Long Term Care Administration

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Long Term Care Administration

• Thursday, March 26, 2009
• Week 12 - Chapter 8
• Environmental Design

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Dr. Powell Lawton

• Gained national attention in the early 1960's for
  his pioneering investigations into the
  psychological and social aspects of aging. During
  his prolific career, he was the first to
  recognize the importance of designing living
  environments for the elderly, particularly those
  with Alzheimer's Disease.
• His groundbreaking studies of the needs of
  Alzheimer's patients and their caregivers, as
  well as his continuing interest in probing areas
  of health and well-being in aging, have continued
  to play a major role in enhancing the quality of
  life of the elderly.

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Environmental Design

• Six Phases Design Process
• Predesign programming.
• Design phase.
• Construction phase with concurrent planning.
• Design review.
• Activation
• Post occupancy evaluation.

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Cost-Effective Design

• Unit configuration to efficiently assign space
  for job-related activities such as record
  keeping, staff meetings and family communication.
• Distances to be travelled so that time used to
  transport residents, food and linen is minimized.
• Processes required to maintain floor, bathrooms,
  furnishings and walls

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Cost-Effective Design, cont

• Allocation pf time to morning care, dining,
  bathing and toileting.
• Bathroom design and equipment.
• Noise associated with group meetings, visits and
  documentation.
• Light glare.

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Unit Configuration

• Wages largest budget item, time money
• Functional arrangement of spaces that are
  appropriate for the population served and
  activities is the basic cost-saving measure.
• Minimize hallway lengths.
• Minimize distances between service areas, storage
  areas and resident rooms.

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Designing Space for Job-Related Activities

• The presence of a large central nursing desk
  gives the message that staff are more important
  than residents.
• Staff can do charting in lounges, kitchens,
  dining areas, while sitting with residents who
  require supervision and monitoring.
• Space still needed for computers, meetings,
  medications, supplies, etc

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Designing Space for Job-Related Activities

• Integrating workspace within the residents
  environment accomplishes two goals
• Encouraging the resident and staff to develop a
  relationship.
• Allowing staff oversight of resident activities.

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Designing Space for Job-Related Activities

• Storage space is often overlooked.
• Unused wheelchairs, lifts, equipment.
• No storage in hallways.
• Tripping and hazard during an evacuation.
• Clutter is time-wasting.
• Obliterates an aesthetically appealing décor.

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Designing Space for Job-Related Activities

• Resident laundries, snack kitchens, extra dining
  room, scaled for family celebrations, adequate
  number of lounges.
• Encourage residents to be independent and
  encourage families to participate in care.
• Can also reduce staff workload.

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Transport Time

• Food and linen transport time has a direct impact
  on costs.
• Shorter distances between resident rooms, dining
  and activities areas
• Small kitchens on units
• Cost analysis should be done to determine whether
  centralized or off-site laundries or food
  preparation is more or less costly than unit and
  in-house services.

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Maintenance Processes

• Time taken to maintain floors, bathrooms,
  furnishings and walls is just as important as the
  initial cost.
• Vinyl floor will outlast carpet 10 times over.
• Carpet easier and less costly to maintain.
• Consider the cost of equipment, supplies and
  labour costs to maintain flooring.

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Time-Consuming Care

• Private rooms and well-designed ensuite bathrooms
  with good equipment can be cost-effective, staff
  work more efficiently.
• Cupboards in the wall between each residents
  bathroom and bedroom.
• Store supplies for the resident where both staff
  and residents can easily obtain them.

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Time-Consuming Care

• Dining arrangements allowing residents to be less
  dependent on staff, promote self-care are
  cost-effective.
• Short travel distances, decrease the need for
  staff to transport seniors.
• If food service arrangements encourage seniors to
  serve themselves, less staff will be required.

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Toileting and Bathroom Design

• Big space for two staff members on either side of
  the resident who cannot self care.
• Residents should be able to see the bathroom from
  their bed.
• Nightlight that highlights the bathroom.
• Grab bars assistive devices independence
• Bathing area hand held showerhead, controls on
  the showerhead end.
• Proper drain for incontinence and pericare.

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Noise Control

• Effective noise abatement reduces resident and
  staff agitation.
• Auditory systems of seniors limits their ability
  to hear conversations with background noise.
• Noise levels in the dining, nursing, foyer, and
  lobby areas are directly related to resident
  behaviours and agitation.

