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Housing and Residential Care for Older Adults

March 2015
Executive Summary
The Center For Health Design

Living Independently

For older adults, decisions about where to live and what types of support services are needed depend on the level of assistance each individual requires. The standard for assessing independence is the ability to perform a number of activities fundamental to self-care. These activities are known as Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). ADLs are basic self-care skills; IADLs are higher-level skills necessary for living independently in the community.

The standard for assessing independence is the ability to perform a number of activities fundamental to self-care.


Activities for Daily Living include: 

  • Dressing 
  • Eating 
  • Taking a shower or bath
  • Going to the bathroom
  • Getting into and out of a bed or chair
  • Walking from place to place

Instrumental Activities for Daily Living include:

  • Shopping for food and medications 
  • Cooking 
  • Laundry
  • House cleaning 
  • Managing one’s medications and finances
  • Transportation


Options on the Continuum of Care for Older Adults

Many types of residential environments are available to older adults. Each option falls on a continuum of care ranging from independent, community-based living to fully supportive residential care settings. 

Adult Day Services

  • Community-based, non-residential setting
  • Offer structured activities and meals during daytime hours
  • Some health services may be provided

Retirement Community

  • For people who are nearly or totally independent
  • Wide variety of housing types available (apartments, townhouses, single-family homes)
  • All residents are older adults (55+)
  • Special programs such as recreational activities and transportation are organized
  • Personal and medical care services are not offered

Subsidized Senior Housing

  • For older adults with low or moderate incomes
  • Generally independent living
  • Some offer assistance with shopping or laundry

Assisted Living

  • Provide individual or shared units
  • May or may not have a kitchen
  • Offer 24-hour on-site staff
  • Congregate dining, activity programs, laundry, and cleaning services are available
  • Nursing services and help with IADLs and ADLs are available 
  • Not regulated by federal government; state regulations and definitions vary widely

Continuing Care Retirement Communities (CCRC)

  • Provide different levels of care based on changing needs of resident
  • Independent living to skilled nursing options all on the same campus

Skilled Nursing Facility

  • Provide 24-hour nursing care
  • Full array of personal, dietary, therapeutic, and social services
  • For residents whose needs are high 
  • May also provide short-term rehabilitation services and chronic care management

Alzheimer Special Care Units/Memory Care Units 

  • Specialized units to meet the needs of people with Alzheimer’s disease and other dementias 
  • Persons with dementia are frequently grouped together on a floor or unit within a larger residential care facility 


  • Offer supportive medical and social programs for terminally ill patients and their families
  • May be offered at home or in a facility
  • Focus on end-of-life issues and palliative care (comfort measures), not treatment of disease


Residential Care Culture Change

The goal of culture change for residential care environments is to move away from an institutional model of care toward one that is residential in scale and person-centered.

Culture change is a national movement to transform the organizational philosophy of living environments, services, and care for older adults. The goal of culture change is to move away from an institutional model of care toward one that is residential in scale and person-centered—where both older adults and their caregivers can express choice and practice self-determination in all aspects of daily life (Pioneer Network, 2015; Rohde, 2012). The culture change movement promotes programs that deinstitutionalize long-term care at every point on the continuum of care.

Over the past two decades, a number of different conceptualizations of culture change have been implemented, including: Wellspring™, The Eden Alternative, and The Green House Project™. The common thread among these programs/projects is the transformation of organizational practices, physical environments, and workforce relationships to support high-quality, individualized care. The Wellspring™ model of culture change mainly focuses on the clinical aspects of care. The Eden Alternative and The Green House Project™ are considered household approaches to culture change, placing additional emphasis on ways the configuration and design of the physical environment can support individualized care.

Household/Neighborhood Model

Over the past two decades, a number of different conceptualizations of culture change have been implemented, including: Wellspring™, The Eden Alternative, and The Green House Project™.


  • Small group of residents
  • Physically defined area within a larger facility
  • Contain dedicated kitchen, dining room, and living room areas in close proximity to bedrooms
  • Consistent staff assignments (same staff work with residents) 

Small House Model

  • Small, purpose-built clusters of free-standing houses
  • Intended for 6–10 residents needing skilled nursing
  • Private bedrooms and baths
  • Central family room and hearth
  • Open-access kitchen and dining area for family-style meals
  • Medical equipment stored out of view
  • Consistent staff assignments
  • Green House Project™ trademarked version of small house model


Moving Toward Improved Quality of Life and Wellness 

A crucial goal of the culture change movement has been to improve quality of life for older adults. Quality of life can be defined as a multidimensional concept comprising physical health, psychological well-being, social relationships, and the physical environment (World Health Organization Quality of Life Assessment Group, 1998). The culture change movement reflects the unwillingness of older adults, their families, and their care providers to accept the status quo of the institutional model of care. It is safe to assume the baby boom generation will continue to demand improvements in the housing and residential care available for their parents and themselves.

Wellness programs promote healthy living through the integration of mind, body, and spirit. They may be housed in free-standing facilities or reside within residential care facilities.

A more recent trend in both community and residential healthcare is the focus on wellness programs and facilities. Wellness programs promote healthy living through the integration of mind, body, and spirit. They may be housed in free-standing facilities or reside within residential care facilities. Frequently offered services include fitness equipment and training, mind-body practices (e.g., acupuncture, massage, chiropractic, yoga, meditation), nutrition education, aquatics, and preventative health screenings. The benefits of exercise, preventative care, and good nutrition to overall health are widely known. They are gaining popularity among older adults, especially as government and employer incentive programs spread across the country. Benefits are also derived from art, music, pet, and horticulture therapy programs.

Design Implications

The design and development of future housing and residential care facilities for older adults will be influenced by:

  • trends away from an institutional model of long-term care toward a small- scale, individualized model of care;
  • preferences for “home-like” architectural features
  • the provision of health and wellness programming; and
  • changing demands and expectations among the baby boomers as they age.

When designing housing and residential care environments for older adults, it is important to consider the level of services and care each facility intends to provide.


Related References

Alzheimer’s Association. (2014). 2014 Alzheimer’s disease facts and figures. Retrived from http://www.alz.org/delval/documents/facts2014_full_report.pdf 

Joseph, A. (2006). Health promotion by design in long-term care settings. Concord, CA: The Center for Health Design.

Pioneer Network. (2015). Definition of common terms used in long-term care and culture change. Retrieved from http://www.pioneernetwork.net/Consumers/PickerGlossary/ 

Robert Wood Johnson Foundation. (2014). Long-term care: What are the issues? Retrieved from http://www.rwjf.org/en/library/research/2014/02/long-term-care--what-are-the-issues-.html 

Rohde, J. (2012). Residential healthcare facilities. Concord, CA: The Center for Health Design.

World Health Organization Quality of Life Assessment Group. (1998). The World Health Organization quality of life assessment: Development of general psychometric properties. Social Science and Medicine, 46(12), 1569-1585.