While considerable attention is given to the emerging field of assisted
living in symposia such as this, over 80% of long term care dollars in the
U.S. continues to be spent on nursing home care. Clearly, we have reason
to be excited about the opportunities assisted living presents as it promotes
the basic tenets of choice, individuality, and privacy with lower rather
than higher costs. Yet with over 20,000 nursing homes across the nation,
we may need to find a solution to the problems that plague these institutions
rather than assume we have found their replacement. The impact of assisted
living is being widely felt in the long-term care industry. Its ultimate
influence is yet unknown leaving many questions as to the eventual role
of the nursing home. Though the role of the nursing home in tomorrow's marketplace
is somewhat uncertain, its survival in very large numbers is likely.
What is certain is that whatever the nursing home becomes, it will be expected
to do more with less. Change is inevitable as consumers and regulators push
for improvements while costs increase and dollars for reimbursement become
more limited. While many have adopted a 'wait and see' attitude, many providers
are searching for direction and willing to try something to move ahead.
This is a brief case study of one such effort.
It is a study of a 210 bed nursing home owned and operated by the Providence
Health System in Seattle. The facility is located on an urban campus that
includes 111 residential apartments and a full array of services for the
people residing in the community. The building houses both an adult day
and a childcare center, a senior meals program, and health clinics.
Institutions in the Providence Health System are expected to conduct a strategic
planning exercise every three years. In 1991 Mount St. Vincent began its
new plan. The facility had a new Administrator motivated and willing to
tackle the difficult questions such a process is intended to raise. The
planning process occurred within a climate of perceived strength and opportunity
rather than within a climate of fear.
The facility's financial condition was strong. Fifty percent of the residents
were private pay. By most standards, the facility was doing a good job.
Hours per patient day were in line, and survey results were respectable.
If community support could be measured by the size of the contributions
made to the Foundation and by volunteers, we were loved. But, the question
we asked ourselves was "Were we really doing a good job?"
As we walked through the long corridors of the five-story facility, we saw
the cold, hard surfaces reminiscent of hospitals from the same era. Floor,
wall, and ceiling materials were designed for durability and ease of maintenance.
Spaces were tight, residents and equipment crowded the corridors. Residents
appeared content, or at least complacent. We seemed to be attending to our
duty as caregivers. People were being fed, clothed, and bathed on schedule.
From a glance, we were clearly doing
the best we could with a slightly outdated building. For many it might have
been enough to suggest a minor upgrade to warm the spaces and improve to
some extent the flow. But this planning team was determined to answer the
question: "How good are we doing from a much deeper and different perspective?"
The strategic planning process was typical in that we began by looking at
outside influences. We were seeing more and more free-standing nursing homes
moving into the sub-acute market with both Medicare and managed care contracting.
The potential for this market appears to be fueling much of investors' interest
in nursing homes today. We looked to our own experience in the hospital
market to see the future of sub-acute or transitional care. As an organization,
Providence was quickly taking advantage of the opportunity to replace empty
acute care beds with sub-acute licensed beds to lower costs and extend care.
If Mount St. Vincent saw its future as primarily offering sub-acute services,
it would have to compete with the hospitals for patients. There was clearly
an opportunity here, but the question was how long would that opportunity
last?
At the same time, we recognized the rapid growth in the assisted living
marketplace. Residents who in the past entered the nursing home needing
a little supervision or support now were living fuller lives in assisted
living facilities. These new facilities were showing up in many shapes and
sizes.
We examined three facilities from my own recent planning and design experience.
The first was a 59-bed facility for people with Alzheimer' Disease. The
facility had three pods of approximately 20 beds each, with each pod being
built around a large country kitchen; a stone fireplace adorned the living
room. Indoor spaces were connected to interior and exterior courtyards with
covered porches to ease the transition between the two. The facility was
located on seven acres with plenty of opportunity for people to get out
into the environment in a safe and controlled fashion.
We found that a good number of nursing home residents had moved into the
facility from the Puget Sound region. It was an example of consumers exercising
choice by moving family members into an alternative, non-institutional setting.
