| Designing Spaces for Memory Care | <p>COVID-19 has affected people and health care systems in multiple ways. Previous flu seasons and outbreaks have demonstrated the challenges of infection control and prevention for vulnerable populations living within the parameters of a closed community.<br></p><p>Meg Sutton, director of interior design at Direct Supply, says that while isolation was also felt during previous flu seasons, it has been a larger issue during COVID, which has led to more client focus on safely visiting family.<br>In her role within the design and construction arm of the company, Sutton works on technical and creative development, professional development of her team, business development and quality control, and memory care interior design.<br></p><p>“What we have seen come out of COVID in terms of design has to do with this idea of dividing\conquering, or creating smaller environments from larger environments,” says Sutton. <br></p><p>Generally speaking, memory care design has always been about limiting exit points and limiting the risk of elopement. “Here that’s still a concern, and it’s still something we incorporate into the designs we do, but now it’s also about how do you get people safely in and out of the building,” says Sutton. </p><h2>Changing Dynamics</h2><p>A priority nowadays for Direct Supply design clients has been how to enter spaces without traveling through other parts of the building, which is something that was not seen before. “Our challenge was how do you create an environment that allows you to see your family regardless of what’s going on in the outside world rather than having this locked-down mode,” says Sutton. <br></p><p>For memory care specifically, having separate entrances available for not only staff but also for families and visitors when allowed to enter into those sections of the building has been critical. “It’s been really important, and one of the ideas that we’ve come up with and that we’ve seen implemented in some areas is this idea of a transition space for memory care,” says Sutton. “This space should be adjacent to the exterior of the building, so again you’re not traveling through other areas of the building to get there.”<br></p><p>Think of a space where a resident, family member, an art teacher, or a visiting physician can enter the memory care space from the outside. “Your exterior space in general and outside space is your first line of defense,” says Sutton.  “How you enter this transition space has become really critical to maintaining relationships outside the building.”<br></p><p>In an assisted living community, one may see a discovery room, a closing room, or even a hospitality suite. “Any of these could potentially be converted or otherwise adapted to that transition space,” says Sutton. “It doesn’t have to be large, and it needs to be occupied by only a few people, but it needs to be accessible from inside and outside.”<br></p><p>Another example is a community that has a transition lobby between the assisted living portion and the memory care portion. “Again, that was originally focused on elopement, but that type of space can also be converted into a receiving lobby where people are coming in directly from the outside, depending on where those places are located,” says Sutton.</p><h2>The Great Outdoors</h2><p>When thinking of spaces where there is a low risk of spreading illness, an outdoor space like a courtyard comes to mind, but there are caveats. While outdoor dining has been a trend for some time, often, seniors don’t use outdoor space because it’s uncomfortable—either too hot, cold, or windy for a fragile population. <br></p><p>“You can’t just take an outdoor patio and throw some chairs on it and call it a rest in space and expect residents to take advantage of it,” says Sutton. “You really need to make sure that it is well-shaded and well-protected from the elements as the best way to encourage people to use it, especially when you are dealing with a fragile population in assisted living or memory care,” she says. Then comes programming—activities that draw people to the space and help everyone understand how it’s being used. </p><h2>Staying Ahead</h2><p>In a challenging year of COVID, collaboration and coordination have taken a different tone for Sutton and her team, which is spread all over the country. The team meets weekly to talk about what’s going on, what the trends are, and how to stay creative. One of the ways is offering a review to help clients stay safe and ahead of the curve.<br></p><p>“We offer our clients a COVID review,” says Sutton. “We take a look at their floor plan—either an existing one that needs refreshing or floor plan upcoming. We talk about how we can divide and conquer the population given their issues with COVID.” Indoor air quality is a large component to the health and wellness of a building, and it is frequently discussed among clients. </p><h2>Future Focus</h2><p>Expect to see a big uptick in renovation and repositioning in the future, such as adding additional beds or adding memory care into assisted living or independent living, says Sutton. This pertains most to providers that were doing well before the pandemic and are continuing to do well, picking up failing communities or aging assets and adding them to their portfolios.<br></p><p>Changes in ownership play into that shift and will lead to marketing communities in a different way, such as marketing separate entrances for staff and visitors. <br></p> | 2021-05-01T04:00:00Z | | Design | Amy Mendoza | Memory care design has always been about limiting exit points and limiting the risk of elopement. |
