Renovations Big and Small Can Help Make the SNF More Like Home

Abstract

With more focus on the concept of person-centered care, skilled nursing facilities are exploring ways to make their residents feel more at home. One way some facilities are doing this is by renovating existing structures and interiors to create a more homelike environment that encourages more social contact. Other facilities are looking at the interior design and flow of the resident common areas and rooms, and redesigning them with an eye on safety and ease of movement. And some simply want to make small changes to make an institutional setting feel more like home. “I really look at settings that support person-centered care — how do we create an environment that allows residents to express autonomy and preference and have those preferences honored?” said Margaret Calkins, PhD, executive director of The Mayer-Rothschild Foundation, which is dedicated to improving quality of life in long-term care. She spoke at the Pennsylvania chapter meeting of AMDA – the Society for Post-Acute and Long-Term Care Medicine. Dr. Calkins described principles of a “new culture” that considers the resident’s physical environment just as important to their health and well-being as their health care. Resident autonomy and control are paramount, and their living environment should allow for increased participation, greater individualization, meaningful relationships, and respect for the resident’s abilities. She cited research in which larger residential units with 30 to 79 residents were associated with higher levels of agitation and aggression, faster cognitive deterioration, and greater emotional disturbances. In contrast, in smaller residences with up to 19 residents, studies show there is less anxiety and depression, less psychoactive medication use, greater social interaction, more resident-staff interaction, and more positive activity, she said. Although there may not be any way to make a large facility smaller, there are renovation options to put all that space to better use. “In the 1960s through the 1980s, the standard group size for a unit was 60 residents, because the code said you could have one nurse at night overseeing 60 patients,” she said. “Why would you make it any smaller? That would be inefficient. What we’ve found over time is that breaking down the scale of the spaces has a huge positive impact.” Smaller groups feel very different, she said. “Imagine living in a space where most of the time during the day you’re in a room that feels like a living room with no more than 10 other people.” Renovating the living environment to help mitigate some of the negative consequences of size is not necessarily inexpensive, she said, but it will positively affect residents. “From an economic perspective it can be more cost-effective in the long run to create a better environment than to continue giving people medications. The challenge to the nursing home is that it has to pay for the environmental modifications, while it doesn’t pay for all the drugs for all the residents. So it’s a question of who’s bearing the expense. The way the payer system is set up, it penalizes nursing homes for trying to do the right thing.” She showed examples of a basic hallway plan with a double loaded corridor; most of the resident rooms were shared rooms. Usually these corridors have no windows and a monotonous color scheme. Open plan designs developed in the 1970s, she said; by the next decade, smaller residences were being built. She pointed to one facility that was created for 12 residents. “When you come out of a bedroom, you come out into a shared public space. In the old hallway design, you come out of the bedroom, look left and right and it looks almost the same. Institutional. You could get confused trying to find the public spaces; it’s difficult if they’re not visible. That’s why when residents walk down the hall, they go into different rooms, which can lead to resident conflict.” So how can older care communities with long corridors renovate to create a more homelike and interesting environment? It’s not difficult, Dr. Calkins said. She suggested built-in display cases at each doorway tailored to each resident. These cases would hold a cue, one that the resident responds to, which can help them find their room independently. “Having that visual cue is more effective in helping people find their rooms than just having their room number and name on the door,” she said. Another option is to give different looks and themes to the hallways, and create a central public space at the end. Separating the public space from the sleeping areas turns this arrangement into a household-like environment. Changing the bedrooms from a four-person ward to a two-person shared room, in which each resident has their own territory and doesn’t have to cross someone else’s space to get to the door or the bathroom, can sometimes be an option. Since the 1990s, more communities that reflect a typical household plan are being constructed. “You open the front door, and there’s a living room, and a dining room, and a kitchen, and then there’s a separation between the kitchen and the public space, and the bedrooms — just the way a house is