housing/care to take place, and do you think it will?
Most likely, it’s already being promulgated by our recent ability to improvise and then widely disseminate working models and solutions for assisted living, small houses of healthcare, hospices, and specialty rehabilitation and palliative services.
We are sorely in need of quality outcome data—more than evidence, more than preferences on the impact of innovations. The first longitudinal data that show several alternatives to stave off full, traditional long-term care will be attention-grabbing.
Will the LTC residence disappear? As long as we continue to outlive a generation of willing, adept, and well-positioned caregivers, we’re likely to need a few people to care for many. Will it have shared rooms, long halls, and equipment strewn in halls? Unlikely.
But imagine what happens as the traditional 120-bed nursing home becomes a series of smaller communities where that group, neighborhood, or cottage—and its virtual members—are crafting something that offsets total care with engaging familiar stimuli for balance, movement, energy and memory development, communication, and oversight.
Imagine an array of settings in any community where it’s easier to function with diminished memory. Imagine a family feeling less guilt and frustration.
Advancing the promise of environments for a lifetime may begin at homes and small groups with people who bond and take a journey together: co-housing, mutual assistance, and families may all re-emerge along with the possibilities of design and technology that provide networks of support. There are able, bright thinkers in LTC who may rise to be part of this vision and pioneers of their own locally fitting choices.
Jennifer Kovacs Silvis is executive editor of Environments for Aging. She can be reached at [email protected].
