~by Richard L. Peck, Healthcare Design Contributing Editor~ 

About 10 years ago, I [Richard Peck] was privileged to be part of the publishing team that founded HEALTHCARE DESIGN. It was an offshoot of a very successful publication we had started in the long-term care field, the DESIGN series of annuals that had grown out of regular coverage of long-term care design by Nursing Homes/Long Term Care Management magazine (now known as Long-Term Living).

I was founding editor of that publication as well—so you can imagine my consternation upon discovering that the acute care architects and designers receiving HEALTHCARE DESIGN reported little interest or involvement in the senior care side of things. They viewed it as a niche field occupied primarily by aging-related design specialists.

Cut to the present day: The silo walls are starting to crumble. Realization is growing that seniors will be many hospitals’ chief customers in the very near future, if they aren’t already. Studies indicate that half of all inpatients in today’s hospitals are age 65 or over. As aging Baby Boomers continue to surge, they will occupy hospitals in growing numbers and with increasing frequency. Already, the over-85 crowd is the fastest growing population sector in America.

Are hospitals ready for this? Will hospitality features—the sum and substance of HEALTHCARE DESIGN during its decade of existence—suffice to accommodate seniors’ needs? If not, what can the field of long-term care design teach us?

Recently, I sought answers from designers and planners already working on the new convergence between acute care design and senior care design. And, very gradually, the pathway ahead is becoming clear, despite lingering confusion.

“I remember asking the designer of a beautiful new hospital wing why the structure wasn’t more senior-friendly,” says environmental gerontologist Esther Greenhouse, an advocate for convergence. “He replied that his firm was already doing this for skilled nursing but that applying this to acute care hadn’t occurred to him. I thought, why not? With today’s demographics, senior-friendly features should be standard for any healthcare design.”

When I spoke with her, Greenhouse was working on a project that might well someday be included among those viewed as the gateway to senior-friendly acute care design—those focusing on the emergency room.

The largest such project to date has been sponsored by Trinity Health, the Michigan-based hospital system with 49 hospitals in 10 states. Its Senior ERs are now operational in 12 facilities, with another six openings planned this year. Trinity Health engaged William H. Thomas, MD, a man well recognized for the past 20 years as a pioneer in long-term care reform, as a consultant.

Thomas is a former family physician and emergency room clinician who spearheaded two breakthroughs humanizing the world of nursing home care: the Eden Alternative, introducing pets, flowers, and gardens as regular features in nursing homes to engage elderly residents; and the Green House, an architectural remodeling of the stereotypical nursing home to make it more homelike for residents.

He has spent the past two decades spreading the word about these innovations, but now, he says, he has a Third Act—a return to his former medical bailiwick with Trinity Health’s Senior ER project.

The Trinity Health ERs are changing the paradigm of emergency department function, says Sue Penoza, director of planning at Trinity Health. “The traditional ER has always been measured by its throughput,” she says. “But Dr. Thomas helped with the cultural change we needed to slow down and spend more time assessing the elderly patient’s overall situation and conditions.”

“In the ER, we used to focus on assessing the patient’s chief complaint,” notes Michelle Moccia, RN, ANP, Senior ER program director, who’s had day-to-day experience at St. Mary Mercy Livonia’s Senior ER in Livonia, Michigan, since it opened in July 2010. “And we prioritized the tasks needing to be done, such as lab tests, around that complaint. It was very fast-paced and quite noisy; it was disturbing to seniors and we missed important information. Today we look for the patient’s total needs: Does he or she live alone? Do they have problems walking or otherwise getting about? Are they experiencing depression from some recent loss, or maybe a nutritional need of some kind?”

St. Mary Mercy Livonia was home to the second Senior ER in the Trinity Health system, but even in the Trinity Health facilities that don’t have a dedicated space for the Senior ER—and there are a few—efforts are made to offer a supportive environment. For example, “pocket talkers” amplify conversation for the hearing impaired, large clocks and signage are more readily visible, and special support surfaces for the ER carts add to comfort and skin safety. In the dedicated ER spaces, features include nonskid flooring, adjustable lighting, recliners for patients and comfortable seating for family members, warming blankets for seniors who are “always cold,” and private rooms rather than bays for enhanced quiet and privacy.

“Dr. Thomas was very effective in leading our staff and leadership toward support for these changes and giving us a real passion for this work,” Penoza says.

There are other signs of the new convergence. “Our firm is jumping in with both feet,” says Jeffrey C. Stouffer, AIA, principal/academic and pediatric practice leader at HKS Inc., the large full-service architectural firm based in Dallas, Texas. “We’ve had very large projects in senior living over the years and now, with the aging of the population, we’re starting to apply the lessons we’ve learned to acute care design.

With child-friendly design, we’ve made some real progress. Senior-friendly design is still in its infancy—if you learn to walk by crawling, we’re at the crawling stage.”

