Humanization of Long-term Care

Architectural, engineering design considerations to optimize facility operations

By Tariq Amlani & Éléonore Leclerc

The COVID-19 pandemic has had a real and devasting impact on longterm care facilities. By the end of 2021, more than 67,000 residents and 39,000 staff had been infected across Canada, of which nearly 16,000 had died due to the disease.

This stark reality underscores the importance of the purposeful design of long-term care facilities. Thoughtful architectural and engineering design can produce safer environments for one of the most vulnerable populations: seniors.

The conversation is not limited to indoor air quality (IAQ) and infectious aerosol dispersion, which have received much of the recent attention. Creating healthy environments demands a more robust and holistic discussion. Key considerations include the number of residents per household, building height, access to daylight, freedom of movement, community engagement, the ability to isolate when required, and delivery of appropriate levels of ventilation and cooling air to maximize IAQ and the environment, while also aligning with climate change and carbon emissions considerations. It is critical to identify some of the most impactful architectural and engineering considerations to increase the performance of long-term care facilities, resulting in healthier, safer and more humanized environments.

From an architectural standpoint, the design of long-term care facilities is complex. It requires a deep understanding of the social model for elder care. This model centres around quality of life considerations. In con-

trast, three distinct issues emerge when elder care is delivered through a more traditional medical model. Seniors tend to feel bored, lonely and/or helpless. Through research and time in Europe and Scandinavia visiting best practice elder care facilities, solutions to these challenges have been identified. Social engagement combats boredom, stimulation decreases loneliness and empowering residents removes the feeling of helplessness. Architectural techniques can help deliver these antidotes.

MEDICAL VERSUS SOCIAL MODEL

On one end of the spectrum, there’s what is colloquially referred to as the ‘warehousing of seniors.’ On the other is a home setting that includes only one or two seniors. The tradeoffs between area, efficiency, cost and staffing are clear. Absent of recognition of the benefits to seniors provided by smaller households, particularly in terms of social engagement, stimulation and empowerment, it is easy to economically rationalize higher density seniors housing. Nevertheless, what the research and design effort has found is designing long-term care facilities to accommodate between eight and 12 residents per ‘neighbourhood,’ with a maximum of three neighbourhoods per floor, creates an ideal mix in terms of clinical efficiency, building area and, most importantly, quality of life.

Designing long-term care facilities to provide residents with freedom of movement is critical. The Hogeweyk Dementia Village in Weesp, Netherlands, illustrates this. Through post-occupancy observation of residents’ movements throughout the facility, it was found that residents utilize freedom of movement as a means of both physical and mental therapy.

Making activity visible is another technique that creates interest and engagement. Examples include café seating with views to the kitchen where food is being prepared, views into the maintenance shop, views to the outside and views of the public realm. Like a residential household where activities are naturally in sight, this strategy helps create a home-like setting. The evidence around the health and well-being benefits of providing access to nature and views is well-established.

DELIVERING CLEAN AIR

Considering single-resident room as the gold standard for infection prevention, there are a host of additional engineering considerations that help to improve the performance of a facility. Currently in Canada, nursing homes, long-term care facilities, assisted-living facilities, hospice care facilities, group homes and chronic care facilities are classified as Class B healthcare facilities. As a result, and in accordance with the building code and CSA Z317.2 — Special Requirements for Heating, Ventilation and Air-conditioning Systems in Health Care Facilities — Class B facilities have lower minimum ventilation rates, limited equipment redundancy requirements, lower filtration rates and reduced infection control requirements, as compared to typical acute healthcare facilities.

Based on the growing body of research and evidence tied to the Wells-Riley equation, which provides a simple and quick assessment of the infection risk of airborne transmissible diseases, there is increasing understanding around the inverse relationship between the risk of infection from air-

t From post-occupancy observation of residents’ movements throughout Hogeweyk Dementia Village in Weesp, Netherlands, it was found residents utilize freedom of movement as a means of both physical and mental therapy. Image courtesy Hogeweyk Dementia Village.

borne aerosols and the rate of clean air delivery. Essentially, the more clean air delivered, the lower the risk of infection. The most obvious source of clean air is air from outside the building that has not yet been circulated through the facility. But there are broad challenges with simply bringing in more outside air, including the significant increased energy consumption associated with heating and cooling it. Designers and engineers need a solution to the pandemic that also recognizes and respects the climate crisis. Primary energy modelling research has been conducted on template buildings across all climatic zones. This research sought to determine the energy impacts of higher ventilation rates and how they could be mitigated by using energy recovery systems. In regions with high humidification and dehumidification loads, it was found that heat recovery enthalpy wheels effectively transfer thermal energy and moisture between departing and incoming air streams to reduce energy demands. The strategic placement of the supply and exhaust fans in this system reduced the risk of cross-contamination. In regions with low humidification and dehumidification loads, exhaust air heat pump recovery proved the most ideal energy recovery strategy, with zero cross-contamination as the air streams are completely separated. In all cases, it was demonstrated that a building running at minimum outside air percentage with no heat recovery, instead of operating at 100 per cent outside air with the appropriate type of heat recovery in place, resulted in lower overall energy consumption. A further system that demonstrated high performance was displacement ventilation coupled with thermal labyrinths. This system configuration has the added benefit of reducing the amount of energy required to provide air conditioning and, in many cases, can run without the use of a chiller or other mechanical cooling system for much of the year.

The final consideration investigated was higher levels of filtration for recirculated air. Research clearly demonstrates upgrading HVAC filters to a MERV 13 from MERV 11 rating improves the infectious droplet nuclei filtration efficiency to 85.9 per cent from 68.2 per cent. In other words, the clean air delivery rate increases by 25 per cent simply by improving the filtration.

These engineering considerations can have a direct impact on reducing the risk of infection and death in long-term care facilities, while helping to reduce the impacts of climate change. Coupled with the noted architectural considerations, this care can be delivered in a humanized setting where seniors flourish and have a high quality of life. The challenge is to distill this knowledge among the larger architecture and engineering community, as Canada embarks on one of the largest long-term care facility construction booms in the country’s history. Biomedical_CHF_Winter_2017_FINAL.pdf 1 2017-10-23 4:45 PM

Tariq Amlani is a mechanical engineer and healthcare leader who has been with Stantec since 2005. He has extensive knowledge and experience working on the procurement, design and construction of new and existing healthcare facilities, and has the ability to operationalize high-efficiency, patient-centric healthcare facilities. Éléonore Leclerc is the Vancouver healthcare studio lead at Stantec. She has been involved in multiple long-term care projects and visited more than 25 exemplar long-term care facilities in 10 countries to better understand how spaces should be designed to support seniors in the full spectrum of their life.

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