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Why 'going green' hasn't taken root in long-term care

April 27, 2011
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I have been in long-term care (LTC) design for more than 17 years and finally have my first LEED LTC project. The city is actually the one pushing for this; the owner has no desire nor do any of my other LTC clients.

I have sat through numerous LEED certification courses and been bombarded with the benefits of “going green” from every manufacturer you can imagine. They always seemed surprised to find out our LTC clients really don’t seem to care.

I have to say that having previously been in-house as an acute care designer, there were many things that we were already doing that were green. Those practices are just now being validated by LEED.

Long-term care, on the other hand, has been slow to come along with the green movement. Some of this has been caused by the lack of stable reimbursement rates of Medicare and Medicaid. Also, there are generally too many different codes that already need to be complied with, let alone attempting to achieve LEED certification. Going green can be seen as certainly costing a bit more in fees on design and construction.

Another possible issue in why the green movement has not taken hold in the independent and assisted living markets is that LEED is typically marketed to commercial designers. Those that would be mandated to do a LEED building are commercial designers working on government-funded and educational projects. Acute care is somewhat engaged, but only in specific states such as California. Other early adaptors to LEED are clients that have a special interest in green buildings, such as corporate headquarters where part of their marketing position revolves around how responsible they are when it comes to the environment.

Those looking for independent living, assisted living and memory care accommodations are most concerned with the care being provided as well as the cost. Design comes much lower in their priorities and environmental impact typically does not even register with them. We may see this change but probably not for another 10 years or so until the Baby Boomers really start entering these communities.

Lisa Cini

President and CEO


Cini is president and CEO of Mosaic...



Some long-term care providers are integrating LEEDS standards into their new buildings. GEDCO is building the first GREEN HOUSE® model of community-based long-term care in Maryland, and have designed it to meet the LEEDS-Silver level of certification. The improvements to the building will provide a better quality of life for the elders living in the building as well as the Shahbazim and other staff assisting them. See www.gedco.org for more information about The Green House Residences at Stadium Place.

During the design and development phase of the Baltimore project, the entire team was devoted to meeting the LEEDS standards. As a starting point, the project reuses a previously-developed site which reduces the environmental footprint of the building. In order to reduce exterior water consumption there will be no permanent irrigation system, and plants will be ed that are adapted to the local climate. Construction materials will be carefully ed so they contain large amounts of recycled content and they are manufactured and extracted regionally. In addition, the contractor has agreed to institute a construction waste management program that will divert at least 75% of construction debris from landfill. Another example of a design change is the HVAC system. The HVAC for this building will be a VRV (variable refrigerant volume) system which allows for individual space control and results in a far more economical and efficient system — it has a higher initial cost but will pay for itself over time through energy and operational savings.

I believe that most long term care providers want to be environmentally responsible however, they are under substantial economic pressures. You have correctly pointed out the lack of stability in reimbursement rates contributes to an uncertain revenue stream which makes adding expense an undesirable option. In addition, development costs for long term care projects are substantial, making any added costs an onerous financial burden to the provider.

I have seen an evolution in the providers where design issues are becoming more of a priority to them. But, these must be seen as providing them with a competitive or economic advantage in order to make sense.

Will it take ten years for the green movement to be incorporated into the design of long term care facilities? Perhaps, but such integration will likely come about due to financial or regulatory factors.

Nice post Lisa-thank you.

First of all thank you for the wonderful article, Lisa. And although I am responding rather late to the blog, I do appreciate you touching on this subject.

I operate at Facility Planning & Project Management Company, LifeStrong. We specialize in developing and sustaining senior living and home-health environments. In my former life, I was the Director of Architecture & Programming for the nation’s largest owner and operator of continuing care retirement communities. In my opinion, the subject of “why “going green” hasn’t taken root in long-term care is two-fold.

First and foremost, clients of senior living facilities are not demanding LEED buildings or green design. And by clients, I am referring to seniors. Sure, the majority of senior living organizations would prefer to implement green initiatives, but only if they can pass along the cost of development to their customers, who, let’s face it, would prefer to stay in their home. Moreover, most senior living customers are of the Great Generation and The Silent Generation. Not to minimalize the needs of these generations of seniors, but their priority is to have a safe and secure roof over head, good quality food and the creature comforts of home - all for a valuable price. The desire to live in a sustainable facility may not be in their repertoire of features they need to live.

Secondly, as I believe others responded, designing and building a LEED or green facility requires more upfront costs to design and construct, approximately 3-5% in most cases. In a time when senior living organizations are struggling with the prohibitive cost of borrowing money and elevated costs to develop, going “green” does not seem to be practical. Until the cost of “growing green” comes more in line with conventional building, or, until return on investments for “green” facilities has been better proven (i.e. lower operational costs over time), or until, perhaps, it becomes more costly NOT to go “green”, this does not seem to be a priority.

However, the Baby Boomers arrival in about 10 years will force us all to rethink senior living models different all together! This is a more discernible generation. They demand a lot more for their money and are accustomed to a more luxurious style of living than their predecessors. The Boomers will demand energy efficiency and sustainable facilities to dwell. Anything else could be viewed as sub-standard, and perhaps, unhealthy. Moreover, I'd like believe that when the Boomers arrive, what we have come to know as “green” design and sustainible construction practices may be built into the federal and state building code. Wouldn’t that be nice?

Until then, my professional opinion is to implement “green” and sustainable initiatives incrementally, beginning with the ones that will result in the highest return on investments for owners and operators, such as installing Variable Refrigerant Volume (VRV) HVAC systems, etc. that someone had mentioned earlier. The benefit is that we can offer a more competitive facility for today’s seniors, while working towards a newer more sustainable model for Boomers and operators in the future.

Thank you for the opportunity to comment.

Eva Moore, Principal / Owner