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Panel Discussion

Satariano: We've had an opportunity today to discuss a variety of living units for older people in various states of health and function. I have to admit it's almost breathtaking in terms of the range and scope of possibilities. Rather than beginning with a question I'd like to open it for questions of our speakers.
Audience: How is the developer planning to market Three Bridges? Will there be direct ownership? Or renting?
Hargarther: I don't know all the innuendos of marketing, but it's a basic lifecare community system where you buy your unit to start with at whatever level you enter, whether it's independent living or assisted living; you pay monthly fees and you are taken care of for life so you can move around the community and move into whatever level of care you need over time. If you are in independent living and you break your hip, you have the opportunity to go into the short-term rehabilitation cottage until you return to your unit.
Diefenbach: Purchase prices are in the range of two hundred thousand something to four hundred thousand something for the larger units and there is a monthly fee as well.
Satariano: One of the points that came up in the course of the two days with regard to continuing care facilities is being able to look down the road, and see a nursing home, and say "That's where I'm going," and that perhaps that thought prompts some sense of dread. To what extent was that a consideration in development of this project?
Hargarther: That was actually taken head-on on day one. We took the very opposite approach than that we have been used to doing. The idea was to put the skilled nursing facility at the heart of the community and make it so special that people feel, "Gosh, I'm glad that's where I'm going to be if it's time to be there." That's been the focus literally from day one.
Diefenbach: We started the project with about a five-hour lecture from our client as to his needs in that respect.
Audience: Ed Setchko is over here; he's a potential resident of this community. I don't know, you might want to say two or three words about why you decided to buy in?
Setchko: The thing that attracted me the most was that these people, apparently, take seriously the future and where we're coming down in terms of what we do with old folk like me. I see this as a place to go to continue my life. I'll be working probably until I die. I like the idea that they have put at the center of this community a learning council which already has integrated itself into the whole Sonoma County and Santa Rosa. We're hooked up with people like Diane and other outfits like the Buck Foundation and the Center for Aging and the like. We're bringing all those nuts and bolts kinds of things into aging, like how we take care of our skin and things like that. To me, that would not drag me into this place. The idea that there are new paradigms coming down, that we are beginning to think of different ways to be after we've done our work for 50, 60 or 70 years, is taken very seriously by these people. I was impressed that architects are thinking this way. And John Scully, the guy who fathered this place, has gone all over the world and pulled ideas in; these people here have integrated all of that stuff. To me, unless you've got a vision of where you're going, you can do the best nuts and bolts deal in the world and it's not going to come out right. So for me to hook up with these people to form a town, a community with a Main Street and with living quarters that are adequate for my needs is great! I can take my library with me which is about three or four thousand volumes. I thought, what am I going to with this when I retire? I can take it with me and put it into the learning center so for me that made it.
Diefenbach: I think that's part of John's reaching out into the community. He's not only been architecturally concerned about reaching out but with the learning center reaching out, with the childcare reaching out. He wants the restaurants to be of a quality that others outside will want to come into the community to enliven the community from the outside. Both ways, people inside going out and people outside coming in; it's not a fenced, gated community. It's part of natural life.
Satariano: That's very interesting. It addresses a point that Peter Calthorpe makes in his book The New American Metropolis. He talks specifically about planned communities or new towns being internally very appealing but one disadvantage he sees is that they tend to be segregated, both structurally and functionally, from the outside. It seems that, at least to a certain extent, this is being addressed in this community to try to integrate the outside with this community. One thing that I kept thinking as we were going through this is, again, many of the particular communities we were talking about, the Cheesecake Consortium yesterday afternoon, I keep thinking back to Gil Kelley and the City of Berkeley; the City of Berkeley representing the rest of the people, so to speak. I'm wondering to what extent some of these ideas could be integrated into the rather significant agenda Gil is having to deal with in terms of in some cases recreating or, as he has indicated, healing the city of Berkeley. I'm wondering how we start dealing with that. This is actually another point that Calthorpe makes, the idea of integrating different types of housing and integrating people at different income levels in part to fulfill this notion of a democracy where you have people of different classes working together. Probably one of the most distressing trends in our society now is that the rich are getting richer and the poor are getting poorer. What do we do as a society to start to deal with that and how do people such as myself, in public health, and those of you in architecture work together to deal with that rather substantial and significant issue.
