COVID + Care Homes: John McAslan + Partners and Architects Foundation Fellowship Report by Melissa Smith

STRATEGIES FOR PROMOTING HIGH-QUALITY, PANDEMIC-CONSCIOUS DESIGN MELISSA SMITH

university of kansas

MIKE LIDWIN

university of tennessee: knoxville advised and funded by:

John McAslan + Partners Architects Foundation

STRATEGIES FOR PROMOTING HIGH-QUALITY, PANDEMIC-CONSCIOUS DESIGN MELISSA SMITH

university of kansas

MIKE LIDWIN

university of tennessee: knoxville advised and funded by:

John McAslan + Partners Architects Foundation

CONTENTS

executive summary

the global context timeline

the scottish condition

literature analysis

lessons from existing care homes

[ CASE FILES ] analysis of holistic care-home models global examples De Hogeweyk Caleb Hitchcock Memory Care Neighborhood Jin Wellbeing County Belong Atherton Neptuna Development [ CASE FILES ] analysis of user experience Life Care Center, Kirkland Spokane Veterans Home Issaquah Nursing and Rehabilitation Center Regency Canyon Lakes Rehabilitation & Nursing Queen Anne Healthcare

31 33 37 39 41 43 45

47 49 51 53 55 57

[ CASE FILES ] twenty-one american care homes informational chart comparison of green spaces

conclusions + reflections

sources works cited dataset sources image citations

bio + acknowledgments

appendix Other Quality Care Schemes of Note Presentation slides

61 63

69 73 75

83 85

2020 ARCHITECTS FOUNDATION/McASLAN FELLOWSHIP

EXECUTIVE SUMMARY Although our context of care homes largely stems from our local neighborhood communities and countries, the elderly population is increasing all over the world, making the study of care homes a global focus for architecture. In considering new care home design, issues of affordability, sustainability, innovation, resident-centered design, health and safety, and integration into the larger community and landscape become important criteria on which to assess care home performance. The goal of this report is to create a resource between John McAslan + Partners and an upcoming built project that seeks to interpret and apply understandings of care home design during the coronavirus pandemic. It includes high quality case studies of care homes as well as lessons learned from care homes that were not successful at limiting the spread of coronavirus in their facilities – seeking solutions to prevent future outbreaks in these potential new care home facilities. Future pandemics and care home infections may be inevitable, but future challenges of care home facilities can be anticipated through thoughtful design. Care home design doesn’t just involve the floor plan of units, but a complete reexamination of the specific rooms, communal spaces, outdoor areas, and connections to community. Moving forward in the age of a global pandemic, it becomes even more necessary for care home design to incorporate interdisciplinary dialogue among designers, specialists, users, and the community. Through our research, we hope to draw to light the successes and lessons of care home design in the United States, Scotland, and the entire world.

1. GLOBAL CONTEXT Privately-funded care homes seem to have more coronavirus-related deaths, likely due to the limitations of private funding that encourage conserving resources during the pandemic. COVID-19 deaths in care homes were linked to a variety of factors, including preexisting conditions like dementia.

4. HOLISTIC CARE HOME MODELS Five exceptional case studies from around the world offered six principles to consider in care home design: a village design scheme, a small household layout, resident-centered design principles, thoughtfully designed outdoor spaces, technological innovation, and the use of sustainable design techniques.

2. THE SCOTTISH CONDITION 1/2 of COVID-19 deaths in the UK involved care homes. In Scotland specifically, 38% of COVID-19 deaths were related to care homes. As of May 2020, 60% of Scottish care homes had at least one case. Smaller care homes had lower rates of infection.

Narrative accounts captured from online blogs, news articles, and Care Home Facility websites helped paint a picture of life in care home facilities during the COVID-19 pandemic. They highlighted an importance for care home design to consider adaptable programs, signage and materials, outdoor spaces, accessible common spaces, and administrative policies.

3. LITERATURE REVIEW Care home design should strategize in two ways: short-term + long-term. Categorizing care homes into zones and gradients can be especially important, including site context.

EXECUTIVE SUMMARY

WUHAN

SEATTLE WUHAN

EDINBURGH EDINBURGH

FIG_1.01 (ABOVE) Positioning the Global Outbreak between the US and UK. (Lidwin + Smith via Hajime Narukawa Laboratory, 2020).

THE GLOBAL CONTEXT

49.5%

OF COVID-RELATED DEATHS IN CARE HOMES INVOLVED DEMENTIA *AS OF JUNE 2020

Although care homes have long developed policies for containing infectious diseases, COVID-19 has highlighted the specific challenges and inefficiencies caused by current policies and care home funding - urging designers to rethink how care home design occurs, and what finances generate such designs. The disproportionate amount of deaths in care home facilities in the US and UK present an additional problem: privately funded care homes tend to have more coronavirus-related deaths. This is likely due to companies being forced to scale back and conserve resources during the height of the pandemic.

9.5

2020 ARCHITECTS FOUNDATION/McASLAN FELLOWSHIP

THE GLOBAL CONTEXT Throughout history, care home facilities have battled with containing infectious diseases and have adjusted policies throughout several global outbreaks such as the 19th century cholera epidemic that swept through the UK, or the 1918 Spanish Flu. 1 Like past histories of pandemics, the coronavirus quickly established an unwanted presence in care homes across the globe - earning the nickname of the American coronavirus “ground-zero,” coined by former US Centers for Disease Control and Prevention (CDC) director Tom Frieden. 2 In fact, as of mid-August 2020, care-homes in the United States experienced more than 45,958 of the 177,129 COVID-related deaths,3 reaffirming care home design as a much-needed area of focus during global pandemics. Even before COVID-19, the Center for Disease Control and Prevention (CDC) estimates that 1 to 3 million serious infections occur every year. 4

CORONAVIRUS + DEMENTIA What makes designing care homes in a post-pandemic future difficult is that COVID-19 has brought to light a lot of the challenges currently faced by care home design. For example, when comparing COVID-19 deaths to preexisting conditions, British researchers found that Dementia and Alzheimer’s disease was the most common main preexisting condition found among deaths involving COVID-19 and was involved in 49.5% of all deaths of care home residents involving COVID-19.5 These findings suggest that care home design needs to accommodate guidelines for infectious disease care, as well as better design for dementia. The two seemingly unrelated diseases go hand in hand when it comes to design responsibilities and considerations. CONNECTION TO MANAGEMENT + POLICIES In addition, both in the United States and in the United Kingdom, there were inadequate policies in place to manage a global pandemic. As of November 2019 in the United States, just months before the coronavirus pandemic began, care-home facilities were transitioning to new regulations from the Center for Medicaid and Medicare Services, which required all facilities to have a designated infection prevention specialist on staff. 6 These policies were largely still in trial mode, where staff of the care home were allowed to make assessments regarding the quality of their own care home, leading to several rating inflations and overlooked lapses. If some policies were already in place to prevent the spread of infections, how did the care homes contribute to over one-third of all the coronavirus deaths as of May 2020? 7

THE GLOBAL CONTEXT

CASES PER 1 MILLIO > 30, 000

10,000.1 - 30,0

1,000.1 - 10,00 100.1 - 1,000 0.1 - 100 0 / NO-DATA

SOURCE: World Heath

CASES PER 1 MILLION CITIZENS > 30, 000 10,000.1 - 30,000 1,000.1 - 10,000 100.1 - 1,000 0.1 - 100 0 / NO-DATA SOURCE: World Heath Organization

FIG_2.01 (ABOVE) Cases per 1 Million Citizens (World Health Organization, 2020).

2020 ARCHITECTS FOUNDATION/McASLAN FELLOWSHIP

FUNDING Part of that answer comes from a lack of funding. For example, in Scotland, Dr. Nick Kempe writes: “there has been a continuing decline in trained medical staff and a rise in unfilled nursing vacancies (52 per cent of private sector Care Homes have nursing vacancies, compared to 15 percent in the voluntary sector). There is little formal training for Infection Control for nonmedical staff in Care Homes.” 8 Countries who have greater private ownership of care homes, saw a larger percentage of care home deaths - perhaps the most alarming being Australia, given how well the country had done in other areas of pandemic control. According to Sophie Cousins in the World Report, the 1997 Age Care Act in Australia separated elder care from health care, causing a free market situation that forces companies to cut costs during times of the pandemic. 9 This cut in funding became especially apparent during the coronavirus outbreak and possibly increased COVID-related deaths in care homes. Aside from statistics on coronavirus deaths, several policies in place are being challenged now for their anti-humanitarian approach to the pandemic. In Scotland, Dr. Kempe cites this problem as care facilities not prioritizing the mental health of care home residents to the same extent as immune health. For care homes across the world, policies encouraged residents to go on lock down, scaring the elderly population into “being told or knowing that they would be likely to die before seeing family members again.” 10

COVID-19 DEATHS IN CARE HOMES

COUNTRIES WITH MORE THAN 1 000 REPORTED COUNTRIES WITH MORE THAN 1 000 REEPORTED COVID-19 DEATHS IN CARE HOMES

PERCENTAGEOF OFCOVID-19 COVID-19 DEATHS PERCENTAGE DEATHS ATTRIBUTED TO CARE HOMES PER PER COUNTRY COUNTRY ATTRIBUTED TO CARE HOMES (AS OF OCTOBER 2020) (AS OF OCTOBER 2020) Canada

80%

Spain

63%

Belgium

61%

France

46%

Sweden

46%

USA

41%

Germany

39%

Israel

39%

Britain

36% 0

20%

40%

60%

PERCENTAGE OFDEATHS DEATHS PERCENTAGE OF

80%

FIG_2.02 (LEFT) Percentage of COVID-19 Deaths Attributed to Care Source:Homes LTCCovid + The WashingtonPost (LTCCOVID via Reformatted from: The Washington Post The Washington Post, 2020).

“Only countries with more than 1,000 [reported] covid-19 deaths [in care homes (as of 16 October 2020)] were shown.” - Washington Post

THE GLOBAL CONTEXT

TIMELINE During 2020, the initial global response to the coronavirus pandemic involved a rush to understand the situation and gather statistics. Throughout the year, policies that prohibited visitation in care-homes were re-examined, as months of lock-down began to reveal the psychological and social detriments that COVID isolation policies had on residents. The fall of 2020 signals a new, much needed focus on care home design, where medical policies to prevent infections merge with social needs of residents. For example, in October 2020, the CDC reexamined their definition of “compassionate care” visitation in care-homes to expand beyond just end-of-life visits. 11 A financial investment of both countries in their care home sectors, in addition to this reexamination of care home needs, presents a needed exploration for architects and designers to join the conversation of care home design. NOTES 1

Wilson, Chris. “‘The Spread of the Pestilence’: A History of Pandemics and Care Homes.” The Independent, Independent Digital News and Media, 25 May 2020.

Barnett ML, Grabowski DC. “Nursing Homes Are Ground Zero for COVID-19 Pandemic.” JAMA Health Forum. 24 March 2020. doi:10.1001/jamahealthforum.2020.0369

Engelhart, Katie. “What Happened in Room 10?” The California Sunday Magazine, Pop-Up Magazine Productions, 21 Aug. 2020.

Centers for Disease Control and Prevention. “Long-Term Care Facilities.” Centers for Disease Control and Prevention, US Department of Health and Human Services, 22 June 2020.

Taylor, Adam. “As COVID-19 Cases Surge, Global Study Paints Grim Picture for Elder-Care Homes.” The Washington Post, WP Company, 16 Oct. 2020.

Provista. “Infection Preventionist Mandate for LTC Takes Effect.” Provista, Provista, 30 Sept. 2019.

Kempe, Nick. “The Predictable Crisis - Why COVID-19 Has Hit Scotland’s Care Homes so Hard.” Common Weal, 20 May 2020. 4.

Centers for Medicare &amp; Medicaid Services [CMS]. “Press Release CMS Announces New Guidance for Safe Visitation in Nursing Homes During COVID-19 Public Health Emergency.” CMS, 17 Sept. 2020.

2020 ARCHITECTS FOUNDATION/McASLAN FELLOWSHIP

A TIMELINE OF THE VIRUS

NOV. 17 earliest potential tracing of known coronavirus case Wuhan, China

DAILY CASES

800k

600k

JAN. 31 confirmed first cases in United Kingdom

MAR. 11 WHO declared COVID-19 a global pandemic

400k

JAN. 25 confirmed first cases in Australia + Canada

FEB. 29 first outbreak in a US care-home facility reported Life Care Center: Kirkland, Washington

JAN. 25 confirmed first cases in United States

APR. 21 52% of coronavirus deaths occur in care-homes Scotland, UK

JAN.

FEB.

2019 2020

MAR. 20 First care home death reported United Kingdom

200k

DEC.

FIG_2.03 (ABOVE) Timeline of the Virus (Lidwin + Smith, 2020).

MAR. 19 adult social care included in UK funding to local municipalities (totalling €1.6 billion) United Kingdom

MAR.

MAR. 27 The Coronavirus Aid, Relief, and Economic Security (CARES) Act is passed (totalling $2.2 trillion) United States

APR.

MAY

APR. 11 USA surpasses Italy for most coronavirus deaths APR. 04 WHO reported that over 1 million cases of COVID-19 had been confirmed worldwide APR. 02 specific procedures and guidance established for the care home residents during the pandemic United Kingdom

THE GLOBAL CONTEXT

MAY 09 New York Times publishes data linking 1/3 of all COVID-19 deaths to care home facilities United States MAY 13-15 care home support package of €600 billion United Kingdom

JUL. 10 CMS announced it will deploy Quality Improvement Organizations (QIOs) across the country to provide immediate assistance to nursing homes in hotspot areas. United States

JUN. 16 care-home contribute over 40% of covid-19 related deaths United States JUL. 03 report released, connecting Dementia and Alzheimer as the most common main pre-existing condition among deaths involving COVID-19 (49.5% of all deaths of care home residents involving COVID-19) England, and Wales, UK

OCT. 18 “Scotland Loves Local” grant is approved to fund small-scale projects that motivate responsible community interaction while maintaining public safety guidelines. Scotland, UK

AUG. 25 CMS established a national nursing home training program for frontline nursing home staff and nursing home management. United States

NOV. 02 £15 million funding package to respond to children/young people’s mental health issues (with a focus on those brought about by the coronavirus pandemic.) Scotland, UK

world

NOV. 04 record 100,000 new daily cases of coronavirus United States NOV. 05 Second lockdown initiated United Kingdom

US UK

JUN.

JUL.

SEP.

OCT.

NOV.

DEC.

COVID STATISTIC first outbreaks + first records

MAY 20 US Dept of Health and Human services releases COVID-19 Relief for Skilled Nursing Facilities (totalling $4.9 billion) United States MAY 13 The Center for Medicare and Medicaid Services (CMS) published a toolkit of recommendation s and best practices for care homes United States

AUG.

CARE HOME REPORTS key findings for care homes POLICY UPDATES + proposed updates for care homes FUNDING FOR CARE HOMES indication that care home design is increasingly important as more funds are directed to their facilities

JULY 06 corona-virus related deaths surpass 130,000 United States

60 THE SCOTTISH CONDITION

60%

OF SCOTTISH CARE HOMES HAD AT LEAST ONE CASE OF COVID-19 *AS OF SPRING 2020

The problem we set out to solve was that Scottish care homes are disproportionately affected by the coronavirus pandemic. One half of COVID-19 deaths in the UK were tied to care homes, and in Scotland 60% of their care homes had at least one case of COVID-19 as of May 2020. Since Scottish care homes were affected by the pandemic more than any other Scottish business or residence type, we believe the design of care homes needs to be researched and then altered to better adapt to a pandemic scenario.

2020 ARCHITECTS FOUNDATION/McASLAN FELLOWSHIP

THE SCOTTISH CONDITION

The U.K. has an ageing population, meaning the ratio of older adults to younger adults and children is shifting towards the older adults. Specifically, Scotland’s population is aging more rapidly than the general U.K. population. Scotland has a total of 1,080 care homes, 815 of which are designated for older adults.1 Most Scottish care homes are commercial entities, 2 which have been experiencing concerning issues for years now – some of which are tied to policy and economics, others to design and the built environment. Prior to the COVID outbreak, roughly 25% of Scottish care homes would have been deemed unable to properly protect people in the event of a pandemic, 3 but only now are actions being taken to address this issue. Resident isolation, poor design, and lack of government regulation during the pandemic negatively impacted the residents and staff, putting thousands at risk. The public care home sector is decreasing in Scotland, being overtaken by the private care home sector. Between 2006 and 2016, the number of registered care homes in the public sector decreased by 28% while the number of care homes in the private sector increased by 7%.4 This posed problems during the COVID-19 pandemic because there was a lack of governmental regulation in the care home sector. Many private care homes were left alone to determine how best to control the spread of the virus through their facilities, meaning each care home had different regulations in place. Towards the end of the spring, the Scottish government took control and set in some universal regulations but by that point the virus has spread through many care homes all across Scotland. As of May 2020, roughly 60% of Scottish care homes had at least one case of COVID-19. 5 Additionally, 7.4% of care home staff have been absent due to COVID-19 compared to just 4% of National Health Service (NHS) staff. 6 This implies that private care homes have had a tougher time controlling the spread of the virus through their facilities than public care homes. As of January 27, 2021, 17% of adult care homes had a current case of suspected COVID-19. 7 COVID-19 has swept through Scottish care homes at a far higher rate than any other businesses or health facilities, and, due to the frailty of the residents, has resulted in alarming death tolls. While one third of U.S. COVID-19 cases were nursing-home related 8 a distressing 38% of COVID-19 deaths in Scotland were related to care homes since the start of the pandemic until Jan 31, 2021. 9 The cause of these high numbers, according to the Scottish Government’s study on the matter of COVID in care homes, is related to a number of factors. One factor is that elderly individuals may not present the same symptoms as adults and youth, such as persistent cough or high temperature. Rather, the elderly tend to exhibit symptoms of “loss of appetite or smell, vomiting and diarrhea, shortness of breath, falls, dehydration and increased confusion, delirium or excessive sleepiness.” 10 Educating staff and others in the community to be more aware of the variety of symptoms could assist in identifying an infection sooner and thus being able to stop it from spreading to more people. Care home size and occupancy were other factors contributing to high COVID rates in care homes cited in the report. Smaller care homes of 20 or fewer residents and care homes that were at occupancy levels significantly lower than their capacity had fewer rates of infection. 11 As designers, we should consider designing more small-scale and spacious care homes, allowing residents to physically distance themselves from one another even when capacity is reached. The built environment of the care homes presented its own unique challenges and dangers during the peaks of the COVID pandemic. Ventilation was a key issue discussed in the Scottish Government’s report, stating that indoor areas with poor or no ventilation cause serious health risks and can increase

THE SCOTTISH CONDITION

CUMULATIVE PERCENTAGE (%) OF SCOTTISH CARE HOMES WITH SUSPECTED COVID-19 CASES (BY LOCAL AUTHORITY)

local authority

20 17 2

7 4

5 31 9 25 16 11 21

14 32

22 29

8 28

CUMULATIVE PERCENTAGE (%) OF SCOTTISH CARE HOMES WITH SUSPECTED COVID-19 CASES BY LOCAL AUTHORITY

percentage

1. Aberdeen City 2. Aberdeenshire 3. Angus 4. Argyll & Bute 5. Clackmannanshire 6. Dumfries & Galloway 7. Dundee City 8. East Ayrshire 9. East Dunbartonshire 10. East Lothian 11. East Renfrewshire 12. Edinburgh, City of 13. Eilean Siar 14. Falkirk 15. Fife 16. Glasgow City 17. Highland 18. Inverclyde 19. Midlothian 20. Moray 21. North Ayrshire 22. North Lanarkshire 23. Orkney Islands 24. Perth & Kinross 25. Renfrewshire 26. Scottish Borders 27. Shetland Islands 28. South Ayrshire 29. South Lanarkshire 30. Stirling 31. West Dunbartonshire 32. West Lothian

50% 59% 53% 78% 64% 47% 73% 64% 83% 68% 85% 73% 40% 47% 74% 71% 60% 55% 79% 75% 54% 76% 13% 65% 81% 54% 60% 81% 66% 57% 50% 48%

6 MAP: GROS, 1998 DATA: Scottish Gov’t, 2020

FIG_3.01 (ABOVE) Percentage of Scottish Care Homes with COVID-19 Cases by Local Authority (Lidwin + Smith. 2020).