Some senior-friendly features becoming more familiar to the acute care side, Stouffer says, are reduced-glare flooring, training of housekeeping staff to avoid over-waxing floors, more sensitive use of lighting, color contrast and soothing nature-based art, and providing quieter, more comfortable waiting areas with minimal exposure to blaring TVs.

Meanwhile, coming from the long-term care side is Daniel Cinelli, AIA, principal and director of Perkins Eastman, the New York- and Washington, D.C.-based architectural firm, and a long-experienced designer of senior facilities. “Right now there isn’t much understanding of what we do on the acute care side, and we’re exploring ways to upgrade knowledge,” he says. “We recently conducted a workshop with the accounting firm Plant Moran, which indicated that their healthcare clients knew little about senior-friendly design. We found clear opportunities for us to work together.”

Cinelli says his firm, which does 25% of its business in senior living, is broadening its focus to encompass “new aging,” a term acknowledging the growing interest by hospitals, hotels, airports, and businesses in addressing the new demographics. “The information has been available on the senior care side for years—the furniture, the lighting systems, the materials and cleaning products, all of these are being used but hospitals aren’t aware of this.”

Diana Spellman, principal of Spellman Brady & Company, has become increasingly involved on the senior care side with her firm’s senior care division and has worked diligently toward merging the two fields.

“I continue to see attention and improvements made to create comfortable, quiet waiting areas with seating that is sensitive to ergonomic issues of height, firmness, and chair arm design. But I still observe the challenge within the architectural design community working with high-glare flooring in combination with large expanses of glass and sunlight, creating way-finding problems for elderly who often perceive dark silhouetted elements,” she says.

Her colleague specializing in senior facility design, Kelley Hoffman, senior designer/project manager, adds, “Acute care designers need to study visual impairment in the elderly, for example, to understand choice of colors, use of contrasting color shades, design of floors without confusing patterns, and way-finding that is effective but dignified.”

Not only patients but staff can benefit from increased attention to aging-friendly design, with today’s nursing corps grouping steadily in the over-50 bracket—the specialty of Laurie Waggener, director of research at Houston-based WHR Architects.

“The aging of the nursing staff is in keeping with the aging of the Baby Boom,” she says. “That’s why when nurses look at floor plans for a new unit, they evaluate them in terms of getting the job done with less physical demand. They look for adequate space on both sides of the bed to safely maneuver and carefully planned headwalls so that they’re not reaching for equipment. They appreciate features like waist-high electrical outlets so they’re not repeatedly bending over to plug and unplug equipment or charging up batteries.”

To Waggener, today’s exemplar of senior-friendly design for both patients and staff is the Jersey Shore Medical Center’s new Northwest Pavilion in Neptune, New Jersey. This patient tower divides a 36-bed patient area into a cluster of three 12-bed neighborhoods. Each neighborhood has a row of six beds on either side of a circular station for care giving staff to work, assemble, and observe patient rooms.

“This design brings the nurses closer to patients. They are able to easily view at least eight of the 12 rooms from a single area and, also important, maintain good sight lines to each other throughout the unit so that they always have a sense that help is at hand, something they frequently report missing with many decentralized layouts,” Waggener says.

The WHR-designed Jersey Shore was not, Waggener acknowledges, necessarily intended to serve as “a unit that specializes in acute care of the elderly (those older than 75)—it was designed for the growing patient acuity and will, in my professional opinion, gracefully address the special needs of this demographic in the future.”

Indeed, true exemplars are difficult, if not impossible, to find (an exception being a Canadian facility, see “The Patient Care Centre,” sidebar). But “everything that rises must converge,” as a theological philosopher once said. The rising need for hospitals that work for people of all ages is converging on a new healthcare design paradigm. HCD

The Patient Care Centre
One purpose-built senior-friendly hospital does in fact exist—but not in the United States. The 500-bed Patient Care Centre of the Royal Jubilee Hospital in Vancouver, British Columbia, has been in operation for about a year and includes most of the design features American designers discuss in the accompanying article.

According to Rudi van den Broek, BSc, MPA, chief project officer for the Vancouver Island Health Authority (VIHA), the design was prompted by the same demographic trends observable elsewhere, but in this case the provincial authority had the authority to make it happen. “VIHA routinely upgrades its 13 acute care campuses as they move through the aging cycle—in this case we replaced an 80-year-old and a 60-year-old facility with the new hospital, and designed the hospital for a 60-year lifespan. In that context, designing for aging was a given.”

It was not, he notes, necessarily a given at first for the architects involved. “The experience of acute care is different for 25-year-olds and 85-year-olds, but some designers just don’t get that and tend to lump all adults under the same umbrella.”

His colleague Robyne Maxwell, RN, BScN, project manager for the Patient Care Centre, adds, “Younger adults can be just as frail as the elderly, but they tend to recover more quickly. But they share needs, and what benefits the elderly very much benefits the younger patient.” Van den Broek himself comes from the senior care facility side of design, having crafted the criteria used for such projects in the province. To him, it was a matter of transferring the same considerations to the acute care side of things. “We wanted to make the design elder friendly, but not elder-only.”