A second facility consisted of a "village" of cottages patterned
after group homes. Each cottage had ten residents and a live-in caretaker.
A central commercial kitchen prepared meals which then were served family-style
in each cottage. Again, the country kitchen and living-room formed the core
spaces in which familiar activities occurred throughout each day. The concept
of the live-in caretaker and small buildings kept both operational and construction
costs in line.
It was significant that both facilities were built using a set of economies
that assured that Medicaid waiver state-assisted clients could afford to
live in either. While both projects are currently private pay and charging
top dollar, as residents deplete their assets and become Medicaid-eligible
the facilities will remain profitable even at the lower rate of Medicaid
payment.
The third facility we examined was an urban project in the Pike Place Market
in Seattle. This building was a State demonstration project for assisted
living. The Providence Health System was instrumental in developing the
project using the model initiated in Oregon. The Seattle Housing Authority
funded and actually owns the building. The State pays approximately $42
per day for each of the 60 residents. By carefully managing the caseload,
residents are served during practically any crisis or any kind of debilitating
condition. This facility is an alternative to the nursing home. Most of
its residents come from nursing homes. Very few return.
Collectively, these assisted living facilities embodied the trend towards
affordable alternatives to nursing home care. In targeting special market
niches as in the case of the Alzheimer's facility or appealing to the imagery
of small residences, or through cleverly designed operational plans, these
facilities offered both street appeal and quality of life.
Mount St. Vincent certainly wasn't the only nursing home being confronted
with competition. Prior to the strategic plan at the Mount, I had just completed
a plan for a similar-sized facility where the decision was made to abandon
earlier plans for a replacement facility and, instead, to direct capital
dollars into assisted living. This collection of small cottages is presently
under construction on property originally intended for a nursing home.
But the Mount wasn't going to abandon its five-story nursing home to go
off and build small cottages. This strategic planning process needed to
address the opportunities as well as the constraints offered by the big
building. To begin looking at potential concepts for the nursing home, we
examined a small facility, named the Bailey Boushay House, which I had had
the honor of working on a few years earlier. It is a 35-bed skilled nursing
facility for people with AIDS. The facility was originally intended to be
a residence meeting the changing care needs of persons with AIDS. However
it needed a nursing home licensure to guarantee a Medicaid reimbursement
rate adequate to meet the costs of delivering terminal care. It is an interesting
nursing home with 35 beds split over two floors. Nursing units have been
broken into small neighborhoods of eight or nine residents with each neighborhood
having its own sun-filled solarium. On each floor, two neighborhoods share
a larger gathering space for dining and outdoor decks. At the center of
the project is a large greenhouse emphasizing nature within the project's
urban environment. Kitchens and laundry rooms were introduced on each floor
to accommodate families and friends who wished to help patients as well
as to visit; here they could help by doing a load of laundry or fixing a
meal.
At the time each of the 35 private rooms met the regulations for semi-private
accommodations; each is equipped with a sofa as well as a bed to create
a living space within the bedroom. To personalize the setting, each wardrobe
has a CD system to enable residents to listen to anything from Vivaldi to
Van Halen.
Our brief tour of other models left us with the impression that alternative
options to the traditional nursing home were not only coming, but were coming
quickly.
In true strategic plan form, we also looked internally to better understand
our own business. We felt the need to take a critical look at the care we
were delivering to our residents. Using the skills and insight of an applied
behavioral scientist, we conducted a series of observational studies with
approximately 1900 observations of resident activity. From these we were
able to derive interesting statistics about the typical day in the life
of a nursing home resident.
We found that residents spent only 32% of their waking day engaged in any
type of activity. Sixty-eight percent of their day was spent either napping
or sitting idle. From the residents' perspective, they weren't receiving
much attention. Interaction with another person accounted for only seven
percent (7%) of a resident's day. Clearly, despite all of our attempts to
create a community within the institution, our residents' lives could be
described as somewhat empty. It wasn't as though we were a bad facility
or that our caregivers didn't care. They were working hard and doing the
best they could with the tools and skills they had. Ours wasn't the only
facility with these statistics; the literature suggests they were similar
or the same in other observational studies. Our studies added to an already
poignant picture of what institutions had become.