2020 ARCHITECTS FOUNDATION/McASLAN FELLOWSHIP

the spread of COVID-19. 12 As winter drags on and temperatures are low, it’s critical that we address these ventilation concerns with both passive and active systems, such as operable windows to fresh air and more efficient HVAC systems. By ratio, Scotland has seen more care home related deaths than the rest of the U.K. This is due to a variety of issues including lacking consensus regarding COVID policies and guidelines, poor design choices, and untrained and strained staff. To learn from mistakes and resolve this issue in the future, we should look to existing care homes that have performed better before and during COVID and overall. We can analyze these better-performing care homes based on a variety of disciplines and principles, then take inspiration from these international care home models to design a better, higher quality, safer care home for Scotland. It is important that designers not only consider the physical impacts of COVID and the built environment on the health of the residents, but also the mental impacts of isolation and anxiety, as these can be just as detrimental to resident health. The following research examines care homes from several disciplines and proposes design guidelines for an improved approach. NOTES

Reilly, Jacqui, et al. “Care Home Review: A Rapid Review of Factors Relevant to the Management of COVID-19 in the Care Home Environment in Scotland.” Cabinet Secretary for Health and Sport, the Scottish Government. 3 Nov. 2020.

Ibid.

Kempe, Nick. “The Predictable Crisis - Why COVID-19 Has Hit Scotland’s Care Homes so Hard.” Common Weal, 20 May 2020.

“Care Home Census for Adults in Scotland.” A National Statistics Publication for Scotland, National Services Scotland, 25 Oct. 2016.

Kempe, Nick. “The Predictable Crisis - Why COVID-19 Has Hit Scotland’s Care Homes so Hard.” Common Weal, 20 May 2020.

Ibid.

Chief Medical Office Directorate, Scottish Government, 31 Jan 2021

Ibid.

THE SCOTTISH CONDITION CUMULATIVE AMOUNT OF SCOTTISH CARE HOMES WITH SUSPECTED CUMULATIVE OF SCOTTISH CARE HOMES WITH SUSPECTED COVID-19 CASESAMOUNT PER 1,000 REGISTERED PLACES BY SECTOR TYPE

(PER 1,000 CARE HOMES OF THAT TYPE)

AMOUNT OF CARE HOMES (PER 1,000 CARE HOMES OF THAT TYPE)

AMOUNT OF CARE HOMES OF CAREOF HOMES (PER 1,000AMOUNT CARE HOMES THAT TYPE)

200

COVID-19 CASES PER 1,000 REGISTERED PLACES BY SECTOR TYPE CUMULATIVE AMOUNT OF SCOTTISH CARE HOMES WITH SUSPECTED COVID-19 CASES PER 1,000 REGISTERED PLACES BY SECTOR TYPE

TYPE OF CARE HOME

private TYPE OF CARE HOME

180

200

public private

160

180

public voluntary/ not-for-profit voluntary/ not-for-profit

140

160

120

140

100

120

100

. PR

.A 10 20

. PR

.A 16 20

. PR

.A 23

. PR

.A 23 20

. PR

.A 30 20 20

. AY

.M 07

0 0 20 20 20 20 02 02 20 .20 .20 .20 L.2 L.2 N. UN UN UN JU JU J J J . . . .JU . . 7 4 9 1 16 0 23 0 30 20 20 20 20 20 20 .20 .20 .20 .20 .20 .20 . . . L L Y Y N N N N N A A (REPORTS U U TIME TAKEN WEEKLY) U U U U U J J J J J J J M M . . . . . . . . . 14 07 16 14 TIME21(REPORTS 23 09 WEEKLY) 30 02 TAKEN 20

.20 AY

.M 07 20 20

.20 AY

.M 14 20 20

.20 AY

.M 21 20 20

.JU 02 0 2 20

TIME (REPORTS TAKEN WEEKLY)

ABOUT GRAPH 01: Voluntary / Non-for-Profit care homes performed better in containing COVID-19 outbreaks than did Privately- and Publicly-Funded care homes.

DATA: Scottish Gov’t, 2020* *Information obtained from the Scottish Government via the Care Inspectorate datastore: DATA: Scottish Gov’t, 2020* https://www.careinspec*Information obtained from the torate.com/index.php/publicaScottish Government via the tions-statistics/93-public/datastore Care Inspectorate datastore: https://www.careinspectorate.com/index.php/publications-statistics/93-public/datastore

PROPORTION OF DEATHS OF SCOTTISH CARE HOME RESIDENTS

PROPORTION OF DEATHSPROPORTION OF SCOTTISH CARE HOME RESIDENTS OF DEATHS OF SCOTTISH CARE HOME RESIDENTS INVOLVING PRE-EXISTING CONDITIONS INVOLVING PREEXISTING CONDITIONS INVOLVING PRE-EXISTING CONDITIONS (02 MARCH - 12 JUNE 2020) (02 MARCH 12 JUNE (02 MARCH - 12 JUNE 2020) 2020)

DIFFERENTIATION

DIFFERENTIATION MEN

Dementia + Alzheimer diesease

DEMENTIA +

Dementia + AlzheimerDISEASE diesease ALZHEIMER

WOMEN

MEN

Symptoms signs + ill-defined conditions

ILL-DEFINED CONDITIONS

WOMEN

No pre-existing conditions

Symptoms signs + ill-defined conditions

DATA:Sophie John, Office of National Statistics *https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articl es/deathsinvolvingcovid19inthecar esectorenglandandwales/deathso ccurringupto12june2020andregist eredupto20june2020provisional# pre-existing-conditions-of-care-h DATA:Sophie John, ome-residents

Ischaemic heart diseases

NO PREEXISTING CONDITIONS

Chronic lower respiratory diseases

ISCHAEMIC HEART

Influenza + pneumonia

No pre-existing conditions

Ischaemic heartDISEASE diseases

CHRONIC LOWER RESPIRATORY DISEASE

Chronic lower respiratory diseases

10%

20%

30%

40%

50%

60%

PERCENTAGE OF DEATHS INVOLVING COVID-19

esectorenglandandwales/deathso ccurringupto12june2020andregist

Influenza + pneumonia INFLUENZA + PNEUMONIA

10%

20%

30%

40%

50%

Office of

National Statistics FIG_3.02 (ABOVE) COVID Cases per Sector Type (Lidwin deathsandmarriages/deaths/articl es/deathsinvolvingcovid19inthecar + Smith, 2020).

REFORMATTED FROM THE *https://www.ons.gov.uk/peopleORIGINAL GRAPH:Sophie John, Officepopulationandcommunity/birthsof National Statistics

60%

PERCENTAGE OF DEATHS INVOLVING COVID-19 PERCENTAGE OF DEATHS INVOLVING COVID-19

ABOUT GRAPH 02: Dementia and Alzheimer’s Disease were the most common preexisting conditions amongst COVID-19 deaths in English and Welsh care homes. One or both of these conditions were involved in 49.5% of all care home resident deaths related to COVID-19.

FIG_3.03 (BELOW) eredupto20june2020provisional# pre-existing-conditions-of-care-h proportion of ome-residents deaths of care home residents REFORMATTED FROM THE involving ORIGINALCOVID-19 GRAPH:Sophie John, of preexisting National Statistics byOffice main condition, occurring from 2 March to 12 June 2020, registered up to 20 June 2020, England and Wales (Sophie John, 2020).

2020 ARCHITECTS FOUNDATION/McASLAN FELLOWSHIP

CUMULATIVE PERCENTAGE (%) OF SCOTTISH CARE HOMES WITH A SUSPECTED CASE BY SIZE CUMULATIVE PERCENTCOVID-19 (%) OF SCOTTISH CARE HOMES

PERCENTAGE OF CARE HOMES

WITH SUSPECTED COVID-19 CASESCASES PERCENTAGE OF CARE HOMES WITH COVID-19

PERCENTAGE OF CARE HOMES WITH COVID-19 CASES

WITH A SUSPECTED COVID-19 CASE BY SIZE

100% 90% 80% 70%

71% 63%

100% 60% 90%

80%

70%

50%

47% 71% 63%

50% 20%

30% 20% 10%

91%

87%

84%

40%

60% 30%

40%

91%

87%

CUMULATIVE PERCENT (%) OF SCOTTISH84% CARE HOMES WITH A SUSPECTED COVID-19 CASE BY SIZE

20%

47%

10% 0%

20%

BEDS 1-10

BEDS 11-20

BEDS 21-30

BEDS 31-40

BEDS 41-50

BEDS 51-60

CARE HOMES(GROUPED (GROUPED BY OF OF CERTIFIED BEDSBEDS OFFERED) CARE HOMES BYAMOUNT AMOUNT CERTIFIED OFFERED)

BEDS 60+

CARE HOMES (GROUPED BY AMOUNT OF CERTIFIED BEDS OFFERED)

70% or or more of care homes with more 70% more of care homes with more 70% or30 more of care homes more than beds had at least one case of than 30 beds had at least onewith case of coronavirus than 30 beds had at least one case of coronavirus DATA: Scottish Gov’t, 2020* coronavirus

*Information on care home size and the number of registered places obdatastore

DATA: Scottish Gov’t, 2020* Government via the Care Inspectorate tained from the Scottish https://www.careinspectorate.com/index.php/publications-stat*Information on care home size and the number of registered places obistics/93-public/datastore tained from the Scottish Government via the Care Inspectorate datastore https://www.careinspectorate.com/index.php/publications-statistics/93-public/datastore

ABOUT GRAPH 03: A more detailed breakdown of the COVID numbers shows that COVID-19 occurrences were even more common among larger care homes, especially in those with more than 30 beds.

QUICK STATS

7.4% OF CARE HOME STAFF HAVE BEEN ABSENT FROM ROUGHLY 7.4% ROUGHLY OF HOME STAFF ABSENT FROM WORKCARE DUE TO COVID-19, COMPARED TO ONLYHAVE 4% OF NHSBEEN STAFF WORK DUE TO COVID-19, COMPARED TO ONLY 4% OF NHS STAFF

ROUHGLY

6 OUT OF EVERY 10 SCOTTISH CARE HOMES HAS

ROUGHLY 6 REPORTED OUT OF AT 10LEAST SCOTTISH HOMES HAVE 1 CASE OFCARE COVID-19, AS OF MAY 2020REPORTED AT LEAST ONE CASE OF COVID-19 AS OF MAY 2020

THE SCOTTISH CONDITION

WEEKLY PERCENTAGE OF DEATHS IN SCOTTISH CARE HOMES LINKED TO COVID-19 (CONFIRMED OR SUSPECTED)

PERCENTAGE OF CARE HOME DEATHS PERCENTAGE OF CARE-HOME COVID DEATHS INVOLVING COVID-19 TO ALL OTHER CARE HOME DEATHS TO ALL OTHER CARE DEATHS

45% 40% 35% 30% 25% 20% 15% 10% 5% 0% JUNE 2020

JULY

AUGUST

SEPTEMBER

OCTOBER

NOVEMBER

DECEMBER

JANUARY 2021

TIME (REPORTS TAKEN WEEKLY)

DATA: Scottish Gov’t, 2020* *Information obtained from the Scottish Government via the Care Inspectorate datastore: https://www.gov.scot/publications/coronavirus-covid-19-additional-data-about-adult-care-homes-i n-scotland/

ABOUT GRAPH 04: Despite early lock down policies, as well as a late 2020 lock down in the United Kingdom, Scottish care homes experienced an increase in weekly COVID-19 cases from September 2020 through January 2021.

CARE HOMES + COVID (A YEAR IN REVIEW): NOV 30 - DEC 06: 269 new confirmed COVID-19 cases among UK care home residents DEC 09: 117 (11% of) adult care homes had a current case of suspected COVID-19.” E Since MAR 09: 6,377 confirmed cases of COVID-19 among UK care home residents at least 1/2 of UK COVID-19 deaths have been tied to care homes

FIG_3.04 (LEFT) Scottish Care Home Cases by Size (Lidwin + Smith, 2020). FIG_3.05 (RIGHT) Weekly Percentage of Scottish Care Home Deaths (Lidwin + Smith, 2020).

03 EXISTING LITERATURE + STRATEGIES

03%

OF SENIORS RESIDE IN CARE HOMES, BUT FACE DISPROPORTIONATE COVID RISKS *MASS. IN “DESIGNING SENIOR HOUSING FOR SAFE INTERACTION”

A literature review analysis of top architectural practices’ suggestions for pandemic-conscious design helped us think about care home design as both a short-term and long-term strategy. Of the various strategies promoted, categorizing care home design into zones and gradients became especially important, as was contextualizing the care home design to its site.

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EXISTING LITERATURE + STRATEGIES As the coronavirus pandemic required the world to adopt a new normal of virtual-offices, stay at home orders, and limited social interaction, architectural firms adjusted, too, using the delays in project timelines and funding to focus on pandemic research. In order to understand lessons learned from care-homes in Washington State, six organizations become a valuable background for architectural strategies to employ post-COVID. Summer 2020 publications from MASS Design Group, Lewis Tsurumaki Lewis (LTL), Foster + Partners, the Street Plan Collaborative, Eppstein Uhen Architects, and The American Institute of Architects (AIA) offered direct architectural strategies as a response to realtime statistics and changing CDC guidelines regarding the air-borne virus. Through the AIA’s webinar The Design of Healthcare Facilities Across Countries, Enrico Nunziata, founder of BCG Engineer, ordered these strategies into two categories: short-term considerations that seek to respond to the pandemic in real time, and the long-term considerations that will could have lasting guidelines for designing care-homes in the future. SHORT TERM VS. LONG TERM APPROACHES Nunziata distinguished the short term problems care homes faced, citing a lack of beds, feelings of isolation among patients, and identifying infected people. 1 In times of a pandemic, quick, often adaptable design solutions are needed, and can be accommodated for through designing extra storage space for beds or multi-purpose spaces (which could double as beds in the event of a pandemic), and designing safe spaces where patients or residents can meet with family and friends without risk of contracting a virus. Even the glass of a window becomes an adaptable design solution when it gets re-purposed as a partition during family visits. 2 In contrast, long-term issues had more systems-oriented solutions; rethinking paths and circulation, decreasing foot traffic by utilizing multiple buildings or entry points, and designing more flexible and easily-convertible areas. 3 During the coronavirus pandemic, it became increasingly more important that components of care homes served multiple functions. Features that were mobile and modular were the easiest to replicate and aggregate for adjusted programs, without sacrificing the integrity of the overall design, since modularity had been incorporated in the architectural design pre-pandemic. According to a document from the AIA outlining design strategies for senior living communities in the wake of the pandemic, another flexible element could be placing mobile dividers with cleanable, antimicrobial finishes in residents’ rooms. 4 These dividers would allow family or other residents to visit residents in their rooms more safely, and could easily be taken down once the visit is over. Outside visiting hours, the dividers could serve an additional function for sectioning off long hallways into smaller households with their own dining and activity areas. 5 This idea would not only make it easier to keep residents apart but also engaged with one another but also could be used to build a new facility based on a modular household scheme. Over time, households could be added, removed, or changed more easily with this modular concept. Modular design is also more cost effective, has faster production times, can be more sustainable because it optimizes resources and can be disassembled and reused or recycled into new modular pieces, and is high quality. 6