Diefenbach: It would be very exciting to work on a project that is right in the city center and how different that would be from this; but even this tries to reach out. An inner city project would not have to reach far. The difficulty is the financial aspect and the cost of land, it just generally doesn't happen.
Audience: What about security and gated communities?
Diefenbach: Security we have, on both the ABHOW and the Three Bridges projects, treated more as a planning issue than as an equipment issue. ABHOW could not be gated; the town would not allow it, yet it is in a very public area and people do cut through it and that's okay. As a planning issue, there are open exterior balcony areas to allow people to walk outside where they can see across to other areas; they can see down; people can see up; you can hear someone if they're in trouble. The general openness about it is very important. On this project security is considerably less of an issue. It is not in a city center nor is it near any well-populated area.
Hargarther: They very specifically did not want the gatehouse approach where you had to pull in and show a card and go through a gatehouse. On the site map you can see that there are small outbuildings at both of the main entrances. They sit off to the side, one is used for an administrative function the other has a lot of storage in it. Both of those are going to be occupied 24 hours a day by personnel who are watching the comings in and the goings out. So there is that security at the perimeter. And then there is the card key system in every unit. There are medical call buttons in every unit. There will be someone going up and down Main Street periodically to make sure that everything is secure. So there's definitely that presence of security but there isn't that overt look of security with gatehouses or fences.
Audience: What about transportation?
Diefenbach: It is a very hilly site, and there are very difficult issues with regard to transportation. Visitors do need to enter at the low side because we wanted to avoid cars on the high side, that was the public pedestrian Main Street. Cars can be parked nearby, the linked structure has an elevator within it that brings people up two floors to the Main Street level. You arrive at the lower by car, are dropped off, come up in the elevator, then you're totally at one level. All facilities are at the same level.
Hargarther: Were you talking about the front steps? On either side there are parking garages in the hillside so you pull into the hillside and park within there and then there are elevators that come up into all the different lodges.
Diefenbach: But there are all these exterior stairs, very integrated into nature, to encourage people to use them if they can and if they want to.
Audience: I have another question for the SMP group, the long-term care unit that you showed, what level of care is that?
Hargarther: That is skilled nursing.
Audience: Then how was the 90 foot rule dealt with?
Hargarther: It was very difficult. There is a nursing station on both floors. The open area that we showed with the amoeba table and chairs, much like the Swedish and Japanese examples, has a wall unit behind it that has everything in it to qualify for the OSHPOD nursing station. We spent a lot of time with the fire marshall trying to establish that the fixed table out there is not furniture in a corridor but can be considered part of that nursing station. From that fixed table in your wall unit of the nursing station, you can get to all seven of those rooms within 90 feet. Then when you go back up the stairs or the elevator to the other seven, there is another nursing station. Right now they will have to staff both of those nursing stations 24 hours a day with licensed people. The chief executive officer is working to put an operational program together where nurses use open radios; there are different kinds of call systems and warning systems in each cottage so that one staffed nursing station is open to both floors at night. If she is successful in doing that then it can be much more cost-effective. If not, we at least have the plan in place and it can operate the other way.
Graeff: One thing I'd like to add to your question and to the question about security, at the Mary Conrad Center in Alaska we decided to make the smartest building we could think to make at the time. That was in 1984. We had a grant from the State of Alaska for $450,000 to see if a smart building could be constructed using computers; we had no takers. Three M and Burroughs thought maybe they could do something with the $450,000 to use computers in a nursing setting. Ultimately they refused the grant because they didn't think the technology was going anywhere in this respect.
