Collaboration and community involvement are common themes in this year's DESIGN roundtable discussion. Jurors become particularly animated when discussing the growing trend of mixed-use communities that are indigenous to their locations and integrate intergenerational activity-as seen in, for example, one urban project that is located adjacent to a vibrant university with an appealing mix of cultural, educational, social, and retail options. Sure, the suburban CCRC model still rules most development models, but industry observers anticipate a migration of adventurous Baby Boomers to inner-ring and inner-city communities and the design challenges and opportunities that trend will present.

As part of DESIGN's editorial coverage, each year our distinguished panel of jurors wrap up its judging duties with a lively roundtable discussion addressing this year's submissions and general trends and issues in senior living design. These seasoned pros, representing architects, interior designers, academics, and providers, are passionate advocates for their clients, their industry, and the residents who ultimately, and hopefully, benefit from forward-thinking, person-centered design.

DESIGN 2011 Jury

Andrew Alden, associate AIA, ASA, GSA, SAGE, senior associate, Engberg Anderson, Inc.;

Mary Bowers, chief operating officer, Senior Living Communities;

Kaye Brown, PhD, adjunct associate professor, Evolutionary Anthropology, Duke University and adjunct associate professor, Anthropology, Boston University;

Amy Carpenter, AIA LEED, principal, WRT/Wallace Roberts & Todd, LLC;

Meldrena Chapin, PhD, IDEC, EDRA, professor of interior design, graduate interior design program coordinator, Savannah College of Art and Design-Atlanta;

David Dillard, AIA, principal, D2 Architecture;

Carol Reitter Elia, ASID, LEED-AP, CR DESIGN;

Mitchell S. Elliott, AIA, chief development officer, Vetter Health Services, Inc.;

Larry Funk, associate administrator, Laguna Honda Hospital and Rehabilitation Center;

Skip Gregory, NCARB, Health Facility Consulting, LLC;

Walter R. Havener, RLA, LEED AP, Lappas + Havener;

Alan Moore, AIA, chairman, CJMW Architecture;

Karen Nichols, executive director, Cascades Verdae;

Jude Rabig, RN, PhD, vice president, Masonic Health Institute;

Barbara Summerford, president, GMK Interiors;

Charlie Wilson, senior vice president, Buckner Retirement Services, Inc.

While this year's submissions included some creative, forward-thinking designs, the number of quality projects was thought to have declined from last year. Jurors suggest the effects of the Great Recession are coming to bear on senior living development. “Last year, we were still seeing projects that were started and completed before the recession,” says Alan Moore. “Now we're seeing the full effects of the recession and its aftermath; that was reflected in more HUD, skilled nursing, and independent living projects. One of the projects we reviewed…was a conversion of an existing medical building to an assisted living freestanding household. These all seem to be part of an effort to do projects with less money. Even at the higher end of the spectrum, we saw CCRCs that were searching for a way to do things at less cost, or for less financial risk.” Kaye Brown suggests the exception to that trend is readily available capital pools for government-funded, institutional facilities.

As new construction is a limited option in tough economic times, some communities are taking a creative approach to renovating existing structures, a challenge “when we have thousands across the United States and we're trying to change the model of care in the existing building,” says Andrew Alden. “If you don't have the capital for new construction, designers have to be creative and do the best they can to meet the needs of the owner within an existing envelope.”

Along with the more integrated approach to developing senior communities comes the challenge of the “not in my backyard” mentality. Says David Dillard: “I think it's human nature to protect your neighborhood; you want it to be quiet and the more activity, the more physical construction, and the more traffic-ambulances and all-you get ‘let's get together and organize.’”

Reimbursement is driving development, too, with jurors observing an aggressive expansion in rehab and skilled nursing facilities (SNFs). “In the last two years, it's gone from 10% of our business to almost 40%,” says Mary Bowers.

PERCEPTION VERSUS REALITY

And yet, the design innovations definitely seem to be focused on the independent living side of senior living, observes Meldrena Chapin. “I was surprised at these massively expensive high-end [projects] that looked like five-star resorts but then their healthcare facilities were back in the Stone Age.” And why would that be the case? “You're trying to lure a spry 76-year-old to live in a ‘resort,’ suggests Charlie Wilson. “There's an institutional de-emphasis set up by a financial model that doesn't pay as much attention to that.”

Adds Wilson: “There are still some very high-end CCRCs that have traditional nursing homes; you'd think that these luxurious communities would have a…much better healthcare component.”

“I agree that the old model is that independent living provided funding to run your skilled nursing,” adds Chapin. “And the skilled nursing was also in the resident's mind as the last place they wanted to go. The idea of household and Green House is starting to change that thinking.”