EXISTING LITERATURE + STRATEGIES

DESIGNATING MATERIAL Other firms wrote about the long-term effect that the placement of auxiliary programs or material choices can have in a care-home. For example, LTL highlights the ability for smooth materials to host stable coronavirus particles for longer periods of time than rough surfaces, 7 creating a summary of material guidelines to consider when renovating or constructing new spaces. Rather than adjust the material choice itself, MASS Design Group compliments LTL’s proposal by calling for a designation of materials. By “Make high-touch surfaces obvious with brightly colored non-porous materials such as paint, tape, or signage,” 8 care homes can better identity high-priority cleaning areas, while making residents more cognizant of the surfaces they touch. In both instances, the performative quality of materials is held accountable for its role in spreading the virus. While architects have long considered material important for thermal, lighting, environmental, and technological aspects, the design profession must now add “infectious properties” to that list of considerations. ESTABLISHING “ZONES” Both long term and short term strategies shared a commonality when it came to designing carehome floor plans: categorize spaces based on traffic and the number of people. Both MASS Design Group and LTL refer to this categorization as a gradient from public to private (“public, semi-public, semi-private, and private”9 ), where the thresholds between each type of space become the most vulnerable moments for the spread of infections. These thresholds are important to consider, because during the height of a pandemic, these gradients become vulnerable transmission points in buildings and can be used to developing policies that allow care-homes to close off their threshold at certain levels, while allowing residents to maneuver around other zones. For example, to reduce the effect of isolation and loneliness in care-homes, MASS Design Group suggests adding more common spaces to each floor, which may seem counter to other CDC guidelines of limiting in person gatherings. Yet, by providing more communal spaces on each floor these spaces would cluster residents together, “still reducing degree of exposure and allowing for easy contact tracing where necessary.” 10 When it comes time for reopening strategies, framing the building as a gradient of exposure also assists in helping identify semi-private, semi-public, and public spaces that will reopen and when. This designation of gradients complimented the AIA’s “3-zone room” between the patient/resident, healer, and family/friends. 11 By ensuring room size can accommodate physical distancing guidelines or by designing and installing movable glass partitions as previously suggested the room can be better zoned to allow functionality and resident comfort, even during a pandemic. The AIA suggests the use of touch-less doors, equipment, and accessories which could make common spaces and the resident room a safer place while still allowing activity, 12 or simply provide enough space or a mobile solution for an in-room dining area for family and friends. 13 Creating modular households could also assist with this, providing the potential to schedule the use of a common dining area (indoors or outdoors) for family visits. Jeffrey Anderzhon in his article, Loneliness for the Elderly in the Time of Pandemic, cites limited social engagement opportunities, lack of access to technology, and minimized participation in organized groups as major contributors to loneliness. 14 Further, loneliness has been linked to poor physical and mental health, increased rate of mortality, increased chance of developing clinical dementia, and high healthcare spending and costs. 15 This data supports the importance of ensuring

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EXISTING LITERATURE + STRATEGIES (CONTINUED) residents have spaces designed for safe interaction even during a pandemic scenario. We must not sacrifice quality of life for preservation of life, especially in such a critical space as the resident room. THE IMPORTANCE OF SITE Additionally, the strategies for designing care-homes extends beyond the scale of material or even the immediate building, but rather must also accommodate site. In their article, “Tactical Urbanism: Reimagining Our Cities post-COVID-19,” Foster + Partners demonstrate that some urban planning infrastructures such as extensive public transportation networks or “vibrant marketplaces” 16 are normally encouraged in urban planning, because public transportation helps eliminate harmful carbon emissions associated with car usage, and vibrant marketplaces become an opportunity for local economic growth and social activity. Yet in regard to COVID-19, these two programs were dangerous in spreading COVID-19 and were unsuccessful at providing safe spaces for the public during quarantine. Instead of focusing future urban planning on these aspects Foster + Partners encourages a focus on parks, pathways, and urban biophilia as a potential combatant to the COVID-19 pandemic because exterior environments lessen the risk of airborne transmission from interior environments, while also parks and trails fulfill the social needs that the public transportation rail lines or indoor marketplaces had functioned as. In their words: “We need places – communal front gardens in place of parked cars – where neighbors can gather, and children can play.” 17 Yet, a lot of design practices that respond to the coronavirus pandemic are ironically contradictory. On one hand, large-scale social interaction should be limited during the height of a pandemic, but designers have to consider the consequence of social isolation – a problem especially relevant for elderly residents in care-homes, including those suffering with dementia. The AIA describes the dilemma as: “Seniors are at increased risk for loneliness and social isolation because they are more likely to face factors such as living alone, the loss of family or friends, chronic illness, and hearing loss. Seniors who are prone to depression, memory issues, or physical issues, either as a chronic matter or specific to geriatric issues such as limited mobility or injury, may deteriorate further in isolating conditions or with limited options for exercise.” 18 Aside from these negative impacts of social isolation, social interaction has added benefits that help populations cope with pandemics and dangerous global events. For example during Chicago’s deadly 1995 heat wave, “the strength of community support – built on years of sitting on stoops and block parties – literally saved lives” 19 due to the ability for neighbors to care for one another and fulfill the physical socialization needed for a healthy body. As Foster + Partners point out, this makes a strong case for communities to continue interactions (albeit responsibly) during a pandemic, despite the high rate of airborne transmissions.

HOW DO ARCHITECTS RESPOND TO CONFLICTING SETS OF URBAN VALUES? The Street Plans Collaborative, an urban research and planning firm based in New York City, released a set of guidelines that look to streetscapes as a logic for adaptive outdoor areas, while hosting larger

EXISTING LITERATURE + STRATEGIES

gathering programs safely. They suggest that “our streets will change at different moments throughout the COVID-19 crisis.” 20 Like LTL’s framing of thresholds as “gradients of exposure,” Street Plans helps frame issues of urban planning around three phases that designers need to accommodate for: 1) stay at home orders/shelter in place, 2) pre-vaccine reopening, and 3) vaccine/post-pandemic occupancy.21 While their report describes urban planning strategies at the scale of city streets, multipurpose logic of streets can be scaled down for use in care-homes, whether considering parking lots, the positioning of new care-homes along the street, etc. Street Plans suggest that the architectural community’s response and understanding of COVID-19 cannot be limited to the current day. Rather, there is a responsibility for COVID-19 solutions to be adaptive to future phases of infection, with the assumption that another global pandemic could become a reality in a rapidly changing global climate. 22 Overall, architecture and planning firms are leveraging conditions of the pandemic to reflect on existing practices and innovate future design responses. Yet, from the selected readings, the research gathered occurred early in the pandemic. Due to a lack of inconsistent coronavirus data in the United States, combined with a developing medical understanding of the virus itself, we have observed that most architectural research addresses the direct spatial consequences of CDC guidelines or medical findings from the virus. These direct consequences of already established guidelines overlook direct experiences of living in a care-home during the pandemic. The challenge with designing care homes, especially when factoring in patients with dementia, is that there is not only one solution. The response to the coronavirus pandemic may have encouraged people to reexamine design as a scientific process, but the next wave of pandemic research must be able to integrate the pandemic experiences of carehome residents, visitors, and staff. For that, we must look to specific care-homes and understand how their specific situations played out. NOTES 1

Webinar: Design of Healthcare Facilities Across Countries, AIA | DC, 28 July 2020

Anderzhon, Jeffrey. “Senior Living: Keeping Connected through Our Shared Crisis.” Eppstein Uhen Architects. 2020.

Banta, David. “Strategies for Safer Senior Living Communities” The American Institute of Architects. 26 June 2020.

Ibid.

AGI-Architects. “Modular Architecture, Why Should it be Chosen?” AGI-Architects Blog. 2020.

Lewis, Paul, et al. Manual of Physical Distancing. LTL Architects, 2020.

Ibid.

Ibid. 7.

Banta, David. “Strategies for Safer Senior Living Communities” The American Institute of Architects. 26 June 2020.

Ibid.

http://www.agi-architects.com/blog/en/modular-architecture-chosen/

MASS Design Group. 2020. “Designing Senior Housing for Safe Interaction.” The Role of Architecture in Fighting COVID-19. MASS Design Group.

Webinar: Design of Healthcare Facilities Across Countries, AIA | DC, 28 July 2020

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Anderzhon, Jeffrey. “Loneliness for the Elderly in the Time of Pandemic.” LinkedIn. 17 May 2020.

Ibid.

Moser, Bruno, Theo Malzieu, and Paula Petkova. 2020. “Tactical Urbanism: Reimagining Our Cities Post-COVID-19.” Edited by Mrinal Rammohan and Anna Watson. +Plus. Foster + Partners. May 14, 2020. 2.

Ibid. 5.

Banta, David. “Strategies for Safer Senior Living Communities” The American Institute of Architects. 26 June 2020. 3.

The Street Plans Collaborative. Streets for Pandemic Response & Recovery. The Street Plans Collaborative, 2020, 10.

Ibid. 11.

Dobson, Andrew P, et al. “Ecology and Economics for Pandemic Prevention.” Science, vol. 369, no. 6502, 24 July 2020, pp. 379–387., doi:10.1126/science.abc3189.

EXISTING LITERATURE + STRATEGIES

72 LESSONS FROM CARE HOMES IN PRACTICE

72%

= AVG. OCCUPANCY FOR 21 CARE HOMES WITH THE MOST COVID CASES *IN THE UNITED STATES OF AMERICA DURING 2020

Five care homes lauded for their design features became case studies for high quality yet safe care home design strategies. In addition, narrative accounts captured from online blogs, news articles, and care home websites helped paint a picture of life in care home facilities during the COVID-19 pandemic. Both sets of case studies helped identify design considerations to accommodate in future care home designs.

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LESSONS FROM CARE HOMES IN PRACTICE METHODOLOGY The challenge of designing care homes, especially when factoring in patients with dementia, is that there cannot be a singular solution. The response to the coronavirus pandemic may have encouraged people to reexamine design as a scientific process, but the next wave of pandemic research must integrate the pandemic experiences of care home residents, visitors, and staff. We will look both to care homes that performed well under the stress of COVID and those that did not to understand how design decisions affected the life within the care home. We employ two parallel case studies: 1. Analysis of Holistic Care Home Models (selected for their architectural innovation) 2. Analysis of Care Home User Experience (selected as a way to integrate user feedback and experience into our findings) 1. ANALYSIS OF HOLISTIC CARE HOME MODELS Five case study care homes were selected from around the globe that represent good design strategies. Each takes a slightly different approach to care home design. By analyzing these care homes we can begin to understand how care home design can improve the lives of the residents and staff. We can also extract good design strategies to be used in future care home designs. Each care home is analyzed based on a set of six criteria derived from the overall goals of the upcoming John McAslan + Partners care home project: affordability, environmental sustainability, technology + innovation, culture + resident-centered design, landscape integration, and health + safety. These criteria appear in other literature analyzing the quality of care home designs.

Affordability

Cost of design, construction, maintenance, and stay. Affects the accessibility of quality care to those with varied incomes.

Sustainability

How does the architecture anticipate future generations through life cycle analyses and material sources?

Technology + Innovation

How will the care home age? Are communication and learning tools integrated into resident experience? Does technology assist staff during busy times?

Culturally Sensitive + People-Focused

How can dignity be preserved while providing necessary assistance for residents, especially for those with dementia? Is the human experience the primary focus for the design?

Landscape Integration

The design should consider its architectural and natural context while engaging external communities and habitats.

Health + Safety

Does the design prepare for future pandemics and protect resident and staff health, especially in common spaces?

LESSONS FROM CARE HOMES IN PRACTICE

INFECTION-RELATED AND SERIOUS DEFICIENCIES BY STATE

COVID CASES PER COUNTY, WASHINGTON STATE 40 0

0 0

9 111

0 0 B

SERIOUS DEFINICIENCIES **

50%

40%

30%

20%

10%

139

6 4

16 121

0 17

20%

2 501

30%

123

100% 40%

INFECTION-RELATED DEFINICIENCIES *

0 1

0 3

* The percentage of Medicare-certifed homes in each state with at least one infection-related deficiency in the past three years. ** The percentage of Medicare-certified homes in each state with at least one serious deficiency in the past three years (deficiencies causing "immediate jeopardy").

2. ANALYSIS OF CARE HOME USER EXPERIENCE In order to understand the specific performance of care-home design in the coronavirus pandemic, five care homes were identified as having more than 50 cases of coronavirus linked to the care home facility: Life Care Center of Kirkland (129 cases), Queen Anne Healthcare (89 cases), Issaquah Nursing & Rehabilitation Center (135 cases), Spokane Veterans Home (72 cases), and Regency Canyon Lakes (52 cases). These care homes were chosen because they differ in geographic location, facility type, size, and relation to overall county cases. For example, despite Spokane County having 11 long term care facilities, 72 cases are from Spokane Veterans Home alone. SELECTION CRITERIA Washington State provided a critical setting for care-home performance in the pandemic, given that “61% of [Washington state’s] coronavirus deaths linked to long-term care facilities.” 1 and by May 2020, 252 of the 312 long-term care facilities reporting COVID statistics in Washington had at least one confirmed COVID-19 case. 2, 3 As the first state to report a hot spot in care-homes, Washington State became the first state to enact policies that closed care-homes to the public. We believe this early closure helps make Washington a better control group than the rest of the United States, because COVID cases after February would have primarily spread internally or through lapses in pandemic protocol, without much new introduction of the virus due to visitors, unlike other parts of the US. NOTES 1

CMS - Division of Nursing Homes/Quality, Safety, and Oversight Group/Center for Clinical Standards and Quality. 2020. “COVID-19 Nursing Home Data.” Data.Cms.Gov. July 9, 2020.

ProPublica, “Nursing Home Inspect,” October 2020.

Yourish, Karen, K. K. Rebecca Lai, Danielle Ivory, and Mitch Smith. 2020. “One-Third of All U.S. Coronavirus Deaths Are Nursing Home Residents or Workers.”

FIG_5.01 (ABOVE) Care Home Deficiencies by State (Lidwin + Smith, 2020). FIG_5.02 (BELOW) COVID Cases per Washington State County (Lidwin + Smith, 2020).

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1. ANALYSIS OF HOLISTIC CARE HOME MODELS In order to understand the current design of care homes, we researched care home models that are praised for both well-executed architectural design as well as performative ability. From a list of twentynine high-quality care homes (Appendix A), five were selected for an in-depth study. The following care homes were assessed based on their affordability, environmental sustainability, integration of technology, resident-centered priorities, landscaping, and prioritization of resident health and safety: De Hogeweyk, Weesp, Netherlands (Molenaar & Bol & Valdillen Architekten) The Caleb Hitchcock Memory Care Neighborhood, Bloomfield, Connecticut, USA (Amenta Emma Architects) Jin Wellbeing County, Khlong Luang, Thailand (Shma Company Limited14 + Openbox Architects15) Belong Atherton, Lancashire, United Kingdom (Pozzoni, LLP) Neptuna Development, Malmo, Sweden (Arkitektgruppen Malö AB) *with greenhouse by Monika Gora

LESSONS FROM CARE HOMES IN PRACTICE

THE VILLAGE DESIGN SCHEME This overall scheme engages the broader community through shops, restaurants, recreational facilities, and clinics, where external community members can interact with care home residents. This scheme fosters a sense of independence for residents, which can be important for cognitive functions while allowing the facility to gain extra revenue through these associated community shops/facilities. SMALL HOUSEHOLD LAYOUT This concept separates residents into “households” of 12 or fewer members, which increases the perceived and actual safety of residents. This layout is both affordable (as modular households can be replicated) and personable (as residents form deep bonds with their house mates). Communal spaces such as kitchens, classrooms, and outdoor spaces encourage residents to socialize. RESIDENT-CENTERED DESIGN A feeling of “home” can improve the memory and cognitive abilities of residents. Resident-centered design creates adaptable spaces and incorporates universal design principles, so as resident needs and abilities change, they can “age in place” in adaptable spaces. This design also encourages personalizing private rooms through integrated storage and display units. It promotes natural lighting and views to outside scenery. Smaller bedrooms encourage socialization in common areas, while long corridors and dead ends are dangerous and make facilities less homelike. Resident health during pandemics can be prioritized through a 3-zone room layout (which permits residents, staff, and visitors to interact safely). THOUGHTFULLY DESIGNED OUTDOOR SPACES For outdoor spaces to be well-utilized, they should accommodate a range of activities from large events to intimate visits or individual contemplation. Native plants and self-sustaining landscape designs require less maintenance and encourage native wildlife, which residents can enjoy. Native landscapes also help make the care home unique to its site - allowing residents to feel a personalized sense of home. Outdoor spaces should be safely and easily accessible to all residents of varying abilities. INCORPORATION OF A VARIETY OF TECHNOLOGY Technology should be used strategically to connect residents to other residents, to staff, and to their family and friends, who may be remote. During pandemic, technology is critical for preventing feelings of isolation and loneliness among residents. Internet cafes and private, in-room technology should be explored. Technology should also support individualized care, making it easier to address the needs of residents at a variety of levels, such as residents with mental or physical impairments. SUSTAINABLE DESIGN TECHNIQUES Sustainable indoor spaces are just as important as sustainable exteriors. The longevity of a care home facility is improved through techniques such as optimized ventilation, energy conservation, inclusion of vegetation, and careful selection of materials. These techniques also improve resident health while limiting operational costs. Other sustainable strategies could include incorporating the use of public transit during resident outings or for care home visitors.