| Tunable Lighting Makes Big Impact on Residents | <div></div>
<div>In a case of science moving from the lab to the real world, skilled nursing and assisted living operators are discovering the ways in which new lighting technology has resulted in improvements to quality of life for their residents well beyond their expectations. </div>
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<div><img src="/Monthly-Issue/2017/December/PublishingImages/corridorDay.jpg" class="ms-rtePosition-1" alt="Corridor with natural daylight" style="margin:5px 15px;" />Called tunable-white LED lighting, the new systems are meant to replace incumbent fluorescent systems. Tunable-white lighting is being promoted as a benefit to providers because it can improve the lighting quality of a facility through increasing light intensity levels, reducing glare, and providing better control when compared with existing systems.</div>
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<div>The goal is to allow residents to maintain healthier sleep patterns, improve nighttime safety, and positively affect other behaviors like limiting outbursts with soothing lighting.</div>
<h2 class="ms-rteElement-H2">Potential is Great</h2>
<div>Still in their infancy stage, tunable lights may help to correct circadian rhythm disruption, which is to say how a person’s internal body clock works to regulate the 24-hour-a-day cycle of sleep, being awake, and other daily activities. By correcting these disruptions, an individual can experience more restful sleep, a decreased chance of becoming depressed, and lower levels of aggression (notably for dementia care).</div>
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<div>Because of this, lighting is an exciting new area for nursing centers to explore as they implement nonpharmacological approaches to improving dementia care, for example, and deploy energy-saving changes to make their complete infrastructure more efficient.</div>
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<div>At night, the body produces large amounts of melatonin, a hormone that induces sleep. When that process is disrupted by so-called blue light (light that does not allow complete sleep, like from a computer screen or other bright source), the body slows production of melatonin, allowing the body to wake up.</div>
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<div>“So, in the natural world it is dark at night and so your body pumps out melatonin. Then the sun comes up, you get exposed to daylight, and there is lots of that sort of blue rich light in daylight and that suppresses melatonin,” says Robert Davis, PhD, senior staff lighting engineer, technical director, Solid-State Lighting Program, Pacific Northwest Laboratory in Portland, Ore. </div>
<h2 class="ms-rteElement-H2">Putting the Principles to Work</h2>
<div>But does tunable lighting help prevent these sleeping and waking issues for residents of skilled nursing centers? One provider, ACC Care Center in Sacramento, Calif., has definitely jumped on the pro-tunable lighting bandwagon, according to Administrator Melanie Segar.</div>
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<div><img src="/Monthly-Issue/2017/December/PublishingImages/MelanieSager.jpg" alt="Melanie Segar" class="ms-rtePosition-1" style="margin:5px 15px;" />“The research has really shown that just like we all take for granted daylight and our sleep patterns, residents don’t typically get the same kind of cues from daylight that we all get as we go about our business,” she says. “It really is different. They don’t have exposure to the light, and it kind of messes with your system. And, we see some of the outcomes from that like not sleeping well at night.”</div>
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<div>As ACC became interested in the lighting issue, it partnered with its local utility, the Sacramento Municipal Utility District (SMUD), to conduct a human-centric lighting project. Though there have been some delays in getting the exact technology into place as contractors are still catching up to the advances in lighting, the overall results have been stunning, Segar says.</div>
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<div>“We did one private room and one semi-private room, so a very small number, [they also did bathrooms and an office] but we did change the lights in the hall to tunable lights, and we’ve seen a consistent difference on that hallway in terms of falls and a major reduction in behaviors,” she says.</div>
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<div>In fact, ACC recorded a 41 percent reduction in agitated behavior in the monitoring period. “And, that seems amazing to me. But we’ve continued to see that there are fewer problems down there [where tunable lights are in place]. So, the phase two project is to put tunable lighting in all of the halls,” Segar says.</div>
<h2 class="ms-rteElement-H2">Lighting Can be a Balancing Act</h2>
