What once could be considered the norm in skilled nursing facilities — shared rooms, bathrooms and common areas — has recently been and will further be closely scrutinized by industry analysts, operators and the architects who design these facilities as the industry emerges from the height of the pandemic.
Martin Siefering, a principal at architecture firm Perkins Eastman, told Skilled Nursing News the biggest changes to the look of nursing homes may not only come from the elimination of shared, common spaces, but potentially reducing the number of beds altogether.
Siefering discussed these topics and more with SNN. This interview has been edited for length and clarity.
Do you think the pandemic is going to change the way that we design and build nursing homes from here out?
Absolutely. I hope that it changes the number of nursing homes that are redesigned and newly built because we need to make changes dramatically to the portfolio of nursing homes that we have today. I think the pandemic is going to make a lot of people see it.
What kind of changes do you think we need to make?
Well, the large traditional institutional nursing homes where 40 to 60 people eat together in a congregate dining area. Where two, three, four people share a resident room or sleep together, where caregivers are moved from one group of residents to another.
Those things just have got to stop for a variety of reasons. I think they don’t create great living environments, to begin with, and they really don’t create safe places for a vulnerable senior to be during a virus outbreak, even if it were just the flu.
Where does the money come from to change this, I think that’s where everybody struggles and has been for years?
That’s the million-dollar question. I think one part of it is, perhaps we don’t need as many nursing beds as we have had. Just to make up numbers, we have 1.6 million roughly nursing beds, could we get by with 1 million nursing beds? Could we take 600,000 people and put them in places that are less expensive than nursing homes?
Some of them in their homes, some of them in some other form of congregate living where they can get services. Right now, they’re not able to access Medicaid in any of those other places. If we can change that, and some states are different. Some states have waiver requests so you can get Medicaid waivers and get those kinds of services in other places, but there’s a huge waiting list to get those waivers and they’re not readily available.
That would be part of it, is to take those 600,000 and move them somewhere else and then focus on the 1 million beds that are left, and how do we make those better by pulling 600,000 people out of nursing home environments, we’d have more space to deal with some of these things and there could be some cost savings. I think the reality is we probably need to look at spending more money on the way we care for seniors. I just think that’s what needs to happen.
As we start to kind of come out from the pandemic, how are you advising clients in terms of positioning their portfolios?
Well, a lot of advice about reducing the number of beds, and that isn’t coming exclusively from architects, this is coming from lots of people who are saying, “Why do we have so many nursing beds? We should be focusing on supporting people in other environments.” Whether it’s in their homes, or in an apartment of some an assisted living or independent living or some form. Can we get them a place to live elsewhere where we can support them?
If someone has an older building that they want to freshen up their buildings on a budget in order to position it for the future?
Well, one thing is that it’s trying to find smaller-scale living environments for people. Some big traditional nursing homes can actually be divided up and made into smaller-scale living environments that are literally quite good. Not many, but there are some that can do that.
Some of them are really, really poor and it’s very challenging to do and the reality is some of them are probably just going to have to be torn down. Nursing homes were never built as flexible machines to support different uses, they were never built the way that modern hospitals are where they build them for a longer period of time to do many different things because they recognize that technology changes.
Where most nursing homes are built in the ’60s, ’70s, and ’80s, there wasn’t a lot of recognition that things were going to change and the residents of the ’60s, ’70s and ’80s are very different than the residents that we have in 2020. My first nursing home is 30 years old and we had an ambulatory unit in that nursing home where everyone was expected to walk. There’s no one who can walk in the nursing home environment today.
There’s some people who can ambulate themselves, but that’s fairly rare, and those who can rely on walkers and wheelchairs and other things. There’s 100% of residents in nursing homes who rely on some form of mobility aid today and walking distances becomes a huge problem.
These ideas of congregate dining, where people are walking hundreds of feet to get to dining, this just doesn’t work and so people have to provide a lot of help. We have staff helping residents move from their rooms to dining and these models are just outdated and they need to be reinvented.
You talked about models being a little outdated, are there any models out there that you think could be part of the answer?
Oh, sure. The greenhouse small house model is something that I know you’re familiar with. We’ve done a lot of work in that model and they’ve had huge success. Data says that their resistance to COVID has been really great.
The overlying data as the quality of life is higher. The resident satisfaction is higher, caregiver retention is higher. Caregivers feel more engaged and more involved and more connected and they hang on and stay, which is a big part of what happened in the pandemic is you have caregivers who are underpaid and having multiple jobs.
You don’t want to blame them, they’re doing everything they can, but they’re part of the problem here. We as a culture are part of the problem for the way we treat them and the residents.
One of the arguments against the greenhouse models is that it doesn’t scale, do you buy that?
No. It’s as much a cultural problem as it is an architectural problem and if you’ve been operating in the nursing world for a long time, you’re stuck in a culture and making a jump from one culture to another is not easy.
