Long-Term Care & Skilled Nursing

Designing for Specialty Care Facilities Elevated Expectations Creating healing spaces for specialty care requires expertise in planning and design, commonly found with a well-coordinated, collaborative team comprising design professionals, a multitude of sub-consultants and building trade representatives.

When a patient no longer requires acute hospitallevel care, but has medically complex needs that still require special attention and care, a Long-Term Acute Care Hospital or Skilled Nursing Facility may be the most appropriate option. Each facility type has distinct requirements for its resident populations, staff and guests.

Table of Contents

Differences Between LTACs and Skilled Nursing Facility

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Utilizing Sub-Acute Care to Enhance System Revenue Designing to Accommodate Varied Patient Acuity and Mobility

Healthcare Planning for a Long-Term Facility

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Designing for Specialty Care Facilities | PAGE 3

A well-designed space has a profound impact on residents in long-term care situations.

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What are the Differences Between Long-Term Acute Care Hospitals & Skilled Nursing Facilities?

While sharing a common mission to provide a safe, nurturing long-term care environment for their residents, Skilled Nursing Facilities and Long-Term

LTAC FACTS

Acute Care Hospitals function quite differently and have unique, specialized requirements. Both facility types require special attention to design elements

123K

not found in a traditional hospital. In addition to clinical care spaces and their required support and staff functions, designers must consider the need for psychosocial spaces such as group activity and dining areas, kitchens and community lounges.

Number of Medicare beneficiaries treated annually in this setting.

The majority of LTAC patients are transferred from intensive care or step-down units in acute care hospitals. Since these patients have serious, and often

$5.4B

complex medical conditions, LTACs focus on treating these critically ill, highacuity patients with intensive, specialized, physician-led care plans geared to the individual patient’s needs.

The goal is to restore patients to an acuity level that lower-level settings, such

Medicare spending on LTAC settings annually.

as Skilled Nursing Facilities, can accommodate. LTACs provide multidisciplinary care. The care team typically conducts daily patient-inclusive rounds in support of patient-centered care. Treatment plans are continually adjusted to meet patients’ clinical, psychological and emotional needs.

Services commonly offered at the more than 400 LTACs in the United States include:

CARDIAC MONITORING

COMPLEX WOUND CARE

VENTILATOR WEANING & MANAGEMENT

LABORATORY & PHARMACY

REHABILITATION & THERAPY

SPECIALIZED IV SERVICES

•PHYSICAL •SPEECH •OCCUPATIONAL

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•LONG-TERM ANTIBIOTICS •TOTAL PARENTERAL NUTRITION

CHALLENGES IN A VALUE-BASED DELIVERY SYSTEM LTACs are the most expensive post-acute care setting due to the intensive level of patient care provided. With the advent of the current CMS admitting criteria, along with pressure from Medicare payers and referrers attempting to keep patients out of higher-cost settings, LTACs must prove their level of provided care is not achievable in a lower-cost setting. If they cannot demonstrate their outcome values, LTACs may face the decision to close.

To define their value and differentiate themselves from other providers, LTACs may consider specializing in a specific service. This will allow LTACs to capture patient populations with more complex medical needs, resulting in better outcomes while filling market needs for services not currently offered. Considering a variety of factors—such as referral rate, organizational mission and patient demographics—LTACs could choose to narrow to one clinical focus, such as sepsis; specialize in treating a particular functional impairment, such as patients who struggle with gait, across all primary diagnoses; or be the destination facility for patients with a specific co-morbidity, such as behavioral health challenges.

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Unlike Long-Term Acute Care Hospitals, Skilled Nursing Facility residents don’t require the intense care of an acute facility. Designed to fulfill basic healthcare needs, Skilled Nursing Facilities provide ongoing treatment,

SKILLED NURSING FACILITIES FACTS

both long- and short-term, for a variety of sub-acute conditions. Although these residents aren’t able to live independently in the home environment, compared to LTAC patients, they are typically more mobile, enabling them to

1.7M

“own” their living spaces and participate in group activities within the facility.

