Over the years, I have been asked by my colleagues to write about what I’ve seen in my 30+ years of experience in senior living design. Years of new concepts and the latest trends have changed senior living models and the industry significantly. However, none have impacted these communities like the devastation of COVID-19.
Raised by three nurses (mother and two aunts), infection control has always been at the forefront of hospital and nursing home design. It was the biggest reason for years of petitioning the government to reimburse for private rooms. The COVID-19 outbreak has emphasized this, meaning senior living care could look very different post-pandemic.
So how do we cope moving forward? While it’s too soon to calculate the full impact of COVID-19, here’s a look at the various senior living models and how they appear to be fairing:
The Old Hub and Spoke Model
The old hub and spoke nursing home communities are being hit the hardest. These are typically older buildings with a high percentage of semi-private rooms as well as central support and shared amenities. This model puts a large concentration of people in a relatively small area, similar to densely populated cities like New York.
That said, one advantage to this model is the ability to set up a quarantine wing with direct access to the outdoors. This building type – single story with double-loaded corridors and an exit at each wing – lets operators establish a separate entrance to enter and exit the wing while avoiding shared spaces including corridors, lobbies, elevators and stairwells.
The New Hub and Spoke Household Model
Like the old hub and spoke model, the new hub and spoke household model has been hit just as hard – both new construction and renovations. The smaller, self-contained households of the new model still share central services and amenities. Even with a higher percentage of private rooms and households of 16-20 residents, it’s still proving to be too many residents. If households are still physically connected, it really doesn’t matter if it’s 16 or 60. The shared common areas are now a conduit for infection. I have seen several projects – skilled and assisted living – where the virus has easily spread from household to household.
The high-rise has similar problems. Yes, you can segregate the floors, but it is impossible to do away with the central core, specifically elevators and stairwells.
Continuing Care Retirement Communities (CCRC)
Our CCRC’s have another set of issues. Most campuses are like small towns made up of hubs and spokes, each serving a different level of care. Shared amenities promote social interaction, not distancing. The connectivity between buildings, in many cases back-of-house, is operationally more efficient. Although the most deaths occur within the higher levels of care like skilled nursing, COVID-19 on a campus brings business as usual to a stop. Independent living residents are either sheltering in place or quarantined in their rooms.
The social interaction and connectivity that was so important for viability of the CCRC is now the conduit for infection. Although we do not see large numbers of people dying in independent living, the shelter in place has resulted in isolation, loneliness, depression and significant loss to quality of life.
Green House Model
The green house model seems to be faring better with key components being the small size and limited connectivity. Before the pandemic, connectivity was vital. The biggest challenge the green house model faced was always its lack of connectivity. However, now the lack of connectivity could be vital for infection control. The 10 residents and staff can practice better social distancing, and there is only one entrance and one exit for each home. Each household is already designed to be self-sufficient, and the ability for both residents and staff to shelter in place is easily achievable.
Pocket Neighborhood Model
I think the pocket neighborhood has great potential. Patio homes clustered around shared common space with in-home services emphasizes social interaction and connectivity but through outdoor space. During this stressful time, one of the positive takeaways is seeing more people reconnect with the outdoors.
To envision how the pocket neighborhood would work, just think of social distancing guidelines. It would be very easy to keep a six-foot distance and have good quality of life in the pocket neighborhood model. No shared entry, just a shared wall. Visual, not physical, connection to all your neighbors with the clubhouse as the point of contact for services and news.
Naturally Occurring Retirement Communities (NORC) and Home Health
Better serving our Naturally Occurring Retirement Communities (NORC) is an age old idea that has never caught on with developers, operators or architects due to a lack of high profit margins in renovating small homes and neighborhoods to be connected and elder friendly. And, until COVID-19, operators saw little benefit in a scattered site concept with no reimbursement. However, during the pandemic, the very small project (4-plex, duplex and/or single family home) could be the safest place to be. Many providers are already moving towards bringing the care to the resident, not the resident to the care.
So how can we make NORC’s pocket neighborhoods? My dream project, even before COVID-19, was to develop an existing older neighborhood into a pocket neighborhood community. The neighborhoods already exist naturally, and many are located near existing senior communities.
To get started:
- Identify neighborhoods with an older population base and a dense concentration of single family or duplex homes with general accessibility and potential neighborhood buy-in.
- Develop a master plan that defines borders and identifies homes that lend themselves to aging in place as well as those for major renovation or demolition
- Create key amenities such as zero lot line, accessibility upgrades, shared outdoor common space and clubhouse. The integral part of the pocket neighborhood is the clubhouse, which is the modern term for senior center. A clubhouse can change programming and activities to reflect the needs at the time.
- Facilitate neighborhood buy-in with mutual benefits, such as having the operator pay for home improvements and some services, to allow senior adults to stay in their home longer, in return for the ultimate gift of their house.
The pocket neighborhood would allow seniors to have convenient access to care but be able to stay in their homes longer and still benefit from shared social amenities.
At this point, it’s still too early to determine COVID-19’s full impact on the future of senior living design. Not everyone can go out and build green houses or a pocket neighborhood model before the next pandemic. However, as communities continue to overcome challenges, we begin to see a glimpse of what senior living care may look like post COVID-19.