A behind-the-scenes look at four outstanding projects

We are proud to present the 2009 DESIGN Citation of Merit winners. The four projects that follow were deemed “the best of the best” by our panel of jurors which included architects, interior designers, providers, and regulators. The highest honor, Best of Show, went to Three Crowns Park, Evanston, Illinois, AG Architecture, Inc. The winning projects range from a county-owned facility to a residence for elderly nuns. The DESIGN entry and review process is detailed and exacting. All entrants had to supply a binder filled with a detailed written description of the project, photographs and illustrations, plans with legends, obstacles and solutions encountered, questions and answers developed by the review panel, and facility and firm profiles. After a two-day review process by our jury, four Citation Award winners were chosen. The winners showed exceptional use of master planning and settings/designs that promote seniors' highest levels of physical and cognitive functioning and emotional well-being in ways that support their dignity, self esteem, and quality of life. These designs enable owners/operators to provide innovative programs and solutions that transcend aging in place and designs that facilitate caregiving functions. Our congratulations as well as those of DESIGN co-sponsors SAGE and The Center for Health Design, to Rick Moore, Horty Elving; Gene Guszkowski, AG Architecture, Inc.; Terry McLaughlin, Community Living Solutions, LLC; and Julie Heiberger of Hoffman, LLC. We have also included entries our jurors chose as Honorable Mentions and the distinctive features that gained them special recognition.

Three Crowns Park, Evanston, Illinois

Gene Guszkowski, AIA, Principal, AG Architecture, Inc.

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One could say Three Crowns Park had “good bones” to begin with. The over 100-year-old main structure is situated in a mature neighborhood in Evanston, Illinois, nestled among beautiful homes and adjacent to a school with a forest preserve. It is on the city's historic register. So when Executive Director Susan Morse became the lightning rod for converting the skilled nursing facility into households and undergoing a complete culture change, architect Gene Guszkowski already had a leg up. The project became a combination of new construction and renovation.

“We knitted two existing buildings together with some new construction,” explains Guszkowski, a principal with AG Architecture, Inc., Wauwatosa, Wisconsin. “The bottom line was what we needed to do was create additional space to give ourselves the ability to expand the nursing home in a meaningful way. We couldn't accomplish all we wanted to do given the framework of the existing building. We used a portion of the third floor of our new construction to expand our nursing home.”

Photography: ©2008 FotoGraphix

Resident-centered care advocate Steve Shields was brought in to help make sure the household concept was facilitated as well as the culture change needed to support it. Shields, a well known consultant in the Midwest, runs Meadowlark Hills, a CCRC in Manhattan, Kansas. Morse took her staff to Meadowlark Hills twice to get buy-in and show them how the household model works. Shields is a disciple of “rampant normalcy” in long-term care building and design, a phrase that became Guszkowski's guiding light throughout the project.

Gene Guszkowski

“You have to start by asking, ‘What is a home?’” explains Guszkowski. “In our society whether you call it a condo, a house, an apartment, or a co-op, you start with a sense of entry, you have a social space such as a living room, you have a place where you dine, a place to prepare food, and a private bedroom. What we were trying to do was take that idea and adapt it to create three, 18-bed households.”

It was felt from a staffing point of view, that if households of 18 could be created, it was a workable number for the staff. The way the existing building was laid out situated the elevators in the middle, so the architect broke the existing layout into two separate households, each with its own front door. “The addition was designed in a way that as one comes up a new elevator, you get off and now you're going through a sequence of being on someone's front porch. You ring the bell, come inside, and you experience a progression of rooms that are like a living room, and a kitchen, then a bedroom,” Guszkowski says.

Next came Guszkowski's biggest challenge. “The client insisted there should be absolutely no service-related crossover,” Guszkowski explains. “For example, if you're in a single-family home, your neighbor doesn't cross through your living room with their dirty laundry to go to the basement. We had to work very hard to separate the zones where people live and socialize and keep them separate from the back-of-the-house area. It was a very disciplined exercise and Steve held our feet to the fire.” That discipline, Guszkowski admits, was the aspect of the project he is most proud of.

