Chapter 4
Nursing Facilities

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A Role for Institutional Care?: The Nursing Home

David Fey, AIA

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.