The Facility Guidelines Institute, an organization dedicated to creating a minimum design and construction guideline for state licensing agencies, has completed a four-year revision cycle through the Health Guidelines Revision Committee (HGRC), resulting in the new “Guidelines for Design and Construction of Residential Health, Care, and Support Facilities,” as well as a sister document, “Guidelines for Design and Construction of Hospitals and Outpatient Facilities.”
The hospital and outpatient facilities’ guidelines were published in March, and the long term care facilities’ guidelines were published in May 2014.

Small House Models On The Rise

These two documents used the 2010 “Guidelines for Design and Construction of Healthcare Facilities” as the basis for revision. The 2014 revisions have separated the long term care design guidelines from the acute and ambulatory care design guidelines because of the desired shift away from institutional settings being used for the care of elders.

With the advent of the Green House Project and other small-scale household models, there is a push for creating more residential, comfortable, and familiar care environments for residents requiring a higher level of care.

The HGRC, a multidisciplinary committee, used a consensus process in creating the new guidelines. A specialty subgroup of more than 40 volunteer industry experts was brought together as part of the 2014 cycle to update, improve, and create the new design guidelines for residential care communities.

The ultimate goal is to provide the framework for environments that support positive resident and staff outcomes and serve to promote the national movement of integrating person-centered practice in the built environment.

Breaking Down Regulatory Barriers

The evolution of communities integrating person-centered values of choice, dignity, respect, self-determination, and purposeful living resulting in the transformation of services has significant implications for the design and construction of the residential communities in which those services are delivered.

One of the unintended barriers to creating positive person-centered care models in long term care settings is often outdated and obsolete regulations and licensing.

This is one of the reasons for the new guidelines, which provide minimum design requirements, as well as appendices that provide additional references for users.

The goal is to provide a set of guidelines that will streamline the design portion of the licensing process for long term care settings, such as nursing homes and assisted living, help authorities having jurisdiction to evaluate design documentation, provide consistency between states, and improve resident care environments and outcomes.

Operations On Board

In order for culture change and person-centered care to occur, it is essential that leadership of a community understand the necessity of evaluating every aspect of operations. This includes the changes required to meet each function from a person-centered perspective and commit the time and resources to educate and train staff.

In addition, every community setting may be different in its approach to its culture change care model. Overall, the goal is to deinstitutionalize and create better outcomes for residents living in the environment. There is no one correct answer or solution that solves the goal and requirements of each individual community.

Whether a provider is completing a new building or repositioning an existing community, every function requires evaluation for centralized versus decentralized services and what creates a successful operational change and implementation for its specific community needs and care population.

For example, in a community located in Pleasant Hill, Tenn., it was determined that a decentralized household model would work for them; however, they had a cook who was very good and created terrific food in the existing institutional setting.

In lieu of completely decentralizing the food service operations, the evaluation of the cooking and serving process included maintaining their well-liked cook.

This was reflected in the operation and design decisions to include two smaller commercial kitchens that would be located and shared between two households. The replacement nursing home included two duplexes with four total households.

Another example is the Wharton Care Center, whose team wanted all private rooms; however, Medicaid reimbursement necessitated some double-occupied rooms.

With this as a requirement, the rooms were not designed in the traditional, institutional manner with beds next to one another.

Instead, person-centered care principles and goals established in the programming process were used to create two sleeping alcoves with a shared bathroom. This worked operationally and still provided resident privacy, while meeting the financial requirements of the community and the population being served.

Organization Of The Guidelines

Part 1 of the new guidelines not only includes information on creating a functional program, but also includes guidance on planning, evaluation of risks, and considerations for the environment of care—all crucial to the success of a residential care setting. The risks are included in the Resident Safety Risk Assessment portion of the guidelines (see Table 1, left).

Common elements, as well as an overlay for designing environments for residents and participants with dementia, a sustainable design section, and information on bariatrics, are provided in Part 2, which is referenced from all of the specific facility sections. Part 2 was established to minimize duplication of information throughout the guidelines and to provide ease of access to common information that impacts all or most health, care, and support environments.

Each facility chapter (Parts 3 through 5) of the guidelines covers different categories and typologies for a variety of care models, providing an understanding and direction for the development of a wide range of senior living environments.

The categories of health, care, and support settings include: nursing homes, hospice, assisted living centers, independent living settings, adult day care facilities, wellness centers, and outpatient rehabilitation centers.

Within each category, typologies are used and designated by both the scale and the model of care in the environment being designed.

For example, the nursing homes section includes information on three different models of care, each of which is supported by a different built environment: traditional, cluster/neighborhood, and household/small house. Each type includes basic descriptions, minimum requirements, and supportive reference information for each type of setting.

A Call To Action

Design professionals should become familiar with and utilize the guidelines, as this initiative requires designer and provider support for adoption by states. Please consider becoming an advocate to removing barriers to person-centered environments by organizationally supporting the new guidelines.
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Jane Rohde, AIA, is the founding principal of JSR Associates, Ellicott City, Md. Rohde champions a global cultural shift toward deinstitutionalizing senior living and health care facilities through person-centered principles, research, advocacy, and design of the built environment. Her clientele includes nonprofit and for-profit developers, government agencies, senior living and health care providers, and design firms. She can be reached at