Nursing Home

by Robert F. Carr
NIKA Technologies, Inc. for VA Office of Construction & Facility Management (CFM)
Revised by the WBDG Health Care Subcommittee

Last updated: 06-02-2009

Overview

Nursing homes serve patients requiring preventive, therapeutic, and rehabilitative nursing care services for non-acute, long-term conditions. Specialized clinical and diagnostic services are obtained outside the nursing home. Most residents are frail and aged, but not bedridden, although often using canes, walkers, or wheelchairs. Stays are relatively long, the majority for life. Nursing homes also care for a smaller percentage of convalescent patients of all ages. These patients are in long-term recovery from acute illnesses, but no longer require hospitalization.

Nursing homes, or sections of them, are often classified into intermediate and skilled nursing units, definitions related to Medicare/Medicaid standards. Intermediate-care facilities have just enough nursing to qualify for Medicaid; skilled nursing facilities meet the more demanding medical standards to qualify for Medicare as well as Medicaid support. The cognitively impaired are frequently housed separately in Alzheimer Related Dementia (ASD) units. See Alzheimer's Foundation of America Excellence in Care Program

Nursing homes present special design challenges in that for most residents the nursing home is not just a facility, but indeed their home. The reality is that in most cases the residents will live there for the rest of their lives and, moreover, rarely leave the premises at all. The nursing home becomes their entire world in a sense. The challenge is to design a nursing home that is sensitive and responsive to long-term human needs and well-being, both physical and emotional.

Building Attributes

A nursing home operates primarily in a patient-care mode rather than a medical mode. Consequently, its more important attributes are those focusing on the general well-being of its residents rather than high-tech considerations. The principal attributes of a well designed nursing home are:

Homelike and Therapeutic Environment

Inherent in any institutional stay is the impact of environment on recovery, and the long-term stays typical of nursing home residents greatly increase this impact. The architect and interior designer must have a thorough understanding of the nursing home's mission and its patient profile. It is especially important that the design address aging and its accompanying physical and mental disabilities, including loss of visual acuity. To achieve the appropriate nursing home environment every effort should be made to:

• Give spaces a homelike, rather than institutional, size and scale with natural light and views of the outdoors
• Create a warm reassuring environment by using a variety of familiar, non-reflective finishes and cheerful, varied colors and textures, keeping in mind that some colors are inappropriate and can disorient or agitate impaired residents
• Provide each resident a variety of spatial experiences, including access to a garden and the outdoors in general
• Promote traditional residential qualities of privacy, choice, control, and personalization of one's immediate surroundings
• Alleviate possible disorientation of residents by providing differences between "residential neighborhoods" of the nursing home, and by use of clocks, calendars, and other "reminders"
• Encourage resident autonomy by making their spaces easy to find, identify, and use
• Provide higher lighting levels than typical for residential occupancies

Efficiency and Cost-Effectiveness

The nursing home design should:

• Promote staff efficiency by minimizing distance of necessary travel between frequently used spaces
• Allow easy visual supervision of patients by minimal staff
• Make efficient use of space by locating support spaces so they may be shared by adjacent functional areas, and by making prudent use of multi- purpose spaces

Cleanliness and Sanitation

An odor-free environment is a very high priority in nursing homes, since many residents are occasionally incontinent, and the pervasive odors can give an impression of uncleanliness and poor operation to family and visitors. In addition to operational practices and careful choice of furniture, facility design can help odor control by:

• Adequate and highly visible toilet rooms in key locations near spaces where residents congregate
• The use of appropriate, durable finishes for each space used by residents
• Proper detailing of such features as doorframes, casework, and finish transitions to avoid dirt-catching and hard-to-clean crevices and joints
• Adequate and appropriately located housekeeping spaces
• Effective ventilation, which may need to exceed nominal design levels
• Incorporating O&M practices that stress indoor environmental quality (IEQ)

Attention to Way-finding

A consistent and well thought out system of way-finding helps to maintain the residents' dignity and avoid their disorientation. It should:

• Use multiple cues from building elements, colors, texture, pattern, and artwork, as well as signage, to help residents understand where they are, what their destination is, and how to get there and back.
• Identify frequently used destination spaces by architectural features and landmarks which can be seen from a distance, as well as symbols, signage, art, and elements such as fish tanks, birdcages, or greenery
• Avoid prominent locations and high visibility of doors to spaces which patients should not enter
• Use simple lettering and clear contrasts in signage (See VA Signage Manual)
• Clearly identify only those rooms that residents frequent

Accessibility

Many residents may be ambulatory to varying degrees, but will require the assistance of canes, crutches, walkers, or wheelchairs. To accommodate these residents, all spaces used by them, both inside and out, should:

• Comply with the requirements of the Americans with Disabilities (ADA) and, if federally funded or owned, with the Uniform Federal Accessibility Standards (UFAS)
• Be designed so that all spaces, furnishings, and equipment, including storage units and operable windows, are easily usable by residents in wheelchairs
• Be equipped with grab bars in all appropriate locations
• Be free of tripping hazards
• Be located on one floor if feasible, preferably at grade. If residents' bedrooms must be located on more than one floor, then dining space must be apportioned among those floors, not centralized

Security and Safety

Design to address security and safety concerns of nursing homes includes:

• Use of non-reflective and non-slip floors to avoid falls
• Control of access to hazardous spaces
• Control of exits to avoid residents leaving and becoming lost or injured
• Provision of secure spaces to safeguard facility supplies and personal property of residents and staff

