Renovations rule in DESIGN 2009

What trends did you identify in this year's entries? Any improvements or regressions compared to previous competitions you've judged?

Wilson: It seems like we had more renovations and new designs focused on culture change and creating neighborhoods. In spite of this, there were still some entries that had the traditional long corridors and large nurses' stations associated with nursing homes.

Steinhauer: Having to judge projects of such magnitude has remained the trend in the four years I have participated. I have to remind myself that these entries are not the average assisted living or nursing home building or renovation project in America these days. These are well-funded, well-capitalized, high-end projects that will not be accommodating the bulk of the baby boomer residential room needs in the very near future. These projects are generally out of the financial reach of most folks. I had hoped that there would have been more subsidized housing entries and inner-city projects as we have seen on occasion.

Gregory: I agree with both comments. The projects we reviewed in our group were a mix of senior apartments, assisted living facilities, and skilled nursing homes and in one case, a temporary housing complex for abused elder persons. So it was a challenge for me to be sure I was not trying to demand more out of the program than was appropriate for the type of project I was reviewing. We did see at least one private/public partnership facility but not as many of the affordable income projects as we have seen in the past. I was especially excited about the renovation projects we reviewed because it showed what can be done to an existing facility working within the confines of an antiquated structure to bring about changes that support neighborhoods. If the initiative toward a more homelike environment is to continue, successful renovations of existing structures must continue to be recognized and celebrated.

Brown: Following up on what Skip said about renovating existing structures, our group reviewed several such projects this year, more than we did last year. I, too, expect this trend will continue and the best and most innovative are likely to be submitted to DESIGN for judging. These projects are costly. Personally, I would like to see designers marry their passion for restoring landmark structures with clearer visions of how these buildings can enhance the functionality and quality of life of resident seniors. Converting a landmark building to destination retail or hospitality or apartments is challenging enough. But making that building barrier-free while providing meaningful social spaces that enhance the structure's significance to the residents is another level of design sophistication. It would help us judge historic renovations if the designers would address the link that exists between residents and their project. (An historic “look back” here would be useful.) Unless told otherwise by the design team, we see these projects through the words of their marketing staff which makes us ask, ‘Why weren't the concerns of the users addressed during the predesign phase?’ Regarding senior apartments, I would like to see designers ask why seniors would pick their project over all others in their marketplace. The answer in the past was that eventually-needed services are discretely adjacent. But that will not be reason enough in the future because of the rapid decentralization of healthcare service delivery. I think the projects that will rise to the top in their respective markets are those that offer meaningful lifelong residency, where residents can direct the care they wish to receive for as long as they wish to do so. As for regressions, I noticed less attention paid to the site and the wealth of opportunities sites present to the project design team. But I was pleasantly surprised by complex and farsighted design goals, such as creating caregiving opportunities for residents to continue their commitments to community, the use of adaptable design elements for future building transformations, and the focused use of art-especially sculpture-to define a project's symbolic center. In all cases, these contributed to creating a real sense of place.

Johnson: My organizational work in aging environments helped to uncover polarized approaches to the designs submitted this year. Most of the projects that were submitted as “new construction” suffered from a lack of hindsight. There were few environmental moves made to redefine the way that care has typically been provided to an aging clientele (i.e., centralized dining, double-loaded corridors, many residents per unit.) The jury is aware that, often, the designer is not in the driver's seat. To this end, I am disappointed in the amount of “homework” many organizations appear to be doing regarding assessing current trends in care, aging initiatives, organizational development, and staff retention/development. Alternatively, many of the renovations/additions that were submitted had thoughtful design solutions that had obviously been informed by an organization taking a look inward at its current clientele and outward in anticipation of upcoming consumers. I was pleased to see decentralized services accommodating smaller groups of clients. These clients were also being afforded a more homelike experience and autonomy through the gradation of privacy within the households (i.e., dining/living areas upon entering the household with bedrooms farther back.) Staffing patterns would obviously have to change from a typical care model to that of person-centered care. The resources available for environmental/organizational development in aging care are numerous. I implore more designers and providers to take advantage of these prior to an environmental investment of this magnitude.

