Aging in place

At a glance…

Architect Shekhar Bhushan shares his perspective on senior living as a result of aging in place and its impact on assisted living.

In the 1980s, as the director of design at a nationally recognized architectural firm that specialized in senior living, I was very involved with the first prototype assisted living models created for Marriot Senior Living Services, the Sunhealth model for assisted living, the assisted living model for ManorCare, and another organization that specializes primarily in skilled care, as well as prototype models for memory-impaired facilities in different parts of the country.

Even then, I strongly believed that assisted living in its purest form, especially as a stand-alone model, did not appear to be financially feasible or practical. Over the years, many stand-alone assisted living facilities (ALFs) have disappeared or have been absorbed by other companies. The country is littered with casualties like Sunbridge, Karrington, and others that were victims of consolidation because they were not flexible enough to make it on their own. Even the once mighty Marriott Senior Living Services merged with Sunrise-and even this last remaining major player in assisted living is having its share of challenges today.

Shekhar bhushan, aia
Shekhar Bhushan, AIA

Window of opportunity

For a resident qualifying to live in a stand-alone ALF, the window of opportunity is relatively small. People wait until the last possible moment before deciding to move into a facility. The realization is usually triggered by an incident that exposes the person’s physical vulnerability. It takes a while to conduct the medical qualification tests and paperwork, and often the person has barely moved in and made a few dear friends when he or she has to move to skilled nursing because of deteriorating health. Although most ALFs are affiliated with a nursing care provider, the move can still be traumatic. Besides being financially impractical because of the larger turnover and disproportionately higher staffing costs, this transition is also devastating to one’s feelings of well-being, security, and orientation.

We find that the only stand-alones working reasonably well today are those that have expanded their services at both ends of the continuum so they can retain their residents longer-into the higher-acuity areas, as well as those at the simpler levels of need at the front end. To further assist in this shift, home healthcare is provided as needed, especially at the front end of the continuum.

Assisted living in a CCRC

When in doubt, I put myself in the prospective resident’s place and ask myself where and how I would want to spend the last years of my life. Isn’t it more desirable to live in the residential/apartment component within the CCRC or even at home until reaching that stage of life? That would certainly be my preference. I could socialize when I want to rather than be moved on a facility-dictated schedule based on staffing convenience.

The majority opinion is that this basic desire is giving rise to the growing preference of “aging in place.” How do we achieve this? The key variable is home health services (Figures 1 and 2).

Minimal Home Health with defined Assisted Living (Current Model)

Effect of Home Health with Flexible Services (Preferred)

The European model

In the European socialist democracies like Sweden, Norway, Denmark, Britain, and France, home health is a prevalent and viable care option because it is funded primarily by the state. It can be, and has been, a large part of the answer for a fairly long time.

As explained earlier, home health/home care provides a variety of service options based on each resident’s specific needs over time. The key is keeping these services affordable, allowing people to age in place in their apartments or home until (1) an injury requires rehab in a skilled care or rehab/Medicare facility, and the person recovers and returns to his or her home/apartment, or (2) the scope and/or frequency of services required involves permanent transition to a skilled care facility. The probability of seniors actually requiring skilled nursing, however, statistically has been shown to be less than 5%.

The ideal solution would be to provide assisted living amenities within the confines of residential living, resulting in facilities designed in a more compact configuration, with apartments wrapped around common spaces as much as possible to minimize travel distances and maximize staff efficiency. Reducing travel distances will be the principal design challenge for this environment. That is why from a theoretical point of view, the perfect solution is probably a high-rise building.

The perfect CCRC

The high-rise apartment building is an ideal hypothetical response to consolidation and the need to cut walking distances. The levels of care would be separated by different floors (Figure 3). The lower floors would offer common amenities and activity spaces, followed by a skilled level floor. The next floor above could provide dementia care. The rest of the facility could be served adequately with an elaborate and flexible home health component for assistance with activities of daily living (ADLs).

The Urban Hi-Rise Model (possibly the perfect CCRC)

As we climb higher, the level of care would decrease and the upper floors would be occupied primarily by residential living. This model can be achieved by conversion of an existing mid-rise or high-rise residential building for much less cost than de novo construction.