Aesthetics

Aesthetics is closely related to creating a therapeutic homelike environment. It is also a major factor in a nursing home's public image and is thus an important marketing tool for both residents' families and staff. Aesthetic considerations include:

• Increased use of natural light, natural materials, and textures
• Use of artwork
• Attention to proportions, color, scale, and detail
• Bright, open, generously scaled public and congregate spaces
• Homelike and intimate scale in resident rooms and offices
• Appropriate residential exterior appearance, not hospital-like
• Exterior compatibility with surroundings

Sustainability

Nursing Home facilities are public buildings that may have a significant impact on the environment and economy of the surrounding community. As facilities built for "caring", it is appropriate that this caring approach extend to the larger world as well, and that they be built and operated "sustainably".

Section 1.2 of VA's HVAC Design Manual is a good example of health care facility energy conservation standards that meet EPAct 2005 (PDF 1.3 MB, 550 pgs) and Executive Order 13423 requirements. The Energy Independence and Security Act of 2007 (EISA) (PDF 740 KB, 310 pgs) provides additional requirements for energy conservation. Also see LEED's (Leadership in Energy and Environmental Design) USGBC LEED for Healthcare.

Related Issues

The HIPAA (Health Insurance Portability and Accessibility Act of 1996) regulations address security and privacy of "protected health information" (PHI). These regulations put emphasis on acoustic and visual privacy, and may affect location and layout of workstations that handle medical records and other patient information, paper and electronic, as well as patient accommodations."

Emerging Issues

There is a growing recognition of the need for dementia day care. This can often be effectively provided within or adjoining an inpatient nursing facility.

There is a need for better non-medical residential facilities for the frail but independent elderly.

Managed care programs for the aged are being developed to prevent, or at least postpone, institutionalization.

Relevant Codes and Standards

Like other buildings, nursing homes must follow the local and/or state general building codes. However, federal facilities on federal land generally need not comply with state and local codes, but follow federal regulations. To be licensed by the state, design must comply with the individual state licensing regulations. Many states adopt the AIA Guidelines for Design and Construction of Hospitals and Health Care Facilities, listed below as a resource, and thus that volume often has regulatory status.

State and local building codes are based on the model International Building Code (IBC). Federal agencies are usually in compliance with the IBC except NFPA 101 (Life Safety Code), NFPA 70 (National Electric Code), and Architectural Barriers Act Accessibility Guidelines (ABAAG) or Uniform Federal Accessibility Standards (UFAS) takes precedence."

To care for residents who are reimbursed under Medicare or Medicaid, facilities must also meet federal standards, and to be accredited, they must meet standards of the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). Generally, the federal government and JCAHO refer to the National Fire Protection Association (NFPA) model fire codes, including Standards for Health Care Facilities (NFPA 99) and the Life Safety Code (NFPA 101).

The American with Disabilities Act (ADA) applies to all public facilities and greatly the building design with its general and specific accessibility requirements. The Architectural Barriers Act Accessibility Guidelines (ABAAG) or the Uniform Federal Accessibility Standards (UFAS) apply to federal and federally funded facilities. The technical requirements do not differ greatly from the ADA requirements. See WBDG Accessible.

Federal agencies that build and operate, or fund, nursing homes have developed detailed standards for the programming, design, and construction of their facilities. Many of these standards are applicable to the design of non-governmental facilities as well. Among them are:

• Department of Veterans Affairs (VA), Office of Facilities Management Technical Information Library contains many guides and standards, including:
  • Design Manuals of technical requirements, equipment lists, master specifications, room finishes, space planning criteria, and standard details.

Major Resources

WBDG

Federal Mandate

Executive Order 13423 Technical Guidance

Products and Systems

Building Envelope Design Guide

Websites

See WBDG Health Care Facilities for generic health care facilities websites

Publications

• Contemporary Environments for People with Dementia by Cohen and Day. Baltimore, MD: Johns Hopkins Press, 1993.
• Design Details for Health: Making the Most of Interior Design's Healing Potential by Cynthia A. Leibrock. New York: John Wiley & Sons, Inc., 1999.—Innovative design solutions in key areas such as lighting, acoustics, color, and finishes
• Design for Dementia by Margaret Calkins. Owings Mills, MD: National Health Publishing, 1988.
• Design of Long-Term Care Facilities by Aranyi and Goldman. New York: Van Nostrand Reinhold, 1980.
• Design That Cares: Planning Health Facilities for Patients and Visitors, 2nd Edition by Janet Carpman, Myron Grant, and Deborah Simmons. New York: John Wiley & Sons, Inc., 2001.
• Designing for Alzheimer's Disease: Strategies for Creating Better Care Environments by Elizabeth Brawley. New York: John Wiley & Sons, Inc., 1997.
• Designing the Open Nursing Home by J.A. Koncelik. Stroudsburg, Pa.: Dowden, Hutchinson, and Ross, 1976.
• Hospital Related Facilities for the Elderly by Alicen Hall. Lubbock, Tex.: Texas A&M University, 1997.
• Nursing Home Design by Benjamin Schwarz. New York: Garland Publishing, 1996.
• Nursing Home Renovation Designed for Reform by Lorraine Hiatt. Boston: Butterworth Architecture, 1991.
• See WBDG Health Care Facilities for generic health care facilities publications