<div>As her center sees the benefits of softening the lighting for sleep and brightening during the day, Segar can understand where cost may be a barrier. Grants from SMUD for the project have eased ACC’s financial burden, and the cost is coming down as costs do with the use of new technology over time.</div>
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<div>There is also the matter of balancing the lighting needs of the resident with the work being done by staff, which is a unique issue for 24/7-hour facilities like nursing care centers. Instead of having the tunable lights come on and off automatically, the areas where nursing needs are greatest allow for manual control of how bright or dim the lights are, Segar says.</div>
<h2 class="ms-rteElement-H2">How the Science Works</h2>
<div>At the same time providers are working to bring technology to their centers and make advances in quality of care, researchers continue to develop ways to make tunable lighting a reality for more institutions, like in long term care.</div>
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<div><span><img src="/Monthly-Issue/2017/December/PublishingImages/corridorMorning.jpg" alt="Corridor in morning light" class="ms-rtePosition-2" style="margin:10px 15px;" /></span><span></span></div>
<div><img src="/Monthly-Issue/2017/December/PublishingImages/corridorNight.jpg" alt="Corridor at night" class="ms-rtePosition-2" style="margin:10px;" />“The main reason people are looking at this is due to some new knowledge we have gained over the last 15 years or so about how <span><span></span></span>the spectrum of light can affect some of the human sleep-wake cycle, and the hormones involved in that,” Davis says. Changes in light can trigger the body to react in different ways, like for example how light in the morning prompts people to wake up, or dimmer light at night reduces stimulation as the body starts the process of moving to its sleep cycle.</div>
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<div>“It is all that same underlying theory that has come forth based on the discovery of a new photo receptor in the human retina 15 years ago,” he says. “The upshot of it is that the medical community has documented that the wavelengths of light seem to affect things like melatonin.”</div>
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<div>Therein lies the problem in any care center that is open all the time when some people are trying to sleep and others are trying to work. </div>
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<div>“There are sort of all those situations and especially in senior care where there is often dementia and other things going on,” Davis says. “If you suppress melatonin in the evening hours or even at night, then you are probably making it harder for people to sleep. And, so exposing people to fairly bright levels of light in the late afternoon or evening is probably going to affect their ability to have a good night’s sleep.”</div>
<h2 class="ms-rteElement-H2">An Environment of Relaxation</h2>
<div>For Davis, the lighting arena is part and parcel of an overall interest in architectural engineering, which at the highest level concerns the view taken from emerging evidence on how the physical environment can increase or decrease stress.</div>
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<div>“We are understanding how institutional environments built around the world in the 1970s and 1980s…how the environment itself if it is ugly and has stressful harsh lighting and noise, results in lots of stress on the immune system,” he says.</div>
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<div>This stress makes it harder for people to heal and get well, and in long term care it hinders a more relaxing, homey lifestyle that is good for all. “If a provider can make the environment more comfortable and pleasant, that can help,” Davis says. And, tunable light can help and make people feel more relaxed.</div>
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<div>“Beyond the color and intensity is the question of how to do we get more light on walls or accent lighting on art work…anything that is more relaxing can make connections to overall well-being.”</div>
<h2 class="ms-rteElement-H2">Lighting Goes a Long Way</h2>
<div>For provider Segar, the ability to make lighting a more natural occurrence for her residents has really moved this technology from a “what if” situation to a “why not” one.</div>
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<div>“I mean, we have one resident who has issues of continuously falling, but with this new lighting he has done remarkably well since being in a room with tunable lighting,” she says. “Before we started we knew nothing about it; now I believe it really impacts the quality of life of residents. A good night’s sleep has a direct impact on behavior. This has the potential to be huge.” </div>
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<div>Reach Patrick at <a href="mailto:pconnole@providermagazine.com" target="_blank">pconnole@providermagazine.com</a>.</div>