The Institution
Looking for reasons for what we saw, we tried to analyze the institution
by looking at its individual systems. Over time short-term operational efficiencies
had become long-term dependencies. If, for example, residents were incontinent,
we were changing them rather than assisting them in going to the bathroom.
If they needed assistance eating, we fed them. We had fallen victim to task-driven
routines where it was easier to do things for someone rather than to assist
them in doing for themselves. The result was that their dependencies were
demanding and extracting more and more time and effort on our part.
The Existing Physical Plant
The existing facility has four floors of nursing units with the typical
unit consisting of 56 beds along a double-loaded corridor approximately
300 feet long. A small dining and activity space was centrally located with
utility rooms located at each end of the long hallway. One reason so little
time was spent interacting with residents was that the travel distance to
these areas was too far. Staff were spending a good portion of their time
simply moving between spaces. In particular there was a large separation
between the area where one would find residents and the area where staff
activities were carried out. Interaction was more likely to occur when residents
were parked in the corridor in front of their room or near the staff spaces.
Often we found this to be the case. The result was the familiar image of
nursing home residents lining the corridors and sitting idle.
The Plan
Our agenda was straight-forward. Bring the values (and some of the street
appeal) of assisted living into the nursing home. Replace the medically
driven model of care delivery with a resident-centered approach emphasizing
resident capabilities and promoting opportunities for residents.
More specifically, we needed to find a way to alter the environment and
our work within it, and to change our entire attitude such that the level
of engagement and interaction with residents and among residents would increase.
We speculated that by increasing interaction, residents' cognitive and physical
functioning might improve, which, in turn, might improve their overall health
status. If we could improve health status, perhaps we could decrease health
care costs, and thus break the spiral of increasing costs that were consuming
our long-term care dollars. By fundamentally altering institutional systems,
we hoped to change our pattern of building short-term efficiencies that
were, in fact, driving costs up each year.
Routines of Daily Life
With a goal of increasing activity levels we set out to re-introduce the
residents to a set of familiar and meaningful activities of daily life.
The institution, almost by definition, had removed people from those activities
of daily life that had given them a sense of purpose that had added meaning
to their lives and for which they had received praise.
I'll offer two examples. The first is laundry. While not an absolute pleasure,
doing laundry is certainly familiar and necessary. One of the first assumptions
of the institution is that laundry facilities should be built for economies
of scale. Mount St. Vincent used 450 lb. commercial washers the size of
a small car. Certainly washing those last five pounds represented a negligible
cost. To ensure operational efficiency, the equipment was located in a laundry
room in the bowels of the building where laundry personnel and activities
were isolated from residents. The residents' perception of this laundry
room was of a black hole that might return your clothing on time, in good
condition, if at all. The institution presumed that residents had neither
the capability or the desire for more control over the care of their personal
laundry.
Likewise, meal planning and preparation had been a central focus in the
lives of so many residents prior to their entering the institution. They
received praise for their efforts. Meal preparation provided satisfaction
and filled a portion of their day. Now the institution set out to make life
simpler for its residents. We had a kitchen that produced 1700 meals a day
with the tray line moving at blinding speed. No room for a resident to help
here. This kitchen was, again, built for efficiency, thus minimizing the
cost per meal. From a resident's perspective, if you lived on the fourth
floor your breakfast would come off the tray at 6:00 am; if you weren't
hungry at 6:30, that was too bad. The system had no room for personal need.
It was interesting that while we were preparing and delivering the food
with efficiency, approximately 40% of it was being returned uneaten. Again,
we assumed the residents had nothing to offer when it came to this very
important element of their lives.
Through our planning process, we introduced the idea that in a resident-directed
facility, individuals not only could contribute, they should contribute
to these and other functions.
We needed to set the stage for residents to engage in these familiar and
meaningful activities. We knew it could work. We had seen it happen in the
assisted living facilities described earlier. At Bailey Boushay we had seen
that when residents weren't capable themselves, families helped them.
