Evidence-based design in long-term care

Architecture promotes the type and quality of care an operator expects to provide. The challenge for designers is to create environments where people live, visit and work while maximizing the usability and operational efficiencies that are different for each user. One tool that designers can use to meet this demand is evidence-based design, or EBD.

EBD is the “process of basing decisions about the built environment on credible research to achieve the best possible outcome.”1 It differs from conventional design practices by the type of evidence that informs the concept and the level of coordination between designer and staff.


Clients rely on their architects to stay current with design standards and innovations. With condensed project schedules and tighter budgets, however, architects should look beyond intuition and trial and error during the design process. Well-researched decisions will improve the quality of life for residents and maximize an owner’s investment in the community.

The conventional design process generally is the same in a project committed to EBD. The primary change is adding steps to research, interpret, incorporate and document EBD solutions. Some fear that reliance on evidence tends to shift toward “cookbook architecture.” Evidence is merely technical information; however, creative thinking is still required to formulate new knowledge in design concepts. The designer will use new ideas to formulate a hypothesis to use as a benchmark for later measurements. At completion, the architect reviews outcomes based on the EBD concepts at work, comparing previous benchmarks to guide future projects.


Stress is a central concept in understanding the relationship between physical well-being and the surroundings.2 As well-being deteriorates, individuals increasingly depend on the environment. The transition from independent assertion to dependent custody is a critical turning point, with a high probability that it will be accompanied by a decline in physical and mental health.

Evidence and experience demonstrates that surroundings have a dramatic influence on older people's socialization, mobility and general health, all of which contribute to stress experienced. Such an intense relationship implies a heightened need for architects to use innovations in design that will encourage positive outcomes. Even small, informed design decisions can have a large impact on residents’ quality of life. The following are a few ideas:

Lighting and daylight. Elizabeth Brawly, a tireless advocate for residents in LTC environments, reminds designers that residents are powerless to modify their environments. Reduced visual acuity, impaired depth perception and insufficient lighting could exacerbate fall-risks and cause daily fear that might contribute to extended anxiety, confusion and anger.

Higher lighting in the dining area means a better view of food and better appetites and calorie intake. It also has been linked to better sleep habits and a generally better quality of life for residents.

Environmental interventions that encourage mobility and independence:3,4

  • Even illumination and elimination of glare
  • Balance of daylight and electric light
  • Combination direct and indirect lighting
  • Gradual changes in light levels—(upon entry from the outdoors
  • Strong contrast—(grab bars in contrasting color)

Homelike environment and smaller units. Momentum for culture change in long-term care is building, and the primary tenets of the movement are dignity and independence. Younger generations will look for enhanced residential amenities as the “medical model” becomes culturally obsolete.

To attract that audience, expect providers to feature residential communities that prioritize resident choice and preferred lifestyle and emphasize social interaction. The personalized environment also suggests that designers and operators adopt a residential vernacular toward the structures, keeping in mind that the typical private home would not have multipurpose and activity rooms. This design approach can make a new home less confusing for potentially bewildered residents.

In addition to homelike aesthetics, smaller units appear to have numerous positive benefits, such as higher motor functioning, greater friendship formation, reduced anxiety and depression, and greater mobility.

Conversely, other studies link large unit sizes with increased staff pressure and were negatively correlated with residents’ quality-of-life outcomes, regardless of their need for physical or psychological assistance.5-8

Healing gardens and views to nature. The pivotal research moment on the influence of nature on our health occurred in 1984, in Roger Ulrich, PhD’s pioneering study on how the view from the hospital room affected the healing process. His findings showed that given either a view to nature or to a brick wall, those who enjoyed the nature view “required less narcotic pain medication, experienced shorter hospital stays and had fewer negative evaluative comments in nurses’ notes.” In the years since that discovery, the body of research has expanded to include many more environments, including long-term care.

Exposure to nature, horticultural therapy and garden settings have been beneficial in:

  • Reduction of pain and stress
  • Improvement in attention
  • Increased satisfaction
  • Stabilized sleep-wake cycles
  • Stronger social integration of residents and
  • Modulation of stress responses

Studies have demonstrated that seniors considered plants, especially flowers, to be extremely important, along with sunlight, fresh air, views of water, wildlife and other nature elements. In addition, some studies have reported that free access to outdoor areas may be associated with positive reminiscences and may reduce some agitated behaviors, medications and lessen fall risks in dementia residents.9-12

Consider that free access is more than simply doors that lead outside. To be truly inviting, the outdoor area should enjoy good visual integration from vantage points inside the building. Staff will be more likely to encourage use of the space, and residents will be more inclined to use it, if they know they can see and be seen.


American gerontologist Nancy Morrow-Howell, PhD, once described aging as “not a simple slope which everyone slides down at the same speed, but rather…a flight of irregular stairs down which some journey more quickly than others.” This definition underscores the need to approach projects with a knowledge base of current evidence for design that will provide better outcomes. By using existing EBD and contributing new informed design recommendations, architects can continue to improve the quality of life inside LTC communities.

Greg Hunteman, AIA, is president of Pi Architects in Austin, TX. He can be reached at ghunteman@piarch.com.


  1. Center for Health Design. What is evidence-based design?, 2007. Available at: www.healthdesign.org/edac.
  2. Gatchel RJ, Baum A, Krantz DS. An introduction to health psychology. 2nd ed. New York: McGraw-Hill, 1988.
  3. Bowman C. Risk management: Lighting's impact on residents, Long-Term Living, October 2008. Available at: www.iadvanceseniorcare.com/article/risk-management-lightings-impact-residents.
  4. Riemersma-van der Lek R, Swaab D, Twisk J, Hol E, et al. Effect of bright light and melatonin on cognitive and noncognitive function in elderly residents of group care facilities: A randomized controlled trial. Journal of the American Medical Association 2008;299(22):2642-55.
  5. Calkins M. Evidence-based long-term care design. NeuroRehabilitation 2009;25(3):145-54.
  6. Brawley EC. Designing for Alzheimer’s disease, strategies for creating better care Environments. New York: Wiley & Sons, Inc., 1997.
  7. Center for Health Design. Peters and Associates becomes the first long-term care specialist to join the list of EDAC advocate firms, July 2010. Available at: www.healthdesign.org/chd/news/press-releases/peters-and-associates-becomes-first-long-term-care-specialist-join-list-edac.
  8. Kane RA, Lum TY, Cutler LJ, Degenholtz HB, Yu TC. (2007) Resident outcomes in small-house nursing homes: Longitudinal evaluation of the initial green house program. Journal of the American Geriatrics Society 2007;55:832-9.
  9. Detweiler MB, Sharma T, Detweiler JG, Murphy PF, Lane S, et al. What is the evidence to support the use of therapeutic gardens for the elderly? Psychiatry Investigation 2012;9(20):100-10.
  10. Cooper-Marcus C, Barnes M. Healing gardens: Therapeutic benefits and design recommendations. New York: Wiley & Sons, Inc., 1999.
  11. Rodiek S. Influence of an outdoor garden on mood and stress in older persons, Journal of Therapeutic Horticulture 2002;8:13–21.
  12. Ulrich, RS. A view through a window may influence recovery from surgery. Science 1984;224:420-21.


Topics: Articles , Design , Executive Leadership