Hargarther: We got a taker.
Graeff: I tell that story, among the many other stories, when you're on the leading edge as they are. We think electronics will become very critical in the next 10 to 15 years for humanizing the environment by freeing up skilled people, and other concerned people, from the menial tasks that we have all been subject to for the last 40 years. It's going to change physically the kinds of planning that you do. For instance, at Mary Conrad we eliminated the nursing station; it's located remotely from where the residents live, and we were able to keep surveillance of the facility through the use of electronics that are benignly located like little spots in the ceiling. We had a lot of problems when we did it; there was a lot of protest about "Big Brother" watching. It's the reverse when you come to the actual folks who come to your facility; they like the security of knowing there is continuous monitoring even if it's electronic monitoring. We think that's going to go a long, long way. There are some new geographical information systems; you can locate a pin anywhere you wish to within a one millimeter grid. When we hired our security consultant for the Mary Conrad Center he asked us how exactly we wanted to know where our people were. Is one millimeter close enough? Does it matter if you know where your people are within one millimeter? We don't know the answers to those questions yet but knowing where your people are is a problem with wandering Electronics will tell you more than you need to know, thus eliminating the need for long corridors with nursing stations at the intersections.
Hargarther: We're at a very awkward moment right now of pushing technology and yet having codes and regulations that are truly impediments to doing that. How can we start to bring one in line with the other is going to be one of our biggest challenges. I hope that at one of these conferences someday we can spend a whole portion on being advocates and getting to the State and to the regulators to get them to understand these contradictions . On the Three Bridges project we caused such a stir, had so much interest from OSHPOD and the State Fire Marshall. We literally had OSHPOD, the State Fire mMarshall, Department of Health Services, and the Department of Social Services all coming to the site physically to see what was going on. We were saying technology can do it and they were saying, "Well, what do you mean? We don't believe it." They wanted to touch the dirt to believe it.
Audience: I have two questions. The first one is for Karen or Bill: Can you give us some sense of what that project is going to cost to live in? Is that something the average architect can look forward to retiring in?
Hargarther: We're trying to set up a deal as the architects.
Diefenbach: We each get a unit included in our fees so we're all set. I think I mentioned it's in the range of a couple of hundred to four hundred thousand to buy in and monthly fees. We're not privy to those numbers. The client does do financial pro formas at great length, has done many, many of them. Some of it relates to his financing options. Financing potential from Japan through his contacts there is at a much more opportune rate than we could imagine here and with the value of the yen to the dollar today it's very timely. He's hoping he'll be able to afford much more on this project than many other locally funded organizations could.
Hargarther: He's pushing the limits of the American marketplace and what our market is ready to take. He has, I believe at last count, a list of 180 people who have given all their information and signed on the bottom line that they're ready to give the deposit the day that they're able to.
Audience: During the last couple of days we spent time talking about life-care, we really haven't touched on the issue of Title 22 versus Title 24.
Fey: I can't comment specifically on Title 22 or Title 24; I haven't done enough work in California to understand the specifics. I know that we spent a lot of time in Washington, Alaska, and Oregon taking a look at the issue of changing things particularly because the Providence model of assisted living is basically going to be a replacement for the skilled nursing facility anticipating every level of care. We took a project to Alaska (this was after Mary Conrad) and tried to explain to the local building officials that we were going to move nursing home eligible people in, but we wanted to build the home under 40-home license and an R1 type of occupancy. We also tried to explain that the reason it was so appealing to us was that we didn't have to staff it as heavily as a skilled nursing facility. There is a lot of education that has to occur. What we found, typically, wherever we've gone is that it's the local building official that's been the problem. We've always had far more success with state officials in terms of enabling us to work and actually getting the state fire marshall to act on our behalf on projects particularly if it's a problem related to locking doors and being able to use the wander-guard type of systems. Local building officials simply can't understand or really struggle with that particular concept. I think there's a lot of education that needs to occur and it's going to happen because of the growth of that particular industry. People are going to push that limit.