Another challenge was how to create outdoor space. Guszkowski says this is an ongoing problem with skilled nursing care, especially on the third floor. “What we did was a bit of a compromise,” Guszkowski says. “Our ‘outdoor’ space is an enclosed sunroom on the third floor. It has large windows on either side that gets a good cross breeze from east to west. There is a hard finish on the floor so it makes it feel more outdoorsy. It has a great view to the drop-off area of an elementary school so the residents can look down at the children and reminisce.”

The project is being completed in phases. In the first phase, the new addition was completed and a portion of the residents were relocated. The scheduled renovation phases are in progress with the team working on the existing areas of the third floor.

“We've tried to deinstitutionalize this project as much as possible,” Guszkowski says. “There are no nursing desks or stations; instead we used nooks. We've taken the bathing areas and tried to turn them into spas. We believe in a lot of little touches.”

-Maureen Hrehocik, Executive Editor

Our Lady of Peace Residence, Scranton, Pennsylvania

Julie Heiberger, AIA, NCARB,LEED ®, AP Hoffman, LLC

Page 40

With an eye to the future, the new home of the Sisters, Servants of the Immaculate Heart of Mary, a 120-bed CCRC in Scranton, Pennsylvania, will not only take care of the order's current care needs, but is poised for public use as the sisters' needs decline.

According to project architect/designer Julie Heiberger, “The sisters were very forward-thinking. They knew they were going to have a certain need for so long based on the trends of their population as they get older. They wanted to make sure whatever they built and whatever resources they invested would be able to accommodate a greater market need later for public use.” Instead of building a typical skilled nursing facility that would be 220 to 240 net sq. ft., with an accessible bathroom having a toilet and sink, they went ahead and chose to build something that was 390 net sq. ft. that includes a living space, a bedroom space, and a full bath with an accessible roll-in shower. “We thought that still might not be enough room to satisfy market demand, so we designed two units that could be combined into one. That would offer a bedroom, a living room, and a dining room, convert one of the bathrooms into a kitchen, and then have a bathroom off the bedroom.”

Photography: ©2008 FotoGraphix

Julie Heiberger

Heiberger didn't run any electrical wires through the wall that could be torn down for the conversion and plumbed-in for future kitchenettes in each unit even if two units were not combined. The infrastructure is in place now for any future conversions. “That was an expense the sisters decided to incur now for the future,” Heiberger says.

The care center is situated within the campus of Marywood University, which the sisters founded in 1915, and is two blocks from the old convent location. The university purchased Marion Convent from the sisters and has since remodeled it into on-site housing for students.

The new building is four stories high; part of the first floor is a Main Street model with a bistro, gift shop, beauty salon, Program for All-inclusive Care for the Elderly (PACE) center, offices, and chapel where the sisters also welcome the public to participate in Mass. There is one main entrance that the sisters and public share. As visitors enter the building, a bronze statue of the Virgin Mary with outstretched arms welcomes them. The statue was created by one of the sisters of the community, Sister Cor Heffernan. Behind the statue is the order's mission statement engraved in the wall. “When you come into the building, you really get a sense of why and for whom the building is there for; you understand that you're in a holy and spiritual place,” Heiberger says. All along Main Street false windows showcase some of the order's history, heritage, artifacts, and current events. Clerestory windows let natural daylight in from above. The building has a security system so it can be locked down and closed to the public.

