This is an exciting time for residential care design, as new architectural models bring great promise for enhancing the way elders relate to their physical environment, their families, caring staff, and other residents. Architects and designers are reassessing the built environment and creating innovative designs with the aim of improving health outcomes, quality of life, social interactions, and the overall efficiency of care delivery.

This new approach will be even more important as the aging community experiences rapid growth in the coming years. 

Culture change in residential care
The traditional built environment, with double-loaded corridors and high patient-to-caregiver ratios, has meant for many a predictable routine lacking in choice, decision, and dignity. This environment is also a poor place for families to visit, especially families with young children. In response, many providers are now moving toward taking a healing environment approach and designing from the perspectives of residents, family members, and staff.

The Sitrin Health Care Center in Central New York recently implemented an innovative cottage-oriented design, inspired by the culture change movement in long-term care. Other notable examples of innovative design and systems philosophy are the Eden Alternative, the Planetree model, The Green House Model, and the Adards Community in Tasmania.

Culture change may be realized with renovations in the built environment and changes in caregiving practices, as well as the more profound implementations embodied in the homelike cottage-based models. Person-centered care, individualized treatment plans, and enhanced choice and autonomy are essential for culture change.  

Evidence-based design features of the built environment
The Cottage Model at Sitrin attempts to reinvent the way residents experience healthcare and community. Nine residential Cape Cod-style homes have been built. Twelve residents live in each of eight houses, and 14 live in one.

Each resident’s bedroom is private with its own private bath and independent lift system. Residents have as much privacy as possible in order to maintain their dignity as they dress, groom, bathe, use the toilet, and receive bedside nursing care.

Other evidence-based aspects of the design include private bathrooms, which have been found to reduce nosocomial infections and improve constancy of care; ceiling lifts to prevent injury to residents and staff; paging systems that notify the nursing aide and supervisor directly, and that automatically produce reports; and environmental control units that provide control of adjusting the bed, window blinds, TV, lights, and telephone, and offer a nurse call function.

The radiant floor heating systems provide warmth and, since they are individually controlled, enhance individual choice and independence. Research shows that workplace productivity is often increased and absenteeism reduced by having the ability to control one’s environment.

Carefully chosen carpeting provides noise reduction and a potential reduction in falls because of its nonslip surface. Fireplaces in living rooms serve as positive distractions and create focal points to enhance social interaction. The cottages also offer therapeutic benefits by having greater access to sunlight and views of nature.

Cottages have private kitchens, allowing for meal preparation and private family meal experiences. This allows the resident to have enhanced opportunities for visitation and socialization, and families with children can have a much more relaxed time with their loved one. Residents are encouraged to ambulate from their rooms and sit in the dining room for meals.

The dining experience is more pleasurable, with large picture windows and the immediate community of 11 other residents. This contrasts positively with the traditional dining experience in a large cafeteria with as many as 50 to 80 residents.

Residents enjoy increased congregation and socialization opportunities since they have not only their own room to converse in, but also a larger number of places to sit and visit with friends, family, and staff. Occupational and physical therapy may take place in the cottages, rather than in large therapy gyms, facilitating verbal communication between the therapists and the nursing staff who engage the resident on a daily basis.

Therapy may be more functionally directed, because the therapist can work with residents on their daily tasks of eating, dressing, transfers, and ambulating within the home. 

The potential benefits to the residents, and other aspects of the transition, were explored in a research project undertaken by Sitrin as a participating member of The Center for Health Design’s Pebble Project. This “before-and-after” study of residents, families, and staff looked at medical, cognitive, and affective changes for residents across the move, as well as aspects of the move’s effects on staff and families.

For example, findings showed that while this aging population’s ability to perform activities of daily living declined with time, the rate of decline was slower after the move than before the move. A paper describing this study will be published in the Health Environments Research and Design (HERD) Journal

Other benefits to residents
Long-term care facilities should be built to optimize the cognitive and physical functioning of their geriatric residents. After moving to the cottages, Sitrin’s residents are better able to ambulate, feed, and dress themselves; use the toilet; and generally care for their basic needs. Other researchers in similar settings have seen similar results.

This may be in part because the cottages have a great deal more open space than the traditional ward. In a more traditional setting, the nurses’ station a few steps down a crowded corridor is often the only place for residents to congregate.

Interestingly, a small but significant lowering in both the systolic and diastolic blood pressure of long-term residents was found. Staff members believe that residents are calmer and more relaxed. In fact, staff generally reports that residents have enhanced care in the new environment, and that staff members’ relationships with residents have improved.

Also, family members find their loved ones less stressed and more relaxed. Calmer living environments result in less agitation for elders, especially those with medically and cognitively compromised stress tolerance. The decrease in agitated, antisocial behavior reported by staff is certainly consistent with a calmer environment. 

Benefits to staff and family
While other researchers have reported that staff members may initially feel some resistance and disruption, we found no evidence for this as staff adjusted to the new work model without apparent disturbance. In fact, staff members perceive a modest increase in the respect they felt from the institution after the move, consistent with anecdotal testimony provided by management.

Managers at the new cottages report less interpersonal conflict among staff and a reduction in requests to change work locations. Family members have noticed the same thing. Job satisfaction was relatively high before the move and remained high after the move, suggesting a generally positive work environment overall.

Family members feel that the cottages create a homelike feeling, compared with an institutional environment. They feel more welcome, and staff members report that famili
es visit more often. Family members find the cottages to be brighter, cleaner, quieter, and more homelike. They have noticed that staff members seem to be less stressed and operate more as a team. 

The business case for cottages
As the new facility was in the planning stages, the state of New York was over-capacity in long-term care beds, and incentivized long-term care providers to downsize the number of nursing home beds. In fact, the state contributed $4.5 million for Sitrin’s $9 million dollar project. Of course, determining the changes in revenue and expenses in a large facility across a transformation such as this is a difficult task.

However, we did notice that costs for linen and bedding decreased about 16% and utilities (admittedly variable) decreased about 4%. Food costs were seen to increase slightly (less than 8%), and staffing costs increased by around 2%.

In total, operating costs rose modestly by less than a 1%, within the range of normal variability. These models have enjoyed savings as staff turnover decreased sharply.

The cottage model has given residents, family, and staff a profoundly enhanced environment for living, visiting, and working. Elders and families often view the traditional nursing home with dread. By paying attention to evidence-based research and implementing innovative design, Sitrin has provided a model for architects and designers to investigate and consider as they work to improve the quality of life for residents in long-term care. HCD

Jacqueline Warmuth, LNHA, MS, OTR/L, is Director of Clinical Rehabilitation at Sitrin Health Care Center. Joanne M. Joseph, PhD, is Psychologist, Associate Professor at Sunny Institute of Technology, Sitrin Health Care Center. William Thistleton, PhD, is Associate Professor of Technology, Sunny Institute of Technology, Sitrin Health Care Center. For more information on Sitrin Health Care Center, please visit