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GLOBAL EXAMPLES OF CARE HOMES THE GREEN HOUSE HOMES AT ST. ELIZABETH HOME East Greenwich, RI (SWBR Architects)

- small planned elder community/skilled nursing facility - divided into “homes” with 12 occupants per home - private facilities (bathrooms/bedrooms) + shared facilities (kitchen, master bathroom, living room) - potential to re-purpose existing unused suburbs and make it multi-generational

P.39

THE CALEB HITCHCOCK MEMORY CARE NEIGHBORHOOD Bloomfield, CT (Amenta Emma Architects)

- a 12-resident addition to an existing facility - designed to be a “home-like” environment - focus on connection to nature and spaces to foster both social interaction and independence

SERENBE Atlanta, GA (Steve + Marie Lupo Nygren)

- a planned community and an example of New Urbanism - single family + row houses (front porches but no backyards) that front common green areas - also includes various shops and services in each of its four hamlets all in good walking distances - each hamlet has a theme: arts, agriculture, health, and education

THE GOLDIN AT ESSEX CROSSING New York, NY (Dattner Architects)

- an urban care home in Manhattan combining housing, healthcare, and community services - rooftop gardens give residents space to be outdoors; the mixed-used base invites in the wider community - provides affordable senior housing as well as community retail and employment

P.37

DE HOGEWEYK: DEMENTIA VILLAGE Weesp, Netherlands (Molenaar & Bol & VanDillen Architekten)

- create a social community that challenges residents to remain active - tailoring design and decoration to lifestyle; there are 7 lifestyles available to be part of - residents with shared interests and backgrounds live together in a “lifestyle group” - the village offers various facilities and services to the town at large

ELTHETO HOUSING + HEALTHCARE COMPLEX Rijssen, Netherlands (2by4 Architects)

- combines home and healthcare into one complex - the different housing blocks vary by level of resident need - a strong focus on avoiding feelings of isolation and on promoting community - adaptable design in the ability to move within the neighborhood as a resident’s needs change

FIG_5.03-18: *Sources vary. See “Image Sources” for complete citations

P.43 33

WIEKSLAG BOERENSTREEK Soest, Netherlands (unknown)

- design allows for independent living even for residents with physical disabilities - careful programming of services encourages community participation and interaction - the design is inspired by the vernacular buildings of the region - the ground floor includes a daycare for people with physical disabilities

BELONG CARE VILLAGE Newcastle-under-Lyme, England (Prime)

- located on a large piece of land and re-purposes an abandoned Grade II listed building - public transportation options help integrate the care home with the broader, local community - includes 24-hour care and independent living - includes a gallery and other features to celebrate the heritage of the local area

LESSONS FROM CARE HOMES IN PRACTICE

MARIONVILLE COURT CARE HOME Edinburgh, Scotland (Gareth Hoskins Architects)

- intended for residents with dementia and high dependency - design based on ‘street’ and ‘houses’ concept - also includes a daycare - focus on sustainable design features

CASTLEBROOK Kenilworth, England (Pozzoni)

- intended for residents with dementia, physical disabilities, and sensory impairments - organized around a ‘household’ concept with decentralized kitchens for each - prioritizes a connection to nature - includes an ‘innovation hub’ for research on-site

ALZHEIMER’S VILLAGE Dax, France (Nord Architects Copenhagen)

- designed with local character in mind to create a ‘homey’ atmosphere - balancing privacy and dignity with community engagement - focus on including both residents and their relatives in the design scheme

BLANCAFORT Blancafort, Spain (Guillem Carrera)

- a social building intended for the town’s elderly population - internal courtyards for each of the two public facilities - includes both a ‘Home’ for the elderly and a ‘Day Center’ - modern yet warm finishes, inspired by the colors of the region

NURSING HOME NENZING Nenzing, Australia (Dietger Wissounig Architects)

- barrier-free design - intended for older people who do not need full-time care - built at a residential scale - focus on sustainable design

GIESSEREI Winterthur, Switzerland (Galli Rudolf)

- designed for multi-generational use out of existing factory halls - includes a courtyard and public uses on the ground floor - wide variety of apartment styles/combinations to support a variety of ages, needs, and abilities - focuses on sustainability and presents a colorful facade

PANORAMA RETIREMENT HOME Laval, Quebec, Canada (ACDF Architects) - high-rise building, modern style - intended for residents with an active lifestyle - prioritizes connection to nature

PACIFIC PLAZA CONTINUING CARE PLANNING RETIREMENT COMMUNITY Guanacaste, Costa Rica (REES)

- includes a healthcare center, assisted living, skilled nursing, memory care, and independent living - includes a hotel, retail center, community center, fitness center, tennis courts, trails, and a pool - active and eco-friendly community - offers private homes in small groupings, quadplex units, and apartment homes

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GLOBAL EXAMPLES OF CARE HOMES (continued) P.45

NEPTUNA DEVELOPMENT Malmö, Sweden (Stiftelsen Södertorpsgården)

- affordable senior housing on premium real estate - encourages the sustainability of the community and surrounding neighborhood - makes a strong social statement regarding the care and treatment of the elderly - promotes successful aging in place

SALEM NURSING HOME Gentofte, Denmark (Salem AELdreboliger Nursing Home)

- intended for very dependent older people - new building built on footprint of the older building - supports four ‘households’ over two floors - supports individuality without isolation while also providing a good layout and access to light

COOP HOUSING AT RIVER SPREEFIELD Berlin, Germany (SCarpaneto Architekten + Fatkoehl Architekten + BARarchitekten) - urban senior living at affordable costs using staggered rent - goals of being a socially just, economically stable, and environmentally responsible urban block - based around 6 cluster apartments for communal living - barrier free spaces are open to the neighborhood with a modular design and shared spaces

P.41

JIN WELLBEING COUNTY Khlong Luang District, Thailand (Shma Company Limited)

- major focus on connection to nature by placing the complex in a forest within the city - very serious ecological sustainable features - designed to inspire retirees to go out and have an active social life - ‘Therapeutic Garden’ connects ‘Aged Care’ building and ‘Clubhouse’ to exercise 5 senses

SENIOR CENTER OF GUANGXI Nanning, China (Atelier Alter)

- the modern design contrasts the humanistic sense of belonging that comes from their culture - site at the edge of urbanization - various recreational services available - centralized shared spaces

KAMPUNG ADMIRALTY Woodlands Drive, Singapore (WOHA)

- Singapore’s first integrated public development - a vertical village (combines a community plaza, medical center, and park with senior living) - the community plaza is fairly public + acts as a community living room - the medical center provides ample daylight as well as lovely views to nature and greenery

SENIOR CITIZEN’S VILLAGE + WELLNESS CENTER Nugegoda, Sri Lanka (Western Care Homes)

- meant to be a luxury location (likely for international residents rather than local residents) - includes a pool, clubhouse, garden, library, tennis court, medical center, and other facilities - offers 140 rooms and 20 villas (each contains a kitchenette, bathroom, living room, and bedroom) - intends to assist with aging population in Sri Lanka

MUNINI DISTRICT HOSPITAL Nyaruguru District, Rwanda (MASS Design Group)

- heavy focus on reducing the spread of disease throughout the facility - part of initiative to develop a set of design standards to improve health outcomes - utilizes slight bends in the building and a central courtyard to maximize the small site - various dedicated outdoor spaces help connect the patients to the surrounding nature

LESSONS FROM CARE HOMES IN PRACTICE

NEW REDEMPTION HOSPITAL Caldwell, Liberia (MASS Design Group)

- goal to optimize systems and avoid future epidemics - ventilation strategies minimize energy use, reduce operational costs, and control infections - exterior waiting spaces reduce transmission of airborne infections - the landscape supports native vegetation, fostering a resilient, sustainable campus

ACEGID Ede, Osun State, Nigeria (MASS Design Group)

- equip the entire African content to stop the spread of future epidemics - designed to increase collaboration between scientists, students, and international partners - utilized the high-tech potential of local materials

GERONTOLOGICAL HUB PROJECT Valdivia, Chile (Fundación Oportunidad Mayor)

- a city plan to include supervised flats and nursing home - leveled streets encourage safe walking - affordable transportation systems encourage an active lifestyle - also proposed for Los Ríos Region

SUMMERSET BY THE RANGES MEMORY CARE CENTRE Levin, New Zealand (Team Architects)

- utilized Hammond Care tools and strategies to design quality home for seniors with dementia - award-winning - designed to support independence - designed around senior suites

PARKSIDE RETIREMENT HOMES Bangalore, India (Mindspace)

- part of Brigade Orchards, an integrated township - connection made to nearby temple - shared activity spaces are distributed across the floors and connected by a central atrium - daylight is harnessed to cast changing shadows throughout the day and keep the space lively

FIG_5.19-31: *Sources vary. See “Image Sources” for complete citations

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DE HOGEWEYK WEESP, NETHERLANDS (Molenaar & Bol & VanDillen Architekten)

FIG_5.32: De Hogeweyk (Unknown via Urban Edge, 2018) FIG_5.33: Site Plan (Niek Roozen, 2012) FIG_5.34-38: De Hogeweyk (KopArt, 2012) FIG_5.39-40: Outdoor (Madeleine Sars, 2012) FIG_5.41-42: Public Spaces (KopArt, 2012)

LESSONS FROM CARE HOMES IN PRACTICE

5 6

sustainability

TECHNOLOGY + INNOVATION

HEALTH + SAFETY

Although De Hogeweyk is considered one of the best care home schemes in the world, it is not affordable. At a cost of €1,789 per square meter (roughly $240 USD per square foot), this care home was costly to build. (The average American nursing home costs $160 per square foot.) Although this care home is largely subsidized by the government, resident care at De Hogeweyk costs about €6,000 ($7,700 USD) per resident per month. These high costs are particularly troublesome for those that may especially benefit from this type of care but cannot afford it. Strategies for designing an affordable care home need to be discussed, for example using affordable materials and construction methods, employing renewable energy to decrease maintenance costs, or having more on-site activities to which community members can purchase tickets. The design process of De Hogeweyk began in 2002, before environmental sustainability became a major issue in the Netherlands.9 Since then, the Dutch Building Decree has set forth technical requirements for all existing and new construction since 1995; these requirements include energy performance standards.9 Although De Hogeweyk meets these requirements, the facility does not incorporate alternative energy sources or water conservation.9 De Hogeweyk, though, has the opportunity to increase its environmental sustainability in several ways, some of which could include using solar panels, supporting the gardening of native plants, installing lowflow fixtures and LED lights as needed, converting their roof areas to green areas, and various other sustainable concepts.

technology

LANDSCAPE INTEGRATION

The ‘technology’ of De Hogeweyk comes in the form of its highly innovative design scheme. The designers pushed the boundaries of the household concept to create a complete village for their residents to support individual living similar to their at-home experiences. This care scheme is also unique because it was designed to be flexible in case it needed to be converted into different care schemes or residential housing.9 With a doctor, physical therapist, and a maintenance team visible on-site, this care scheme is both innovative and conscious of the needs of its residents, who all live with dementia. Using evidence from studying dementia and design, this care scheme was designed to support independence and familiarity.

culture

ENVIRONMENTAL SUSTAINABILITY

The designers of De Hogeweyk sectioned households by allowing residents to choose between seven lifestyles (pictured left, in order); Artisan, Christian, Cultural, “Het Gooi”, Homey, Indonesian, and Urban. Home decor, daily activities, and meals vary depending on which lifestyle the residents choose. Resident care is prioritized by splitting the form into households, which make it easier for staff to care for and pay individualized attention to the residents. The households are situated on the site depending on lifestyle, for example the urban lifestyle is closer to areas with more activity. The exterior design of the households also varies to assist residents with memory loss in navigating to their homes. The interior garden is designed such that residents can go outside on their own safely, which is important to health and wellbeing.

landscape

CULTURE + RESIDENT-CENTERED

De Hogeweyk was designed with the intent to be well-integrated into the surrounding community. While the interior of De Hogeweyk is often vibrant with life, the exterior is simple and blocky, not matching well with the architectural landscape nearby. Although the look seems off at first, the scale is well adjusted to the residential scale of the town. In terms of integration into the cultural landscape of the community, De Hogewerk had the right idea. All town residents, as well as outsiders, are welcome to enter the facility to use the amenities such as the restaurant and theater and interact with residents. However, the entryway could have been designed to be more welcoming to visitors.

health + safety

affordability

AFFORDABILITY

The design of De Hogeweyk was carefully considered to keep resident safety in mind, while providing them a life full of the experiences they were used to at home. For example, the garden was placed inward and designed to allow residents to go out on their own and, as many design guidelines suggest, long corridors were left out completely to avoid visibility and fall risks. Because the scheme is divided into households, that makes separation of residents during a pandemic scenario much easier. Although life became complicated and residents were not able to access facilities the same way, having a household scheme meant they could maintain at least some human contact within their households. The interior garden also provides residents the chance to meet in small groups safely outdoors while maintaining physical distancing.

2020 ARCHITECTS FOUNDATION/McASLAN FELLOWSHIP

THE CALEB HITCHCOCK MEMORY CARE NEIGHBORHOOD BLOOMFIELD, CT, USA (Amenta Emma Architects)

FIG_5.43, 45-48:, Project Photographs (Robert Bensen Photography, 2015). FIG_5.44: Plan (Amenta Emma Architects, 2015).

LESSONS FROM CARE HOMES IN PRACTICE

AFFORDABILITY

affordability

The Caleb Hitchcock Memory Care Neighborhood (CHMCN) has won several awards including Special Recognition for the AIA National Design for Aging, Argentum Senior Living by Design, and Senior Housing News Design and Architecture, but it’s lacking in affordable options. The cost for living at the CHMCN is an estimated $8,300 USD per month.10 (The national average in the United States falls around $3,700 per month.)10

sustainability

HEALTH + SAFETY

Aside from complying to the base environmental regulations regarding energy performance standards in the state of Connecticut, it does not appear that CHMCN has used any additional sustainable designs or resources. The building’s unique sloped roofs would have afforded an excellent opportunity to provide southfacing solar panels. The centralized service core also would provide a good opportunity to use some form of rainwater collection and distribution throughout the apartments. The grounds also could have been better populated with native plantings and designed to allow and encourage residents to venture outside on their own.

technology

TECHNOLOGY + INNOVATION

A key component of the residents’ program is a computer-based memory program called “Never 2 Late.”11 This program is designed to encourage residents to interact virtually with family and friends, in the hopes of preserving memory and creating a sense of normal familial interaction. The CHMCN is using this program to explore the use of technology in memory care. The use of technology has become even more important to examine and test during the COVID-19 pandemic, as it is often the only way residents can interact regularly with their friends and family outside the facility.

culture

LANDSCAPE INTEGRATION

The design supports the residents through its strong connection to nature. The form is organized around a 100-year-old oak tree which not only serves as a beautiful view but also a useful way for memory-impaired residents to track time and the changing of the seasons. The second major resident-centered design element is the homey architecture reminiscent of the region. This home-like environment has been shown to improve and promote residents’ mental health, general wellness, and safety. The easily navigable small house layout reflects a traditional American home, as does its architectural detailing. Further, the residents are encouraged to stay active and involved in the community through regular events such as art and music therapy, yoga, visits to the larger facility’s secure garden, and off-campus outings.

landscape

ENVIRONMENTAL SUSTAINABILITY

The CHMCN is a 12-resident addition integrated into the larger senior living community of Duncaster in Bloomfield. In addition to integrating the addition into the larger facility, the architects also took care to integrate the addition into the surrounding nature, modeling the form off of the iconic 100-year-old oak tree the residents call “Charter Oak”. The main communal sitting area is oriented south, towards the Charter Oak, providing the residents with exceptional daylight and an excellent view of nature and great inspiration for their art therapy sessions. The palette of the interior is also reminiscent of the surrounding nature in color, texture, pattern, and material. The senior living community is integrated into the culture of the community at large through occasional outings outside of the senior living facility campus.

health + safety

CULTURE + RESIDENT-CENTERED

The health and safety of the residents was a serious consideration for the architects and owner when designing the facility. Research into dementia led the architects to design a home-like environment to help put the residents at ease and promote their health, wellness, and safety. They also maximized natural light and views to the outdoors as both are shown to improve patient mental and physical health. The proportions of and connections between the interior spaces, with no long hallways or dead ends, were also carefully designed to foster both social interaction and independence. Because it is a 12-resident home-like addition, it is also relatively easy to close off during a pandemic scenario, keeping the patients safe while also allowing occasional interaction between household residents.

2020 ARCHITECTS FOUNDATION/McASLAN FELLOWSHIP

JIN WELLBEING COUNTY KHLONG LUANG, THAILAND (Shma Company Limited14 + Openbox Architects15)

FIG_5.49-51: Jin Wellbeing County (Panoramic Studio, 2018) FIG_5.52: Plan (Shma Company Limited, 2018)

LESSONS FROM CARE HOMES IN PRACTICE

AFFORDABILITY

affordability

This is an interesting scheme because rather than paying on a monthly basis, residents are intended to purchase the units. A one bedroom unit, for example, sells for roughly $120,000 USD (or 3.69 million baht). This type of unit comes with access to all of the amenities. Should the resident need special care, it is included in the unit’s purchase price and fees. This scheme, though, is quite costly and is certainly not accessible to everyone, although someone of a lower income experiencing mental or physical health dilemmas could benefit significantly from a space like this.

sustainability

HEALTH + SAFETY

Sustainability was one of the project’s 3 major guiding principles, along with physical wellbeing and sense of community. 40% of the site area is green space, far surpassing the standard requirement of 30%. The ecology was designed to be self-sustaining over time. Water management was designed to handle flooding during wet seasons and supply adequate water during dry seasons, for example their use of the bioswale. The ecosystem is intended to support other native wildlife to maintain and enhance biodiversity. The tropical plantings were designed with climate and culture in mind, mimicking the native plantings in and look of a natural tropical forest.

technology

TECHNOLOGY + INNOVATION

Jin Wellbeing County is the first senior-oriented mixed-use development in Thailand; it includes long term residences, commercial space, and a hospital. The County integrates assisted living, independent living, and standard residents into one holistic design. The careful and innovative design solutions allow residents and users of varying ability levels to live comfortably together. The facility is equipped with a tracking system and a 24-hour emergency unit if needed. The large scale of the project is also a technological and innovative achievement, given the amount of coordination needed between the facilities, homes, and amenities.

culture

LANDSCAPE INTEGRATION

Jin Wellbeing County prides itself on providing individualized care for residents with Alzheimer’s and other memory impairments, considering the individual’s body, mind, and spirit. The scheme involves multi-generational living as a central concept. Cross activity between groups is encouraged through the use of communal spaces and events. Medical personnel are available on-site to give advice and assistance, making the residents feel more safe and care for. The architects also sought an age-in-place concept which they called “Design for LIFE”. To do this, they focused on creating flexible spaces and residence layouts. As needs change, supports and details can be added or subtracted.

landscape

ENVIRONMENTAL SUSTAINABILITY

The goal of the Jin Wellbeing County was the address the problem facing Thailand of the increasing aging population; this connects the goals of the residents and facility with the goals of the community at large. The garden space also supports biodiversity within and outside the facility. Internally, the therapeutic garden encourages residents to spend time outside and exercise their five senses in the environment. Jin Wellbeing County acts as a small town in and of itself, somewhat similar to idea of De Hogeweyk except on a far larger scale.

health + safety

CULTURE + RESIDENT-CENTERED

With doctors and health professionals staffed throughout the facility, residents feel more comfortable and confident. The facility is in an urban setting, but the lush landscaping provides extensive interaction with nature and the outdoors, which has been proven to aid in the mental wellbeing or residents with Alzheimer’s and dementia. This facility is unique because it acts both as a hospital for residents with serious conditions associated with aging, such as memory impairments and stroke recovery, but also provides a permanent housing option. The designers implemented concepts of Universal Design to create a space accessible to people of varying ability levels. The outdoor space was designed also to accommodate an ambulance if necessary.

