One-on-one with…Addie Abushousheh, PhD

Addie Abushousheh, PhD, executive director of the Association of Households International (AHHI), is an independent consultant and researcher who specializes in senior living environments. Many in the long-term care (LTC) industry know her from her work with Society for the Advancement of Gerontological Environments (SAGE). She recently stepped down as the organization’s treasurer to focus on completing SAGE PLACE (Programming for Living and Achieving Culture Change Environments), a program that helps LTC organizations work through any challenges in their operations, policies, procedures and staffing patterns before they lock themselves into a building design.

Never one to sit still for long, Abushousheh has studied architecture, organizational development, gerontology, research, mediation negotiation and non-profit management. She also has just started her nursing home administrator’s license internship. She says one of the main reasons her life has followed this particular path is the close relationship she had with her best friend—her grandmother. Abushousheh recently shared her thoughts on the current trends in senior living design with Long-Term Living.


One of the reasons that I have taken this particular slant is how close I was with my grandmother. She was my best friend, and I got to live in a nursing home with her for a month. I still stay in nursing homes as much as possible, because there is no better way to learn than fully and completely immersing yourself in the experience. In fact, a lot of people advocate for that now.

I try to base my decisions or establish my evidence base on consumer or stakeholder priorities. I look to the people who are perceived of as doing the best of the best to inform what I’ve put out there for others to digest.


Right now, because of the regulatory climate surrounding skilled nursing and assisted living, what I’m seeing is that the folks who would have years ago lived in skilled nursing are now living in assisted living. This is not necessarily new to the industry, and it has been widely acknowledged. The thing is that we have a lot of leeway and leverage to able to respond to consumer-driven priorities, and I think we’re limiting ourselves right now. I think before we’re locked into a regulatory stronghold in assisted living, we really need to do some digging and take the deep dive into what the priorities will be for people who are going to living in these environments 20 or 30 years from now.

Philosophically, I think we need to stop thinking of people living in these environments as “them,” because honestly it’s our future selves. We are them. And I would advocate starting to have conversations that involve more people. Go into the community that’s surrounding the organization, go into the community within the organization, and involve the least likely characters, such as facilities folks, people who are providing transportation to the assisted living organization, not-for-profits in the area and educational institutions. All of these folks represent potentially really good ties to be made. I don’t think we’re fully capitalizing on that.

We are still seeing new communities of care being built out in the middle of nowhere. And in terms of the upcoming priorities of the Baby Boom population, they don’t really want to be planted out in a cornfield. There’s a real desire to stay involved, engaged and have naturally occurring amenities that downtowns and city centers provide.

Cities have naturally occurring opportunities for intergenerational connections. I don’t see any reason why we should be segregating people of a particular age or ability. We should be accommodating them in their abilities and providing as much opportunity for facilitation and self-sufficiency as possible, and I don’t think that that means you have to take them away from everyone else. I, personally, don’t want that.


One of the things I was most impressed by recently was a continuing care retirement campus [that] decided to build a full-on community wellness center. It was like the combination of Gold’s Gym with a holistic wellness center. It was someplace that definitely would have been a draw from a social interaction perspective. And that I thought was pretty cool, because that seems like a way for communities to use what they have available to them in terms of their land and their programming as a way to draw people from the surrounding community in, and to draw people from within their own community out.

A lot of things are taking place outside the arena of traditional continuing care that have been gaining more traction. People are creating alternatives if they’re not satisfied with the current selection. So we’re seeing co-housing and co-op and intergenerational communities and some low-income housing that has age-specific or age-friendly features coming into communities.

And then certainly I think that the now-national family care dollars are going to make a difference in terms of the number of people who are really seeking out CCRCs.


I think we don’t want any elements of a facility screaming “acute care” or “aging specific.” Keep everything simple, sophisticated and socially driven, then layer the support services on top of that. When we say long-term care or continuing care retirement community, care is implied, and we should be able to take that for granted. It shouldn’t be the full focus of the community. We need to focus our design, our operation, our policy and our procedures on enabling people to live as they see fit and providing the care that they need to do that.

I was talking to a woman who just moved into the independent living portion of a CCRC. And this place is over-the-top nice. If I could live there now, I would. This woman’s granddaughter came to visit her, and she’s been told, “Grandma moved into a long-term care community.” Certainly we all come with a lot of preconceptions about environments we think we understand based on historic evolution. Instead, this little girl walks into the building and says, “Wow, gram, they don’t insult you here!” And the thing that was informing her was looking around at the amenities and the design of the space. I wish I could have been there to watch the look on that little girl’s face. Because I love it when I talk to people and they have a preconception of what long-term care is.


I can’t even begin to imagine what the expectations and options are going to be. I mean, when I buy a cell phone now, it’s outdated when I walk out of the store. We’re in such a rapid evolution period from a technological standpoint, and that’s a bandwagon that long-term care definitely needs to hop on. We don’t take advantage of a fraction of the information systems that are available to us.


It sounds silly to say this, but it’s kind of a commonsense move back to residential environments. Ever since long-term care was established, we have gained credibility and a financial foothold as an extension of acute care. That shaped our physical environments and our operational approaches.

But I don’t think what we realized was that, especially for people who have a cognitive impairment, it’s the equivalent of sending any of us to live in a WalMart. We are sending people who have a reduced ability to process information into spaces that look like a warehouse or a hospital. And then we are surprised when they have what we refer to as maladaptive behaviors. And then we medicate them and overmedicate them.

What I’m talking about with a “return to a residential-type environment” is that we are moving more and more toward setting things up in a way that mimics a home environment, with residential routines built around relationships. This is something I see industry-wide, whether it’s assisted living or memory care or skilled nursing or hospice. We’re incorporating things that are familiar to residents and that they can participate in meaningfully. And we’re making room for family affairs. Not only family that would come in to see them, but the family that they develop when they are living in these communities. It’s such a commonsense kind of move, but, then again, how common is sense?

In addition, one of the things that has become absolutely clear, as I have been among and between communities and talked with residents and staff, is that pretty much all you see now is private bedrooms and private bathrooms. That’s in all the renovations and most of the new buildings you see being built. If a community isn’t doing that, they’ve already missed the mark and they’ve already outdated themselves.

Finally, we’re seeing a lot of decentralization of the kitchen, so you are seeing functional kitchens in these smaller residential environments with fewer people. If residents can assist in preparing meals and setting a table and so on, they’re really involved. We talked about not wanting to go out and be planted in a cornfield; literally, there are communities where residents during corn-harvesting season will be shucking corn to help feed the entire community for the evening’s dinner. I know that if I can get in the middle of growing and cleaning and cooking vegetables, I’m going to be happy woman, so what I’m trying to do is steer the industry toward my preferred future.

Ron Rajecki is a Cleveland-based freelance writer.

Topics: Articles , Design , Executive Leadership , Housing