Some design firms that cater to the skilled nursing community have not built traditional, more institutional nursing homes for some time, steering clients toward single-occupancy, small home models.
For firms like Roanoke, Va.-based SFCS Architects, the Biden administration’s call to promote private rooms in the nursing home industry meets the moment and plans for future design norms.
SCFS Architects Principal Amy Carpenter said it’s mostly been nonprofit nursing home clients coming to the firm to renovate or build new to include private rooms. Carpenter has had personal experience staying in a semi-private nursing home, reinforcing her passion for de-densification in her work.
SFCS designs nursing homes with an eye toward private settings and the small home model, which replicates a house rather than a hospital setting – but with clinical access. The firm has a presence in North Carolina, Virginia, Pennsylvania and Kentucky.
This interview has been edited for length and clarity.
Aside from infection prevention during a pandemic, why are private rooms so sought after?
Have you ever stayed in a semi-private room in a hospital or elsewhere? Say you were in a strange town, and the only hotel had a room that you had to share with strangers. How would that make you feel?
I’ve done a series of stays in nursing homes. One of the places that I had to stay was in a semi-private room. The term semi-private is kind of like being semi-pregnant, you either are or you’re not, there’s no in between. With semi-private rooms there really is no privacy.
What else about your stay at that nursing home influenced your thinking on private rooms?
I had a roommate – she had dementia. She was constantly waking me up in the middle of the night and it was just a really uncomfortable situation. Having lived just one day in that situation, I really can’t endorse putting any of our elders in that situation because that’s where they’re living for the rest of their life.
If you’re not willing to share a hotel room with a stranger, why would you be willing to live the rest of your life with one? Or to flip the table and turn it to the operator’s perspective, why is it okay to put vulnerable elders in that situation when you’re not willing to do that in your daily life?
How did this experience influence your work at SFCS?
We’ve for years been advocating for private rooms, for all the reasons that I mentioned, and you know, we also find a lot of value in the small house design, trying to reduce stress and agitation on the residents by grouping them into smaller groups of rooms.
We’ve also come up with a lot of clever ways of nesting rooms, so that we’re not doing long, double-loaded corridors. We’re trying to minimize the corridors as much as possible. By nesting rooms, you can also decrease the travel distance that residents have to walk from their room to common spaces. These are all hallmarks of the small house design. But they make a big, big difference in quality of life and longevity, just encouraging people to continue to walk because they only have to walk a small distance.
So are nursing home clients mostly asking for small home, private room models?
We haven’t designed shared rooms in a long time. For providers that do have these three- and four-bed rooms, they need to maintain the same census, they have to find a way to add more rooms and then break up the existing rooms to be private, which can be done – it’s not necessarily easy, but it can be done. I’ve seen some really creative ways of dividing up floors that have all three- and four- bed rooms to make them all private. But the provider has to make a strong choice whether or not they’re going to decrease their census by those numbers or if they’re going to maintain their census by adding a new building next door to spread out the population.
What does your client makeup look like currently for these types of builds?
A lot of the nonprofit clients, a lot of the faith-based groups. They’re people who really understand the culture change model and small home design, they understand how beneficial it can be for the residents and also the staff that work in those communities. They’re the primary ones I see.
There are some for-profits that have also bought into the small house model and understand the benefits of private rooms. I have talked to other for-profit clients … they’re like, well, we just can’t afford to build that much and they’re worried more about the first cost than any kind of payback.
Are there any legislative efforts or financial incentives out there to push architecture firms more toward single-occupancy rooms?
I know in Florida, they had changed the regulations a few years ago to strongly push projects that way, to be more small house, single-occupancy rooms. Wisconsin also is pretty forward thinking in that regard.
It’s not like we’re getting a financial incentive to push for private rooms, we just know it’s the right thing to do. Certainly, any of the design awards that are out there look for private rooms. I know that the Environments for Aging Design Awards have for a long time strongly discouraged side-by-side shared rooms, they wouldn’t accept publication of projects that had that feature. All of us in the senior living space understand the benefits and know that’s just the right thing to do.
This ‘nesting’ design is so different from the usual layout of a nursing home – can you go into a bit more detail on that?
Think about a hotel or typical hospital where you have a rectangular block of rooms, where you know, one side is the corridor and one side is the window and wall, and then on either long side is another room. Instead of just having a rectangle next to a rectangle and lining them up down a hallway, we tried to interweave the rooms where maybe they’re wrapping a corner where you have the bathrooms overlap, and the rooms instead of being all aligned around a hallway, they turn the corner so you have four resident room entrances that are all facing each other.
So the small home model promotes more resident walking if they’re able?
Shorter hallways or nonexistent hallways help with ambulations, getting people out of wheelchairs or not having them depend as much on wheelchairs. Certainly the small home model and private rooms support personal choice and autonomy. Once you walk out of your room, your door at your room, you can immediately see to a common space or you are oriented to the outside so that there’s less issues with wayfinding and wandering because you know where you’re going.
Anything else to add about the logistics of private rooms and the small home design? Financial benefits?
When you have a shared room, you have to match up genders, you have to kind of know the personalities of the people that are going in that room because not everybody will work together. You also have to start thinking about infection control, an even bigger issue now. Every day you have a bed sit empty you lose money. You start saying Ok, well if I have, you know, five semi-private rooms, but five of those beds are empty because I can’t match up genders or all these other factors, that’s a cost. If you had all private rooms, you can easily fill them because you don’t have to worry about matching genders. You don’t have to worry about personalities as much.
What about quality of life tied to private rooms?
There’s better personal autonomy and making decisions about, you know, your space. It’s that general concept of, this is my space, and I control what I do in that space. I can set my own temperature, I can turn off the light when I want to, I can decorate the walls and put up pictures that are meaningful to me. Features are really important for a person’s wellbeing. It’s definitely more possible in a private room than when it’s shared.
What other design aspects help with resident wellbeing?
In private rooms you’ve got access to a window. There’s also things like, in some of my stays in care settings, the nightlight was too bright … if you’re in a shared room, your roommate is getting up in the middle of night, maybe turning on lights, maybe going into the bathroom and making a lot of noise. If you’re in a private room, you get to control the lights, you determine what lights go on and off. Your sleep is not as disturbed so that impacts your health greatly. We’re designing night lights to have an amber color and a very low level of light – they’re not strong enough to wake you up in the middle of the night so you can get back to sleep after going to the restroom.