New healthcare design guidelines address long-term care

Design professionals and long-term care providers are often confronted by codes, standards and guidelines that may be unclear, outdated or difficult to use because they have been adapted from and integrated with those written for more acute-care environments such as hospitals. These guidelines also tend to be far more clinical and institutional in nature, which conflicts with the emerging trend in long-term care toward more person-centered built environments.

So what if there was a design guideline that was specifically developed for the unique requirements and new models of long-term care and related support services? And what if it was all in one volume dedicated solely to those services, such that it could be easily adopted in whole or in part by different state agencies that license everything from nursing homes to assisted living to adult day care facilities? Services and care within residential and nonresidential built environments are usually not all licensed by the same state agency.  Therefore, if all of the code information was available in one place and then adopted by different state agencies, there would be a single comprehensive code and reference for design professionals, operators and regulators. That is definitely something to be excited about.

The good news is that since 2009, the Facility Guidelines Institute (FGI) has been working with industry experts in senior living, including gerontologists, various types of facility care providers and owners, design and consulting professionals, researchers, evidence-based design advocates and regulators to create a comprehensive new volume, entitled Guidelines for Design and Construction of Residential Health, Care, and Support Facilities. These guidelineswill provide guidance, consistency and opportunities for “authorities having jurisdiction” to not only evaluate existing and traditionally designed facilities, but to also support those working on transforming and repositioning existing elder care communities to include person-centered care models. These models integrate core person-centered values of choice, dignity, respect, self-determination and purposeful living into their culture.


The transformation of elder services, based on person-centered values and practices has significant implications for the design and construction of the residential communities where those services are delivered. Transformation to a person-centered culture requires the creation of built environments where both elders and their caregivers are able to express choice and practice self-determination in meaningful ways at every level of daily life.

One of the unintended barriers to creating positive person-centered care (PCC) models in long-term care and nonresidential care settings is the often outdated and obsolete design regulations for licensing. The existing Guidelines for Design and Construction of Health Care Facilities, currently adopted by many states, were originally written for hospitals and have not been easily adapted to the many emerging new models of elder care. Person-centered settings are designed not on the traditional hospital-based institutional model of care, but as supportive living environments that better reinforce quality of life for the residents.

In response to the field of design professionals seeking to evaluate and provide innovative new changes in eldercare community models, the Facility Guidelines Institute (FGI) has devoted substantial time and resources to the development of these new guidelines. To be published in 2014, the Guidelines for Design and Construction of Residential Health, Care, and Support Facilities will support the national movement which is integrating person-centered practice and built environments into residential care communities.  These new guidelines, created with an interdisciplinary volunteer team, are a milestone document created to support the evolution of LTC environments, while providing consistent guidance for providers, design professionals and “authorities having jurisdiction.” The ultimate goal is to provide the framework for environments that support positive resident and staff outcomes.


The new Guidelines cover different categories and typologies for a variety of care models, providing an understanding and direction for the development of a wide range of future senior living environments. The Guidelines are divided into part sections and chapters. Part 1 is dedicated to functional programming, environment of care considerations, resident safety risk assessment and other general planning information for all types of facilities. Part 2 is dedicated to “common elements” that are referenced from all of the specific facility chapters covered within the new Guidelines. This section includes design criteria that are common to all facility types, as well as overlay sections that assist design professionals in addressing the special needs of residents with dementia, mental health diagnoses and cognitive and developmental disabilities, as well as bariatric needs.  

There is a dedicated section that includes sustainable design criteria and references for residential health, care and support facilities, in addition to minimum building system design criteria for plumbing, electrical and heating, ventilation and air conditioning (HVAC), and communication, data and call systems. Part 2 also includes architectural detail, surface and furnishing needs for LTC settings and nonresidential support facilities.

Part 3 covers residential health facilities and includes specific criteria for nursing homes and hospice. The nursing home chapter includes information on three different models of care, each of which is supported by a different built environment: traditional, cluster/neighborhood, small house/household. The hospice chapter outlines adult day care hospice, home-based hospice, small ambulatory residential care hospice, small nonambulatory residential care hospice, freestanding, hospital-based and nursing home-based hospice facilities. Both the nursing home and hospice chapters include a model characteristics chart for easy reference.

Part 4 addresses residential care and support facilities including assisted living facilities and independent living settings. The assisted living chapter provides guidance for the design of small (five or fewer residents), medium-sized (no more than 16 residents) and large model (more than 16 residents) settings and a model characteristic chart for each care model type. The independent living settings have been provided primarily as a reference for those working on continuing care retirement communities (CCRC), community-based service models for independent living projects and aging in place care models. Although independent living settings are not usually licensed, the committee felt providing guidance to this related physical environment was important because of the delivery of home-based services and the desire of elders to age in place.