To create this environment, two things had to happen. First we had to introduce
the functional elements of a home if we were to encourage participation
in household activities. Second we had to redistribute resources. Our laundry
and dietary departments were large, for example. If only these functions
were decentralized, a sizable number of employees who carried them out could
then be free to interact with our residents.
If we expected residents to adopt roles and responsibilities for household
tasks, we needed to reduce the size of the groups. Fifty-six individualsthe
current number of residents per unit, and a number derived for staffing
efficiencieswas too large to handle meal preparation. Household tasks were
more easily accomplished by groups of six or eight individuals. The existing
building limited our ability to reduce group size, but we attempted to reduce
the size to a number which would feel more like a household. We borrowed
this idea from the assisted living examples and the AIDS facility mentioned
earlier. It is, in fact, a design typically employed in special care units
elsewhere in nursing homes.
We initiated a remodeling program in which we broke each of the long-corridored
nursing units into two smaller neighborhoods. Within each, we eliminated
clusters of resident rooms to create common space. In the common spaces,
which we left open to the corridor, we created a country kitchen
at one end and a den at the other end. This den became the staff work area.
We converted additional resident rooms into laundry rooms with washers and
dryers and tables and chairs for the residents.
By adding a kitchen and laundry room we hoped to create opportunities for
engagement and interaction among the residents. Now a resident may watch
as activities occur in the kitchen rather than sitting in front of the nurse's
station for attention. Without the laundry room a resident would never have
had the opportunity to feel the warmth of a towel coming out of the dryer.
By opening spaces we hoped to eliminate one of the many factors that contributes
to boredom and lethargy in institutionsthe corridor itself. To achieve the
open feeling while providing adequate space to exit, we have had to use
coiling doors recessed into the ceiling. By co-locating the common and support
spaces, we hoped to eliminate any reason for parking residents in the corridor
and leaving them there.
In eliminating resident rooms we were doing two things. The first was to
reduce the size of a unit or neighborhood and create a better opportunity
for personal identity. The traditional nursing unit held a large group of
faceless people. With smaller groups we hoped that people would be thought
of more as individuals. We also were trying to correct the balance of personal
living space, common space, and support area. Over time, Mount St. Vincent
had converted common space to revenue-producing resident rooms. At the same
time, staff numbers had doubled, leading to more need for support space.
This new remodel sought to find a better balance.
We chose to remodel one half of a floor at a time in order to minimize the
number of residents who would be displaced at any one time. By doing this,
normal attrition happened while downsizing; thus we avoided laying off a
large number of staff and moving residents to another facility. The amount
of time we will be under construction has been extended. This extension
has allowed us the opportunity to learn from early experience and to make
adjustments in the remaining units to be remodeled. Given that many of our
concepts were new and untried, we expect plenty of changes. Given the lengthy
timeframe required for designing, and to obtain permits, alterations in
the design can be introduced throughout the remodeling process.
We began the remodeling process with an outpatient rehabilitation suite
which included spaces for physical, occupational, and speech therapy. These
activities were intended to generate additional revenue to support the rest
of the project. In addition in these spaces we introduced an outpatient
stroke rehabilitation program which has been very successful.
The next project was a sub-acute unit. It has been only marginally successful
due to the competition from similar units in the area hospitals. While the
neighborhood was designed to encourage residents and patients' participation
in familiar routines, this sub-acute unit, unfortunately, still operates
much like a hospital unit. As mentioned earlier, for this project to be
truly successful, we would need a change not only in the environment and
work processes, but also in attitude; unfortunately, attitude change has
been difficult to achieve in this reimbursement-driven unit.
Our first long-term care unit was just recently finished. Remodeling will
continue for the next two years as the contractor works his way through
the building, one neighborhood at a time. During that time, we hope to listen
and watch intently as residents move into their new homes. We will continue
to observe and test whether, in fact, we were able to meet our objective
of increasing resident interaction. We hope that with each completed neighborhood
we come closer to solving the problems of institutional living and thus
to creating a true home for our residents.