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Building Smaller Spaces Can Have Large Effects on Resident Satisfaction, an interview with Mitchell S. Elliott, AIA

October 2017
Interview
The Center For Health Design

While at Vetter, you participated in multiple building projects. The scope of work included freestanding buildings, additions, and renovations, along with other capital improvements for rebranding. What did you do to ensure effective collaboration and gain insight into the day-to-day operations and culture for each of these environments?

I believe the design and planning process should always begin with a deep understanding of previous challenges and past successes. The Vetter organization is constantly incorporating lessons from post-occupancy evaluations (POEs) of previous projects they have developed, designed, and constructed. In the past, we would pursue feedback, impressions, and reactions by asking questions of residents, team members, and anyone else who influenced the culture of the care community. We would ask questions like, “What works? What doesn’t work? What could we have done better?” It was amazing how much feedback we would receive just by asking, and then truly listening to their responses.

We also engaged consultants in various disciplines—dietary, life enrichment, maintenance, administrative, and so on. By involving so many disciplines within the care community, we could gather a range of feedback and perspectives. From there, we documented that information and shared it with the design team of consultants, architects, and contractors involved in the project. Those providing the feedback would also receive a summary of the POE process. It’s one thing to gather the information, but if you don’t share the findings in a collaborative way, it won’t be beneficial to the next project.
 

On one project, you worked closely with the operations and clinical teams at Vetter to better understand staffing strategies based on acuity and diagnosis. Those staffing patterns drove the connected household design, which Vetter has refined to maximize staff efficiency and effectiveness. What is a connected household design, and how has downsizing the environment impacted residents and staff?

The first time we developed a connected household design concept—the arrangement of multiple households connected by a shared space—was in 2000, when we opened Brookestone Village in Omaha, Nebraska. Our main premise was that instead of transporting residents to a single dining venue, we could bring the food to a smaller-scale dining setting closer to resident rooms. Most of the design concepts developed for Brookestone Village were a result of the research we were doing on effective environmental design for residents with Alzheimer’s disease.

Based on lessons learned from our research, we started talking about downsizing. We began looking at the size of the environment and how much of a positive impact scale had on the resident experience. We studied what impact the scale of the living environment could have on relationships. The smaller-scaled environment fostered a better relational connection between residents and care team members, allowing caregivers to become better acquainted with their residents. We thought, If this design is good for residents who have cognitive challenges, why wouldn’t it be fitting for residents who are fully capable and have their short-term memory intact?

This doesn’t sound so groundbreaking today, but in the late ’90s, we were taking some pioneering steps in smaller environments and resident-centered care.
 

What types of amenities are in a household?

I feel that a household is defined by the presence of living and dining spaces dedicated to the specific household. At Vetter, we also included a bathing spa in each household. This reinforced the Vetter mission of “Dignity in Life.” The other aspect that is paramount to an effective household is permanent staffing: A dedicated, consistent team of caregivers reinforces the relational benefits of the household. The “connectedness” of the smaller-scaled environment gives residents access to a multitude of support services and shared amenities, such as housekeeping, laundry, life enrichment programs, restorative care, therapy and rehabilitation, salon services, worship centers, bistros, cafes, ice cream parlors, coffee shops, movie theaters, and a shared serving kitchen. This shared concept keeps the arrangement financially feasible without compromising the key elements within the household. 
 

Did you use research to inform any of your designs?

At Vetter, we looked outside of the organization to other long-term care and senior living organizations that had a similar passion for excellence. Culture is very important, and our research actually extended beyond long-term care and into successful hospitality models. The purpose was to figure out how to create a world-class experience for our residents.
 

Is 20 the maximum number of residents? How many residents live in a connected household?