<div> </div> | 2017-12-01T05:00:00Z | <img alt="" src="/Monthly-Issue/2017/December/PublishingImages/corridor_t.jpg" style="BORDER:0px solid;" /> | Management;Design | Patrick Connole | Tunable-white lighting is being promoted as a benefit to providers because it can improve the lighting quality of a facility through increasing light intensity levels, reducing glare, and providing better control when compared with existing systems. |
| What To Look For In A Turnaround Property | <div>Turnaround properties in the seniors housing market can offer plenty of opportunities for success. After all, the facility is already in place and has an existing customer base and staff. In some cases, an infusion of funds and more efficient business practices could lead to profits relatively quickly. But, in other cases, low-performing properties may have serious, underlying issues that could be difficult to overcome. </div>
<div>Success is not just about investing in a turnaround and pulling a profit; it’s also about avoiding a bad investment in the first place. Here are some things to keep an eye on when getting involved in a turnaround property.</div>
<h2 class="ms-rteElement-H2">Assess Expertise</h2>
<div>The most important thing for borrowers to understand is their own expertise and strengths. Turning around properties isn’t a hobby, and it isn’t easy. If an investor has a particular expertise and can apply this skill set to a struggling business, he or she often can turn failure into success. <br><br></div>
<div>Expertise in the seniors housing market comes in many forms. Some investors are well-versed in creating new clinical programs, or are experts in the overall operations of such facilities. Others may have access to capital to invest in the aging infrastructure of a property. Whatever one’s expertise is, know it, and keep it front and center when evaluating the investment. </div>
<h2 class="ms-rteElement-H2">Identify The Problem, Check Compatibility</h2>
<div>Properties in need of a turnaround are faltering for reasons that can vary dramatically from property to property. A facility may suffer from a bad reputation, or it may be outdated and seem unappealing. Other properties may be too expensive or in an undesirable location. In some cases, the property could be inefficiently managed. <br><br></div>
<div>Banks will conduct extensive due diligence on the target property before providing funding. But smart borrowers should do their own due diligence and research to identify specifically why a property needs a turnaround.<br><br></div>
<div>Once a property’s strengths and weaknesses have been evaluated, an honest assessment is needed to see if the property and investor make a match. <br><br></div>
<div>For example, if an investor is experienced and highly knowledgeable about the latest clinical programs, a property that’s poorly managed or has a bad clinical reputation might be a good fit if the investor is able to partner with local hospital systems or physicians and offer new and innovative therapy programs. However, if a facility has a lot of deferred maintenance or is in a state of disrepair, then bringing therapies and services without an infusion of capital to upgrade the infrastructure may not be a good match.</div>
<div>Remember: Discovering that an investment is not the right one is, in and of itself, a success.</div>
<h2 class="ms-rteElement-H2">Present The Plan</h2>
<div>As previously noted, good lenders will do their own due diligence. However, even if research indicates the investor’s target has good potential, lenders will want to see that the borrower has done his or her homework as well with a coherent, thorough presentation. <br><br></div>
<div>It’s important to work with a lender and show how one plans to get from point A to point B. Tell the lender about your expertise. Tell them what you believe is currently impeding the property’s success. Explain how your company is uniquely equipped to address those current impediments. And, finally, lay out your strategy for making the property a success.</div>
<h2 class="ms-rteElement-H2">Red Flags</h2>
<div>Many turnaround properties can be made into viable, successful facilities by the right investor with the right plan. However, some red flags make lenders (and perhaps even investors) think twice about investing:<br><br></div>
<div>■ Major deferred maintenance. Construction time and costs can be notoriously difficult to project. Keep in mind that construction will often disrupt normal operations. For instance, if a wing needs to be rebuilt, then all of the patients in that wing will need to be relocated or discharged. This could result in added costs and a loss of revenue. In order to succeed, make sure that the company has capital set aside for those leaner cash flow times created by the construction schedule.  <br><br></div>
<div>■ A poor clinical reputation. Unlike many investment factors, reputation cannot be easily measured, predicted, or controlled. <br><br></div>
<div>Some low-performing properties suffer from bad reputations that may have been caused by poor quality of services over a long period of time. Whatever the cause, once a facility has developed a bad reputation it can be extremely difficult to change the opinions of prospective clients. Rebranding efforts, such as name and logo changes, may be ineffective.<br><br></div>