This solution is in line with green design principles and has other advantages:

  • Distances traveled by residents to all amenities, entertainment, and retail are dramatically reduced as are distances traveled to socialize with other residents.

  • Less land usage

  • Lower material consumption

  • Lower and more efficient energy consumption

  • Lower operational staff needs because of reduced walking distances and reduced kitchen staff with a combined, central kitchen

  • Fewer cars result in lower parking requirements, which can be further supplemented by the use of common-use cars.

  • Strategic urban locations allow convenient access to entertainment, restaurants, and social events, especially if located on bus and local commuter train routes. An urban setting provides access to parks and other green space, while providing safety in an easily monitored environment.

A great service to offer in a high-rise facility is a concierge service that caters to each individual’s needs: getting directions, making travel arrangements, reservations to restaurants and theater, and sporting events, as well as access to health clubs, dry cleaning, pizza delivery, and so on. Ideally, retail, shopping, and entertainment venues would be downstairs, adjacent to the building, or within walking distance.

This urban solution does have a few drawbacks, however. It may not be allowed in certain suburban zone districts that have height and density restrictions. Chances are there will be less surrounding green space. Urban settings also have higher noise levels.

A compact footprint

The smallest units must increase from the older 450- to 600-sq.-ft. studio and one-bedroom models to 750- to 850-sq.-ft. units, depending on the market, with a much higher proportion of one-bedroom plus dens. The primary (and relatively controversial) thought is to limit the size of the medium and larger living units to less than 1,300 square feet. Here is why I support this plan:

  • A 1,200- to 1,250 sq.-ft., two-bedroom unit can be furnished with quality amenities for the same or lower cost as a larger unit. The kitchen and bath could be a higher level of design and finish and high quality lighting could be installed.

  • The emphasis will trend toward a higher level of design, with minimal use of hallways to offer maximum flexibility and creates a feeling of spaciousness.

  • The high-rise approach translates into a smaller overall footprint, resulting in shorter walking distances.

  • A smaller footprint translates into lower cost from a foundation and roof standpoint. A smaller, more compact structure will result in lower overall gross areas to heat and cool, further resulting in lower energy and building costs

  • A high-rise will result in a more “green” design, using less material resources.

  • Smaller living units will be easier to clean and maintain.

Other design-related suggestions

All residential units will have to be designed with maximum thought given to universal design or ease of maneuverability within the apartment. This will mean more creative solutions in the kitchen and the bath as well as doorways. Unit designs will need to meet the needs of residents at all levels of physical ability. Lighting will have to accommodate the needs of residents with failing eyesight with warmer, softer, and more indirect light.

As time passes, there will be increased pressure on zoning regulations in prestigious suburban townships to better address the advantages and inevitability of more dense developments. The high-rise option will minimize suburban sprawl in favor of more compact, efficient, and taller structures. In major metropolitan cities on the eastern seaboard, such as Boston, Philadelphia, and New York, there are often fewer height restrictions and higher densities allowed closer to the center of town.

Final cautions

The chief aspect not addressed in the home health model is the need for socialization. An “advanced” component of home health will have appropriately qualified staff assist the individual with community-based outreach programs, effectively supplementing the residents’ interaction with family and friends.

The exception is advanced memory-impaired residents. This component may take on a different shape as science gets closer to finding a cure for Alzheimer’s disease. The memory-impaired component must be designed with flexibility so the product does not become obsolete as the industry and science progress.

Scratching the surface

This article does not represent a complete or comprehensive set of conclusions or ideas on the subject of the impact of aging in place, on assisted living, or the operation or design of our campuses. But if it starts to scratch the surface in the areas it addresses, it has served its purpose. The hope is that a few new thought-provoking ideas will surface as a direct consequence in this fast-changing and relatively young industry that will lead to better solutions that will benefit us all. To see how compact design can be achieved in a suburban setting, visit

Shekhar Bhushan, AIA, is President of SB-Architecture PC, Inc., Centennial, Colorado.

For further information, phone (720) 221-5412 or e-mail To send your comments to the editor, e-mail

Long-Term Living 2010 January;59(1):20-23

Topics: Articles