There are for-profit models that have adopted the small house model and they find a way to make it work. We find some clients who found that there’s actually a better financial performance in the greenhouse model than there was in a traditional model.
Any for-profit greenhouses models that you look at that you think could be a good example for people to use as inspiration for lack of a better term?
Well, Otterbein is a client of ours. They’re non-profit. They’re in Ohio and we’ve done several communities of small houses for them where they buy a piece of land and we design and build five houses on each one and they have a satellite system spread out all over and they found them to be incredibly beneficial to them financially and operationally, but it was hard work.
Architecturally, it’s one thing. Architecture is one and done, you do it, you build it, and the building is in place. Culturally, it’s an everyday thing. You got to change culture, move in, maintain, maintain, maintain culture constantly. That’s challenging.
To shift gears a little bit, there’s been a lot of talk about the move to private rooms. What are your thoughts on private rooms in nursing homes?
I don’t know how we cannot do it. I don’t think we have a choice. COVID is just this little blip along the way but the consumer says they don’t want it. The consumer is going to do everything they can to avoid moving into a nursing home because most nursing homes are semi-private.
We need nursing homes to be a place where people not necessarily want to live, but choose to live. We need to make them a quality enough place for them to be comfortable. Nobody will ever want to move to a nursing home.
The conversion to private rooms, is that creating issues? Just from a physical plan perspective, do people need to be thinking about how they really redesign stuff for the future?
Well, in some cases, it’s as simple as taking a two-bedroom and removing a bed and calling it a private room. That’s not hard, but it has a financial implication. You’re reducing your census. In this moment, a lot of people’s census is way down anyway. There are people who are doing that now, who are pulling beds out of rooms and converting to private rooms.
Whether the demand will go back up, I think that’s a big debate. If we have 1.6 million beds and there’s around 30% vacancy right now, it depends on whose numbers you’re using. Are we going to go back up to something higher than that? Probably, it’s going to go higher than where we are now but how is it going to go back up to the rates we were running before? I doubt it.
Obviously, nursing homes have a limited amount of CapEx that they can spend. How are you recommending that people use it best if they’re going to make some changes?
It’s tough because there are no easy answers. We’ve done some fairly economical work where we haven’t really touched the resident rooms and we’ve just gone in and tried to break up the larger congregate dining rooms into smaller spaces by reconfiguring some things. As you get smaller living environments, some buildings take that fairly easily, some buildings don’t.
It’s taking advantage of the bonds that you’ve got. Each one is different. Cultural change is not free but it’s less expensive so going to fixed assignments for staff, for instance, so you don’t have staff moving from care of one group to another group to another group from day to day or week to week so that you have fixed assignments where the caregivers stay with a fixed group of residents across long periods of time so that they get to know each other.
Also, in the pandemic situation, it just prevents the spread of the virus because you’re having caregivers coming in contact with many fewer residents.
I keep hearing the word culture — it’s not something that I was expecting to hear during an interview about the design of nursing homes. Why is that important to the physical building as well?
The building isn’t a machine. The buildings are a place where residents live, and staff work. If the building doesn’t support the kind of relationship that you want between residents and staff, then the building isn’t very useful. We feel like we need to understand the culture of residents, the culture of staff, and the types of relationships that residents have with staff.
We need to build architecture that supports those relationships. For instance, food is a big part of our culture. What kind of choices do people have in food? Do they have a choice about when and what they eat? Are they required to eat a specific time every day the same way?
Can somebody recognize that somebody is not in a great mood so can they make something special for them that day to help lift their spirits that day? If you have a caregiver who knows the resident, they can know that kind of thing. They have a facility that will support them.
Little things like, can you make breakfast within a place that the residents can participate in? I don’t mean participate as in helping but they can say, “I’d like oatmeal today,” and they can have oatmeal. Or, “I’d like a scrambled egg today. I’d like to have scrambled eggs today.” Or, “I’d like extra maple syrup on my pancakes.”
If the facility is designed to support that, that’s the best thing. You need to understand the culture of residents and caregivers to create the kind of environment that we’re into. That would be great.
There has been a lot of fantasy discussion around reimagining the future of nursing homes. What do you think is a realistic vision for the long-term future of nursing homes?
I think we have to be patient. This is the most monstrous of all cruise ships you’re talking about. It’s an industry that relies on capital reimbursement for built forms, it’s going to take time to change that. We’re going to have to be patient about that but we’re going to have to put something in motion that begins a process that allows us to be patient because right now, everybody’s upset and angry and hostile about it.
If there was some positive movement and said, “Here’s where we want to be 20 years from now or 15 years from now,” or, “Let’s put some things in motion, let’s begin to make progress.” We haven’t made progress towards anything as a country in the way we care for elders in a very long time.
You should add to that, for those who have money, they have lots of choices. For those who don’t have money, nothing has improved for them in a very long time.