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Noise Control

• Noise reduction coefficient (NRC) is a scaler
  representation of the amount of sound energy
  absorbed upon striking a particular surface.
• An NRC of 0 indicates perfect reflection an NRC
  of 1 indicates perfect absorption.
• Minimize sound control by sound-absorbent
  materials on flooring, window coverings and walls
  such as book cases.

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Noise Control

• Fans, heating ventilation air conditioning (HVAC)
  ice machines, cleaning equipment, elevators,
  electrical devices.
• Table coverings, felt gliders reduce noise.
• Public address systems only used for emergencies.
• Staff use hand held remote phones including for
  staff to resident communication such as nurse
  call systems

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Spaces for Natural Interaction and Noise Abatement

• Good interpersonal space design for conversations
  and interactions.
• Chairs are often lined up in a row.
• Smaller lounges, hallway alcoves, residential
  furniture arrangements.
• Small clusters where 3-4-6-8 can sit facing
  eachother.
• Quiet rooms are helpful.

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Spaces for Natural Interaction and Noise Abatement

• Televisions should be limited to specific areas
  and purposes.
• Televisions, inhibit conversations.
• Dementia residents have difficulty distinguishing
  reality from the television screen, it triggers
  behaviour problems.
• Adequate seating is needed in hubs.
• Lounges, meals, movies, music, relaxation

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Nurses Stations

• Assisted living settings have reception areas
  rather than formal nurses stations.
• Welcoming centre for information and informal
  conferences.
• Influence interactions and encourage face-to-face
  communications.
• Low counter tops, home design.
• Staff lounges or meeting areas for short breaks
  or private conversations.

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Light and Glare

• 300 lux level minimum average illumination (50
  foot candles)
• Each bedroom must, in the opinion of the medical
  health officer, have sufficient natural or
  artificial illumination to provide task or
  reading, bathroom and general illumination
  sufficient to meet the needs and preferences of
  each person in care accommodated in the bedroom
  (ACR).

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Light and Glare

• Artificial and natural light can cause resident
  anxiety and irritability.
• Shiny areas on floors wet falls.
• Reflection in mirrors, windows, glasslike
  surfaces ambiguous images illusions.
• Mate surfaces reduce glare, distortions and
  paradoxical images.

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Safety and Security Systems

• Prime directive safety and security.
• Exit control, fire safety, falls prevention,
  poison control, issues in LTCF.
• Perimeter security systems monitor all exit doors
  magnetic locks and wander guard.
• Oakfield Estates beds, toilets, residents are
  monitored by sensors providing info to central
  database on weight, vitals, sleeping and exact
  location.

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Comparing Costs of Building and Renovating

• Hiatts Analysis includes capital, operational
  costs (new staff, lost days), interim costs
  (catering), compliance (asbestos removal),
  contingency funds.
• Life cycle useful life of a building in terms of
  materials, systems and spaces.
• Non-profit 30 60 years.
• Three categories of expenditures
• capital costs, consumables, labour.

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Design Issues

• Six Specific Issues in LTCF Design
• Accessibility and Aides.
• Safety
• Colour-contrast and brightness
• Redundant Cuing
• Lighting and Communication
• Control Systems

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Accessibility and Aids

• Principle design feature is accessibility.
• LTCF should be wheelchair accessible.
• Sidewalks, parking areas, steps curbs.
• Light switches, electrical outlets, work surfaces
  and sinks may not be accessible for persons in
  wheelchairs.
• More accessibility more independence and more
  capability for self care routines.

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Other Safety Considerations

• Dark areas on floor are holes and shiny areas are
  wet or icy for dementia resident.
• Contrasting colours poor design.
• Bright lighting dark patches poor design.
• Venetian blinds are not advisable.
• Translucent shades of continuous cloth, ok
• Transparent blinds should be avoided.

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Colour Contrast and Brightness

• Colours appear faded for seniors.
• Blue and green cannot be distinguished as the
  cornea of the eye yellows with age.
• Signage large enough to read and text contrasting
  with the background.
• Signs are not just labels, they are wayfinding
  tools.
• Signs should be placed at decision points.

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Redundant Cuing

• Using multiple cues together that appeal to
  different senses.
• Sensory loses of the elderly include vision,
  hearing, olfaction, skin sensitivity, joints and
  muscle feedback.
• Example, dining room signs, words, symbols,
  special lighting, smell of fresh bread wafted
  outward by fans.