To facilitate a home-like environment, a Skilled Nursing Facility is often designed using the neighborhood concept with each neighborhood having

Number of Medicare beneficiaries treated in this setting annually.

access to a common community lounge and living spaces for activities, dining, education and wellness. Additional spaces geared to resident personal needs, such as 24/7 access to snacks and beverages; laundry; and personal grooming, may also be provided.

Click Here

to read our thought leadership on Skilled Nursing Facilities and LTACs

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$29B Medicare spending on Skilled Nursing Facility settings annually.

Required to provide a basic level of care, centralized nursing workspace is provided on all floors with basic clinical support. Medical professionals work with residents upon arrival to assess their condition and create individualized care plans. The goal is to help residents function at the highest possible level and ultimately return to independent living. Similar to LTAC staffing, multidisciplinary care teams provide daily assessments to ensure residents receive the appropriate services, understand their individualized care plan and progress accordingly.

Common services offered at Skilled Nursing Facilities include:

WOUND CARE

PAIN MANAGEMENT

POST-HOSPITAL & POST-SURGICAL CARE

DAILY MEDICAL MANAGEMENT

OBSERVATION & ASSESSMENT OF

REHABILITATION & THERAPY ACTIVITIES AND EXERCISES

•CONDITION CHANGES •REHABILITATION NEEDS •POTENTIAL FOR IMPROVEMENT CHALLENGES IN A VALUE-BASED DELIVERY SYSTEM Similar to LTACs, the healthcare industry’s drive to provide patient treatment in the lowest cost-appropriate setting is affecting the service offerings of Skilled Nursing Facilities. In addition to post-acute Medicare reform, other factors such as decreasing hospital admissions, are forcing Skilled Nursing Facilities to re-evaluate their fee-for-service performance to compete in a value-based market. Since they are generally less expensive than LTACs, Skilled Nursing Facilities face an increase in higher-acuity patient referrals as referring partners substitute post-acute care settings.

Developing quality standards for staff, admission processes and patient transition protocols enables Skilled Nursing Facilities owners to identify improvement areas and potential challenges to address in order to succeed in a value-based system.

Embracing these long-term strategies, which

Implementing target metrics, such as readmission

necessitate new programs and clinical investment,

rates and reducing patient length of stay, can help

ensures high-quality outcomes. To better serve the

offset the cost demands of clinical and program

needs of the higher-acuity patients they are taking on,

investments.

Skilled Nursing Facilities must expand their services to include additional offerings.

Designing for Specialty Care Facilities | PAGE 9

02

Utilizing Sub-Acute Care to Enhance System Revenue

As healthcare systems endeavor to control costs and maintain market share in increasingly competitive markets, adding sub-acute and skilled nursing service lines can contribute to the diversification that helps overcome the loss of traditional fee-for-service payment models.

Simultaneously, these services can create a brand-enhancing continuum-of-care within an organization’s primary service area, positioning them as the provider of choice for savvy babyboomer consumer populations.

By now we’ve all seen the data – the first of the economy-driving baby-boomers turned 65 in 2011 and by 2030 it’s predicted that more than 20% of the U.S. population will be at least 65 (up from 13% today). Moreover, by that same time, the number of 85-year-olds will increase by more than 50% and the number of 100-year-olds will triple. These statistics, coupled with the prevalence of chronic illnesses such as Alzheimer’s, cancer and diabetes within that age group, reinforce the concern we should all have about the shortage of skilled nursing beds (between 2000 and 2009 the total number of skilled nursing facilities dropped almost 9%).