Proffitt: Holistic wellness centers and rehabilitative services are being combined in several projects we saw. The trend continues to elevate these spaces into a spa experience versus a medical treatment. There appears to be an increase in the number of nursing entries and several won citations for taking the environment to the next level for the benefit of residents even within a modest budget. Beyond creating beautiful spaces, attention is also being paid to operations that make a difference to the experience of the residents. For example, a county nursing home in Wisconsin used a basement level and elevators to discreetly service the households and effectively banish carts out of sight and sound to the back of the home.

There were a few regressions in some of the submissions. Some emphasized décor over substance. For example, we saw a remodeling project for a rehabilitation unit which kept the side-by-side bed arrangement in a semiprivate room which also had a shared toilet room. The focus of the renovation was updating the finishes. However, such an arrangement not only compromises resident privacy, but also is challenging to operate as four people must share a bathroom. We also saw a newly constructed 180-person nursing home with a centralized dining program. This arrangement not only results in an institutional experience for the residents, but also becomes a labor hog for staff three times a day who must transport residents. The money spent on the enhanced décor could have been more effectively used. We also continue to see tall, cavernous dining spaces in several projects, even those that are based on a small house model or a green house model. Such spaces are acoustically challenging to hold conversations and are not conducive to creating a residential environment. Options for smaller spaces to dine should always be included.

Alden: Building upon what Mark said, it seems to be a continuing discussion of what an owner/provider values-where to put the financial backing? Over the years we have seen a positive trend toward impacting the design of resident spaces, not just the major public areas. However, financial implications are always present when considering renovation or new construction, and often the component with the highest potential for increasing revenue takes precedence. Thus we have inequality in the same campus, a well-designed wellness center which creates a new gateway to the community adjacent to the same old side-by-side room designs. Hopefully, the settings will continue to re-evaluate and renovate the existing environment to increase resident privacy and dignity.

Bowersox: I agree with most of the earlier responses. I also reviewed more renovation projects this year and found that most were quite creative to the solutions of difficult problems. These included converting standard nursing units with double occupancy rooms to neighborhoods with all private rooms and common areas to serve independent people with a greater variety of interest and to provide a variety of spaces for wellness programs. As we get closer and closer to the boomer generation entering its 70s and moving into the senior communities, these types of market repositioning will be required. A number of the submissions did not include enough information on the entire community to have a complete understanding of how the renovated area fit into the social structure of the community. A requirement of next year's entrants should be that a site plan showing all aspects of the community must be submitted along with the more detailed floor plans.

McLaughlin: Some of the most interesting projects showing examples of culture change seemed to be “type” specific (i.e., skilled, assisted, CCRC) Many of the CCRC submittals seemed to focus more on the hospitality aspects and less on the models of care. Like last year's submissions, there were some very creative renovation projects, of both large and small scale.

Is sustainable green design more noticeable in this year's entries than last? If so, in what way?

Steinhauer: I believe my group would have concluded that whatever we saw that was “green” was only the basic and customary applications that don't really reach the green intent.

Gregory: We saw only one design that was to be LEED certified. For the most part, conservation was not a significant factor in the projects we reviewed, however one project was a reuse of an old mill and that was exciting because of the idea of historical continuity and place and for the effort at recycling and reuse of materials.

Brown: We have a long way to go to make senior environments get on board with green design.

Johnson: We had several projects that were utilizing LEED-based guidelines, but only one that was pursuing LEED certification. I would agree with Kaye, that we have a long way to go. Senior environments are responding to so many changing needs that it is going to be up to the designers to incorporate principles of green design.

Proffitt: Our group saw a few projects that mentioned green design in their descriptions, but it was not always obvious in the architecture. It is my belief that green design should not just sustain the earth's resources but also sustain people in a meaningful way. One project in progress showed a usable green roof that created a destination for physical activities and sporting events which effectively accomplished both goals.