2020 ARCHITECTS FOUNDATION/McASLAN FELLOWSHIP

BELONG ATHERTON LANCASHIRE, UNITED KINGDOM (Pozzoni, LLP)

FIG_5.53-57: Life Care Center of Kirkland, “Gallery,” https://lcca. com/locations/wa/kirkland/gallery

LESSONS FROM CARE HOMES IN PRACTICE

AFFORDABILITY

affordability

The Belong company was created out of two non-profits, and when designing Atherton they focused on affordability. For this reason, the 12-residents households are more of an “extended family” concept.9 Affordable and flexible use of space was a key driver of the overall design.9 The inclusion of the assisted living facility provides residents with more options for care; there are many purchase and rental options depending on the residents’ needs. The integration of the public into the facility also helps offset costs, as the public can use many of the common facilities including the bistro, hair salon, shop, and internet cafe.

sustainability

HEALTH + SAFETY

Although the facility uses no alternative energy sources or water conservation methods, it was designed to conserve energy by the thermal mass of its load-bearing masonry walls and concrete floors.9 The glazing they selected minimizes solar gain and heat loss.9 The design exceeds all minimum daylighting requirements.9 The daylighting also helps the mental and physical health of the residents. The facility uses low-energy light fittings.9 Rooms have their own heating controls, intended to reduce energy demand.9 Material choices were intended to reduce future maintenance needs, such as factory-treated cedar and stucco.9 Local tradespeople helped with construction, reducing transportation needs.9 Building materials were sustainably sourced.9

technology

TECHNOLOGY + INNOVATION

Innovation came in the form of highly flexible design, such as quite large bedroom and communal areas exceeding national standards.9 This flexible design can go so far as to be converted into small apartments should the region’s demographics shift in the future, thanks to the large bedrooms and en-suite bathrooms. Additional technological features include doorbells to access resident homes, hidden service doors, and memory boxes. The facility also has an internet cafe for residents who like to use the web to communicate with friends and family. The fire engineering strategy also sets this facility apart in terms of innovation. The solution is a combination of a water-mist system, fire compartmentalization, and a thorough evacuation procedure.9 Ultimately their fire design helped allow and maintain the domestic scale in a large facility.

culture

LANDSCAPE INTEGRATION

There are three household layouts, each oriented around a large communal center containing a kitchen, a dining room, and a living room. Residents have private bedrooms, each either their own bathroom that is visible if doors remain open. The household layouts have helped residents feel more safe and care for. Additionally, residents’ needs are considered through the design of large bedrooms where residents can comfortably bring some of their own possessions. It also helps with changing equipment and furnishings if and when resident needs change. The shape and size of bedrooms varies by resident, adding a personal sense to the design. The entry to the bedrooms simulates a small porch. In common areas, residents can choose between busier zones or more private zones depending on their feelings in that moment.

landscape

ENVIRONMENTAL SUSTAINABILITY

Located in a more urban setting, it was important for the facility to be integrated into its surroundings. The bistro sits at the street corner, welcoming the public inside. Most common areas look out at the town and its activity. The building sits close to the sidewalk, only buffered by a few meters that were required by the city.9 Materials complement those common in the city. The large building is brought to a more residential scale by breaking up the facade with bays, balconies, and varied architectural details. The public has access to all of the hub facilities, which significantly reduced stigma against care homes.

health + safety

CULTURE + RESIDENT-CENTERED

The six self-contained households, each housing 12 residents, prioritize resident care while also encouraging independence. The households are also easier to section off in a pandemic scenario than a more traditional care home. The scheme responds to varying levels of care needs, from more independent residents to those with dementia. The residents report feeling safer in the household scheme than in previous care homes because they can see staff around very often.9 Significant care went in to designing for residents with dementia, such as familiar furnishings, household layout, clear kitchen cabinets, and the inclusion of doorbells. Color and shade contrast was carefully considered for the visually impaired. Large balconies on the upper floors allow easy and safe outdoor access; there is also a staffed garden at grade.

2020 ARCHITECTS FOUNDATION/McASLAN FELLOWSHIP

NEPTUNA DEVELOPMENT MALMO, SWEDEN (Arkitektgruppen Malö AB) *with greenhouse by Monika Gora

FIG_5.58: Neptuna Development (Arkitektgruppen, 2006) FIG_5.59-60: Plan + Detail (Monika Gora, 2006) FIG_5.61-62: Neptuna Development (Arkitektgruppen, 2006)

LESSONS FROM CARE HOMES IN PRACTICE

AFFORDABILITY

affordability

Keeping the apartments affordable was a major goal of the project. Neptuna offers low-cost senior housing with many facilities, including a library, restaurant, and health spa.12 Occupants are required to be at least 55 years old, but most are roughly 75.9 The facility is owed by a non-profit corporation.9 The residents are placed of a newly developed and popular seafront community.

sustainability

HEALTH + SAFETY

To make the development more sustainable, the designers planned for the community to be able to harness and use their own energy, for example solar and wind energy.13 The area prioritizes pedestrians and cyclists over vehicles. The public bus system runs on a mixture of natural gas and biogas.9 The site itself is a redevelopment, reused from the former industrial district. The town uses a storm-water management system.9 The Neptuna facility provides recycling and waste management services and the ventilation system is energy-conserving.9 Water conservation is required by local regulations.9

technology

TECHNOLOGY + INNOVATION

Public transit was a major technology incorporated into the site from early on in the design process.12 The design and structure of the dome-like greenhouse, modeled as biophilic design, was also very technical and resulted in a pleasant green space even in colder winter months. Another innovative design aspect was the ability of the designers to create a multi-story building that succeeds in comfortably and safely housing the older population.9

culture

LANDSCAPE INTEGRATION

A major goal of the project was to design a facility that allowed residents to age in place, without having to move between apartments or facilities as they age and their needs change. Further, the hope is that the other younger residents of the community will stay and age there as well. The residents share many common areas such as the library, gym, and spa overlooking the Sea, giving them many options and opportunities to leave their rooms and engage with the larger community.13 The apartments are small in size compared to the common areas, further encouraging residents to stay active in their community. Culture is further emphasized by providing places for residents and the community to sit outside, referred to as “go nowhere” places.13

landscape

ENVIRONMENTAL SUSTAINABILITY

The site was critical for Neptuna. The older population of Sweden was placed central with this development, helping decrease stigma against the elderly and care homes. The development is mixed use, and is connected seamlessly to other business and commercial areas in the neighborhood. The streetscape is filled with unique architecture and good views of the native landscape, including the Baltic Sea. The modern building design blends well with its surroundings and does not appear old-fashioned.

health + safety

CULTURE + RESIDENT-CENTERED

The streets are highly pedestrianized outside the complex, creating a safe environment for the older population to travel through.13 The streets were also designed to include plenty of views of the Baltic Sea and of new sculptures and plantings.13 This is important for older populations who struggle with feelings of depression and isolation. Staying connected with the community also helps decrease feelings of depression and isolation and provides a solid network should a resident fall ill or need assistance.

2020 ARCHITECTS FOUNDATION/McASLAN FELLOWSHIP

2. ANALYSIS OF USER EXPERIENCE DURING COVID-19 In order to understand the specific performance of care-home design in the coronavirus pandemic, five care homes were identified as having more than 50 cases of coronavirus linked to the care home facility: 1. Life Care Center of Kirkland (129 cases) Kirkland, Washington, USA 2. Queen Anne Healthcare (89 cases) Seattle, Washington, USA 3. Issaquah Nursing & Rehabilitation Center (135 cases) Issaquah, Washington, USA 4. Spokane Veterans Home (72 cases) Spokane, Washington, USA 5. Regency Canyon Lakes (52 cases) Kennewick, Washington, USA These care homes were chosen because they differ in geographic location, facility type, size, and relation to overall county cases. For example, despite Spokane County having 11 long term care facilities, 72 cases are from Spokane Veterans Home alone. OUTCOME Most accounts from living in a care-home during the pandemic reflected on moments of isolation and the missed activities residents valued in their routine. When distancing was able to lessen within the interior of a care home between residents and staff, the activities they participated in did not seem to change as much as how or where the activities where held, suggesting a need for programs to be accommodated in multiple areas of a building - or at least the need to think about flexibility in programs, especially when systems (like circulation in the hallway) become stagnant and open opportunities for new engagements.

LESSONS FROM CARE HOMES IN PRACTICE

RETHINKING PROGRAM Hallways and doorways became one of the most referenced spaces when it came to lock-down, social activities in care homes. Not only did the long circulatory corridors provide adequate distancing to hold bingo games or conversation, but also the doorways into residences were places of congregation. SIGNAGE + MATERIAL MARKERS Using colors to mark out high traffic surfaces helps make residents and staff aware of touching surfaces, while also providing key focus areas for staff to clean thoroughly. Signs were also important during resident experiences, by letting residents know adjusted policies and what thresholds they were crossing into in regards to morepublic zones versus more private, residential rooms. OUTDOOR SPACES Although outdoor spaces are largely cited for improving the health of residents, especially for dementia patients, the outdoor spaces at care homes that had a significant amount of coronavirus cases were largely under-designed. Frequent use of modular furniture suggests that the maintenance of the outdoor spaces is often a low-priority. Design landscapes that suit the climate, as well as furniture that performs well in all weather is especially important in comparison to the picnic setup most commonly found. LACK OF ACCESSIBLE COMMON SPACES Most of the care homes studied for their performance during the coronavirus pandemic closed off their common spaces, providing little face-to-face contact for residents. While these temporarily unaccessible spaces need to be rethought in terms of how they can be activated safely during the next pandemic, the furniture in the common rooms were often very rigid and unaccommodating for wheel chairs and appeared uncomfortable. INTEGRATING POLICY WITH DESIGN Most care home policies involved procedures and building uses for residents who are staying at the care home, without detailing for any new residents who may be moving in, returning from the hospital, or moving out. There is a need to think about the flows in and out of a care-home beyond visitors, detailing policies for new residents and for the residents’ belongings should they leave the care home to stay at the hospital. In addition, for the case of dementia patients, the case studies showed that new temporary staff fillings and their new outfit requirements of gloves and masks had a direct influence on the spatial experience in a care home - disorienting residents and causing day to day activities to seem alien when

2020 ARCHITECTS FOUNDATION/McASLAN FELLOWSHIP

LIFE CARE CENTERE, KIRKLAND KIRKLAND, WA, USA (FOR-PROFIT, CORPORATION) SITE PLAN

ABOUT As an “old, single-story stucco building, lined with hedges, that has functioned as a nursing home for more than 30 years,” 1 Life Care Center, Kirkland maintained a five-star rating before becoming the epicenter in the early spread of the pandemic in the United States. This care home highlights several issues of care home performance, including existing problems with even ranking care-home performance. Until 2020, quality measures were self-reported by the individual facility without much outside auditing. 1

FIG_5.63: “Site Map,” (Lidwin + Smith via Google Maps, 2020). FIG_5.64-67: Life Care Center of Kirkland, “Gallery,” https://lcca. com/locations/wa/kirkland/gallery

LESSONS FROM CARE HOMES IN PRACTICE

“The nurses wheeling sick residents out the front — sometimes holding white bedsheets around the stretchers to shield the patients from the photographers waiting at the side of the road.” 1

“Helen was 98 years old, and she understood everything. This was largely because she never allowed the door to her and Twilla’s room to be closed — all the better for eavesdropping” 2

Large entrances provide room to maintain distance from other visitors, especially when the approach into a building includes large circulation outdoors. Yet, the crisis of a pandemic brings about a crisis of privacy. Designers should accommodate the interior circulation of both healthy residents and visitors, as well as the unfortunate (but necessary) transportation of sick residents outside of the facility.

When pandemic policies restrict residents from in-person communication with each other, there is a desire for maintain auditory communication.

“Visitors to Life Care saw signs on the wall noting that there was a respiratory outbreak in the building.” 5 Existing literature brings attention to way finding devices, like MASS Design’s proposal for signage to call out highly trafficked/touched surfaces. 6 There is an opportunity for way finding signage to delicately communicate the current health of the building (ex. which rooms are currently under quarantine, current policies about using spaces). Also, many facilities have stacked chair on tables to signify common spaces are closed, but how can furniture design anticipate times when common spaces are vacant?

“They had seen nursing aides go room to room without washing their hands” 7 The proximity of hand-washing stations - not just hand sanitizer disposals - may help influence hand-washing practices, reducing the potential for the infection to spread by contact when staff and visitors rotate through various spaces in the building, defined by LTL as “gradients of exposure.” 8

1-3, 5, 7, 9 4,6 8

Engelhart, Katie. “What Happened in Room 10?” The California Sunday Magazine, Pop-Up Magazine Productions, 21 Aug. 2020. MASS Design Group. 2020. “Designing Senior Housing for Safe Interaction.” The Role of Architecture in Fighting COVID-19. MASS Design Group. Lewis, Paul, et al. Manual of Physical Distancing. LTL Architects, 2020.

“Sometimes, there wasn’t even time to clean up after a resident was sent to the hospital...it weirded her out to see old hairbrushes and oxygen tubing lying on abandoned beds.” 3 Beyond simple storage, there is a programmatic need for a space that accommodates the potentially infected belongings of residents in order to clean out oxygen tubes and store belongings when residents are in the hospital. This compliments the existing proposal of MASS Design Group, who called for programmed adaptable spaces to accommodate grocers and medical suppliers during pandemics. 4 When examining aerial images of Life Care Center, Kirkland, it becomes apparent that there are very few designated outdoor areas to congregate at the carehome. At the neighborhood scale, the nearest park to the care home is more than a ten minute walk away.

“Sometimes, she would cry because the nurses redirecting her looked alien and strange in their surgical masks.” 9 How can architecture help familiarize residents when staff uniforms and protocols disrupt a sense of place and home? In the specific case of dementia patients, the nursing home loses a sense of familiarity when regular staff wear disorienting medical outfits, not to mention some of the staff themselves are unfamiliar being temporary substitutes when other staff call in sick. How can architecture compensate with this familiarity during routine procedures such as meal deliveries or regular checking of vitals?

2020 ARCHITECTS FOUNDATION/McASLAN FELLOWSHIP

SPOKANE VETERANS HOME SPOKANE, WA, USA (GOVERNMENT-STATE OPERATED) SITE PLAN

ABOUT The City of Spokane’s eleven long-term care facilities were performing well by May 2020, with the exception of this particular facility, which accounted for 61 of the 87 COVID cases (more than 70% of Spokane’s cases). 1 As observed from Google Maps, Spokane Veterans Home is located immediately adjacent to a health services corridor, which includes a large hospital and care center. While other care-homes advocated for increased activity outdoors, SVH is surrounded by a landscape of asphalt parking lots, making outdoor activity especially difficult.

FIG_5.68: “Site Map,” (Lidwin + Smith via Google Maps, 2020). FIG_5.69: Jesse Tinsley, Spokesman Review, 27 APril 2020 FIG_5.70: Spokane Veterans Home via Facebook, “Photos,”https://www.facebook.com/wsdva/ FIG_5.71-72: Spokane Veterans Home, www.dva.wa.gov/veterans-their-families/ veterans-homes/spokane-veterans-home

LESSONS FROM CARE HOMES IN PRACTICE

While none of the collected articles described the entrance of Spokane Veterans Home, most of the media studied included a picture of the Veterans Home from the street - with the road sign visible in the foreground and parking lot in the middle ground before the care home. In addition to the lived experience of entering and exiting the home, how does the image of the new care homes reflect in the media, especially when the care home becomes a topic in the news?

“The one thing about going to the cafeteria, you get a chance to fraternize with everybody, to talk and joke around. There would be probably 50 of us there for breakfast,’ he says. ‘I miss that.” 3 Quality care home design must accommodate various uses of space, but should also consider the hierarchy and regard that different spaces have to residents. The daily routine of breakfast becomes a valued ritual for socialization.

“She can barely make out the shape of her dad in a white T-shirt through the reflection of herself in a mask. He doesn’t have the strength to sit up close to the window to talk.” 6 Although window visitations are frequently mentioned throughout the care homes studied, architects should be careful about assuming that simply designing more glass facades will facilitate face-to-face visitations for residents and their families during the peak of future outbreaks. Glassed divisions for the bedrooms of residents were difficult to still visit between, because of the furniture, sill depth, and energy of residents to stand, among other varying factors.

Dreher, Arielle. “How Spokane and the Tri-Cities Took Different Approaches to Slowing Virus’s Spread in Long-Term Care Facilities.” Spokesman.com, The Spokesman-Review, 4 May 2020. 2-3 Criscione, Wilson. “Spokane Veterans Home Isolated Residents Back in February Due to Respiratory Illness — with No Way to Test.” Inlander, Inlander, 23 Apr. 2020. 4 Lewis, Paul, et al. Manual of Physical Distancing. LTL Architects, 2020. 5 Criscione, Wilson. “A Daughter’s Harrowing Journey to Support Her Father in His Fight with COVID-19.” Inlander, Inlander, 28 Sept. 2020. 6 “NEWS RELEASE - Spokane Veterans Home COVID-19 Positive Residents Will Transfer to Mann-Grandstaff VA Medical Center.” Washington State Department of Veterans Affairs, Washington State Department of Veterans Affairs, 23 Apr. 2020.

“We have a handful of private rooms, but we don’t have enough...There wasn’t enough space so that everyone could be in their own room.” 2 While new, unbuilt care homes can reconsider the size of rooms in their designs, existing care homes are restricted by their existing footprints. Several facilities described the shortage of private rooms, and in the case of Spokane Veterans Home, the governmentfunded care home had especially minimal space, trying to maximize square-footage and cost. How can shared rooms be divided in order to isolate infections while still providing an intentional, caring addition that preserve a sense of home? Despite a lack of green space around the care-home, the sidewalk medians in between parking spots became a canvas for the community to express well wishes and artwork. Accounts of staff lining up on the sidewalk to welcome COVID-recovered patients back from the hospital represent an additional program of the side-walk for pop-up events. Like LTL’s analysis of parking adaptions, 4 the pavement around care-homes is an important space that should be reclaimed as intentionally programmed space in anticipation for future pandemics.

“The VA Medical Center infrastructure offers several capabilities that the Spokane Veterans Home simply does not have and will not be able to acquire without significant capital improvements. These include...isolated COVID-19 positive zones with specified engineering controls” 6 The Spokane Veterans Home addressed its COVID-19 infected residents by teaming up with the VA Medical Center, where sick residents were transported to recover from COVID-19. This raises two important questions: 1) Should architects design care-homes to be self-sufficient and self-recovering in future pandemics, or is it better to think about designing a network of care-homes that pool resources during unprecedented times? 2) How does care-home design accommodate and add programmed spaces for infected positive zones with specified engineering controls?

2020 ARCHITECTS FOUNDATION/McASLAN FELLOWSHIP

ISSAQUAH NURSING + REHABILITATION CENTER ISSAQUAH, WA, USA (FOR-PROFIT) SITE PLAN

ABOUT Despite a dense forest with neighboring creeks and walking trails connected to high school recreational fields, the exterior design of Issaquah Nursing and Rehabilitation Center (INRC) mostly accommodates vehicular traffic (see main entrance image). Due to the frequent rotation of short-term visitors for their rehabilitation stays (and encouraged short-term stays due to the cost), COVID-19 numbers were especially high.