As healthcare reform and improved outpatient care continue to reduce inpatient bed demand, sub-acute and skilled nursing service lines can help maintain the viability of smaller community hospitals by leveraging existing facilities to capture new markets. The Social Security Act permits certain small, rural hospitals to provide swing-bed services. This arrangement allows these facilities to increase Medicare patient access to post-acute skilled nursing care and maximize operational efficiency by balancing physical plant capabilities with unpredictable demands for acute and long-term care. To qualify for this CMS regulated structure, a hospital must: • Be located in a rural area as defined by the United States Census Bureau (it is worth noting that hospitals in “urban clusters” still qualify) • Have fewer than 100 beds (excluding newborns and ICUs) • Have a Medicare provider agreement as a hospital • Not have had a swing-bed approval terminated within the last two years • Be substantially in compliance with Skilled Nursing Facility participation requirements • Not have had a nursing waiver granted

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Urban systems and facilities are facing some of the same demand issues as their rural cousins, but must also deal with some additional challenges: • It is becoming common for once active, vibrant facilities to find their inpatients suddenly redistributed to other system facilities due to the continuing frenzy of mergers and acquisitions, not to mention insurance plan alignments.

• The high cost of urban construction coupled with the uncertainty that surrounded healthcare reform caused many systems to delay replacing their aging inpatient facilities. As a result, non-compliant double-occupancy patient rooms are still common (and simple conversions of double-occupancy rooms to single-occupancy can wreak havoc on staff ratios and operational efficiencies).

• The “safety-net” status of many urban hospitals often resulted in a poor payer mix that was further eroded by CMS’ decrease in Medicaid and Medicare Disproportionate Share Hospital (DSH) payments.

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Nevertheless, urban facilities can find an unseen benefit in sub-acute service lines that can help obviate these issues. While the double-occupancy patient unit isn’t always well suited for conversion to single-bed acute care rooms (or the modern technology that comes along with them), it’s very well positioned for re-purposing as skilled nursing facilities (either as multi-bedded suites or as single occupancy rooms). Creating an alternate, revenuegenerating purpose for outdated acute-bed facilities can enable systems to dedicate the required capital to replace them, a win-win situation for both their acute and sub-acute patients.

Of course, it isn’t as simple as hanging out a shingle advertising that your facility now offers sub-acute beds. The targeted-consumer generation is more demanding and sophisticated than their predecessors, and has more choices about where and how they spend their money. While facilities differ depending on a variety of regional and socio-economic factors, successful facilities share some universal attributes: CLEANLINESS

DE-INSTITUTIONALIZED ARRANGEMENT

You can’t hide the sights and smells of a poorly

Historically, sub-acute units were planned and run like

maintained facility. Consumers are more likely

medical facilities. Centralized nurse stations; rigidly

to choose a simple, well-ordered and spotlessly

enforced medication/meal times; and long, double-

maintained facility over a luxuriously appointed one

loaded corridors were the norm. To appeal to today’s

that is chaotic and dirty.

consumers, the “village” model—which creates

GOOD FOOD Since sub-acute patients typically have much

smaller “communities” that provide more socialization options and a home-like atmosphere—is preferred.

longer stays than those in acute settings, providing

ACTIVITIES

nutritious and appetizing food choices is even more

Today’s skilled nursing facilities aren’t places for

critical to patient satisfaction. How special diets are

patients to convalesce in bed all day – they are active

accommodated, the dining area atmosphere and the

communities where residents can lead a full life.

helpfulness of servers should all be carefully planned.

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KENT DOSS

Every project is an opportunity to help our clients realize their missions and

EXPERIENCE When choosing a facility, the alignment of staff capabilities and care models with the needs of the potential resident is often a

goals in innovative, exciting ways.

As Regional Vice President and Principal, Kent is responsible for all phases of project delivery, from

deciding factor. Exhibiting knowledge and experience in caring

preliminary project planning through

for specialized needs, such as Alzheimer’s; behavioral issues,

design and construction. He has

such as agitation, wandering or depression; and other specific conditions can help ensure that a facility is the top choice within the community.

When sub-acute and skilled nursing service lines can align community needs and operational commitment with a solid business-case, they can be key contributors to a System’s financial performance and perceived value within the community.

RENOVATION DESIGN CONSIDERATIONS:

served as project manager on a variety of engagements ranging from limited interventional modifications to largescale buildings and campus-wide development.

Understanding the importance of alternate project delivery methods, Kent has completed Stanford University’s Center for Integrated Facility Engineering program for virtual design and construction.

When renovating a hospital to include a Long-Term Acute Care or Skilled Nursing unit, there are many factors to consider.

