In the Spring 2015 Environments for Aging Design Showcase, seven projects included the word “household” in their description, while another half-dozen or so made reference to such attributes as “homelike,” “residential,” and “intimate.” The trend toward household models was mentioned repeatedly by jury members during deliberations, as well. There’s no question that household models have had an extraordinary impact on the way elders can live and be cared for today. But what exactly constitutes a household in our industry?
By and large, the household model has been continually gaining momentum as a preferred approach within the realm of skilled nursing, memory care, and assisted living communities. In the majority of these cases, the environment is intended to serve as a familiar and residential long-term home that supports residents’ care needs and enables them to achieve individual and collective well-being. Households have emerged and evolved as a reaction to the traditional institutional nursing home paradigm that resulted from governmental regulations adapted from those originally created for hospitals and medical facilities.
Among the first communities to embrace this new way of thinking were those that provided care for individuals with Alzheimer’s disease and related dementias. Key features of such settings included (1) a smaller resident population; (2) an absence of double-loaded dead-end corridors; and (3) resident rooms oriented toward common spaces characterized by domestic scale, character, and function. Shortly thereafter, the notion emerged of subdividing sprawling nursing home footprints into smaller, self-contained groupings of resident rooms, which were variously referred to as “pods” or “clusters.”
In its current form, the development of a continuum of household models represents an important shift in the decentralization of services, distribution of resources, and allocation of decision-making authority. The similarities, however, frequently stop there as many households are being developed and tailored to meet the needs of care providers and respond to the market within different geographic regions, population densities, religious and secular markets, etc.
Some households emerge from the creative renovation of outdated buildings while others are newly constructed. Some are interconnected (side-to-side or floor-to-floor) while others are built as independent, stand-alone structures. The number of residents living in households varies, as do the options for sleeping accommodations and shared living spaces. Household care providers have also devised multiple options related to food preparation and dining.
Against this eclectic canvas of shapes and colors, the uniform operational and environmental standards of the Green House households (developed by Dr. Bill Thomas in the early 2000s) stand in sharp contrast. These standards have served as a testing ground for evidence-based design and operations and have given many care providers the confidence and means to turn their household model aspirations into reality.
The many permutations notwithstanding, the essential qualities of all of the various expressions of the household model have remained fundamentally the same: smaller, family-style group settings that are residential in character and therapeutic in nature, and which employ consistent cross-trained staff to engage with and support elders in living fulfilling lives.
Common ground
In 2010, doctoral students at the University of Wisconsin-Milwaukee’s (UWM) Institute on Aging and Environment conducted “A Stakeholder Survey on Culture Change and the Household Model,” with the goal of developing a common understanding of the philosophical and operational underpinnings for these varying strategies. That spring, a group of 27 survey participants recognized for their culture change advocacy and long-term care household expertise assembled for the annual think tank convened by UWM’s Center on Age and Community.
Although the group resisted developing a household definition that they felt might result in restrictive regulations and codes, the household experts did reach consensus on the following fundamental principles of the household model (list courtesy of UWM Center on Age and Community/UWM Institute on Aging and Environment, prepared by Mark A. Proffitt, Addie M. Abushousheh, Migette L. Kaup, and Anne Basting):
A household:
- is a small grouping of residents (typically 10-20) and their dedicated staff that functions with the purpose of fostering self-directed, relationship-based life.
- has pleasing, homey spaces with a functional kitchen at its hub—nurturing daily life, responding to individual residents, and fostering community life.
- is intimately sized with clear boundaries and a variety of spaces typical of home, including the flexibility of private and shared bedroom spaces, as desired by the residents.
- includes clinical best practices; the tasks, routines, and pleasures of daily life; and cutting-edge technologies to encourage life choices and promote functionality, mobility, wellness, and growth.
- is facilitated by an empowered, self-led team of residents and staff; is reflective of true home; fosters a good life for everyone; and is supported by the resources of the organization.
- has been positioned, through the design of its parent organization, with the autonomy and accountability for its leadership to respond to individual resident needs and the responsibility to create meaningful household life. In other words, the households, together as a team with the administrator and director of nursing services, become the vehicle for all operational decisions and administration, replacing the traditional department structure.
Since that time, there have been many discussions, symposia, white papers, and conference seminars devoted to this subject. Some of these have contributed additional nuances of meaning, but these core principles still hold true for the vast majority of projects claiming to incorporate the household model in the planning, design, and operation of their communities.