FIG_5.73: “Site Map,” (Lidwin + Smith via Google Maps, 2020). FIG_5.74: Issaquah Nursing & Rehabilitation Center, “Gallery,” https://www. issaquahnursing.com/ gallery IMG 5.75-77: Issaquah Nursing & Rehabilitation Center via Facebook, “Photos,” https:// www.facebook.com/ issaquahnursing/photos/?ref=page_internal

LESSONS FROM CARE HOMES IN PRACTICE

“Residents and their loved ones meet under our portico by the main entrance.” 1 Issaquah Nursing and Rehabilitation Center demonstrates adaptive uses of space that MASS Design Group anticipated in their “Strategies for the Public Realm,” when they wrote: The buffer zone between the entry of the building and the curb is an opportunity to not only establish clear way-finding to help those unfamiliar with the building, programs usually housed inside can be redirected here.” 2 Unlike staged photos of common rooms, several residents are pictured in wheelchairs, challenging one’s consideration of traditional furniture kit-of-parts for a room. If residents are not primarily using seating around a table, how might the furniture provided in the common rooms be better adapted to the needs of the residents and allow for new engagements for those in wheelchairs? When state-wide policies restricted visitors from entering Issaquah Nursing and Rehabilitation Center (INRC), in-person interaction first came in the form of various “carts” the staff would push throughout the halls. Described much like hotel room service or or the food trucks of major city streets, the hallways of INRC adopted a modified urbanity in the delivery of “crafts, games, and cookies” 7 to quarantining residents, yet no mention was ever made to any architectural spaces that accommodated such deliveries. Gifts from family and friends were eventually delivered, raising questions about the ability for residential mail boxes and mail services to expand during the height of pandemics and care-home isolation policies. Although designated as a long-term care facility for some, the Issaquah Nursing and Rehabilitation Center (INRC) includes patients who only stay for a few days to a few weeks for their rehabilitative care. Due to the rehabilitative nature of the facility, it was especially difficult during the coronavirus pandemic to limit new infections as residents came in and out of the facility. INRC presents another case for architecture tying into policies and management that govern the way the care home performs.

1,3, Issaquah Nursing & Rehabilitation Center. “COVID-19 Updates.” Blog, Issaquah Nursing & 5-7 Rehabilitation Center, 2020. 2 MASS Design Group. 2020. “Designing Senior Housing for Safe Interaction.” The Role of Architecture in Fighting COVID-19. MASS Design Group. 4 Avamere at Albany. “How Senior Living Communities Are Handling COVID-19.” Blog: Senior Healthcare News & Events, Avamere Family of Companies. 2020.

“On Wednesday, we invited residents who are able to engage in doorway visits. Social distancing was observed, masks were worn, and folks chatted about their favorite vacations.” 3 While the 5-10cm depth of door thresholds seems minimal, “opening one’s door” became a literal practice to symbolize the gradual reopening of the care-home between residents. While doors are often noted as important opportunities for residents to express their individuality and have creative ownership in their home, they also are re-purposed as unsuspecting, yet important, socializing moments. For Avamere Family of Companies, a national network of care facilities, doorways became important when “bingo moved to hallways, with each resident sitting at their doorway entrance to participate.”4

“The patios have been open. Residents who can and wish to go outside are able to spend time on the patios, socially distanced by at least 25 feet from other residents. Fresh air and sunshine are wonderful mood boosters” 5 During the height of the pandemic, public scrutiny of care-homes often resulted in policies that went beyond medical guidelines. The highly publicized 6-feet distance in the United States became 25-feet at Issaquah Nursing and Rehabilitation Center.

“...located on five scenic acres above the Issaquah Creek...our facility is a bird and squirrel sanctuary with frequent visits by deer and bald eagles.” 6 INRC features their five acre property on their website, specifically relating how nature is helpful for dementia patients in regards to “improved sleep patterns, balanced hormones, and decreased agitation,” 7 reaffirming aspects for healthy buildings proposed by Harvard’s Healthy Buildings Program.

2020 ARCHITECTS FOUNDATION/McASLAN FELLOWSHIP

REGENCY CANYON LAKES KENNEWICK, WA, USA (FOR-PROFIT, CORPORATION) SITE PLAN

ABOUT Regency Canyon Lakes Rehabilitation & Nursing is largely undocumented for its coronavirus practices and experiences, making it difficult to draw specific conclusions, despite being a worthwhile study given the facilities’ 50+ coronavirus cases. When possible, design considerations were pulled from press releases and website announcements. Also, several of the facility’s pictures mimic the same environments described by other care homes, so narratives are interwoven from other care homes when applicable.

FIG_5.78: “Site Map,” (Lidwin + Smith via Google Maps, 2020). FIG_5.79-82: Regency-Pacific, Photo-Tour. https:// www.regency-pacific. com/senior-living/ wa/kennewick/regency-canyon-lakes-rehabilitation-and-nursing-center/photo-tour

LESSONS FROM CARE HOMES IN PRACTICE

“Entrance to the communities is restricted to the main entrance only. All additional entrances and exits are secured.” 1 During the height of the pandemic, several long term care facilities, including Regency Canyon Lakes, opted to close all entrances except their main entrance requiring all visitors, deliveries, staff, and residents to enter through the same threshold. While MASS Design Group provides suggestions on widening entrances for more distance,3 how can one entrance be used to separate all the various traffic entering the building, while allowing care homes to manage access of just one entrance?

“For some people, the [common room] parties could be a bit hammy. The costumes, the playlists, the syrupy, exaggerated way that everyone seemed to speak to the residents.” 4 Several of the Regency Canyon Lake photos display a largely unprogrammed common space with tables and chairs - additive furniture in an otherwise boxy room, leaving a lot of responsibility for entertainment on the are-givers of the facility. This becomes especially difficult when interest in group events varies for residents. How can common spaces be designed to maintain the flexibility of program events, while distinguishing spaces so that more residents will feel at home congregating there?

“Restriction of all visitors for residents with the exception of resident’s at end of life.” 5 Most protocols for care home visitation plan for moments when both the visitor and resident are assumed to be healthy, so the extra precautions of social distancing and adding screens between them (ex. windows or temporary dividers) are simply additional measures to further ensure infection does not spread. Yet, for patients who are on hospice care, nearing the end of their life, how can visitation space be accommodated and - in some ways - safely break COVID protocol to ensure a respectable, intimate encounter before when residents are not likely to get better? 1,5 3 2,4

“Visitor Restrictions Due to COVID-19.” Regency Pacific, Regency Pacific Management, 2020. “Designing Senior Housing for Safe Interaction.” The Role of Architecture in Fighting COVID-19. MASS Design Group. 20. Engelhart, Katie. “What Happened in Room 10?” The California Sunday Magazine, Pop-Up Magazine Productions, 21 Aug. 2020.

“She heard the nurses moving around. Their whispers. She heard the heaving of the oxygen machine. At some point, someone had closed the curtain that divided the room, but it didn’t do much to mute the noise. The beds were so close together that each woman could hear the other breathing — and that was true on a normal day, before the coughing.” 2 The bedrooms of Regency Canyon Lakes Rehabilitation & Nursing uses similar furniture used by care homes across the world - where curtain dividers bend along the ceiling to provide curtained divisions. Yet, the arrangement of shared rooms leaves little opportunity for privacy between roommates - making it especially difficult when one roommate is sick. There is a need for shared bedrooms to have degrees of programmed room divisions for moments of visual privacy, sound privacy, and complete privacy (potentially dividing air flow in the room to avoid contamination through airborne viruses). Regency Canyon Lakes is minimally landscaped with what-appears-to-be a vacant, unkept lot adjacent to the property. In analyzing how residents can interact outside, the outside furniture is very standard, suggesting that replacement and upkeep of furniture is a priority when considering how to design spaces. To address this, architects should design features of care home spaces to be easily replaced or added. Regency Canyon Lakes does not provide many updates via social media or blog posts, but their Facebook account features staff gifts received during the coronavirus pandemic. In all photographs of provided lunches, open food (sometimes in a buffet style format) raise questions regarding the existing programmed dining spaces in care home facilities and designing future spaces that allow meals to be served or collected without contact contamination. Provided lunches in the forms of sandwich platters, pizza boxes, and cookie trays should not necessarily be turned away simply because they aren’t individually packaged. Rather, how can the architectural space of kitchens and serving areas be arranged to allow safe food collection?

2020 ARCHITECTS FOUNDATION/McASLAN FELLOWSHIP

QUEEN ANNE HEALTHCARE SEATTLE, WA, USA (FOR-PROFIT, CORPORATION) SITE PLAN

ABOUT Queen Anne Healthcare initially had zero cases of coronavirus associated with their facility, sparking University of Washington’s medical team to come and conduct their own coronavirus testing, confirming the cases at zero. Since May 2020, however, Queen Anne Healthcare has not been spared of the coronavirus. According to Avamere, the company in charge of running Queen Anne Healthcare, the total cases at Queen Anne Healthcare has spread over the summer months with the facility having 89 resident cases and 41 staff cases - the most of any Avamere property.

FIG_5.84: “Site Map,” (Lidwin + Smith via Google Maps, 2020). FIG_5.85-87: Queen Anne Healthcare, https://www.avamere. com/queen-annehealthcare/ FIG_5.88: Ted S. Warren, https://www.oregonlive.com/galleries/ NVUV7PXGWFFIBGGVCO4UK3WWEE/

LESSONS FROM CARE HOMES IN PRACTICE

The entrance to Queen Anne Healthcare is perhaps the least photographed space of the facility, and the positioning of the building on the street - where visitors drive around the rear of the building first - further hides the entrance. As a larger scale consideration for new care home design, the entrance the location of Queen Anne Healthcare has allowed the front parking area to become a protected gathering space and allows opportunities for the front entrance to be converted for other programmatic uses, given the flow of visitors and staff in and out of the building is more regulated during times of peak pandemic infections. When common spaces closed during the height of COVID-19, the Avamere Company (owner of the Queen Anne Healthcare facility) created an app, “LifeLoop,” 2 to connect residents with family and other seniors at Avamere locations across the country. It becomes an interesting case when considering the role of care facilities and the services they provide not only in the physical environments and care, but also in the digital platforms used to communicate. In the spirit of holistic design, how can the physical buildings utilize technology to encourage more participation in these digital platforms?

“ As certain markets begin to open back up on a limited basis, some excursions have resumed” 3 While it is important to design for visitor areas in the care homes, it is also important to acknowledge moments when the residents themselves become visitors to other spaces in the larger community (such as market places). By mid September, Queen Anne Healthcare resumed excursions for residents. Although their dedicated green space is not enormous, the spaced seating and green atmosphere of the outdoor area appears very cozy and desirable for residents. Due to the fact that Queen Anne Healthcare performed well at having no coronavirus cases until May of 2020, the use of their green spaces could be considered as a potential example of the benefit green spaces provide.

1 2 3 4 5

Avamere Health Services. “@Avamerehealth.” Instagram, Instagram from Facebook, 2020 Gusinow, Sander. “First to Fight.” Oregon Business, 7 July 2020, www.oregonbusiness.com/ article/health-care/item/19101-spotlight-first-to-fight. Avamere at Albany. “How Senior Living Communities Are Handling COVID-19.” Blog: Senior Healthcare News & Events, Avamere Family of Companies, 28 Sept. 2020. Ryan, Jim. “Nursing Homes across the US Plead for More Testing during Coronavirus Crisis.” OregonLive: Oregonian, Advance Local Media LLC, 23 Apr. 2020. Avamere: Family of Companies. “COVID-19 Data.” Avamere Family of Companies, The Avamere Family of Companies, 1 June 2020,

Of the many Instagram pictures posted on Avamere’s Instagram account, 1 the biggest transition of care home space occurred in the hallways. Formerly long, empty corridors to promote circulation became long socially distanced avenues for various activities ranging from Bingo to chair exercise classes. When movement throughout the building is drastically reduced, how does stagnant circulation space become programmed activity space? Queen Anne Healthcare is located in a prominent spot along the Seattle hills of Aurora Bridge, providing the care home with close proximity to local Seattle life possibly encouraging the “excursions” that the care home took after reopening to the public.

“Public access to COVID-19 related data supports... [our] commitment to providing transparent and timely information to residents, their families, and the communities we serve.” 5 Of the five care homes studied in Washington State, the Avamere Family of Companies, owner of Queen Anne Healthcare, was the only care home that published their COVID-19 data in an easy to view website, allowing transparency into the practices maintained in the facility. Queen Anne Healthcare was one of 19 nursing homes in the Seattle region without a single known case of COVID-19 as of mid-April 2020. Due to the lack of COVID cases, University of Washington medical staff deployed “drop teams” to verify their COVID status. This is particularly interesting for Queen Anne, because their 60 cases of coronavirus mostly spread after the initial May 24th reporting of cases. Should architects be designing care homes with the ideas of future pandemic testing in mind? Drop teams deployed pairs of medical staff to test residents, one “hot” staff member who went into rooms to collect specimens, and one “clean” member who managed the cart outside in the hallway. 4

2020 ARCHITECTS FOUNDATION/McASLAN FELLOWSHIP

3. TWENTY-ONE CARE HOMES WITH THE MOST COVID-19 CASES IN AMERICA Using data from the New York Times, we isolated twenty-one care homes that had some of the most coronavirus cases in their facilities as of October 2020. Through further data collection from individual state data sets as well as ProPublica and the Medicare website (updated by the U.S. Centers for Medicare and Medicaid Services), we were able to compare various statistics and characteristics for our twenty-one identified homes. Of our research, we find it most interesting that of the care homes studied, the average occupancy rate for a care home was 70% during the coronavirus pandemic. This is especially important for designers because it signals two key principles for future care home design: 1) the management policies of care homes may play an important role, given that the struggle to contain the outbreak does not seem to be a result of not enough space, and 2) despite having extra beds available to shift residents around during the pandemic, the average 30% vacancy of care-homes was still not enough to control the spread of the virus. There is a need for designers to consider the adaptability of unused rooms, especially alternative uses for rooms when future pandemics occur.

% OF OCCUPANCY FOR 21 CARE HOMES WITH THE MOST COVID-19 CASES IN THE UNITED STATES 54.03%

50%

80.83% 75.95%

63.20%

60%

70%

80%

72.20% 59

PERCENT OF BEDS OCCUPIED DURING THE COVID-19 PANDEMIC

90%

LESSONS FROM CARE HOMES IN PRACTICE

AMOUNT OF COVID-19 CASES PER 100 BEDS

AMOUNT OF CARE HOME DEFICIENCIES IN RELATION TO COVID CASES PER 100 BEDS (AS REPORTED BY PROPUBLICA) 160 140 120 100 80 60 40 20 0

120

100

NUMBER OF DEFICIENCIES (IN PAST THREE YEARS)

AMOUNT OF CARE HOME DEFICIENCIES IN THE PAST THREE YEARS (AS REPORTED BY PROPUBLICA) 5 11

FIG_5.89 (LEFT) Percentage of Occupancy for 21 Care homes with the Most COVID-19 Cases in the United States (Lidwin + Smith, 2020).

30.95

116

FIG_5.90 (ABOVE) Amount of Care Home Deficiencies in Relation to COVID-19 Cases Per 100 Beds (Lidwin + Smith, 2020).

NUMBER OF DEFICIENCIES (IN PAST THREE YEARS)

100

FIG_5.91 (BELOW) Amount of Care Home Deficiencies the Past Three Years (Lidwin + Smith, 2020).

2020 ARCHITECTS FOUNDATION/McASLAN FELLOWSHIP

COVID CASES D IVOC CO COVID HTAED PER 100 D DEATHS % OF # CASES # DEATHS CERTIFIED FO # E A R RA PER 100 # OF T BEDS CARE HOME NAME LOCATION OCCUPANCY (TOTAL) (TOTAL) BEDSR S TN E D I S E RES BEDS RESIDENTS Bergen New Bridge Medical Center Paramus Veterans Memorial Home PruittHealth Palmyra Nursing Home Meadowbrook Manor of Bolingbrook Soldiers' Home in Holyoke

% 4 2 Paramus NJ 574 9 412 71.78% . 2813 res. 66 res. 64.81 91 staff % 7 4 Paramus NJ 336 0 214 63.69% . 1990 res. 81 res. 86.9 93 staff 1 staff % 4 1 Albany GA 250 8 159 63.60% . 1685 res. 26 res. 99.6 81 staff % 8 6 Bolingbrook IL 298 7 161 54.03% . 249 421 58.05 % 2 2 Holyoke MA 277 0 210 75.81% . 236 763 85.2 % 4 1 200 152 76.00% 231 21

11.5

24.4

10.4

14.09

27.44

FutureCare Lochearn Nursing Home

Baltimore

115.5

10.5

Symphony of Morgan Park Rehabilitation

% 8 1 Chicago IL 294 7 219 74.49% . 2022 res. 26 res. 68.71

8.84

% 4 2 Hackensack NJ 180 8 132 73.33% . 1491 res. 32 res. 110.56 50 staff 1 staff % 0 3 Jackson NJ 234 3 133 56.84% . 1532 res. 49 res. 83.76 43 staff % 8 2 North NJ 247 5 155 62.75% . 1349 res. 40 res. 78.14 Bergen 59 staff 1 staff Chicago IL 222 171 77.03% 183 17 82.43 % 0 1

18.33

20.94

16.6

7.66

98.86

15.91

% 3 3 Voorhees NJ 190 3 128 67.37% . 126 3 res. 42 res. 90.53 46 staff - 166 Zion IL 244 144 59.02% -68.03

22.11

97 80.83%

unknown

Hackensack Meridian Health Bartley Healthcare The Harborage Nursing Home Woodbridge Nursing Pavilion Redwood Springs Nursing Home Voorhees Center Nursing Home The Grove at the Lake Nursing Home Gallatin Center for Rehabilitation + Healing

Visalia

Gallatin

% 5 2 176 111 63.07% 174 28

120

162

unreported

135

11.44

The Citadel at Salisbury Nursing Home

4 2 New% Milford NJ 236 9 189 80.08% . 102 5 res. 26 res. 68.22 59 staff 1 staff % 9 1 Salisbury NC 160 5 103 64.38% . 1392 res. 18 res. 86.88

11.25

Preakness Healthcare Center Nursing Home Century Villa Nursing Home

% 1 2 Wayne NJ 406 9 298 73.40% . 1147 res. 31 res. 57.88 121 staff % 5 1 Inglewood CA 84 61 72.62% 51 9 60.71

7.64

10.71

CareOne at New Milford Nursing Home

The Suffield House Nursing Home Carroll Lutheran Village Assisted Living

Suffield

% 6 1 128 102 79.69% 50 16

39.06

12.5

Westminster

% 2 1 103 69 66.99% 50 8

48.54

7.77

ABOUT CHART 01: Twenty-one of care homes with the most COVID-19 cases in the United States of America were categorized by a variety of factors including percent of capacity and green spaces offered. Of the twenty-one care homes, the range of occupancy was 54-81%.