• Access and security

Click here to visit Kent’s Thoughts page.

• Community engagement if appropriate • Layout and organizational clarity for intuitive wayfinding • Neighborhood concept with centrally-located spaces on units for common activities and dining • Shared activity, education, meeting and wellness functions • Opportunity for outdoor activity and recreation space (gradelevel or roof garden) • Resident bedroom options featuring single and shared occupancies that maintain resident privacy and dignity • Appropriate caregiver work and support zones • Adequate, centrally-located spaces for necessary diagnostic services • Innovative models to meet support needs, such as supply chain, pharmacy, lab testing, dietary services, etc.

Designing for Specialty Care Facilities | PAGE 13

Henry J. Carter Specialty Hospital and Nursing Facility, Bronx, NY Photographer: Halkin Mason

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03

Designing to Accommodate Varied Patient Acuity & Mobility

While traditional hospitals offer several general medical specialties, Long-Term Acute Care Hospitals and Skilled Nursing Facilities have the ability to apply strict care standards to a handful of specific ailments. Since these facilities treat patients for an extended period of time, a thoughtful and studied design approach to guarantee comfort, safety, durability, flexibility and context will ensure that caregivers, patients and residents have a beautiful and equitable environment.

Carefully selected colors, textures, patterns, artwork and graphics must be well-coordinated and integrated into the overall design. Studies prove that the physical environment directly influences patient outcomes, as well as the experience of visitors and staff. The design of a patient room, designed to minimize noise levels and provide access to the outdoors, all affect resident quality of life (from sleep habits to health status), resident safety and staff stress. In a facility that treats short-term (no more than a 100-day stay) and long-term (up to 10 years of residency) patients, it is essential to create a home-like atmosphere while maintaining stringent hospital design standards.

The design must take varied patient acuity and mobility levels into account. Flexible public spaces with many potential uses are recommended and, ideally, should accommodate residents, visitors and staff, as well as community members. Selecting furniture and finishes that are of a residential scale, combined with an aesthetic appropriate for the resident demographic and community, ensures that the facility doesn’t feel institutional. Include furniture of varying sizes to recognize various resident physical profiles and mobility capacities. Features should include warm woods and textiles, with vibrant colors and patterns, balancing the desire for beautiful furniture and the ability for furniture to withstand daily use for years.

Conducting user meetings with facility leaders and front-line staff, and receiving regular input from focus groups is important to ensure the physical environment is in-sync with an organization’s reputation, mission and values, as well as gain insight into patient and clinician needs. These meetings allow the clinicians who work in the spaces each day to express their goals and concerns. They are also able to address what does and does not work for the particular patient population in the long-term healthcare environment. Using detailed user reviews, virtual and physical mock-ups can aid in selecting and approving appropriate furniture for all facility areas including lounges, dining rooms, resident rooms, clinical areas and offices.

Designing for Specialty Care Facilities | PAGE 15

CREATING A COMMUNITY Including unique amenities and program-rich elements, such as worship spaces, library, art rooms, teaching kitchen, and performance space used by residents and the community-at-large into the design of Long-Term Acute Care Hospitals and Skilled Nursing Facilities creates a sense of community among residents and links the facility to its surroundings.

While not commonly found in traditional hospital settings, these amenities and program elements are essential in the long-term care environment. These communal living and dining spaces encourage and empower residents to engage with others in an appropriate setting, or to have quiet, introspective moments, It’s important to provide positive distractions, including art, music and images of nature by way of views of the surrounding community or access to the outdoors.

Communal spaces serve a multitude of functions. Shared spaces create opportunities to socialize and form relationships with their fellow residents. Travel to and from these spaces gets residents out of their rooms and provides a chance to get additional exercise.

Moreover, communal kitchens and dining spaces allow patients to share the dining experience and have access to additional food items and condiments as needed. Assistance from staff is readily available in a community dining room, allowing staff to manage patient nutrition and ensure medications are taken with meals.