Alden: Although many green design ideas require minimal additional upfront costs, for example providing ample yet controllable day-lighting, often the “high-tech ideas” and green-based materials require a notable increase in upfront cost. The long-term advantages of wisely using resources and providing a higher quality environment, not to mention energy savings, usually outweighs the initial upfront capital costs. However, since we are talking about cold hard cash, increased upfront costs are always difficult to rationalize. Over the past few years we have seen the beginning of an “enlightened” trend, one in which owners place value on green components and accept the increased upfront costs, with the realization of long-term benefits. This is evident in the number of projects mentioning green design ideas. They may not be officially certified, but the ideas are present. The push for a green design mentality is similar to the efforts to recognize the importance of “design for aging” a few decades ago. Hopefully, we will not have to wait 20 years for green design to become a standard component in senior-specific environments.

McLaughlin: Other than one project that incorporated a reheat system into the design, the submissions employed means and methods that are becoming the norm for the industry.

Were there any “common threads” identifiable in the submissions, such as more attention to room sizes, having more upscale common areas, using certain building materials, or more access to nature/natural light, as a few examples?

Wilson: In the nursing facility entries we had a lot more private rooms including showers versus semi-private with no showers in the rooms. It seems like people understand that the market wants privacy and personal space.

Gregory: I thought there was more attention being given to lighting in many of the projects, but we still saw some really awful examples of glare on hard floor surfaces, so this is an area that still requires more work.

Brown: Regarding skilled care, private rooms are larger. Many look in plan almost like AL units. Nursing stations continue to disappear. I saw the household size continuum expanding, where some communities are downsizing to five resident rooms/households while others are pushing that number to 25 units which for me, typifies the size of neighborhoods. Size matters and there is a premium to be paid for “small.” But there is a wide range out there that suggests that small household size is a viable model and therefore the bar has been raised. Notable “threads” I saw were more use of “low grade” spaces (i.e., underground, low-light) for new expansions and retrofits, and increased attention to creating amenities inside projects that attract the outside community. Several projects focused more on programmatic spaces than the building's exterior, which in the tough financial times of today is, I think, an approach that will resonate well with prospective residents.

Johnson: I was pleased to see quite a few nursing functions incorporated into living/dining areas within resident households. There were, however, several submissions that still had the “Grand Central Command Station!” These, again, were glaring examples of an organization not exercising due diligence prior to the design phase. Alternatively, there was a dramatic change in ceiling treatments this year by most submissions. There were more with residential-style lighting and fewer had 2 x 4 ceiling tiles with fluorescent lighting. There was also more attention in plan and narrative toward supplying and preserving views from resident rooms and common spaces.

More of the skilled nursing projects submitted seemed to be addressing culture change and were distributing nursing functions throughout the neighborhood. Independent living common areas were definitely taking on more of the image of hospitality environments.

McLaughlin: I think more often the skilled resident/toilet room layouts are showing greater sensitivity to the needs of the residents and the staff assisting them. What was really encouraging was the number of projects that were pushing the envelope regarding the preparation of food in the households. This is a tough code issue in many states. The providers, architects, and state officials deserve a lot of credit for their efforts in making this happen.

What features did you see that were particularly encouraging of resident independence? Of staff support and efficiency?

Wilson: Several assisted living, nursing, and memory care entries showed a great amount of detail focused on resident use in the neighborhood kitchen areas which included a low counter for residents with wheelchairs to help with meal prep.

Steinhauer: It is hard for me to visualize, much less judge, features I saw that are particularly encouraging of resident independence when there are no residents appearing in the photos, nor any evidence of resident participation in the planning process. Just because nice-looking chairs are neatly facing each other in a podlike square doesn't mean they are accessible, easy to rise from, easy to move when a resident in a wheelchair joins in.

Gregory: I agree with Michael. Our group had similar questions, ‘Where are all the people?’ I understand that getting permission to use people in photos is a step, but it is not a difficult step. I hope that for future entries we can be sure to make a point to ask for photos of the projects with people actually using the spaces that are being created.

