Exploring evidence-based and green design in long-term care | I Advance Senior Care Skip to content Skip to navigation

Exploring evidence-based and green design in long-term care

February 20, 2013
by Addie Abushousheh, PhD, EDAC, Assoc. AIA
| Reprints
Click on image to view design gallery

Like some critics' reaction to climate change, there are those within the field of aging who would rather pursue a “business as usual” approach than respond to an imminent exponential increase in the aged population. This article explores the application of evidence-based design for those within the long-term care (LTC) industry who want to address both of these global phenomena simultaneously.


Evidence-based design (EBD) is the process of basing decisions about the built environment on credible research to achieve the best possible outcomes.1 While, the EBD process is not prescriptive, it is benefitted by a scientific approach where one or a combination of several carefully identified inputs produce measurable and reliable outputs. The Center for Health Design envisions a world where every healthcare environment is designed to improve both the quality of care and outcomes for patients, residents and staff. Today there is a body of knowledge that supports strategies in acute care and, increasingly, ambulatory care settings that are linked to improving outcomes.

The evidence base underlying design in LTC, however, is typically not as straightforward and more difficult to locate. Care providers are continually making adaptations and innovations that respond to their clientele, local markets, reimbursement patterns and regulations; consequently, there is no one style or procedure that fits all applications. This kaleidoscope of change within the LTC industry makes it difficult to know precisely what may lead to what.

LTC researchers are looking for related evidence-based approaches that may be successfully applied to LTC settings such as those within the field of Environment & Behavior or Environmental Design Research. One place to begin looking for overall planning recommendations and specific design details tied to therapeutic goals is from a free searchable database called “Dementia Design Info.”  This information has been mined from a variety of sources ranging from peer-reviewed resources to practitioner-based practices. 

Additionally, pioneering care community leaders are augmenting their operational performance based on organizational development approaches, such as: CQI, LEAN, Six Sigma, Applied Positive Deviance, transformational and facilitative leadership as well as network and team-based distributed management.

The number of anecdotal LTC provider reports is growing in magnitude and frequency such that repeatedly employed strategies are being identified and are beginning to build an evidence base for the design of LTC environments and operational improvement.4 The biggest challenge continues to be the variation that exists from one LTC provider to another. 

A literature review conducted in 2006 by the Colorado Foundation for Medical Care revealed six common threads, which are referred to as the “constructs of culture change.” The use of these constructs has been most prevalent among LTC providers that were fully implementing innovative organizational, environmental and operational person-centered care.

If looking for strategies associated with culture change, the Pioneer Network is an easily accessible source for information. Pioneer Network advocates for elders across the spectrum of living options; and is working towards a culture of aging that supports the care of elders in settings where individual voices are heard and individual choices are respected—whether it is in nursing homes, transitional care settings or wherever home and community may be.5

Not only are LTC providers working to incorporate person-centered care, they are also working to support the environment. The efforts of the U.S. Green Building Council (USGBC) intended to measure “Green Design” have culminated in LEED (Leadership in Energy and Environmental Design) building metrics and rating systems for building design, construction and operation. LEED has been adapted for Healthcare environments, including licensed and federal inpatient, outpatient and LTC facilities because these environments have round-the-clock occupancy and operations and are often subject to strict regulatory and programmatic demands. Despite healthcare specific metrics, the overarching goals of the LEED certification system for Green Building Design remain consistent.7

Increasingly, LEED certification is being pursued by LTC providers and designers who are constructing both high-rise and single-story buildings. An emphasis is being placed on increasing and improving day-lighting strategies as well as using LED light layering that responds to age-related sight deficiencies. Similarly, emphasis is being placed on high-efficiency mechanical systems that may be independently controlled from single-occupancy room to room.