Making it fit
Creating true households within the confines of the outdated facilities with which many providers are saddled can be a daunting task. Yet there have been, and continue to be, many notable efforts to do so. Two such projects are OakBridge Terrace at Saint Andrews Estates in Boca Raton, Fla., and Epworth Villa in Oklahoma City. In each case, an older, underutilized building was repurposed into a household-based assisted living community. Beginning with a person-centered philosophical approach to housing and caring for its aging residents, each community reconfigured traditional independent living buildings into multiple discrete groupings of all-private assisted living apartments clustered around intimately scaled gathering spaces, in turn linked to central “destination” amenities such as communal activity and wellness venues.
Yet the far greater challenge that exists for many providers and designers is how to adapt the confining and/or inflexible structures of a vintage medical-model nursing home into something representing a viable household environment. More often than not, this entails significantly reducing the number of certified beds by converting former side-by-side resident rooms into private rooms and carving out space for multiple household core amenities such as living, dining, kitchen, and spa. At Lutheran Life Communities’ Pleasant View CCRC in Ottawa, Ill., that’s precisely what was done with a dated four-story skilled nursing facility.
Each of the three racetrack-plan resident floors was transformed into two self-contained households that accommodate 15 residents each. To begin with, the large central nurses’ station on each floor was eliminated. In its place, the elevators now open into a neutral zone, from which one enters each household through a “front door.” Each side of the floor has its own dining, gathering, and bathing spaces, with most rooms converted for single occupancy and furnished with a private shower. The staff station is reduced to a desk in the country kitchen, with residential flourishes such as indoor “porches” to promote socialization.
Such projects are neither easy nor inexpensive, and for some providers the only feasible course of action is to “make do” or bulldoze and start afresh. Yet given the vast inventory of 30- to 50-year-old nursing homes in existence in the U.S., this remains a challenge worthy of concerted effort.
Building from scratch
At the other end of the spectrum, there have been some intriguing new developments involving intimately scaled and residentially articulated multiple household buildings, such as the Phase 2 expansion for Kendal in Granville, Ohio, which includes a mix of renovations and additions. The Cottages at Hearthstone in Pella, Iowa, and The Neighbors of Dunn County in Menomonie, Wis.—both providing skilled nursing care—take the approach of grouping a number of smaller wood-frame structures, each including one or more households, into familiar residential “neighborhoods,” thereby creating a homelike sense of place that extends beyond the confines of the individual dwelling.
As we’ve seen with other projects, as well, such neighborhoods can be linked by a “Main Street,” which in turn leads to a “town center,” where common services and amenities might be accessed. This pattern is a logical extension of the concept of household as the basic unit of a senior-care community, and one that has in fact already become fairly well established in many larger senior living communities.
Regulatory support
In recent years, there have been a number of initiatives focused on making regulatory frameworks more accommodating of creating homelike environments in long-term care, including the creation of households. Among these have been revisions included in the 2012 edition of the NFPA Life Safety Code (LSC), which the Centers for Medicare and Medicaid Services is currently in the process of adopting, to permit the inclusion of furniture in hallways, open kitchens, and gas or electric fireplaces. Additional changes are on the way for the 2015 LSC code cycle. With the publication of its 2014 Guidelines for Design and Construction of Residential Health, Care, and Support Facilities, the Facility Guidelines Institute has drawn a critical distinction between residential long-term care settings and the more institutional category of hospitals and outpatient facilities. As more states adopt these guidelines into their regulations for senior living facilities, this also paves the way for the creation of more truly person-centered environments.
As we move forward with this important new way of thinking about environments for aging, we must keep in mind that a household, in its truest sense, is first and foremost about the people who share it. The organization or the place are secondary. The importance of effective leadership, operations, and staffing within care communities seeking to embrace person-centered care through adoption of the household model cannot be overstated. No amount of thoughtful planning, clever design, or home-like decor can overcome deficits or lack of commitment in any of these areas.
Robert C. Pfauth of LifePlace Designs is a senior living architect and a board officer of the SAGE Federation. He can be reached at [email protected]. Addie M. Abushousheh, PhD, is a gerontologist, researcher, and consultant for organizational and environmental development in the continuum of care. She can be reached at [email protected]. Both are based in Milwaukee.