Diefenbach: In California there's a task force that works with OSHPOD, is anybody here a member of that task force? How is that going?
Audience: It's slow going.
Hargarther: But it's interesting that task force even exists because what happens is you're calling OSHPOD on many antiquated codes and regulations. What I always point out is that these planning regulations have us planning the old Florence Nightingale wing and here we are trying to design hospice-like care centers and we're forced into, you know, "well, you've got to have room so many feet from this and that," and everything's lined up so strictly that it almost forces you to design an old module immediately.
Diefenbach: Sometimes you resort to solutions to get by these regulations and we do here as well; the roll-down coil door to shut off a two-story space, for example, isn't necessarily the safest option for other reasons but there's no other way to do it.
Noell: I have one point to add. There are different organizations around the country that are springing up essentially to fight the variety of rules in many jurisdictions. One of them is the National Coalition of Nursing Home Reform. Another was recently formed in Wisconsin, its initials are SAGE. I don't know what the "A" stands for, something like Society for Gerontological Environments. There are a number of conferences and gatherings, you know, the natives are restless, we're tired of it.
Audience: Could you say something about bringing furniture to Three Bridges?
Hargarther: The life-care communities in Japan are almost exactly what we're proposing to do at Three Bridges. A lot of the common spaces will be designed, the interior design will be done. In all the private, independent units you bring everything that you want. You also can participate, in particular the early residents, in selecting finishes in each of their units. In the assisted living and skilled nursing facilities we are going to be providing beds, the window treatments, the floor coverings, and the wall coverings. In skilled nursing we'll be doing the love seat and the hutch next to it but in every one of the assisted living and skilled nursing rooms we are providing a space that individuals can bring a significant piece of furniture that is special to them. In Japan they always hadI call them altars, that's probably not the right worda shrine to their deceased spouses, something that was very important to them, something they had in their homes which they brought to theie room, and they would bring their favorite piece of furniture as well. That's what the intent is here. You obviously can't bring a whole household to a single room, but there are definitely accommodations being made to bring some belongings.
Audience: You could bring in a lighting fixture?
Diefenbach: I would think so.
Hargarther: Yeah, I think you would be able to.
Diefenbach: A lighting fixture but certainly not a bed. That's the one element they don't allow us.
Hargarther: And that's back to licensing.
Audience: I just wanted to go to the issue that was raised, I would love to see a conference built around identifying the issues which many of us are aware of. I've worked in Washington and the State of California as an advocate for some of these issues. There are organizations, it's possible to put together coalitions. I'm not saying that's a short-term solution; anybody that's worked in this arena knows that it's not, but I think it is timely. I think we have the community behind us to identify the issues and to start applying pressure. We have case studies and we could make some good strong cases now for some of these issues. We're not getting what we say we want from the regulations; they're not working and, in fact, in many cases they work against us. I think secured rooms and perimeters for wandering or dementia, that sort of thing is an excellent example. We want not to have people killed in fires and, yet, when you put fire doors on rooms of frail elderly who can't get out of the room you're going to get exactly what you say you don't want. I would love to see a conference built around attacking this issue.
Audience: Are you aware of how the staffing ratios of the facilities you visited in Japan compare with the ones here?
Diefenbach: There are much higher ratios of staff to occupants. Primarily because of the 100% employment situation in Japan. It's just a cultural thing; everyone is employed in Japan. There isn't unemployment and therefore a lot of young people are used, at a very low salary, to support the nursing staff.
Audience: Were these publicly financed facilities in Japan?
Diefenbach: No, all six of the projects we showed to you are privately developed and privately financed by two individuals, Koji Muriyama and Hasa Galason, one with an interest in architecture, the other with an interest in public health. They joined together 25 years ago to start the first development in Japan.
Hargarther: They are all set up as not-for-profit.
Audience: But the residents pay with private payments?
Diefenbach: Yes.