Drawing inspiration from the sights and sounds of the surrounding neighborhood provides residents with a sense of belonging to the community beyond the facility’s walls. Incorporating a neighborhood theme into signage and wayfinding can create a distinct signature color and vibe for each unit or floor, which can then be reinforced through a rich art program.

READ Designs Delivered: Henry J. Carter Specialty Hospital & Nursing Facility Henry J. Carter Click on the title above to read the full project profile on the Henry J. Carter Specialty Hospital & Nursing Facility. Comprising an entire city block, this facility seamlessly combines a Long-Term Acute Care Hospital with a Skilled Nursing Facility while also creating a sense of community within a hospital.

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PATRICIA MALICK

Environments have the power to set our expectations, lift our spirits and

SAFETY IS PARAMOUNT The commitment to patient safety should be inherent, especially when patients have varied acuity levels; complex, and often chronic, medical conditions; and compromised mobility. At no point should the design, including the space layouts and configurations; and components within such as lighting, materials and the finish or furniture selections, be detrimental to

inspire hope. The design of the interior environment can positively affect the expectations of patients and their loved ones.

In every space people use, furniture is needed and creates an impression.

For a space to be functional as well as healing, healthcare furniture is typically utilized in more ways than

the health and safety of the residents.

might be expected in a hotel or office.

Patient rooms are designed to promote healing, featuring

As a founding Principal of the firm and

elements that support restoring a patient’s ability to move around independently and with confidence. To accommodate

Practice Leader for Interior Design, Pat has been an integral part of Array’s evolution. Her passion for collaboration

mobility limitations, features that reduce fall risk, such as easily

allows Pat to serve as a critical link

accessible handrails, slip-resistant flooring and warm, wood-

within the design team, inspiring them

tone floors, rather than carpet should be considered. Visionimpaired residents can perceive busy floor patterns as uneven, causing them to believe their eyes are “playing tricks” on them.

Collaborating with the client on a flooring mock-up can be an ideal way to show all stakeholders their options, while also testdriving the materials in an active healing environment.

to develop a consistent theme and recognizable brand within the context of a major clinical environment.

With more than 30 years of experience in healthcare design, she has been at the forefront of advancing the role of interior design beyond the confines of applied color, pattern and texture into

Click here to watch as we test various flooring materials at New York

a more holistic approach focused on

Presbyterian Hospital in New York City.

patient safety, empowerment, culture change and improved outcomes. This

Consider installing multiple lighting options, including embedded

approach maximizes the potential for

floor lights leading to the bathroom, controlled by the patient’s

an ideal ‘patient-as-guest’ experience.

pillow switch to reduce falls and injuries due to room darkness.

Click here to visit Pat’s Thoughts page.

Designing for Specialty Care Facilities | PAGE 17

04

Healthcare Planning for a Long-Term Facility

Henry J. Carter Specialty Hospital and Nursing Facility, Bronx, NY Photographer: Halkin Mason

In planning an urban, long-term facility, there are many factors to consider. First and foremost is to establish an understanding of the typical patient. While it’s common to have such facilities geared toward a geriatric demographic, it isn’t unusual to serve other, younger populations, such as those recovering from ongoing neglect of basic healthcare services—leading to chronic disease and symptoms resulting from substance abuse. There may not be an equal distribution of male and female residents, and behavioral health care needs often accompany such cases.

Recognizing the need to provide daily activities and individualized treatment plans, residents, when able, can participate in a variety of therapeutic activities, including physical; occupational; speech and hearing; recreational; and psychology. It’s important to centralize these services so they are easily accessible to the residents able to leave the patient care units. If unable, residents should have the opportunity to engage in a variety of activities on the units depending on the type of facility and resident capabilities.

If the site permits, secure outdoor access affords residents the opportunity to decompress, breathe fresh air, experience the seasons, and, if part of the service offerings, engage in therapeutic gardening activities. If not available outside, a greenhouse may suffice for gardening activities.

