Eco-Senior Living

ECO-SENIOR LIVING A Survey of Emerging Senior Housing Trends

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ECO-SENIOR LIVING A Survey of Emerging Senior Housing Trends Allison Peitz, Prarthan Shah, Kelly Weckman Advisor: Andrew Herdeg 2021-2022

What can we learn from the intersection of senior living, health, wellness, and biophilia?

ABSTRACT This project compiles and assesses information on current senior housing challenges, demographic and market trends, and financial structures to identify priorities for designing senior housing. These include the importance of limiting spatial and relational displacement and the positive impacts of exposure to nature and natural references. The architectural community has expressed a growing interest in biophilic design, the theory that people possess an inherent affinity for nature (Kellert, 2018). This paper explores the topic’s relevance to the design of senior housing in an effort to promote joy in aging.

KEYWORDS Senior Housing, Biophilia, Active Adult, Aging In Place, Continuing Care Retirement Communities 5

INTRODUCTION We are at a critical point in time in which the populous baby boomer generation is entering retirement, causing a “silver wave.” The Joint Center for Housing studies projects the “number of households aged 75-79 will increase 49% in 20182028,” and this large cohort of seniors will need housing, and ideally housing that can fit their changing needs as they age (Housing America’s Older Adults, 2019). A paper by the Center for Retirement Research at Boston College points to a desire to age in place. Of 3,586 respondents, 53% of homeowners stay in the house they owned at 50 for the rest of their lives.

17% move only once at retirement age, 14% move frequently based on job-related issues, and 16% move later in life to assisted living or nursing homes due to health problems (Munnell, et. al., 2020). Senior housing communities that can adapt to the changing needs of aging seniors are becoming a commodity, and as this sector grows there is an opportunity to explore models of senior housing and envision thoughtful and inspiring typologies.

Parallel to this is an increased collective awareness regarding the health benefits of nature and spending time outdoors.

Ever since the landmark study in 1984 by Roger S. Ulrich correlating views to nature with shorter hospital stays and less pain medication, the health benefits of biophilic design have been widely studied and are becoming common knowledge. However, seniors are inheriting senior living facilities that didn’t benefit from this knowledge. There is an opportunity for Lake|Flato to develop a unique approach to senior housing centered around biophilic design, pulling from our pre-existing areas of expertise.

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Shifts in Senior Housing Trends The baby boomer generation has marked a fundamental shift in senior housing preferences and trends. As a whole, the generation is more highly educated and more ethnically and racially diverse than previous generations (Frey, 2010). They also have fewer children, are less likely to be married, and have a greater prevalence of separation and divorce (Hughes, 2004). Furthermore, throughout their professional lives, the baby boomer generation comprises a larger percentage of women in the work force, and boomers occupy more managerial positions than previous generations (Frey, 2010).

These generational lifestyle changes have also led to shifts in preferences and priorities as baby boomers have begun transitioning into senior housing communities: Aging in Place Chief among these is the desire to age in place. Aging In Place refers to the idea that, as one ages and care become more intensive, one’s home or community is able to accommodate an individual’s changing needs to prevent displacement to a new facility.

Active Adult The second major shift is the preference for Active Adult communities. Active Adult is a new model for senior housing targeting the “healthiest and youngest segment of Seniors” which emphasizes “active living programming and recreational facilities” (Active Adult Research Brief, 2021). The impetus behind Active Adult communities is to maintain one’s physical and mental capabilities to support a high quality of life for as long as possible. Active Adult is senior housing

reinvented; it is “a new product appealing to baby boomers (‘not my parents’ retirement home’),” which rejects the fear and negativity often associated with senior housing and instead offers a brighter, healthier, more promising vision of the future (The Era of the Active Adult - The Golden Years, 2021, p. 8).

Balancing Priorities Beyond the ability to age in place and maintain an active lifestyle, the new generation of seniors is looking for a high quality of care, a sense of community, and financial feasibility.

Affordability presents a significant barrier to entry, and may limit a person’s ability to choose a community that supports their lifestyle preferences.

Owners and operators of senior communities must balance resident needs and preferences while maintaining a profitable business model and maintaining safe, healthy, accessible environments for residents.