Audience: That's another good thing about Three Bridges; it is a non-profit corporation and that's been very sticky for the State, the County, and the City because they've never dealt with a non-profit corporation for life-care before. Also, the way you go into this there's an equity level you buy into, and a non-equity level, that you don't buy into. That makes a huge difference. So you can go anywhere from two hundred thousand to six hundred thousand.
Diefenbach: If you don't have an equity buy-in, I think the monthly rates are higher than if you have an equity buy-in.
Audience: How much will it cost to build this?
Hargarther: Independent living, design estimates are at about $85 a square foot. Assisted living and the Main Street components are up at about $140 a square foot. The skilled nursing is pushing $175 a square foot. There is definitely money being put in up front that is returned to the investors but long-term they do have 501C-3 status as a non-profit entity. So in the future any money coming into the community has to be put back into the community; it can't be used for profit.
Audience: I wonder what the profit is for the developer?
Diefenbach: None, it's a non-profit organization; he's not doing it for profit.
Audience: What the corporation does is set it aside because what we guarantee to the residents in exchange for that is life-care for life. So, if you die the next day, you don't get the money back. But if you live for 40 years and in the last thirty years of your life you need very costly care, 24 hours a day, because you suffer from Alzheimer's then, you know, we need that money to help give that care.
Hargarther: And it's very heavily monitored; I mean, they're watching profits.
Satariano: Let me just make some final comments. This refers to some things I said yesterday morning. I think one of the facts in aging research is the tremendous variability that exists among people in a particular age group. We tend to focus on the similarities. Someone who is 65 is more likely to have health problems than someone who's 45 and that's certainly the case but it's not very interesting. The most interesting fact in aging research is the tremendous variability. We know this from our own experiences that some people who are 75 are very happy and other people who are 75 are not happy. The most important question is, why is that the case? Why do some people do well while other people do not? That really is the goal of research. My field is epidemiology and we're very interested in the epidemiology of aging to understand these things. And not only to understand about the people who have problems but also to understand more about the people who seem to do so well. The idea is that if we can understand more about those people who are well, perhaps we can mimic in some way what makes them well, and design interventions to help those people who are not doing so well. The ultimate goal of the research and programs for older people is to postpone limitations and disability. Probably, when all is said and done, there's very little we can do to extend a lifespan. Obviously some people are working in that area but there's maybe five to ten years you can extend a lifespan. What we can do is postpone the time the person spends with limitation or disability that's pushed toward the end; so the period of limitation and disability occupies fewer years toward the end of life. That really is the goal.
I think as we begin to do research in this area, particularly as we begin to talk to people in other fields beyond epidemiology and public health, the more we realize that those factors that determine why some people do well and others do not are not solely based on the individual and that individual's capacity. You can have two people who have the same functional capacity if you measure it in terms of cardiac reserve and pulmonary function but, yet, you find that one person does much better than the other. It may be, and often is, that one person may live in a single-story house and the other person lives in a two-story house and as they both get older, it's more difficult for the person in the two-story house to get up and down stairs. So one person is able to function and lead a fuller life while the other person is not.
Those of us in public health find it very exciting when we think of what we can do to help people postpone limitations and disability. What we are learning from conferences like this is that we don't only have to focus on issues like diet or exercise intervention, as important as those things are, but we now can think about the environment itself and the type of work that most of you are doing in terms of design. I remember in the late sixties, Marshall McCluhan talking about technology as being the extension of our senses, that technology really can extend vision and hearing and other senses. I think of housing design as being in that category, as well. So, when we think about ways to improve the lives of older people and to postpone limitations and disability we can think about the environment that people live in. It means that we have a much more comprehensive agenda to deal with. That's what I find to be exciting.
I've been at Berkeley since 1989; I remember talking to Diane shortly after I arrived about trying to do something in this area and finally we got around to doing it. It's taken a while. That's how things work at the University. But I hope this is really the first step and I would like to have future conferences in which we do have the opportunity to focus on particular areas.

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