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Lighting

• Uniform, indirect, variable intensity lighting
• Night lighting highlight the toilet.
• Rope lighting under the handrails.
• Wall scones for indirect light.

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Communication Systems

• Phones in resident rooms.
• Computers and internet access.
• Call systems link staff with residents.
• Staff can use pull cords to get assistance.
• Flashing strobe lights for emergency system for
  the hard of hearing.

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Air Quality Control Systems

• Circulate and change air regularly.
• Eliminate noxious odors.
• Continence products, deodorizers, eliminate any
  odors caused by bodily wastes.
• Adjust air pressure, positive and negative, can
  improve air quality.
• HVAC system

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Accessing the Environment

• PEAP Professional Environmental Assessment
  Protocol
• Maximizing awareness and orientation
• Maximizing safety and security
• Providing privacy, stimulation and coherence
  (regulation), and stimulation and coherence
  (quality)
• Supporting functional abilities

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Accessing the Environment

• PEAP, cont
• Providing opportunities for personal control,
  continuity of the self.
• Facilitating social contact.

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Impact of a Consumer-Oriented Model of Care on
Design

• Support or inhibit choice.
• Individuality
• Independence
• Privacy
• Dignity
• Residential atmosphere
• Feelings of security
• Control over the environment

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Assisted Living Settings

• Regnier definition a long term care
  alternative that involves the delivery of
  professionally managed personal and health care
  services in a group setting that is residential
  in character and appearance, it has the capacity
  to meet unscheduled needs for assistance, while
  optimizing residents physical and psychological
  independence.

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Assisted Living Federation of America

• Largest national association exclusively
  dedicated to professionally-operated assisted
  living communities for seniors. ALFA's
  member-driven programs promote business and
  operational excellence through national
  conferences, research, publications and executive
  networks. ALFA works to influence public policy
  by advocating for informed choice, quality care
  and accessibility for all Americans seeking
  assistance with long-term care.

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Assisted Living Federation of America

• COMMUNITY SYSTEMS
• INFRASTRUCTUREA Place in the Action BY ANYA
  MARTIN Placing common areas off the main
  circulation route is just one example of how
  architects are looking at how today's seniors use
  common spaces. Spaces and flow planning are based
  on the behavioral needs and desires of residents.

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Homelike Settings

• If the photos of a long term care facility can be
  mistaken for a family home, then the setting has
  achieved a homelike environment.
• Begins with the exterior façade, residential
  scaled porches, window details.
• Look more like family residences than hospitals.

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Dignity

• Design provides for private ensuite bathrooms
  which are safe and accessible.
• Staff respond with respect and courtesy.
• Care plans and activities acknowledge uniqueness.
• Residents are addressed by their proper names at
  all times.
• ADLs assistance promotes independence and choice.

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Privacy

• Central social need, more important when people
  live in a congregate setting.
• Individual space, permit emotional adjustment
  when confronting a barrage of personal and social
  stimuli.
• Private rooms a must.
• Decorated to ones own taste with familiar
  furnishings, personal taste and style.

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Individuality

• Heterogeneous in care and therapy needs.
• Resident focused care models with individualized
  assessments.
• Rooms should be large enough to permit more than
  one furniture arrangement.
• Space should allow for their own photos,
  treasures, and clothing.
• Locked area for seasonal storage.

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Choice

• Better well being, less use of daily assistance,
  social and recreational activities, integration
  within the community.
• Environment controls for heating, lighting,
  fresh air in residents rooms.
• Choice in whom they associate.
• Dining room table mates.

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Independence

• Reduced travel distance enhances independence.
• Bathing spaces in ensuite bathrooms.
• Wheel-in showers, hi-low bathtubs.
• Care of animals plants Eden Alternative, self
  maintenance, helping eachother, taking
  responsibility, resident independence is fostered
  Quality of Life.

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Investigating Consumer and Staff Views into the
Design Process

• Design objectives and reduction of users
  anxieties regarding change.
• Reduction in errors that would lead to increased
  construction costs.
• Encouragement of positive attitudes.
• Creation of a sense of community.
• Opportunity to reassess organizational dynamics
  and policies.
• Identification of design features important to
  residents and visitors.