It really depends on a number of factors. Vetter’s largest household is designed for 27 residents. However, I don’t recommend an environment or a population that large, because you start to lose some of the intimacy of a household at that size. The ideal size is typically driven by the staffing required to provide quality care for the acuity levels of the residents, and a scale that will contribute to the quality of life for the resident. This is a fine balancing act between what is best for the resident and what is best for staffing. We experimented with different sizes and staffing models and found that, for memory support households (those dealing with cognitive challenges), 15 residents seemed to be the best fit. In terms of long-term care, we determined that a 20-resident household was more efficient. The size of a household is also driven by the reality of fluctuations in census. The different staffing models for day, evening, and night shifts will also impact the size or scale of the connected household. At Vetter, we found that connecting the households, versus developing the freestanding small house models, were effective in dealing with all of these potentially conflicting issues.
 

Did the connected household design have an impact on resident and employee satisfaction?

Once we implemented the household concept design in 2000, every one of our new buildings followed the pattern of “smaller is better”—and we saw significant benefits to our residents. One of the critical areas impacted by the connected household design was the food preparation and serving process. Instead of bringing residents to the food, we decided to bring the food to the residents. By incorporating the kitchen and dining room into each connected household, the maximum travel distance to dining was reduced by more than 50 percent. This increased resident, employee, and team member satisfaction, and strengthened the relationships between providers and residents. The concept also allowed residents to remain independent for a longer period of time, a hallmark of the Vetter mission.

By incorporating the kitchen and dining room into each connected household, the maximum travel distance to dining was reduced by more than 50 percent. This increased resident, employee, and team member satisfaction, and strengthened the relationships between providers and residents.

In addition to the positive outcomes related to food services, we found that household designs tend to support private resident rooms more effectively. Expanding the number of private rooms is one way we can respond to market demands, as well as infection control concerns.
 

The Society for the Advancement of Gerontological Environments (SAGE) has developed several design principles for senior living environments based upon a set of values. As president of SAGE, can you share some of these values and the logic behind them?

SAGE’s mission is to promote collaboration among architects, interior designers, service providers, regulators, residents, researchers, manufacturers, educators, students, and all the constituents in senior living. There are several core values that drive that mission: First, environments must ensure physical safety. Second, environments should be therapeutic resources—enabling the provision of quality care. Third, design should be holistic, and it should focus on the well-being of the residents, staff, and caregivers. Fourth, SAGE encourages innovation, experimentation, and to support your methods with evidence that shows that design matters.
 

How did SAGE develop its core values?

The core values resulted from the Omnibus Budget Reconciliation Act (OBRA) of 1987. This was federal legislation that impacted reform in nursing homes and changed how care was evaluated. OBRA was a driving factor in helping the long-term care industry define and maximize quality of life for elders. The early pioneers in SAGE developed our design principles to enable and/or reinforce privacy, involvement in care plans, accommodation of individual needs, freedom from chemical and physical restraints, and participation in life-fulfilling activities.
 

What was the philosophy behind the SAGE Place program?

SAGE Place is an evolving tool designed to help leadership teams of care organizations develop their vision casting prior to engagement with an architect. This is a pre-design tool intended for boards, providers, and care communities to articulate who they are, what they want to achieve, and how they are going to achieve it. I would imagine architects and interior designers will use SAGE Place to assist care communities throughout the design process.

SAGE Place is still under development, but I’m anticipating that it will be available sometime in 2017.
 

How can everyone collaborate to build a successful project?

I think having each team member at the table early in the planning and design process is paramount. Providers and consultants must all participate in goal setting. Because there are many decisions to make throughout a given project, it is helpful to be able to look back to overreaching goals and vision statements that the group established at the outset.
 

About RDG Planning & Design

RDG Planning & Design is a diverse network of planning and design professionals, united to create meaning together through purpose-driven design. With major offices in Omaha and Des Moines, RDG offers professional services in architecture, landscape architecture, interior and lighting design, strategic planning, urban design, community and regional planning, and environmental graphic design. RDG has been serving clients since 1965 and has active projects in more than 25 states. For more information, visit www.rdgusa.com.

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