Brown: With more and more projects increasing the involvement of staff during the pre-design programming phase, the projects' users are likely to get the workspaces they want which should, in turn, lower staff turnover rates and create higher staff efficiencies. I have every hope that staff involvement-especially frontline staff-with the design team during pre-design will quickly become the industry norm. Regarding supporting resident independence, wherever we saw the use of universal design principles, we knew the design team wanted residents to be in charge of their lives. Fortunately, I saw more universal design this year than last.

Johnson: I agree with all of the earlier comments. The submissions that stood out had obviously incorporated staff, residents, and family into the design process. The thought of taking on a multidisciplinary planning phase like this seems like a daunting task for most organizations. But, again, there are resources out there to help inform and guide the process to successful completion.

Bowersox: There seems to be more attention to staff areas and staff overall comfort to add to work satisfaction to improve staff retention.

McLaughlin: The use of swing-up grab bars is becoming more commonplace.

What evidence did you see of staff, family, and resident involvement in design?

Wilson: Staff, family, and resident input into the design process is still lacking in many of the projects. It may seem like a lot of work, but if done properly, can really enhance the livability of the environment. SAGE, P.L.A.C.E. is a program developed by SAGE through a grant with the Rothschild Foundation in Chicago to take this inclusive design approach to a new level. We hope to have this service available later this year.

Steinhauer: I agree with Charlie about staff, resident, and family input being deeply lacking. We have not yet converted our readership fully into the SAGE-end of the marriage. I liked the idea of stakeholders other than the marketing person, assisting in writing parts of the questions and answers. Wouldn't we naturally expect this to occur if there was a fully integrated culture change in the building? We have always endorsed the notion of encouraging architecture design firms to place a culture change agent at the design team table early in the process. Is that message getting through strong enough?

Brown: I am a bit more optimistic. One project I saw, a hospital, spent two years preparing their staff for the culture-changed environment they would work in when the project was built. Fortunately, the proposed building completely supported the new operating philosophy the staff was being taught. I suggest this is a great leap forward for one acute care corporation to make. We also saw more green houses designed this year than last, where culture change is the bedrock from which all design decisions are made.

Johnson: The project that was considered “Best of Show” by the jury had obviously spent a lot of time with staff, residents, family, consultants, and designers. I absolutely applaud their efforts! This, however, was one of few exceptions. Most projects didn't include any residents or staff in the images submitted and obviously omitted them from the design process. This is a real shame because it is a missed opportunity and could result in some expensive and potentially avoidable mistakes.

Proffitt: Several of the new construction projects looked formula-driven and not person-driven. Renovation projects were clearly the winners for involving more stakeholders in the design process compared to the new construction as might be expected. Existing projects have a clear advantage by being able to easily assemble a team of residents, family members, and staff members who can provide insight. This is not always easy to accomplish for new construction, but it certainly is an obtainable goal.

Bowersox: There seems to be either a modest amount of outsider involvement or, as mentioned earlier, a great amount as in the “Best of Show” project. Outsider involvement in the design process takes a longer planning period. The design professionals must include fees to cover the additional hours. The loss of staff time must also be addressed. Therefore, the administration of the organization must be committed to outsider involvement for it to occur. Administrators may also be concerned about control. Outsider involvement may lead the project in directions that the administrators are not comfortable letting the process determine the outcome. The level of outsider involvement in the design process is really determined by the organization and not the design professional.

McLaughlin: As a whole, there wasn't as much resident or staff involvement as we would like to see. But there were several good examples of outside involvement in the planning process. In particular, one project that incorporated the PACE project with a religious order, required a good deal of thought in creating an environment that utilized a new healthcare model, while recognizing the autonomy of the order.

Were there any surprises or especially unique uses of space or features in this year's entries?

Wilson: We had a small house model that had an apartment over the garage. This space was used for a spouse or family member to live. I wonder how successful this is and if this particular community would do this with future small house nursing models.

Gregory: Our group reviewed an old mill that was converted to become a part of a senior housing facility. The mill section contained most of the social functions with some “loft” apartments on the second floor and a “walk through history” corridor as part of the first floor experience. Even the old brick smokestack was saved and integrated into the design. It appeared to us that this space might be used to bring people in from the community and might act as an interface between the community and the seniors living in the facility.