Often the physical environment is the barrier that prevents residents from staying in their local community. Independent living settings include a small-scaled freestanding house, cottage or attached house, or an apartment with or without related common space (including a CCRC). 

Part 5 covers nonresidential care and support facilities and includes adult day care facilities, wellness centers and rehabilitation outpatient facilities. The adult day care facility types include adult day, adult day healthcare, and Program for All-inclusive Care for the Elderly (PACE). The development of a new wellness center facilities chapter was included because of the trend and focus on wellness and healthy living versus disease-based solutions. The rehabilitation outpatient chapter includes references for design criteria needed to serve older adults, including those with dementia. 


The recommendations in the guidelines are less prescriptive than those in its newly retitled sister document, the Guidelines for Design and Construction of Hospitals and Outpatient Facilities. This difference is intended to facilitate the design and delivery of more homelike environments suited to the particular culture and characteristics of the residents of each elder community.

One prescriptive model and one approach could not possibly accommodate the range of program requirements required to support the uniqueness of each type of community and service, so the Guidelines support several different options including more traditional designs. The programming process is covered in detail as the basis for well-designed and well-constructed LTC environments. The new Guidelines will generally follow the format of the original Guidelines for Design and Construction of Health Care Facilities, with text written as code language so it can easily be adopted by states to regulate design and construction of included facility types. Informative appendix information and detail is also included.

As significant stakeholders, LTC providers have a very important role to play in the development of these guidelines. Their experience and insight can help illuminate the critical issues that need to be addressed, and help make this new volume both realistic and practical. Providers can be part of this new development in two ways. First, provide comments on the proposed text of the new guidelines.The complete text is open for comment through March 20, 2013. Residential care providers, gerontology experts, design professionals, administrators, facility managers, regulators and other interested parties are all invited to review the content and submit their comments and suggestions for revision.

All comments must be submitted through an electronic system hosted by the Facility Guidelines Institute. Visit to download the draft document and access the comment system. Second, LTC providers can help be the catalyst for the adoption of these new guidelinesby contacting local state officials and letting them know that they are in support of adoption of the new FGI Guidelines for Design and Construction of Residential Health, Care, and Support Facilities by their state. Providers should help explain to officials that this is a very necessary step in support of the revolutionary improvement of LTC settings for residents living in long-term and short-term care settings and using community-based services. Tell them that you want your state to be a place that supports a positive culture of aging. Working together, we can help ensure a better quality of life for everyone.

The text of the new FGI Guidelines for Design and Construction of Residential Health, Care, and Support Facilities was prepared under the leadership and direction of Jane Rohde, AIA, FIIDA, ACHA, AAHID, LEED AP, by the Specialty Subgroup (SSG) on Residential Care Facilities, a multidisciplinary subcommittee of the 2014 Health Guidelines Revision Committee (HGRC).

The work of the SSG on Residential Care Facilities was made possible by the continuing advocacy and support of The Hulda B. & Maurice L. Rothschild Foundation and Robert N. Mayer, PhD, its president. The Rothschild Foundation has long supported and been involved with numerous initiatives with many different organizations to create person-centered models and regulations to improve the environments designed for elders we serve.  Contact Rohde at and Mayer at

The HGRC is responsible for updating the Guidelines for Design and Construction of Health Care Facilities. The SSG had individual experts and volunteers as well as participation from other industry groups, including but not limited to the Hulda B. & Maurice L. Rothschild Foundation, the Environmental Standards Council of The Center for Health Design, the American Institute of Architects Academy of Architecture for Health, American Institute of Architects Design for Aging Knowledge Center, the University of Minnesota, the Pioneer Network, the ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) 170 and 189.3 development committees, the National Center for Assisted Living, the American Academy of Healthcare Interior Designers, the American College of Healthcare Architects, and the Vancouver Coastal Health Authority.

Resources for Person-Centered Care

Pioneer Network 

Culture Change Now 

The Eden Alternative™ 

National Alliance of Small Houses 

The Green House® Project 


With Seniors in Mind 

Society for the Advancement of Gerontological Environments (SAGE) 

Jane Rohde will present a session on the FGI's Guidleiness for Design and Construction of Health Care Facilities at the 2013 Environments for Aging Conference, to be held April 6-9 in New Orleans. For registration information, click here.

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