The phrase about history repeating itself usually has a negative connotation. However, there are aspects of long-term care that would be good to repeat. In the middle ages, a philanthropic community was developed in Augsburg, Germany, by the Fugger family; it was called the Fuggerei. The community was set up predominantly for widows and older pensioners—a retirement community of sorts—and was supported by a wealthy and powerful financier in the 16th century (Jakob Fugger “The Rich”) who minted coins for the Vatican and was key in steering Europe’s spice trade.
But perhaps the most interesting aspect of the Fuggerei is that it still operates today as an affordable community supported by the Fugger family foundation trust. It contains a chapel, herb garden, communal green areas, café, private residences, and walking streets. Residents have a sense of pride; it is viewed as a privilege to live in the Fuggerei.
There is even a history of care management services located within the walls of the community that were once on the outskirts away from the center of town. Today, tourists visit the community, and the fee for entry is utilized for improvements. The community once used long metal bars with distinctive shapes at each end to identify their units in the dark (prior to electricity being implemented). Plumbing was added, negating the need for the chamber pot. It has a bomb shelter and survived WWII, save a roofs being replaced. And other than attempting to accommodate automobiles, it remains intact as a vibrant social, historic community.
The only two statutes still on the books are for residents to pray for the Fugger family three times per day, and to use the back gate and pay a fine if you come in past 10:00 p.m. So the story goes, but it’s unclear whether these two chartered items are enforced. The cost of living in the Roman Catholic community has not changed in over 500 years—in current U.S. dollars, annual rent is $1.23.
A Fuggerei for the Future
As someone who has worked in senior living for over 25 years, the freshness of the ideas in the Fuggerei are now being considered for communal type living or co-housing. Some groups of residents are bound together because of sustainable living desires, but any affinity can be used to develop a community that supports the residents. The approach can be expanded to include multiple generations, care models for services needed, and communal or separate meals based on the charter and agreement of the residents coming together to live and enjoy one another.
In recently evaluating an assisted living setting, the place seemed very sad. There wasn’t any vitality or joy spotted in the setting. I was with one of my colleagues, and as we were leaving, she said that my parents or hers would hate this place—just as we both would. Therefore, we must constantly push the envelope. I challenge designers to create something truly reflective of the community aspects of the Fuggerei, interpreted in a contemporary rendition.
Fortunately, another aspect of the past has become popular in deinstitutionalizing long-term care settings. It was once held that elders still had purpose within an extended family. They either tended to children, helped with gardening or hunting, maintained equipment and buildings, and (in my grandmother’s case) cooked or provided meals.
These simple aspects of everyday living are often missing from institutionalized care. Dr. Bill Thomas realized this and created the Eden Alternative and the environmental embodiment of the concept in the Green House Project. The concept is straightforward in that instead of creating institutions based on outdated acute care settings, it provides complete homes that reflect every aspect of typical daily life.
Consider the 10/90 rule. A resident lives in a care setting because they need certain levels and types of services. Prior to end-of-life care, about 10 percent of the work revolved around services needed, but the other 90 percent is living. The goal is to maximize the potential of living as fully as possible, focusing on capability versus disability. Understanding an individual not by diagnosis, but as a unique human being who enjoys certain foods, activities, and visitors.
We are still not at a tipping point, but over the last 10-12 years, great strides have been taken to evolve extended care settings into a kind of small household that allows for care to be given with as much much normalcy as possible on a day-to-day basis. For those with dementia and other types of frailties, smaller environments have improved outcomes by providing a more manageably sized environment that encourages residents to focus on their potential.
Ultimately, the goal is to provide an environment where my grandmother still has the opportunity to cook or do laundry as part of the communal approach to living together in a typical day. Even as a resident’s abilities waiver, we can provide a familiar setting that improves outcomes and enables potential. I often use my personal experiences as the litmus test for determining how person-centered an environment is. It takes personal relationships among staff members, residents, and family members to create a team that supports the individual. Design is essential in supporting the care models desired, and it will continue to change and improve the future.
Jane Rohde is the founding principal of JSR Associates, Inc., 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. She speaks internationally on senior living, aging, healthcare, evidence-based design, and sustainability. She is the first recipient of the Environments for Aging Changemaker Award presented by the Center for Health Design. For questions or comments, reach her at firstname.lastname@example.org.