D HS 00 S

LESSONS FROM CARE HOMES IN PRACTICE

COVID DEATH RATE OF RESIDENTS

GREEN GREEN D IVOC GREEN SPACES SPACES #S OF RECORDEDH TA E D DEFICIENCIES # OF # OF # OF PATIENT GREEN SPACES PER PER 00 1 R E P OWNERSHIP IN PAST 3 YRS BUILDINGS STORIES WINGS ROOM TYPE B SPACES PER BED BUILDING STORY S D E

GREEN SPACES PER WING

5 .31 3 private1 and 4 Semi-Private 4 .84 2 2 Semi-Private 6

23.49%

gov-county

40.70%

gov-state

15.48%

for-profit

16.87%

for-profit

32.20%

unknown

14%

stateowned, veterans for-profit

12.87%

for-profit

21.48%

for-profit

32.03%

for-profit

29.85%

non-profit

10%

for profit

25%

33.33%

---

25.49%

12.95%

27.19%

0.007

1.33

1.3

0.018

0.8

4 .30 1 private 1 and 3 0.012 semi-private 9 0 1 1 3 6 .4 private and 1 0.003 semi-private 4 4 2 1 6 10 . 7 private and 3 0.011 Semi-Private

0.33

0.2

0.5

0.3

0.01

0.33

0.7

0.007

0.67

0.7

0.75

1.67

3 3 1 1 4 3 .8 private and 3 0.017 semi-private 4 9 2 1 3 1 .0 private and 5 0.021 semi-private .26 1 6 4 Private1 and 0 0 Semi-Private 6 . 1 6 4 2 N/A7 2 0.009

0.5

for profit, LLC for-profit

116

1 9 1 1 1 5 .5 Private 3 0.017

0.6

for profit, individual for-profit

1 1 2 1 1 11 . 2 private and 0 -semi-private 1 4 3 Private 0 0

0.6

0.67

0.5

0.7

1.33

0.4

0.3

for-profit, LLC for-profit

5 .30 6 private 1 and 2 Semi-Private 4 8 .8 3 3 semi-private 2

n w o 14 1 1 8n privatek and 5n 0.042u 5 semi-private 4 4 1 18 1 3 4 .1 private and 2 0.008 2 semi-private 5 2 1 43 1 1 7 .1 private and 5 0.031 5 semi-private 6 .7 18 1 4 3 11 private and 4 0.01 4 semi-private 1 7 1 28 1 1 3 .0 N/A 1 0.012 1

15%

gov-county ownership non-profit

16%

for-profit

5 .72 1 1 Private 4

0.031

0.6

12%

non-profit, church

7 7 . 1 5 1- and7 22 person suites

0.019

0.4

FIG_5.92 (ABOVE) 21 Care Homes with the Most COVID-19 Cases in the United States (Lidwin + Smith, 2020).

2020 ARCHITECTS FOUNDATION/McASLAN FELLOWSHIP

COMPARISON OF GREEN SPACES The diagram shows a comparative analysis of the amount of usable outdoor space incorporated into certain care home schemes. The left column shows care homes in the United States with some of the highest instances of COVID-19 per resident. The right column shows care homes located across the globe that are noted for being particularly well-designed or innovative. It is clear that the more successful care homes have significantly more usable outdoor space. The inclusion of a high number of varied and well-designed usable outdoor spaces indicates a care home’s focus on holistic resident wellness. Moving forward, the inclusion of more usable outdoor space for resident health and satisfaction should be seriously considered by all designers and care home owners.

AMOUNT OF GREEN SPACES PER BUILDING (AS OBSERVED VIA GOOGLE IMAGERY) 0

1.33

2.6

NUMBER OF DEDICATED OUTDOOR SPACES PER BUILDING ON FACILITY PROPERTY 63

FIG_5.93 (LEFT) Amount of Green Spaces per Building (Lidwin + Smith, 2020).

S WITH HIGH HIGH WITH HERTIFIED HIGH ASE TOHIGH CERTIFIED BED RATIOS BED RATIOS WITH HIGH BED RATIOS HIGH SE TO CERTIFIED BED RATIOS IGH O CERTIFIED WITH HIGH SE TOHIGH CERTIFIED BED RATIOS WITH CERTIFIED BEDRATIOS RATIOS ERTIFIED BED GH SE TO CERTIFIED BED RATIOS Egs TO CERTIFIED BED Nursing Home Home RTIFIED BED RATIOSRATIOS

Nursing ng HomeHome Nursing gHome Home Home cases per certified bed ertified bed sursing Nursing Home Home ome ases per certified er certified bed bed ases perbed certified bed certified bed ertified ases certified bed es perper certified bed rtified bed

LESSONS FROM CARE HOMES IN PRACTICE

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Caleb Hitchcock Memory CareNeighborhood Neighborhood Care Caleb Hitchcock Memory REDWOOD SPRINGS Caleb Hitchcock Memory Bloomfield, Care Neighborhood Bloomfield, CT,USA USA CT, USA Bloomfield, CT, Care Neighborhood CareCA Neighborhood Visalia, Bloomfield, USA Bloomfield, CT,CT, USA

CALEB HITCHCOCK Bloomfield, CT, USA

myra Nursing Home ng Home yra Nursing ursing HomeHome yraHome Nursing sing Home Home ng per certified ertified bed myra Nursing Homebed acases Nursing Home g ases per81 certified es total, staff bed erHome certified bed staff per certified bed sases total, 81 staff 81 staff certified bed ertified bed total, 81 staff bed ases certified bed 1s staff staff es perper certified bedstaff srtified total, otal, 8181 staff aff

Belong Atherton Belong Atherton Belong Lancashire, UK Belong Atherton Lancashire, UK Atherton Belong Atherton Lancashire, UK Lancashire, UK Belong Atherton Belong Atherton Lancashire, UK Pozzoni, LLP Pozzoni, LLP Belong Atherton Lancashire, UK PRUITTHEALTH PALMYRA Lancashire, UK Belong Atherton Belong Atherton Pozzoni, Pozzoni, LLP LLP Lancashire, UK Lancashire, UK Albany, GA Pozzoni, Lancashire, UK LLP Pozzoni,LLP LLP Pozzoni, - 99.60 COVID-19 cases Pozzoni, LLP Pozzoni, LLP Pozzoni, LLPcertified beds per 100

BELONG ATHERTON Lancashire, UK

nter&for Rehab & Nursing hab Nursing er for Rehab & Nursing Rehab & Nursing er for Rehab & Nursing ehab Nursing hab & &Nursing 9certified cases per certified bed bed ter for Rehab & Nursing for Rehab & Nursing b &total, Nursing cases per es 61certified staff per certified bed bed staff per certified bed scases 61bed staff 61 staff rtotal, certified bed certified total, 61 staff cases per certified bed 1s staff staff ses per certified bed bed sertified total, staff otal, 6161 staff aff

Kendal at Ithaca Kendal at Ithaca atNY, Ithaca Ithaca, USA Kendal at Ithaca Ithaca, NY,Kendal USA Kendal at Ithaca Ithaca, NY, USA Ithaca, NY, USA Kendal Ithaca Kendal atat Ithaca Ithaca, USA Perkins Eastman Perkins Eastman Kendal at Ithaca Ithaca,NY, NY, USA Ithaca, USA Kendal atNY, Ithaca Kendal at Ithaca Perkins Eastman Perkins Eastman Ithaca, USA Ithaca, NY,NY, USA Ithaca, NY,Eastman USA Perkins Eastman Perkins Perkins Eastman HAMMONTON CENTER Perkins Eastman Perkins Perkins Eastman Hammonton, NJEastman

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Neptuna Development Neptuna Development Neptuna Development Malmo, Sweden Neptuna Development Malmo, Sweden Neptuna Development Malmo, Sweden Malmo, Sweden Neptuna Development Neptuna Development Malmo, Sweden Arkitektgruppen Arkitektgruppen Malmo AB Malmo AB Neptuna Development Malmo,Sweden Sweden Malmo, Neptuna Development Neptuna Development Arkitektgruppen AB greenhouse byMalmo Monika Gora Arkitektgruppen Malmo AB greenhouse by Monika Gora Malmo, Sweden Malmo, Sweden Malmo, Sweden Arkitektgruppen Malmo AB greenhouse by Monika greenhouse by Monika Gora Gora FUTURECARE LOCHEARN Arkitektgruppen Malmo AB Arkitektgruppen Malmo AB greenhouse by Monika Gora Arkitektgruppen Malmo AB greenhouse Monika Gora greenhouse bybyMonika Gora Arkitektgruppen Malmo AB Baltimore, MD Arkitektgruppen Malmo AB greenhouse by Monika Gora bycases Monika Gora -greenhouse 115.50greenhouse COVID-19 by Monika Gora

Rehab & Healing &for Healing r Rehab & Healing ab & Healing r&Healing Rehab & Healing Healing 9certified cases certified bed bed or Rehab & Healing Rehab &per Healing Healing cases per certified per certified bed bed cases perbed certified bed er certified bed certified cases certified bed ses perper certified bed ertified bed

Bloomfield, CT, USA

- 98.86 COVID-19 cases per 100 certified beds - 174 total COVID cases

- 168 total COVID cases

- 108.33 COVID-19 cases per 100 certified beds - 260 total COVID cases (199 resident)

KENDAL AT ITHACA Ithaca, NY, USA

NEPTUNA DEVELOPMENT Malmo, Sweden

per 100 certified beds - 231 total COVID cases

Sun City Tachikawa Showa Sun City Tachikawa Showa Sun CityKoen Tachikawa Kinen SunKoen City Tachikawa ShowaShowa Kinen Sun City Tachikawa Showa Kinen Koen Tachikawa, Japan Kinen Koen Tachikawa, Japan Showa Sun CityTachikawa Tachikawa Showa Sun City Kinen Koen Tachikawa, Japan Showa Tachikawa, Japan Sun City Tachikawa Showa Kinen Koen Kinen Koen Sun City Tachikawa Sun City Tachikawa Showa Tachikawa, SWA SWA Kinen KoenJapan Tachikawa, Japan Tachikawa, Japan Kinen Koen Kinen Koen GALLATIN CENTER SWA SWATachikawa, Tachikawa, Japan Japan Tachikawa, Japan SWA SWA SWA

Gallatin, TN

SWA SWA - 135.0 COVID-19 cases SWA

per 100 certified beds - 162 total COVID cases

SUN CITY TACHIKAWA Tachikawa, Japan 64

70 CONCLUSION

MORE THAN

70%

OF CARE HOMES WITH MORE THAN 30 BEDS HAD 1+ COVID CASE *AS OF SPRING 2020

Six design principles contribute to quality care home design: affordability, sustainability, innovation, resident-centered design, health and safety, and integration into the larger community and landscape. In order to ensure high quality design throughout a project, interdisciplinary approaches are necessary. We hope that our research into these principles will assist John McAslan + Partners in their design and construction of a new care home prototype for Scotland.

2020 ARCHITECTS FOUNDATION/McASLAN FELLOWSHIP

CONCLUSION: IMAGINING NEXT STEPS Our research identified design strategies that foster resident comfort, staff satisfaction, and general health and safety in care homes. We studied care home research from several fields, high quality care home designs across the globe, and care homes that performed poorly during COVID. This helped us pin down several design features of successful care homes that should be implemented in the design of a new Scottish care home model. Architecture has the unique ability to affect all people in an intimate way, whether or not we realize it, though our daily interaction with the built environment. This insight guided us in our research as we sought to learn ways that architecture could improve the lives of older and at-risk populations, in general and even during a pandemic. As we researched care home case studies and COVID data we had several design principles to consider when determining how relevant each case study was to our research: affordability, sustainability, innovation, residentcentered design, health and safety, and integration into the larger community and landscape. These principles helped us select specific case studies and guide our research. A GENERAL SYNOPSIS Through the use of our guiding principles for good care home design ,we discovered successes and shortcomings of various international care home models. These models inspired a set of design strategies to include in a new Scottish care home model. For example, while there were many excellent care home design case studies, we found that many high quality care homes were not affordable due to large up-front building costs or costly management (sometimes both). High costs cut off some of the most at-risk elderly people from quality care in a pleasant, healthy environment. For this reason, the Neptuna care home in Sweden became an excellent case study because it is affordable elder care located in a newly redeveloped area on high-value water-front property, placing the seniors central in the community. In researching the relation between design and COVID, we hoped to identify several clear design decisions that weakened architecture’s role in managing COVID outbreaks. These decisions could then be avoided in the design of the new Scottish care home model. Unfortunately, the issue proved more complex than anticipated. Dr. Joe Allen of Harvard University’s Healthy Building Program provides guidelines on how to make physical interior environments healthier for users. During our research we found that the under-performing care homes that did not meet his guidelines, for example lacking minimum recommended green space, had significant trouble containing the spread of COVID in their facilities. However, we also saw that care homes considered “healthy” based on Dr. Allen’s guidelines still struggled to contain the virus in their facilities. This shows that architecture may have more than one role in designing healthy spaces. The first role is designing a healthy building in which ventilation systems, material choices, facility organization, and room layout are successfully designed to decrease the spread of a viral infection. The second role is more nuanced, involving the design of spaces that allow for and encourage human practices and policies that protect against infection. This requires a multidisciplinary approach to designing adaptable spaces that work alongside policy and people to protect all users.

CONCLUSION

AREAS FOR FURTHER CONSIDERATION The most critical takeaway for any projects or research moving forward is the importance of an interdisciplinary approach to care home design. Care home design is most successful when designers gather a variety of viewpoints, including healthcare professionals, psychologists, and current care home residents. While the case study format we took was useful in getting a glimpse into care home design and performance during COVID, these were only snapshots of the full picture and cannot fully describe the care home situation around the world. However, because of the abundance of care home and elder care research already available, the case study format proved to be more beneficial for our specific purpose of designing a better care home model in Scotland. Because both of us are American students and our mentors and advisors were mainly American or European, many of the care home examples came from these regions, although there are excellent examples worldwide. Our understanding of what constitutes a good care home is biased by our geography and culture. Because of this, we attempted to learn more about models of care in other regions of the world but unfortunately do not have as clear of a picture of these models as we do of our own. Because this new care home will be located in Scotland, though, we tailored our design approach to Western cultures that are more similar to the general Scottish lifestyle. NEXT STEPS Following our research documentation, the Fellowship is taking a turn towards the real-world application of our research. John McAslan + Partners along with Legal & General will be designing an affordable care home in Newcastle with the intention of using our research and input to address issues of affordability, sustainability, innovation, resident-centered design, health and safety, and integration into the larger community and landscape through design. We hope to use some of the design principles learned through our research, such as the importance of outdoor spaces, a smaller, more domestic care home size and occupancy with better ventilation, and a clear connection to the community and culture at large, to design a successful new care home model for Scotland. ADDING TO ARCHITECTURAL DISCOURSE An aspect of architecture that we gleaned from the research was the importance of an interdisciplinary approach to the design of a high quality care home. Our research required us to seek expert opinion on dementia design, care homes, nurse staffing, and environmental health. We believe successful care home design will also need to seek interdisciplinary input to adequately manage holistic health concerns going forward. Designers will need to think critically about the potential for architecture to learn from its user groups and adapt to new guidelines as future events continue to alter our idea of normalcy. Care homes are critical for us all to consider, either from the perspective of designers, health officials, current residents, or future residents. Our hope is that by understanding and learning from the events of the coronavirus pandemic, architects can look at housing issues facing a variety of insecure communities, such as the elderly and the house-less, and extend the principles learned to many future housing designs. 68

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FIG_2.02

FIG_2.03

jwKCAiAsOmABhAwEiwAEBR0Zlpt0eH0AqCdIPOoFXyzAZHnOf5fWNrHZfWgcGkYvMKRuOg3RfMH9hoCyNAQAvD_BwE

nursing-homes-research-lessons/

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FIG_3.03

j9BRAvEiwA0UAWXpgvUcfaDV1amfeq80lrr2XOVy1v2mFK_xI0f_Okgk7pNeD5IOD7ghoCWTEQAvD_BwE#!