laid out,” Dr. Calkins said. For individuals with dementia, opening a door to a unit with a long corridor with bedrooms on either side doesn’t make sense. “When you open up the front door to your house, does it open up to the bedroom? No. You come to the public areas of the space. It makes sense.” Small renovations can make toileting easier for residents. In new construction, designing the bathroom to be highly visible from within the room makes the toilet easier to find, particularly for individuals with dementia. Dr. Calkins described an experiment in which a curtain was used to conceal the toilet. “The toilet was still accessible, but we found when the curtain was closed, the toilets were used less frequently,” she said. “When toilets were in clear view, they were used eight-fold times more often, just because they were visible.” Creating visual contrast by using bold paint colors on the walls and floor can make finding the toilet easier as well. “We know that people with dementia have a contrast perception deficit,” she said. By contrasting the toilet from the floor and walls in the bathroom, the toilet becomes a “beacon,” Dr. Calkins said. “You can’t miss it. It’s really visible. And that’s what we want. Are your bathrooms white on white? I don’t know why we have to think it has to be all white; white isn’t a cleaner color than any other color.” Another inexpensive option is to install a night light above the toilet to provide low ambient light and make it easier to find in the middle of the night. Making the light amber colored will be less disruptive to sleeping patterns. An innovative approach to making bathing areas more inviting is to involve residents in making changes. In one example, Dr. Calkins described a facility administrator who went to each floor and provided staff with a limited budget to make improvements to their bathing rooms. Staff took the residents out to select paint colors, and they added a table and basket for guest towels — inexpensive, yet significant improvements. In another example, they changed the paint and installed some decorative shelving with a small curtain that hid the tub controls. More baskets, shelving and inexpensive stick-on tile made the area look more like a spa, Dr. Calkins said. “While you’re sitting here taking a tub bath, you’re not in a torture chamber; you’re looking at something nice.” The residents were proud of the spaces they created, she said, and looked forward to showing them off to visitors. A homelike environment is associated with improved intellectual and emotional well-being, greater functionality, less aggression, less use of psychoactive medication, and less anxiety, Dr. Calkins said. Research on institutional lighting suggests that when light levels are higher than the regulated standard, resident agitation is reduced, Dr. Calkins said. At mealtime, increased light and contrast resulted in an increased caloric intake over time, one study found. While bright light therapy can help reset circadian rhythm and decrease agitation, it’s difficult to expect residents to sit long enough to benefit from it. “Better to spend time outside,” she said. Twenty minutes spent outside in natural light, preferably in late morning, seems to help reset circadian rhythms. “Have spaces where people can do things outside. If you bring food, they will come,” Dr. Calkins said. “Take your morning snack outside. Don’t lock the doors in secured areas.” In one study conducted in five care communities, she noted, researchers found an increase in agitation among residents who didn’t go to outside spaces. A homelike environment is associated with improved intellectual and emotional well-being, greater functionality, less aggression, less use of psychoactive medication, and less anxiety, Dr. Calkins said. More facilities are now using décor that suggests a homelike environment, although the jury is still out as to exactly what that comprises; one resident’s love of chintz might be another’s design pet peeve. “There is little consensus what it takes to define an environment, but most people feel they know it when they see it,” she said. Unmatched, domestic-style furniture, accessories, and improved lighting will usually suffice. An electric fireplace in a public area adds a cozy warmth. It may seem counterintuitive, but turning the nursing station into an activity area can create a place where residents want to spend time. “Yes, staff needs work space, but we’re finding different ways of doing it. The charting may happen in a different place, behind doors. For medication distribution, rather than the institutional cart, you can get inexpensive pieces that look like furniture. If you know you’re going to be distributing during meals, then bring this out, put it in the dining room, and it’s not the big medical cart going through the dining room that you’re trying to make feel like a home space,” she said. SNFs can spend a little or a lot to create a more homelike environment, and an assessment that includes resident input can help guide decision making. The goal is always to put patient safety and comfort first to create a pleasing environment that they can call home. Carey Cowles is the managing editor of Caring for the Ages.