<div>Most business is generated locally for health care facilities such as these, and a name change, new tagline or logo, or a fresh coat of paint won’t make prospective clients forget a bad reputation. Partner up with local hospital systems and prominent physicians in the local market before undertaking a turnaround of this kind. <br><br></div>
<div>■ Valuation exceeds cost of a new build. The cost of a new build is not a complicated formula, but it is a critically important one. There is rarely ever a reason to buy a turnaround property at a valuation that would actually exceed the cost of building a new facility (provided land is available and a borrower doesn’t need a Certificate of Need for the project). Most patients will opt for a newer facility over an older one.<br><br></div>
<div>An investor who pays more for an existing facility than the cost of a new build will have to demand higher prices than the market is willing to pay. If an investor is offering something unique in the marketplace such as urban location or amenities that would be hard to duplicate, then it might be a good fit. <br><br></div>
<div>There are certainly exceptions to every rule, and many turnaround properties can be revived and made into healthy businesses. Success will happen when an investor spots a property that is the right match.<br><br>Imran Javaid is managing director of Healthcare Real Estate at Capital One Bank. He can be reached at <a href="mailto:imran.javaid@capitalone.com" target="_blank">imran.javaid@capitalone.com</a> or (301) 280-0212.</div> | 2015-11-01T04:00:00Z | <img alt="" src="/Monthly-Issue/2015/November/PublishingImages/finance_t.jpg" style="BORDER:0px solid;" /> | Finance;Design | Imran Javaid | Success is not just about investing in a turnaround and pulling a profit; it’s also about avoiding a bad investment in the first place. Here are some things to keep an eye on when getting involved in a turnaround property. |
| Design Gets Person-Centered Guidelines | <div id="__publishingReusableFragmentIdSection"><a href="/ReusableContent/4_.000">a</a></div><div> </div>
<div>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.”</div>
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<div>The hospital and outpatient facilities’ guidelines were published in March, and the long term care facilities’ guidelines were published in May 2014. </div>
<h2 class="ms-rteElement-H2">Small House Models On The Rise</h2>
<div>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.</div>
<div><br>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. </div>
<div><br>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.</div>
<div><br>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. </div>
<h2 class="ms-rteElement-H2">Breaking Down Regulatory Barriers </h2>
<div>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. </div>
<div><br>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. </div>
<div><br>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.</div>
<div><br>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. </div>
<h2 class="ms-rteElement-H2">Operations On Board</h2>
<div>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. </div>
<div><br>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.</div>
<div><br>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. </div>
<div><br>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.</div>
<div><br>In lieu of completely decentralizing the food service operations, the evaluation of the cooking and serving process included maintaining their well-liked cook. </div>
<div><br>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. </div>
<div><br>Another example is the Wharton Care Center, whose team wanted all private rooms; however, Medicaid reimbursement necessitated some double-occupied rooms.</div>
<div><br>With this as a requirement, the rooms were not designed in the traditional, institutional manner with beds next to one another. </div>
<div><br>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.<br><span id="__publishingReusableFragment"></span></div>
<h2 class="ms-rteElement-H2">Organization Of The Guidelines
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<div>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).</div>
<div><br>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. </div>
<div><br>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.
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<div><br>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.<br><br></div>
<div>Within each category, typologies are used and designated by both the scale and the model of care in the environment being designed.</div>
<div><br>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. </div>
<h2 class="ms-rteElement-H2">A Call To Action </h2>
<div>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. </div>
<div>For more information, go to <a target="_blank" href="http://www.fgiguidelines.org/">www.fgiguidelines.org</a>. </div>
<div><br><em>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 <a target="_blank" href="mailto:jane@jsrassociates.net">jane@jsrassociates.net</a>. </em></div>
<div> </div> | 2014-07-01T04:00:00Z | <img alt="" src="/Monthly-Issue/2014/PublishingImages/0714/feature_t.jpg" style="BORDER:0px solid;" /> | Policy;Management;Design | Jane Rohde | 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.
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