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gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/deathsinvolvingCOVID19inthecare-

FIG_3.04 - 05

FIG_5.01

FIG_5.02 FIG_5.89 - 93

sectorenglandandwales

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IMAGE SOURCES FIG_1.01

FIG_2.01 FIG_2.02

FIG_2.03 FIG_3.01 FIG_3.02 FIG_3.03

FIG_3.04 FIG_3.05 FIG_5.01 FIG_5.02 FIG_5.03 FIG_5.04

FIG_5.05 FIG_5.06

FIG_5.07 FIG_5.08 FIG_5.09 FIG_5.10 FIG_5.11 FIG_5.12

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FIG_5.13 FIG_5.14 FIG_5.15

FIG_5.16 FIG_5.17 FIG_5.18 FIG_5.19 FIG_5.20 FIG_5.21 FIG_5.22 FIG_5.23 FIG_5.24 FIG_5.25 FIG_5.26 FIG_5.27 FIG_5.28

FIG_5.29 FIG_5.30 FIG_5.31 FIG_5.32 FIG_5.33 FIG_5.34 - 38 FIG_5.39-40 FIG_5.41 - 42

Nord Architects Copenhagen. “Alzheimer’s Village.” Archello. 2020. https://archello.com/project/alzheimers-village Adrià Goula. “Day Center and Home for the Elderly of Blancafort.” ArchDaily. https://www.archdaily. com/783918/centre-de-dia-i-casal-de-gent-gran-de-blancafort-guillem-carrera# Albrecht Imanuel Schnabel. “Nenzing Nursing Home.” ArchDaily. 2014. https://www.archdaily. com/547190/nenzing-nursing-home-dietger-wissounig-architects/5410e6cfc07a80dfae000099-nenzing-nursing-home-dietger-wissounig-architects-photo Galli Rudolf. “Giesseri.” Galli Rudolf. 2019. https://galli-rudolf.ch/projects/Mehrgenerationenhaus-Giesserei

Adrien Williams. “Panorama Retirement Home.” Dezeen. 2019. https://www.dezeen.com/2019/08/26/panorama-acdf-architecture-retirement-home-quebec-canada/ REES. “Pacific Plaza.” REES. Retrieved 2021. https://www.rees.com/our-work/senior-living/continuing-care-retirement-communities-planning/pacific-plaza-continuing-care Igor. “How to See the Best of Malmö in One Day?” Igor. https://igor.stojakovic.net/hr/kako-vidjeti-najboljeod-malmea-za-jedan-dan/ David Hughes. “A Study of Salem Nursing Home.” Design for Aging. 2012. Ute Zscharnt. “Coop Housing at River Spreefeld.” ArchDaily. 2013. https://www.archdaily.com/587590/ coop-housing-project-at-the-river-spreefeld-carpaneto-architekten-fatkoehl-architekten-bararchitekten Shma Company Limited + Openbox Architects. “Renderings.” Shma Company Limited + Openbox Architects. 2018. Atelier Alter. “Senior Center of Guangxi.” ArchDaily. 2014. https://www.archdaily.com/553442/senior-center-of-guangxi-atelier-alter Patrick Bingham-Hall. “Kampung Admiralty.” ArchDaily. 2017. https://www.archdaily.com/904646/kampung-admiralty-woha “Proposed ‘Senior Citizens’ Village and Wellness Centre’ in Nugegoda.” Daily News. 2020. http://www. dailynews.lk/2020/03/02/finance/213020/western-care-homes-invests-rs-500-mn-elderly-care-village MASS Design Group. “Munini District Hospital.” MASS Design Group. 2018. https://massdesigngroup.org/ work/design/munini-district-hospital MASS Design Group. “New Redemption Hospital Caldwell.” MASS Design Group. 2017. https://massdesigngroup.org/work/design/new-redemption-hospital-caldwell MASS Design Group. “African Centre of Excellence for Genomics of Infectious Diseases.” MASS Design Group. 2017. https://massdesigngroup.org/work/design/african-centre-excellence-genomics-infectious-diseases Yury Gubin/Alamy. “Libertad in central Valdivia.” The Guardian. 2017. https://www.theguardian.com/cities/2017/nov/13/chile-valdivia-elderly-older-people-gerontological-hub-ageing-crisis-pensions “Summerset by the Ranges Memory Care Centre.” Team Architects. 2017. https://www.teamarchitects. co.nz/projects/senior-care-and-living/home-of-compassion-new-dementia-unit/ PHX india, Mindspace. “Parkside Retirement Homes.” ArchDaily. 2018. https://www.archdaily.com/901829/ parkside-retirement-homes-mindspace “De Hogeweyk.” Urban Edge Architecture. 06 July 2018. https://www.urbanedgearchitecture.co.uk/all/senior-living-hogeweyk-part-2/ Niek Roozen, “Site Plan,” Detail-Online. 2012. https://www.detail-online.com/article/dementia-village-de-hogeweyk-in-weesp-16433/ KopArt. “De Hogeweyk.” Detail-Online. 2012. https://www.detail-online.com/article/dementia-village-de-hogeweyk-in-weesp-16433/ Madeleine Sars. “Outdoor Spaces of De Hogeweyk.” Detail-Online. 2012. https://www.detail-online.com/article/dementia-village-de-hogeweyk-in-weesp-16433/ KopArt. “Public Spaces of De Hogeweyk.” Detail-Online. 2012. https://www.detail-online.com/article/dementia-village-de-hogeweyk-in-weesp-16433/

FIG_5.43,45 - 48

FIG_5.44 FIG_5.49-51 FIG_5.52 FIG_5.53 - 57 FIG_5.58 FIG_5.59 - 60 FIG_5.61 - 62 FIG_5.63 FIG_5.64 - 67 FIG_5.68 FIG_5.69 FIG_5.70 FIG_5.71 - 72 FIG_5.73 FIG_5.74 FIG_5.75 - 77 FIG_5.78 FIG_5.79 - 82

FIG_5.84 FIG_5.85 - 87 FIG_5.88

FIG_5.89 FIG_5.90 FIG_5.91 FIG_5.92 FIG_5.93 FIG_5.94

Robert Bensen Photography. “The Caleb Hitchcock Memory Care Neighborhood.” Amenta Emma Architects. 2015. https://amentaemma.com/portfolio/duncaster-retirement-community-the-caleb-hitchcock-memory-care-neighborhood/ Amenta Emma Architects. “Plan.” Amenta Emma Architects. 2015. https://amentaemma.com/portfolio/ duncaster-retirement-community-the-caleb-hitchcock-memory-care-neighborhood/ Panoramic Studio. “Jin Wellbeing County.” Shma Company Limited + Openbox Architects. 2018. https://shmadesigns.com/work/jin-wellbeing-county Shma Company Limited + Openbox Architects. “Plan.” Shma Company Limited. 2018.

https://shmadesigns.com/work/jin-wellbeing-county Photographer Name. “Belong Atherton.” Pozzoni, LLP. XXXX Architektgruppen. “Neptuna Development.” Arkitektgruppen Malö AB. 2006. https://www.arkitektgruppen.nu/portfolio/neptuna-vastra-hamnen/ Monika Gora. “Plan + Detail.” Gora. 2006. https://gora.se/projects/the-glass-bubble Architektgruppen. “Neptuna Development.” Arkitektgruppen Malö AB. 2006. https://www.arkitektgruppen.nu/portfolio/neptuna-vastra-hamnen/ Mike Lidwin + Melissa Smith via Google Maps. “Site Map.” 2020. Life Care Center of Kirkland. “Gallery.” Life Care Center of Kirkland. Retrieved 2020. https://lcca.com/locations/wa/kirkland/gallery Mike Lidwin + Melissa Smith via Google Maps. “Site Map.” 2020. Jesse Tinsley. “The Spokane Veterans Home.” The Spokane Review. 27 April 2020. Spokane Veterans Home. “Photos.” Facebook. 2020. https://www.facebook.com/wsdva/ Spokane Veterans Home. “Photos.” Department of Veterans Affairs. Retrieved 2020. www.dva.wa.gov/veterans-their-families/veterans-homes/spokane-veterans-home Mike Lidwin + Melissa Smith via Google Maps. “Site Map.” 2020. Issaquah Nursing & Rehabilitation Center. “Gallery.” Issaquah Nursing & Rehabilitation Center. Retrieved 2020. https://www.issaquahnursing.com/gallery Issaquah Nursing & Rehabilitation Center. “Photos.” Facebook. Retrieved 2020. https://www.facebook. com/issaquahnursing/photos/?ref=page_internal Mike Lidwin + Melissa Smith via Google Maps. “Site Map.” 2020. Regency Canyon Lakes Rehabilitation & Nursing Center. “Photo Tour.” Regency Canyon Lakes Rehabilitation & Nursing Center. Retrieved 2020. https://www.regency-pacific.com/senior-living/wa/kennewick/ regency-canyon-lakes-rehabilitation-and-nursing-center/photo-tour Mike Lidwin + Melissa Smith via Google Maps. “Site Map.” 2020. Queen Anne Healthcare. “Photo Gallery.” Avamere Family of Companies. Retrieved 2020. https://www. avamere.com/queen-anne-healthcare/ Ted S. Warren. “Dr. Thaun Ong Giving Instructions to a Team of University of Washington Medical Providers.” Oregon Live. 17 April 2020. https://www.oregonlive.com/galleries/NVUV7PXGWFFIBGGVCO4UK3WWEE/ Mike Lidwin + Melissa Smith. “Percentage of Occupancy for 21 Care homes with the Most COVID-19 Cases in the United States.” 2020. Mike Lidwin + Melissa Smith. “Amount of Care home Deficiencies in Relation to COVID-19 Cases Per 100 Beds.” 2020. Mike Lidwin + Melissa Smith. “Amount of Care home Deficiencies in the Past Three Years.” 2020. Mike Lidwin + Melissa Smith. “21 Care Homes with the Most COVID-19 Cases in the United States.” 2020. Mike Lidwin + Melissa Smith. “Amount of Green Spaces per Building.” 2020. Mike Lidwin + Melissa Smith via Google Maps. “Green Spaces.” 2020.

ABOUT

MIKE LIDWIN is a 2020 Bachelor of Architecture graduate from the University of Tennessee’s College of Architecture + Design, where he double majored in Architecture and Modern Foreign Languages and Literatures with an Italian Concentration. In addition to the Architects Foundation/McAslan Fellowship, Michael’s research experience includes the 2018 UT Finland Summer Architecture Institute and the 2019 Aydelott Travel Award. In 2021, Michael will begin his Fulbright Research grant in Milan, Italy, where he will investigate the effect of temporary exhibitions on Milan’s urban fabric, specifically as it relates to new developments and housing projects. He is a part of the IBIDEM City Design Research Platform, where he enjoys collaborating on competition projects and research with Milanese designers outside of traditional architecture coursework.

MELISSA SMITH is a fifth year architecture student at the University of Kansas. She will be graduating spring 2021 with a Master of Architecture. In addition to the Architects Foundation/McAslan Fellowship, Melissa has also been a research fellow with HDR (based in Omaha, Nebraska), during which time she studied healthcare access, architecture in rural America, and the issues facing rural Americans today. Melissa has interned at three architecture firms, the most recent being ACI Boland Architects in Kansas City where she is helping the firm research and design rehabilitation hospitals across the country. Melissa studied abroad in fall 2019 for four months in Copenhagen, Denmark where she grew her passion for sustainable architecture and traveling. She has also been Architecture Student Council Vice President at KU’s School of Architecture and Design. In addition to architecture, Melissa is passionate about dance, cooking, concert-going (although perhaps not at the moment…), and watching Netflix.

ACKNOWLEDGMENTS Research for the Architects Foundation/ McAslan Fellowship is generously funded by The American Institute of Architects (Architects Foundation) and the John McAslan Family Trust. We are extremely thankful for the scholarship’s 2020 selection committee for having faith in our proposals and in our own scholarship. During the course of our 2020 Fellowship, we received an abundance of help from several selfless, incredible individuals. John McAslan and Paul East of John McAslan + Partners, as well as Marci Reed and Vincent Mandes of the Architects Foundation, were instrumental in overseeing our fellowship work and advising us throughout the project. Their creativity and ingenuity during the coronavirus pandemic helped us develop research work that was both relevant to the current times, as well as conducive to the unexpected virtual format this summer would take.

at identifying quality care home designs. The American Institute of Architects provided an important line-up of virtual webinars and lectures that contributed to our ideas. Presenters at the Design of Healthcare Facilities Across Countries Webinar, Enrico Nunziata and Noushin Ehsan, inspired us to analyze both the global context of care home design as well as specific coronavirus data in relation to healthcare facility performance. Finally, we would like to thank the Clinton Global Initiative University Conference for creating a virtual 2020 conference that served as inspiration in examining architecture’s role in the coronavirus pandemic. We look forward to presenting our research at the 2021 conference in Edinburgh, Scotland.

We also extend our gratitude to Dr. Jo Hockley and Prof. Mary Marshall of the University of Edinburgh, who met with us early in the transition of our research focus regarding care homes. Their specific input into the role of dementia care in care home design, as well as their willingness to let us ask many questions, provided us with excellent resources and information to begin our understanding of care home design. In addition, Alexia Mercieca (PhD candidate at the University of Edinburgh) and Jeffrey Anderzhon (Eppstein Uhen Architects) were instrumental

APPENDIX

OTHER CARE HOMES AND SCHEMES OF NOTE

THE UNITED STATES

The Summit, at Rockwood’s South Campus Natatorium, Brightview Severna Park Spring Lake Village The Burnham Family Memory Care Residence AAHSA 2010 Idea House Encore Mid-City Midvale Senior Center Rotary Terrace The Trousdale Leonard Florence Center for Living Deupree Cottages Montgomery Place Park Homes at Parkside Childers Place The Greenhouse Homes at St. Elizabeth Home Serenbe The Goldin at Essex Crossing

CANADA

Georgian Bay Retirement Home The Village Panorama Retirement Home

THE NETHERLANDS

Cranendoncklaan Middelwijck Middenbeemster Humanitas Retirement Home Zoetermeer Vivaldi Care Home Oude Dijk Monastery Extension Wiekslag Krabbelaan Weidevogelhof Eltheto Housing and Healthcare Complex Wiekslag Boerenstreek

THE UNITED KINGDOM

Housing for the Elderly Pitcrocknie Village Care Home Sir Thomas Allen Centre Rose Lodge Care Home Meadow View The Brook Marionville Court Care Home Belong Care Village Castlebrook

GERMANY

Diakonie Church and Nursing Home Coop Housing at River Spreefeld

FRANCE

Maison De Retraite St. Brieuc’s Elderly Establishment Alzheimer’s Village

Spokane, WA // Perkins Eastman Severna Park, MD // Hord Coplan Macht Santa Rosa, CA // Perkins Eastman Hartford, CT // Amenta Emma Architects unbuilt // unknown Huntsville, AL // Hord Coplan Macht Midvale, UT // EDA Pleasanton, CA // HKIT Architects Burlingame, CA // SmithGroup Chelsea, MA // DiMella Shaffer Cincinnati, OH // SFCS Archits Chicago, IL // Nagle Hartray Danker Kagan McKay Hillsboro, KS // Parkside Mennonite Retirement Amarillo, TX // Mary E. Bivins Foundation East Greenwich, RI // SWBR Architects Atlanta, GA // Steve + Marie Lupo Nygren New York, NY // Dattner Architects Penetanguishene, Ontario // Rhonda Desroches Langley, British Columbia // NSDA Architects Laval, Quebec // ACDF Architecture Budel // 2.0 Architects Middenbeemster // BLANCA architecten Deventer // unknown Zoetermeer // HOSPER + SEED Architects Tilburg // Shift Architecture Urbanism Baarn // Zorgpalet Baarn-Soest Pijnacker // multiple parties Rijssen // 2by4-architects Soest // Oomen Architecten Rockfield, Oban, Scotland // Elder & Cannon Architects Pitcrocknie, Alyth, Scotland // Glenisla Developments Sunderland, England // Age UK Sunderland Exmouth, England // unknown Derbyshire, England // Glancy Nicholls Architects Coleraine, Northern Ireland // GM Design Associates Edinburgh, Scotland // Gareth Hoskins Architects Newcastle-under-Lyme, England // Prime Kenilworth, England // Pozzoni Dusseldorf // Baumschlager Eberle Berlin // Carpaneto + Fatkoehl + BARarchitekten Sceaux // Philippe Dubus Architects Saint-Brieuc // Nomade Architectes Dax // Nord Architects Copenhagen

APPENDIX

SPAIN

Blancafort

AUSTRIA

Lohbach Residential and Nursing Home Hainburg Nursing Home Nursing Home Nenzing

SWITZERLAND

Elderly Care House Multigenerational House Giesserei

DENMARK

Salem Nursing Home

SRI LANKA

La Serena Embassy Medical Center Senior Citizens’ Village and Wellness Center

RWANDA

The Burato District Hospital Nyarugenge District Hospital Rwanda Biomedical Center... Physician’s Plaza and King Faisal Hospital Munini District Hospital

CHINA

Senior Center of Guangxi

SINGAPORE

Kampung Admiralty

CHILE

Clinica Familia Hospice Gerontological Hub Project

COSTA RICA

Pacific Plaza Continuing Care Planning Retir. Community

NEW ZEALAND

St. Josephs Home of Compassion, New Dementia Unit Maida Vale Retirement Village Horowhenua Masonic Village, New Care Suites Oceania Heathcare Care Suites The Care Village Papaioea Place Social Housing Summerset by the Ranges Memory Care Centre

AUSTRALIA

Korongee The Village by Scalabrini

Blancafort // Guillem Carrera Innsbruck // Marte.Marte Architects Hainburg // Architekt Christian Kronaus + KNOWSPACE Nenzing // Dietger Wissounig Architects Bevaix // Geninasca Delefortrie Architectes Teufenthal // Gautschi Lenzin Schenker Architects Winterthur // Galli Rudolf Gentofte // Rune Ulrick Madsen + others Uswetakeiyawa // unknown Colombo // Perkins + Will Nugegoda // Western Care Homes Burera District // MASS Design Group Kigali // MASS Design Group Kigali // Oz Architecture Kigali // Oz Architecture + Boulder Associates Nyaruguru District // MASS Design Group Nanning // Atelier Alter 676 Woodlands Drive // WOHA Santiago // unknown Valdivia // Fundación Oportunidad Mayor Guanacaste // REES Silverstream, Upper Hutt // team architects New Plymouth // team architects Levin // team architects multiple locations // Oceania Healthcare Rotorua // Ignite Architects Palmerston North // BOON Levin // team architects Tasmania // Thomson Adsett Drummoyne // Brickerton Masters

OTHER CARE HOMES AND SCHEMES OF NOTE

THE UNITED STATES

CANADA

Georgian Bay Retirement Home The Village Panorama Retirement Home

THE NETHERLANDS

THE UNITED KINGDOM

Housing for the Elderly Pitcrocknie Village Care Home Sir Thomas Allen Centre Rose Lodge Care Home Meadow View The Brook Marionville Court Care Home Belong Care Village Castlebrook

GERMANY

Diakonie Church and Nursing Home Coop Housing at River Spreefeld

FRANCE

Maison De Retraite St. Brieuc’s Elderly Establishment Alzheimer’s Village

APPENDIX

SPAIN

Blancafort

AUSTRIA

Lohbach Residential and Nursing Home Hainburg Nursing Home Nursing Home Nenzing

SWITZERLAND

Elderly Care House Multigenerational House Giesserei

DENMARK

Salem Nursing Home

SRI LANKA

La Serena Embassy Medical Center Senior Citizens’ Village and Wellness Center

RWANDA

The Burato District Hospital Nyarugenge District Hospital Rwanda Biomedical Center... Physician’s Plaza and King Faisal Hospital Munini District Hospital

CHINA

Senior Center of Guangxi

SINGAPORE

Kampung Admiralty

CHILE

Clinica Familia Hospice Gerontological Hub Project

COSTA RICA

Pacific Plaza Continuing Care Planning Retir. Community

NEW ZEALAND

AUSTRALIA

Korongee The Village by Scalabrini