Market Challenges The ability to age in place, while strongly preferred by the new generation of seniors, comes at a premium. New developments accommodate aging in place in one of two ways. The first path is to provide convertible units and the second is to provide a variety of unit types within the same community. The first path requires greater investment up front, and eliminates displacement. The second approach is more cost effective, requiring less up-front investment, but requires residents to change units within the larger community as new needs arise. This second approach balances the desire to age in place with cost considerations and is adopted more frequently.

While access to nature does not necessarily come at a premium, a great deal of the senior housing stock available today does not appear to capitalize on nature’s restorative benefits. In part, this can be attributed to constrained budgets and resources. However, many biophilic strategies may be implemented for little or no additional cost.

The Stigma of Senior Living Senior living communities, assisted living environments in particular, carry a stigma that discourages many seniors from joining these neighborhoods (Hrybyk, 2012). Diverse communities (inter-generational, differently abled) present a more attractive prospect for many because they are less structured and invite a broader set of perspectives, abilities, experiences, and backgrounds to enrich the communities (Wave of Diversity Heading Towards Senior Housing, 2018).

Figure A. Share of 65+ population in total U.S. population (Statista, 2020) 7

BIOPHILIA AND RESEARCH OUTCOMES View through a window may influence recovery from surgery Ulrich, R. S. (1984) OVERVIEW: This was a landmark study investigating the restorative influences of a view to a natural setting.

PARTICIPANTS: Forty-six patients who received a cholecystectomy (gallbladder surgery) and were between the ages of 20 and 69 were included in the study. Those with a history of psychological disturbances, and those who had severe complications from the surgery were excluded.

METHOD: Pairs of patients were matched based on sex, age (within 5 years), weight, whether they smoked, general nature of previous hospitalization, floor level of their hospital room, and the time frame of the surgery (within 6 years of each other). During recovery, one member of each pair had a view of trees, and the other of a brick wall. A nurse, with no knowledge of which scene was visible from each room, recorded information for each patient: number of days hospitalized from day of surgery to day of release, number and strength of analgesics each day, number and strength of doses for anxiety, minor complications (headache, nausea) requiring medication, and notes relating to a patient’s condition or course of recovery.

RESULTS: Per the records, patients with window views of trees spent an average of 7.96 days in the hospital, versus 8.70 for patients with a view of a brick wall. Patients with 8

Clinton Corners Residence designed by Lake|Flato

1221 Broadway designed by Lake|Flato

the tree view also received fewer negative evaluative notes from nurses: 1.13 per patient, compared to the patients with the brick view who received an average of 3.96. During days 2 through 5, tree-view patients received fewer analgesic doses of medication than the wall-view group. There were not statistically significant differences between the two groups with respect to anti-anxiety drugs.

The results of this study suggest that a window view with a natural setting has restorative effects, although authors of the study did point out that a lack of stimulation and movement in the “built” view (a static brick wall in this case), rather than the lack of natural scenery, could be responsible for the variation between the two groups.

APPLICATION: Designers should incorporate views of natural scenery into regularly occupied spaces for occupants to experience restorative benefits.

Viewing nature scenes positively affects recovery of autonomic function following acute-mental stress Brown, et al., 2013 OVERVIEW: This study investigated whether prior viewing of images of nature would affect heart rate variability (HRV) and stress recovery. High HRV is associated with better health and provides a measure of autonomic nervous system (ANS) performance (Brown et al., 2013).

PARTICIPANTS: The study included 23 participants: 17 female, and 6 male, aged 36.91 ± 11.09 years. All were University support staff independent from the research group.

Images shown to participants either depicted nature environments (A, B) or built environments (C, D) .

Image Source: Brown, Daniel K., et al.

Participants were not using medication that would affect cardiovascular health or ANS. METHOD: After a psychological questionnaire and a subsequent 15 minute period of rest, participants were shown slides depicting either nature scenes (containing trees, grass, fields) or scenes of the built environment (man-made, urban spaces with minimal natural elements). Participants then took part in a 5-minute cognitively demanding mental stressor. Afterward, physiological data were recorded for a period of 5 minutes. The psychological questionnaire was then repeated.