Also on the first floor is a PACE center. This program allows providers to deliver all services eligible participants need. The provider receives a stipulated sum of money per participant and is responsible for the care of that participant until the end of his or her life. The PACE team determines the best care plan and focuses much more attention on wellness and preventive care. During the initial planning phase, the need for a way to fund the care of the more frail sisters was evident. The sisters partnered with PACE provider Geisinger Health Systems, which leases space from the sisters and provides services not only to the order, but also to the greater Scranton community. “It's a win/win situation,” Heiberger says. “Geisinger has a base of clients in the sisters that doesn't require them to venture into the community to transport participants back to the center. Many participants of the program are sisters who live within the building. For the sisters who are eligible for the program, much of their healthcare cost is no longer a burden to the order.”

At the opposite end of the first floor Main Street are the residences and an elevator lobby which takes the sisters to their living quarters. The four floors are divided into three wings with a total of 12 households and 10 sister rooms within each. Each household includes a kitchen, dining room, living room with a fireplace, and a laundry room. The entrance to each household also has a “front porch” with doorbell and mailbox. The kitchens are designed for accessibility and allow for wheelchairs to use all of the appliances, including the sink and cooktops, which are open below. The wall oven has a side swing door to help with accessibility. One household, dedicated to sisters who are more frail, is located closest to the sisters' community dining on the third floor to reduce transportation. Another household is designed for sisters with dementia and is located on the first floor with access to a secure outdoor courtyard.

“The whole building is a progression of public to semi-public to semi-private to private,” Heiberger says. “The sisters wanted to welcome interaction with the students and outside community, but still needed to maintain their internal sense of community and privacy as well.”

Each sister has her own private living space with access to a balcony or patio, bedroom, and full bath with roll-in ADA shower. “I remember during the open house, one of the sisters grabbed me and pulled me into her room. She was so proud to show me her own private bathroom. In the old convent they had to share one and it was down the hall,” Heiberger relates.

The sisters were very involved in designing Our Lady of Peace Residence. There was a committee of five sisters who worked with Heiberger on the main building; subcommittees were assigned to the chapel, administration, Main Street, and households depending on the sister's area of interest. “All of the committees overlapped, though, and coordinated with one another,” Heiberger reports.

The most gratifying aspect of the project for Heiberger is the very positive reactions she received from the sisters when the project was complete. “There's a great deal of personal satisfaction to hear the sisters say how much they love their building, how many compliments they get, and how it meets their mission and values,” Heiberger says. “It really reflects who they are, that we listened to their needs, and were able to bring their vision to realization.” Heiberger is also pleased that she was able to meld the private and public aspects of the project. “This project has very diverse components that most projects don't have. There was a very public component in Main Street, administrative needs, a worship component, a living component, and basically an adult daycare component. It's a very complex program to get all those different pieces to work together and maintain the privacy of the sisters, for whom the building was created.”

-Maureen Hrehocik, Executive Editor

Park View Health Center, Winnebago, Wisconsin

Rick Moore, AIA, ACHA, Principal, Horty Elving

Page 38

Many times the beauty of a facility goes beyond bricks and mortar. Such is the case at Park View Health Center, Winnebago, Wisconsin. Since Park View was completed in May of last year, the county-owned skilled nursing facility's staff retention is up, resident satisfaction has soared, residents are getting more visitors, the administrator can plan proactively, and they have a waiting list. To anyone in the long-term care industry, those are all beautiful things.

Architect Rick Moore, AIA, ACHA, principal with Horty Elving, Minneapolis, Minnesota, says he gives the county a lot of credit for looking forward and having the faith in Horty Elving to design the 168-bed facility. The design philosophy is that the household concept and staffing efficiency go hand in hand during the design process. “One of the first things we do before we start designing is to ask the staff what the staffing ratio is between nurse's aides and residents. In the case of Park View, it was one to seven, which means it is fairly heavy care. That gave us a neighborhood of 21 with two households; one with 11 residents, the other with 10,” Moore explains. He then used those figures to determine how many beds could be accommodated and stay within budget. All of the rooms are private, a feature that delights residents who have never experienced such privacy. For the staff, resolution of roommate conflicts is nonexistent. The staff is also happy with the closeness of the neighborhoods to common areas which reduces staff walking distances when transferring residents and helps build relationships between residents and staff.

