Parts 1 - 3
by: Jeffrey Anderzhon, FAIA
Evolutionary Steps in the Creation Part 1
of Household Models of Care
I recently sat through an internet video promoting a new assisted living residence in the Midwest. In this video, the
developer boasted of having individually created the household model of elder care. This is not the first such statement I
have heard, nor from the first individual to have made that claim. Such self-promotion is fundamentally provided by the
claimants in order to sell something: care services, design services or consulting services, by touting themselves as being
the most knowledgeable or most experienced within this area of elder care.
But if so many diverse individuals stake a claim on creation of this model of care, who can really be correct? Probably
the nearest statement to being accurate is that they all are, at least to one degree or another. As with any knowledge-
changing idea, there is a construction of knowledge base, trial and error, experience and history, which ultimately leads
to the successful introduction, development and implementation of that idea. Then, over time, that idea continues to
evolve into differing iterations, both good and bad. Whatever one may think of Christopher Columbus, he didn’t create
the idea of a round world, but simply collected information and knowledge previously generated, passionately embraced
it and then positively acted on it. Then additional explorers added to this body of obtained knowledge.
Much the same can be said for the small house or household model of elder care, whether nursing or assisted living.
In the United States, prior to the prevalence of organized or licensed long-term care, individuals were provided the
long-term care and living services they required within the confines of a home, one that was generally of a close family
relative. As families became more geographically diverse with multi-income households, this evolved into privately
owned residential care models which, for the most part, were housed in a large home in the community converted into a
congregate aged care setting. The number of residents was restricted to the size and number of original bedrooms in the
AN ASSEMBLY LINE APPROACH
In the middle of the twentieth century, highly organized and institutional elderly health care came into being through a
number of government financial initiatives that favored staff efficiency and a sort of “assembly line” approach to long-
term resident care. Double-loaded corridors, shared-occupancy rooms, central bathing and centralized dining and social
spaces, all of which were based on the prevalent acute care model, ruled for some forty years, and, in some places, is
clamoring to remain in place even today.
EVOLUTION OF THE HOUSEHOLD APPROACH
In the late twentieth century, assisted living began making its presence known in the United States. Highly influenced
by the collaboration of care and built environment from Scandinavia, this model provided a more residential, non-
institutional and home-like environment coupled with a much less overt staffing presence for those individuals whose
health did not require the full rigors of nursing care. Residents and their families quickly discovered this more resident-
oriented model and flocked to it, often migrating out of institutional nursing environments.
EVOLUTION OF THE CARE MODEL
In order to maintain some semblance of financial stability, nursing homes began to see the need to reinvent themselves
into that resident-oriented, home-like model of care in conjunction with the built environment and staffing model. So,
all of this history, combined with a number of forward thinkers and passionate professionals’ input, led to the household
model of elder care. It was not a single individual awaking in the middle of the night having had an epiphany, but a
number and variety of folks who were truly concerned about the quality of care for the elders and brave enough to push
for change. This group of forward thinkers includes that developer whose internet video I watched. The real point is this:
we should spend less time claiming bragging rights and more time working hard to provide the most compassionate
care and most comfortable environment for our elderly population.
SIZE MATTERS, PARTICULARLY Part 2
IN LONG-TERM CARE HOUSEHOLDS
Every designer who has worked in the long-term care or assisted living arena has an opinion on the correct number
of residents a senior care household should have. The original Greenhouse® in Tupelo, Mississippi was pegged at
10 residents. The flurry of design activity following that introduction provided households ranging from 10 to 20
and generally proved to be experiments in balancing number of residents, staffing requirements, siting constraints
and returns on investments. Unfortunately, designs of households are too often driven by the construction budget
and convenience of resident room layout determined by the designer. This is not to say that these parameters are
not important because they are. However, in the life cycle of the building being designed, the initial capital costs are
overshadowed by operational costs. Thus, balancing the number of residents in a household with the staff (on each shift)
must be a prime consideration addressed early in the design process. In addition, the connectivity between adjacent
households can have a profound effect on shared staffing, particularly on the evening or night shifts.
For example, if the sponsor is attempting to achieve about 5 hours of direct care per resident per day, this can be
accomplished with two CNAs plus one nurse on both the first and second shifts of the day and one CNA and a shared
(½) nurse on the night shift if the household is 12 residents. With the same staffing it translates to 4.2 hours if the
household is 14 residents and 3.75 hours if the household is 16 residents. One can quickly see that it is more difficult,
and more expensive, to try to staff at this care level as an increase in residents within a household occurs.