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Henry J. Carter Specialty Hospital and Nursing Facility/ Bronx, NY Photographer: Halkin Mason

PERSONAL AMENITIES Faith plays an integral role in the healing process for many residents. Including spaces for worship and religious services may benefit residents, who may spend significant time in the long-term care setting. While shared multi-denominational spaces may be sufficient, dedicated religious spaces, such as a chapel, temple and mosque, may be necessary depending on resident numbers and regional religious preferences. Additionally, personal care functions such as beauty/barber shop, resident laundry, and financial services may be provided.

Residents are typically transported out of the facility for complex diagnostic and treatment needs; however, basic services including routine primary, gynecologic and dental care may be provided within the facility, along with simple procedural and basic diagnostic imaging modalities. The appropriate administrative and support services, including but not limited to general administrative services; medical staff; nursing administration; employee health; infection control; safety and security; pharmacy; materials management; equipment and supply processing; food preparation; even wheelchair maintenance and fitting, may be necessary depending on patient capacities and conditions.

PATIENT ROOM DESIGN Understanding that residents may spend significant time at a long-term care facility allows designers to recognize and address the individual’s personal needs while simultaneously affording a sense of community.

New models of care use the concept of neighborhoods to drive the design, each with an identifiable image; shared common spaces for wellness, education, activity and dining; and individual spaces including the resident room and bathroom.

Whether in private or semi-private suite configuration, the ability to create privacy and maintain dignity is essential. While private rooms are ideal, semi-private configuration can benefit the resident better suited to the company of others and in need of companionship. With semi-private occupancy, it’s important to maintain personal space and provide sleep-privacy. It may be preferable to have a toe-to-toe configuration rather than a side-by-side configuration if possible.

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LISA LIPSCHUTZ

Watching my parents age has provided me with incredible insights regarding the design of environments for longterm care. I have seen how simple

The ability to personalize one’s space is also beneficial; each resident should have their own: • Storage closet or cabinet for personal belongings • Shelf or display board for personal items and memorabilia • Lockable box for safekeeping • Access to a personal telephone and television

solutions in wayfinding and color can empower an elderly individual and change their perspective on the world around them.

--------------------------------------------As one of Array Architects’ lead planners, Lisa has a deep appreciation for and understanding of the built healthcare environment. Lisa’s work is informed by regular interaction with clinicians, strategists, colleagues and family advisory representatives.

Her sensitivity to the quality of the healthcare experience allows her to incorporate healing-centered design strategies.

Lisa’s specialty in planning and design is evident in projects spanning the continuum of healthcare delivery sites and services, from Long-Term Acute Care Hospitals to Cancer Centers, from NICUs to Surgical Suites.

Click here to visit Lisa’s Thoughts page.

Designing for Specialty Care Facilities | PAGE 21

All rooms should have a window with shading device control and residents should have control of room lighting.

If the toilet room serves two residents, consider providing two sinks so each resident has their own sink/specific location for personal toiletries. Plan the toilet room location to minimize falls; provide a handrail for support; and minimize thresholds at floor transitions. Additionally, space for wheelchair maneuvering, including turn-around and storage should be provided.

Consider room zoning to support staff work, patient care and resident seating, as well as visitor space. Staff workspace should have access to hand washing, sharps and in-room charting if planned. The degree of required clinical services in the resident room depends on the facility type; a skilled nursing bedroom will require fewer services compared to a long-term acute care bedroom. Plan the location of such services based on clinical need, including required quantities, staff ability to access them and maintain required clearances for patient care, and necessary medical equipment at the bedside.

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We Are Healthcare Architects We are a team of architects and designers with unique backgrounds, but we all have one thing in common - we share a strong desire to use our expertise and knowledge to design solutions that will help people in moments that matter most.

This focus makes us leaders in our field. There’s a degree of compassion, empathy, and sensitivity that goes into every project that we touch. It’s designing a nurse station with sight lines to every patient. It’s building a Behavioral Health facility without corners, so that patients are safe. It’s translating the operational needs through the technical details to fine tune the lighting system in a neonatal unit so caregivers can match the lighting to each baby’s stage of development. It is a deeper understanding, honed through relationships spanning decades.

Together, we discover optimal solutions with our clients. It is our four decades of specialization that allows for effective communication, collaboration and precision in the complex, changing world of healthcare.

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