Moore designed the service elevators at the centers of the service cores between the households. All food, linens, and trash go up and down the four service elevators to the basement. “You never see a cart in the corridors,” Moore says. Because the service elevators are in the service core it prevents residents from going to the basement. Something else you won't see in the facility is much carpeting. “We pushed hard for more carpeting in the corridors to give it a quieting, homey effect, but the staff was adamant that we have hard surfaces because of the heavy care level. It's an ongoing debate in every project we do!”

The resident rooms are all private with freestanding furniture. The sloped ceilings are more residential in feel and work as the reflectors for the cove uplights for a softer homelike effect. Each household has a courtyard or a porch. The doors to the porches or courtyards are equipped with wander protection and are equipped with door status indicator lights at each door. Since the campus is located adjacent to a county park, the residents can enjoy beautiful views from the comfort of their own room. All of the resident rooms are 45 degrees off of north to allow all of the rooms to get some sun in every day. Nature trails are also adjacent for use by residents and family for walking and having picnics. “This environment makes visitors feel more comfortable, as if they are visiting someone in their own home,” Moore says.

Photography: Viken Djaferian, FotoGraphix

Rick Moore

Wayfinding was an important element in Moore's design. “We purposely tried to make wayfinding easy. If you can make the path to get somewhere direct, it will be easy to find.” The neighborhoods are shaped like two “Vs” back-to-back, forming a “hub” between the two neighborhoods. “If the neighborhoods have 21 residents, that means 42 residents for a nurse supervisor and a social services person. We were trying to get management where it needed to be in terms of residents,” Moore says. The point where the two “Vs” come together is an entryway from the outside that was designed so families could enter and go right to the neighborhoods. Elevators at these entries take them to the upper floors. “One could bypass the main entry and everything in-between and just go directly up those elevators,” Moore says. “We made it as simple and easy as possible to encourage visitors.”

Moore is most proud that all of the elements he sometimes struggles to make come together, all came together at Park View. “We might get the households the way we want them on a project, but the delivery system for food or goods can't be hidden in a discreet manner, for example. In this project, it just all came together.” Moore again credits the county with allowing him to make an efficient, comfortable building for residents that, in some cases, other LTC facilities won't take. “In some instances, county commissioners won't want a facility to look too fancy because they're worried about constituents thinking they're not spending county money wisely. Park View is a good balance.”

-Maureen Hrehocik, Executive Editor

Hayward Area Memorial Hospital and Nursing Home

Terry McLaughlin, NCARB, AIA, Cofounder & Chairman, Community Living Solutions, LLC

Page 36

Terry McLaughlin, NCARB, AIA, knows when to be the teacher and when to be the student. He also knows the more people see their input in a project, the more accepting they'll be of the outcome. It was his inclusion of the staff, residents, and residents' families in the planning process of Hayward Area Memorial Hospital and Nursing Home that he attributes much of the project's success.

“If we don't understand the day-to-day operations from the perspective of the providers and know what the residents are expecting, we will fail,” says the cofounder and chairman of Community Living Solutions, LLC, Neenah, Wisconsin. McLaughlin held focus groups with the staff, residents, and residents' families before the new $6 million construction was begun. He continues to have focus groups every month while construction is ongoing. McLaughlin credits the staff working for the past three years with Action Pact, a culture change organization, in helping them change their culture from the bottom up. “If you're used to driving a '57, three-speed Chevy and you're given a six-speed Ferrari, you're going to lose a couple of transmissions along the way (if you're not trained to drive it),” McLaughlin says. The staff had already started to implement some updating in their spa areas of the old building to start getting residents and staff used to culture change.

