Last year's ASHE/PDC conference represented the first time that hospital futurists began looking at the full
continuum of care. With the tying of reimbursements to readmission rates, the acute care market is now including transitional and long-term care as part of the overall continuum.
From a long-term care perspective, the majority of continuing care retirement communities (CCRCs) approach the continuum by requiring a resident to continually move—that stands in contrast to a future which is focused on bringing services to residents; augmenting isolation issues with community centers and recreational programs; and providing adult day care. There are situations with residents with dementia and high levels of physical needs that may require different types of settings, but the future is clearly not in the institutional care model of the past.
The expectation is for household and small house models, where management and staff can reposition existing settings and community areas to incorporate choice and help residents thrive. Designers can assist by creating care environments that go beyond the requirements of the Americans with Disabilities Act (ADA) in order to meet the specific needs of older adults. These include appropriate grab bar configurations for the care population, appropriate door widths, the thoughtful placement of handrails, and smaller-scaled environments that are more manageable by potentially frail elders. The ultimate design goals are to support residents, create environments that provide as much independence as possible, and contribute to as much life "normalcy" as possible.
coming together for care
These changes in how transitional and long-term care situations are structured mirror similar, broader changes in our healthcare system. As attendees of the recent American Public Health Association (APHA) conference in Boston made clear, it is time to bridge and connect the built environment with public health concerns. Whether in the United States or abroad, wellness starts with the basics: healthy water, nutrition, safe housing, and access
to coordinated services. Healthcare is no longer a discussion focusing on the physical plan, but a
conversation with the community at-large, end-users, and healthcare staff aimed at addressing the current and future needs of the overall community.
A number of years ago, my firm competed in
a housing design competition for the community
surrounding Johns Hopkins Hospital in Baltimore. Our proposal included a review of precedents from other countries; the need for evaluating education
services, vocational opportunities, access to health, social, and wellness services; and an infrastructure for creating a walkable neighborhood with amenity support (i.e. grocery stores, libraries, and transportation)—all of which are crucial parts of a successful design and master plan. After reviewing our proposal and subsequently speaking with the sponsors of the competition at the Neighborhood Design Center, the competition chair stated, "Baltimore City isn't ready for you yet!" Although it has taken awhile, that time has arrived!
Simply put: Innovative partnerships, reaching beyond comfort zones, comprehensive evaluation of impacts, understanding community needs, and communication with a capital "C" are the healthcare strategies of the future. As traditional barriers are broken down; improvements and modifications to zoning and planning regulations, licensing and building codes, and standards to improve community-based care opportunities are achieved; and inclusive multidisciplinary teams are created, a comprehensive discussion on sustainable models that truly address healthcare needs can occur.
The timing is right to create community-based solutions, and the design industry has been doing just that. The new "Guidelines for Design and Construction of Residential Health, Care and Support Facilties" from the Facility Guidelines Institute is due out in early 2014, and designers can now reference the Senior Living Sustainability Guide, available at withseniorsinmind.org.
generations of hope
An example of these solutions in action can be found in the development of Bastion (joinbastion.org), an intentional community being built in New Orleans. This project, overseen by Executive Director Dylan Tete, utilizes the Generations of Hope Community Model (ghdc.generationsofhope.org) for creating intentional community as an intervention.
The Generations of Hope model includes a multigenerational approach, which involves identifying a vulnerable population and then creating a supportive community that includes a senior component. Bastion, in particular, includes the creation of housing and services for wounded warriors, including those with traumatic brain injuries (TBIs), and surrounds them with retired military personnel and seniors.
Everyone in the community, young and old alike, come with the full knowledge that they are responsible for volunteering. There is a common goal: to create a positive environment for wounded warriors and their families to heal and become reintegrated into community life. There are vocational opportunities and volunteer and activity coordination services. The community has been planned to engage the neighborhood and includes community gardens, fitness and exercise programming, and an overall wellness planning component.
The most recently completed Generations of Hope community is Bridge Meadows (bridgemeadows.org). This unique, multigenerational community is located in the Portsmouth neighborhood in North Portland, Ore., and includes adoptive parents, foster children and elders. The community is a solution where families agree to adopt or become the guardian of children from the state foster care system within one year of moving into Bridge Meadows, in order to provide permanency and stability for youths. The elders living in Bridge Meadows provide over 10,000 hours of service each year, providing purpose to their lives by choice. Models like Generations of Hope contribute to health and wellness by focusing on life instead of one's perceived limitations. Coming together as a community is one way that healthcare providers can get involved, recognizing that a person is not defined by a medical diagnosis.
Healthcare is part of daily living, but it can no longer be siloed and separated from the community-at-large. The inclusion of multigenerational living within a community as part of the coordination of services is now required. It is time for care to be person-centered; instead of focusing on the 10 percent of a person's care needs, our communities and healthcare institutions need to place the emphasis on the 90 percent of the "living" portion of life, while providing the care required. New care models and approaches to health and well-being are no longer part of an institution, but located where services are needed: within the community. As such, the future of healthcare design will depend on the larger evolution of integrated community design.
Jane Rohde is the founding principal of JSR Associates, Inc. located in Ellicott City, Md. She champions a global cultural shift toward deinstitutionalizing senior living and healthcare facilities through person-centered principles, research and advocacy, and design of the built environment. Clientele includes nonprofit and for-profit developers, government agencies, senior living and healthcare providers, and design firms. Rohde speaks internationally on senior living, aging, healthcare, evidence-based design, and sustainability.