As the past few months have shown us, a high percentage of SARS-CoV-2 (or CoVid-19) infections have been within senior care facilities (nursing homes, skilled nursing care, assisted living, and memory care). This high rate is understandable, as a conventional nursing home is a large facility with a dense long-term population. The residents tend to have some dependency on intimate contact with staff in their daily routines, and most have somewhat compromised immune systems as well as comorbidity factors that make the virus more deadly.
Is there a better way to organize our senior living facilities? In light of this pandemic, many are now seeing the benefits of the “Small House” approach, which Childress & Cunningham used to design a new 70-bed facility on Christian Care Communities’ campus in Bowling Green, Kentucky.
What Is The Small House Concept?
The essential goal of this approach is to change the feel of the building for residents, so that it is perceived more as a home and less like an institution. The protocols enacted by many states to restrict access by visitors and limit the movements of nursing home residents have made those residents feel even more like they are trapped in an oppressive institution. A Small House facility counters this sense in several ways:
- by being organized into “neighborhoods” of about a dozen residents each
- short hallways lead promptly to shared living spaces
- single-occupant bedrooms provide personal private space
- complete residential amenities such as a functional kitchen allow residents to pursue their own aims
- all necessary support spaces, like laundry, are replicated in each neighborhood
The term “Small House” is sometimes used interchangeably with “Green House”, as they share some overall design principles. However, The Green House Project is a specific certifying body that has a number of affiliated facilities across the country, whereas “Small House” is a more generic term that refers broadly to the design approach. Some jurisdictions have made attempts to formalize a definition of “Small House”, such as California’s stipulations for Small House Skilled Nursing Facilities (https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/SHSNF-Pilot-Program-Standards.aspx).
Does a Small House Facility Cope with CoVid-19 Better?
Several recent articles such as these from Senior Housing News and The New York Times point out that CoVid-19 cases have been lower in Small House or Green House facilities. The most obvious reason why this should be so is that each Small House neighborhood can readily be isolated from other care facilities on a campus, limiting exposure to just a dozen residents and their caregivers. But there are other subtle advantages, as well.
The building that C&C designed for Christian Care Communities was comprised of six neighborhoods, with varying levels of care. Infection protocols could potentially be different, since, for instance, memory care patients may be otherwise physically well and lacking comorbidity risks, while they are also already movement-restricted. Temporary care, however, sees more frequent patient turnover and must adopt more of the practices of hospitals, including room sterilization. The clustering into neighborhoods provides clear demarcation points for where a given protocol will be enforced.
The staff assigned to each neighborhood can be trained to perform more of a universal role and thus fulfill all of the support tasks for that one neighborhood, rather than having multiple specialized workers who perform a limited role for a large number of residents. This limits the number of social contacts, adding to the social distancing that comes from sharing living spaces with only a dozen residents. In a conventional large nursing home, there may be some specialized staff who work only part-time, holding another job elsewhere that means they can bring an increased level of exposure with them. Universal workers can be full-time and dedicated to their neighborhood.
Since each neighborhood is designed to contain a functional residential kitchen, it is possible for meal service to be decentralized. Conventional nursing homes with a large communal dining room have had to resort to serving meals only in patient bedrooms, but within a Small House this protocol might be relaxed. The redundancy of shared spaces like living and dining rooms allows for some flexibility in case one neighborhood does encounter an infection.
Aside From Small House Plans, What Other Measures Can Be Taken?
While the Small House neighborhood has many benefits, there are still other steps being taken that can be applied in all types of senior care facilities. A primary focus is on visitation, as sadly the visits by loved ones represent a potential infection vector. Many facilities have found ways to place visitors on the opposite side of a glass panel, such as limiting them to a vestibule space and providing phones. In order to keep such an approach from feeling like a prison visit, it would be best if the protective glazing is adjacent to two comfortable spaces, with the visitor lobby also being easy to clean between uses.
A dedicated public washroom that is accessible to the visitor lobby would enable certain protocols, and it might be necessary to locate a nurse station to oversee the visitor lobby and ensure that those protocols are observed. Some facilities do not have a space that can serve as such a visitor lobby, and have employed movable temporary screens to subdivide a space, however these might not substantially affect air circulation and thus still allow some infection risk.
Technology can play a significant role, as smart TVs could allow patients to use video conferencing instead of personal visits. Senior care centers have been making more use of social media, as well, allowing loved ones to see what is going on inside. RFID tags can be employed to help seniors navigate the building without needing to touch elevator buttons or door handles; these could be sensor-controlled or voice operated, and many nursing homes already use such tags for wander management.
Frequent-touch surfaces like handrails and door knobs could employ antimicrobial materials like copper, and HVAC systems could employ technologies like UV-C lamps or Needlepoint Bipolar Ionization for air stream disinfection. For more ideas on possible building retrofits, please see our prior article on viruses and building design.
Other broad design options that would need to be explored during preliminary design include giving residents some access to private outdoor space, even if they are confined to their apartment or neighborhood. This might be in the form of small balconies, or as was done at Christian Care Communities, larger neighborhood-sized balconies and patios. For a memory care wing, any outdoor space must be protected so that patients are unable to wander away; this same protection ensures that outside visitors cannot contaminate the space. The overall site design should also take into consideration how deliveries, staff, and visitors can all be screened in some manner as they arrive, preferably to different arrival points.
Is There Another Alternative to Nursing Home Design?
Some experts are anticipating that aging-in-place will gain in popularity, which means that private homes will be renovated to include accessibility features to enable independent living, rather than entering an assisted living facility. Certainly this can be done, and at Childress & Cunningham Architects we have performed such design services for our clients.
However, many seniors find that their level of independence declines over time, and they ultimately need professional long-term care. At Christian Care Communities, the new Small House neighborhoods add multiple levels of care to a campus that already contained many independent living apartments, so that the changing needs of residents can be met.
The Small House approach has been successful in light of this pandemic, and this can be confirmed by reviewing data such as that compiled by a USA Today survey of senior care facilities, organized by state (link:https://www.postcrescent.com/story/news/investigations/2020/05/01/nursing-homes-covid-19-do-any-near-you-have-coronavirus/3015488001/) . One can look up Christian Care Communities in Warren County, KY, directly, and see that as of May 23rd, they had reported only 3 CoVid infections among staff, and zero infections among residents. Another source with more recent data is data.cms.gov with a searchable database; one can see that “Christian Health Center” in Bowling Green, as it is recorded there, had reported only 2 cases (and no deaths) among residents through October 25th, 2020. This data may change over time, but if infection ever does spread more broadly to their residents, they will be in a better position to protect their other residents because of their Small House neighborhoods.