The State of Wisconsin, through the Medicaid program, is offering a fiscal incentive to nursing home providers to replace their old facilities with new, state-of-the-art, resident-centered care designed buildings. To meet the requirements for a total replacement facility, the facility must incorporate Green House and SAGE attributes in the design, have 80% private rooms with private bath, be 50 beds or fewer, and serve an 85% Medicaid/Medicare resident population (as measured from the cost report used for the annual calculation). The incentive increases the allowable capital cost reimbursement within the Medicaid formula. Selection by the State of Wisconsin to participate in this program gave the Hayward team the financial wherewithal to set some exciting project goals. McLaughlin says there will be enough beds in Wisconsin in the long term even with the financial incentives. “We are in the bottom of the trough between the Greatest Generation and Baby Boomers. If we can just get through the trough and get a couple of years down the line, the numbers will start going back up,” McLaughlin explains. In Northwest Wisconsin, smaller facilities in a number of counties and rural areas have either gone out of business or downsized and McLaughlin says this has created a better balance.

Illustration: Tom Lemkuil

Terry McLaughlin

The existing nursing home at Hayward was connected to a hospital and took on many institutional-like characteristics. McLaughlin made sure the 50 new rooms in two neighborhoods each with five clusters of five resident rooms offer privacy, opportunities for community, and abundant natural light. In fact light, McLaughlin says, was foundational to the basic concepts of the project. The old nursing home is two stories. The ground floor isn't used by residents so they have no immediate access to the exterior. The nursing home overlooks 600 acres of wooded land with a 100-acre lake. “In this part of Wisconsin, people are a hardy bunch and they love being outdoors,” McLaughlin says. “A lot of the design is based on interior courtyards. Every household has two interior courtyards.” One courtyard is set up as a healing, spiritual place with a butterfly garden. The other is set up with play structures for grandchildren. The two distinct courtyards help in wayfinding, says McLaughlin, and they have become focal points that the residents remember. McLaughlin also says he cannot find a location in the building, except a public toilet, that does not have an outside view.

While the room sizes are about 280 sq. ft., they appear larger because of how they're designed. “I think the reason the rooms appear large is that you enter the room on a diagonal. It's a third again the length of a normal room. When you come through the door, the diagonal on the opposite end is a corner window which includes a social area. So what you're doing is looking directly outside. You've got all this light coming in.”

To create the intimacy of a household with the communal dining spaces, McLaughlin used sliding walls. The two neighborhoods of 25 rooms are separated by the main street corridor. When a larger dining space is needed for holidays or a family gathering, the walls simply slide to the side. Two fireplaces, one at each end of the space, anchor the room.

McLaughlin says he is most proud of the opportunity to change the world. “I think everyone has the desire to be a part of change in some way, but to actually commit to it and be a part of the process, is what it's really all about. We're honored to do it.”

-Maureen Hrehocik, Executive Editor

Jury comments:

Sojourn Rehabilitation Center, AG Architecture, Inc.

AG Architecture, Inc.

“Use of natural light and bamboo in corridor space provides a therapeutic healing environment.”

Fairmont Care Center, Hanna Z. Interiors, Ltd.

Hedrich Blessing

“By taking existing social spaces, that were not well designed, this project created a new social center with a new kitchen, bistro, movie theater, game area, and solarium, and opened the whole area up to the corridor so it could be utilized and seen by more residents.”

Victoria Heights, Stantec Architecture

Ema Peter Photography

“Kids' intergenerational engagement, sustainability, and LEED® certification are great!”

Bentley Commons at Keene, Merlino Design Partnership, Inc., and Stampfl Hartke Associates

Alain Jaramillo Photography

“The use of an existing historical building is a great marketing tool for a clientele resistive to a supportive care environment…and this looks like anything but a typical care environment. (We) commend this team on their efforts!”

AltaMed Adult Day Health Care and Primary Care Center, AltaMed Health Services Corporation, and Barrio Planners, Inc.

Lefteris Photography

“Good example of a community outreach facility working with a limited budget, relating the design to the community it serves.”

Design Environments for Aging 2009 2009 March;():28-33

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