Brown: I noticed new synergies. The PACE program was brought in so residents could continue serving the elder-care needs of community-dwelling seniors. There was adult day care linked to extensive primary care space and a wellness center that incorporated numerous cultural themes to attract local residents, including dynamic signage visible to passing motorists. Several established CCRCs focused on creating dynamic hubs that revitalized their communities rather than projects that simply added units to the community. In these projects we saw well-linked adjacencies and synergies, many with window walls for previewing and visual integration. The “deluxe” element this year seemed to come from curved walls and carefully planned adjacencies based on good circulation patterns, all of which contributed to linked spaces gradually being revealed. I hope we see designers using site opportunities in this same imaginative way in the future. Regarding symbolic centers, the designs I saw used endemic symbols which had meaning for the communities rather than imported symbols used elsewhere. These designers, who undoubtedly spent extra time understanding their clients, deserve our thanks.

Johnson: Community integration was what stood out this year. We saw one project that had a kids' day care program in the building. Another catered toward a college crowd in the central atrium area. The restored mill project was a great example of using a historic community icon to facilitate integration. There were other projects that had worship spaces and community auditoriums. I think that this is a great area to extend design effort and facility dollars.

Proffitt: I agree with Addie on the growth of community engagement being seen in more projects. Beyond engaging the community in the design process, it is also equally important to consider how senior living environments are part of community life. One CCRC created an arts and cultural center which partnered with 20 different community-based organizations to provide programming. We also saw a small house nursing home being designed with an independent living apartment located on the second floor which could be a perfect fit for a couple with different care needs, families, or even staff. This idea could easily be adopted by others to foster interdependence where people mutually support one another.

Bowersox: I agree with Kaye and her analysis of the project that involved the PACE program. I was in her group and reviewed the same projects. I am also a strong believer that the most successful senior housing and long-term care projects must be more involved in the community, community services, and to bring the community into the senior-related program. Maintaining and participating in community involvement is one of the highest priorities that the boomer generation will be bringing with them as they impact the industry.

McLaughlin: I agree with Addie's comment about community integration. The PACE project encouraged intergenerational interaction with the neighboring university students. The adult day care/wellness clinic worked on two fronts. They actively developed relationships with senior living facilities in the community, while creating an environment that encouraged walk-in traffic. D

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Every year, as part of our DESIGN coverage, our jurors, all members of SAGE, participate in a roundtable discussion. This year they met with DESIGN Executive Editor Maureen Hrehocik, to comment on the submissions and discuss trends, innovations, and problem areas noticed in the entries.

Our panel did an extremely conscientious job judging the entries over two full, blustery January days in Chicago. All of this year's Citation of Merit award winners should be very proud their work passed the jurors' exacting standards.

Jurors participating in the roundtable include: Andrew Lee Alden, associate AIA, SAGE, GSA, ASA, senior associate, Engberg Anderson, Inc.; Jack L. Bowersox, manager, Life Wellness Communities Development Company, LLC; Kaye Brown, PhD, adjunct associate professor, Department of Evolutionary Anthropology, Duke University; Skip Gregory, NCARB, bureau chief, Office of Plans and Construction, Agency for Health Care Administration; Addie M. Johnson, organizational change agent, Jewish Home & Care Center, Milwaukee, Wisconsin, and PhD, Student College of Architecture, University of Wisconsin; Russell R. McLaughlin, AIA, SAGE, architectural designer, AG Architecture, Inc.; Mark A. Proffitt, fellow, doctoral student, Institute on Aging and Environment, School of Architecture and Urban Planning, University of Wisconsin-Milwaukee; Larry A. Schneider, project executive-associate, SAGE Wisconsin chairman, Plunkett Raysich Architects, LLP; Michael J. Steinhauer, OTR, MPH, FAOTA, principal, The Steinhauer Group, LLC; Keith Stohlgren, vice president and executive director, Lake Forest Place; Charlie Wilson, vice president of operations, Buckner Retirement Services. Joe Wronski, principal, architectural designer, JWDesign Studio, LLC was also a jury member.

Design Environments for Aging 2009 2009 March;():7-13

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