Chapin was “pleased to see that in all of the submissions, it's very obvious that the status quo has changed to the household model. It's very common to see that now, whereas five years ago the household model may have been a new thing.”

REGULATIONS/RESTRICTIONS

The household model presents obstacles, says Moore. “The household model is a nightmare in terms of regulations because in every county in every state we encounter a different set of rules, and those rules are often enforced by people who have a limited understanding of them because they're just not regulating this project; they're in charge of the all the food-handling facilities and day care centers in the area. And between the health department regulations and the fire safety regulations, it's a mess. You can design everything by the book but until you sit down with the authority having jurisdiction, you really don't know where you stand, and even then you don't know,” explains Moore.

The earlier in the process designers meet with the regulatory authorities, the better. But that means knowing what the program is going to be, says Moore. “Are you going to be frying food in the unit? That's a huge issue. You can microwave all day without worries but once you start frying you need fire suppression systems, typically.”

Adds Mitchell Elliott: “Something to keep in mind is that CMS [Centers for Medicare & Medicaid Services] is enforcing a 2000 Life Safety Code which was probably developed in the mid-'90s, long before households ever came into play; but the last thing to do is blame regulations for lack of creativity.”

CULTURE CHANGE CHALLENGES

The roundtable participants engaged in a lively exchange on the culture change movement and its ramifications for senior living design. A lack of understanding of the concept (still) was observed among senior community staff and residents and even developers, some of whom may assume its implementation means increased costs, operationally and design-wise. “There's this big gap between what is culture change, what phase of it we're in, who understands it,” Chapin says. “I think that's changing; it's growing and you can't put the challenges of culture change into just one arena because it's so complex.”

Moore chimes in: “We're involved in several communities where we're renovating older SNFs to accommodate culture change and we're finding that the existing independent living residents of the CCRCs are very skeptical of what we're doing. And if you ask what improvements we need to make in this nursing home, what we think of as culture change is not what you hear. What you hear is: ‘I want a private shower in my room.’ ‘I want bigger closets.’ You don't hear ‘I want to be part of a household with a social center.’ I've seen facilities where culture change has been implemented with what appeared to be significant benefits for residents within those households. But that message is not getting through to the independent living population.”

Elliott encourages architects and designers to engage residents in dialogue about desired features in their living environment and to include representatives with a social services background or a wellness background. “I think we'll hear ‘I want to control my privacy,’ ‘I want the ability to get up when I want to get up and go to bed when I want to go to bed,’ and ‘I want a shower daily.’ It should be the resident driving change.”

But an institutional mind-set is still ingrained in many elders, regardless of whether changes have occurred at the community level, suggests Karen Nichols, a provider. “They [residents] expect to be woken up and I just had an incident here where a daughter called us, livid because we hadn't told her what time we were going to wake up her mother. When I said to her ‘Your mother's going to get up when she wakes up,’ she said ‘What? I don't understand that.’”

DETAILS MATTER

While the roundtable participants focused primarily on “big picture” issues this year, they also gave voice to the design details that can make a big difference in the comfort and quality of a resident's life-things like the seamless transition between exteriors and interiors, an increased use of natural light, a commitment to sustainability, attention to back-of-the-house spaces for staff, integration of new technology developments, and clever and thoughtful elements like one project's garage with a heated floor. Seemingly small details can score big points with these discriminating professionals-like the cozy corner window seats in a hospice resident's room that offer a serene view of the wooded exterior, while affording valuable extra storage space.

Skip Gregory criticizes projects that he feels don't offer enough versatility in the residents' rooms. “I didn't see alternate bed [arrangements], for instance, in any of the designs that we looked at and there were some rooms that, while they may have been pretty nice…prevented alternate arrangement of furniture. That's something we should to focus on more: giving choice.”

Carol Elia sees growing incorporation of fitness/wellness centers into communities. “I am getting more calls about finding space on my clients' sites for this type of thing. And the fitness centers I am approached with do not just include weight training or cardio equipment; they include juice bars and healthy eateries, spas, pools, and often involve the proactive wellness of residents. We will see wellness centers in assisted living becoming more than a vacant room with a recumbent bike.”

The jurors do take enjoy skewering some of the clichés of today's senior living design, including massive porte cocheres, country kitchens, and a preponderance of what they called Prairie-style architecture. After all, not every senior cares for rustic décor. There are many developers, and designers, too, who cling to outdated assumptions of demographic preferences. What about seniors who have a more sophisticated, modernist sensibility? Who's catering to that niche? It's something designers and developers should consider as they plan future projects. D

Design Environments for Aging 2011 2011 March;():8-14