In addition to the effect that staffing may have on the design of a household, the creation of a household size that
accommodates a sense of “family” should enter the design mix. While there are certainly large nuclear families, most of
us have been a part of families that are populated with less than 20 individuals and, for that matter, less than 10 to 12.
When entering a congregate living situation, most of us can more easily assimilate into that group when it is a smaller
one. In addition, it becomes somewhat more intuitive and comfortable in that process of assimilation when the physical
environment is smaller and approaches replication of a single-family home or apartment size.
In the end, a well-designed household does not result from a set formula nor is it the result of a proscriptive process.
A good household design utilizes the client’s marketing requirements, their occupancy requirements and their ability
to appropriately staff the households. Embracing a resident-oriented model of care means designing household size,
staffing and physical environment that provides a sense of space, place and belonging, giving residents an enhanced
sense of dignity and independence. It is not a magic number, but good, solid understanding, as well as arduous work by
the designer that results in an appropriate size of household for each individual application.
DESIGNING HOUSEHOLDS Part 3
FOR THE RESIDENTS
The design of households has evolved into several differing approaches regarding layout of resident rooms and
their relationship with social/community spaces, support spaces and services. These layouts are only limited by the
imaginations of designers with their clients’ input. Each layout or variation is meritorious by simply being another step
in that evolution of design. However, we can perhaps over-simplify the layouts of households by categorizing them
into three basic approaches: the short corridor household, the hearth household and the hybrid household. Each of
these layouts has advantages and each has challenges, but when coordinated with the acuity level of residents, staffing
availability, site constraints and operational considerations, they can each provide successful results which enhance the
quality of life for the residents.
SHORT CORRIDOR HOUSEHOLD
As its name suggests, the short corridor household layout consists of a short distinct corridor that leads from more
public spaces, such as the living and dining rooms, to the more private spaces of the resident bedrooms. This approach
complies with the intuitive division of domains as expressed by Christopher Alexander in his book “A Pattern Language,”
and delineates the separation of public and private household domains. The advantages of this approach can be
that the residents have an innate ability to quickly adapt to the household’s layout as it mimics that of most single-
family homes or apartments. Additionally, this layout will generally allow the introduction of natural light into a greater
area, and deeper, into the household rooms, particularly the social rooms such as the living and dining areas. The
disadvantages can include a more linear building layout with a diminished visual access to resident rooms by staff who
may be working in or near those social rooms.
Hearth households generally have resident rooms situated around a central hearth room or collection of centralized
social spaces. The resident rooms have direct access to the central hearth room and as such, residents have the
opportunity to visually access the activities that take place in these social areas. Typically, there is no distinct corridor
or circulation delineation so staff visual access to resident rooms is enhanced. However, one could argue that resident
privacy is diminished and the intuitiveness of the short corridor household is lost, at least minimally. Additionally, it can
be somewhat difficult providing natural light into the heart of the hearth room as it can become more “buried” in the
layout. This layout is advantageous for residents with cognitive difficulties as they have ready access to visual cues of
activity or meal preparation from their resident rooms.
The hybrid household is a combination of the hearth and short corridor households. The distinction is primarily that the
hybrid household distributes the social spaces along the length of the household providing some privacy of resident
rooms along a corridor but also opening that corridor to social spaces such as a den or family room. This layout
arrangement can be beneficial for drawing residents through the household with a variety of spaces and variety of
activities as well as enabling significant natural light to penetrate most spaces in the household. Within the context of a
household typology, this approach would be somewhat of a compromise while still providing some distinction between
public and private domains. Staffing oversight of a variety of scattered social rooms could be problematic but needs to
be balanced by the enhanced sense of independence residents might feel in such a layout.
Each design approach should be carefully analyzed in order to arrive at the design solution which best fits the clients’
needs and, more importantly, the residents’ needs. It can be a complicated process that undoubtedly will be full of
compromise to achieve the appropriate relationships of operation, budget and resident care. However, if completed
collaboratively with an open mind on the part of all involved parties and with an understanding of all options and their
ramifications, the process can be rewarding and the result can be successful.
JEFF ANDERZHON, FAIA eua.com
Senior Planner : Design Architect
[email protected] | 414.291.8148
milwaukee : madison : des moines : denver