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Aging in place

January 1, 2010
by Shekhar Bhushan, AIA
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Why the “high-rise” concept might be the answer

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.