RESULTS: The findings suggest that viewing nature scenes prior to a stressor can improve the body’s stress recovery process after the stressor. The results point to restorative properties inherent in nature.

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APPLICATION: In design, whenever possible, the team should prioritize views to nature (trees, grass, fields, etc.). If views to nature are not possible in all spaces, brief experiences with nature in or nearby a space may suffice.

Morbidity is Related to Green Living Environment Maas, et al., 2009 OVERVIEW: This study investigates morbidity, assessed by a physician, as opposed to self-reported health, and its relationship to green space in participants’ living environments. Though this study does not define morbidity, this is assumed to be referring to the epidemiological term meaning “the state of being symptomatic or unhealthy for a disease or condition” (Hernandez, et al., 2020).

Hardberger Park Urban Ecology Center designed by Lake|Flato

PARTICIPANTS: This study pulled data from two existing data sets.

METHOD: The researchers obtained morbidity data from medical records of 195 general practitioners in 96 practices in the Netherlands. This information was then cross-referenced with percentage of green space within a 1 km and 3 km radius around the zip code for each household. The research team referenced a national database for land use types, and to count as green spaces in the data set, the land had to be dominated (more than 50%) by green in the 25 x 25m grid cell. Street trees, roadside vegetation, and other small-scale green spaces were excluded unless they comprised half or more of the grid cell.

Then, multilevel logistic regression analyses were 10

Naples Botanical Garden designed by Lake|Flato

performed, controlling for demographic and socioeconomic characteristics to determine any possible correlation between morbidity and proximity to green space.

RESULTS: There appears to be a significant relationship between percentage of green space located within a 1 km radius of a person’s postal code and the annual prevalence rate for 24 disease clusters. Postal codes with 10% more green space than average correlate with lower prevalence rates of the disease clusters studied.

A significant relationship was present between the prevalence rate of 24 disease clusters and the percentage of green space in a 1 km radius, with anxiety disorders and depression having the strongest relationship. For a 3 km radius, only anxiety disorders, infectious digestive system diseases, and medically unexplained physical symptoms were lower. The relationship between green space and disease clusters was more pronounced in children younger than 12 years, and those between the ages of 46 and 65.

APPLICATION: The proximity to green space seems to be critical; for clients, selecting a site close to public green space, or including an adjacent green space as part of the program, are strategies that can be employed in order to encourage regular use and enable occupants to enjoy significant mental and physical benefits.

Landscape Planning and Stress Grahn, et al. 2003

health and their use of urban open green spaces in and near their city.

METHOD: Three towns with about 25,000 inhabitants, three cities with about 40,000 inhabitants, and three cities with about 100,000 inhabitants were selected. Within each city, the researchers identified five categories: old city center, areas built immediately adjacent to the old city center, areas built in the 1940s and 1950s, areas built in the 1960s and 1970s, and areas built in the 1980s onward. A questionnaire was sent to 2,200 random individuals in the nine towns. Nine hundred fifty-three responses were returned, and the addresses were sorted per the five categories. The questionnaire collected personal data such as age, sex, and profession. It also asked about number and duration of visits to open green spaces in the town and asked respondents to assess their health in a number of categories.

RESULTS: The findings suggest that both frequency of visiting green spaces and time spent per week in green spaces positively correlate with lower stress. Distance to green space also appeared to be important, as the findings suggested that respondents did not compensate for lack of green spaces in or near their residential area with more visits to other public green spaces.

APPLICATION: Access to green space seems to contribute to lower stress levels; designers should consider proximity and ease of access with regard to green spaces in projects.

PARTICIPANTS: Nine hundred fifty-three respondents in nine Swedish cities answered a questionnaire regarding their 11

DEMOGRAPHIC TRENDS

“If help with basic daily living activities is needed, on a scale of 1-10, how important is it to do the following?”

Aging In Place According to AARP’s 2018 Home and Community Preferences Survey, 86% of people 65 and older desire to stay in their homes and communities (Binette, 2018). Communities with care options that can adapt to residents’ changing needs help to minimize displacement.

“What I’d really like to do is remain in my community for as long as possible”

“What I’d really like to do is remain in my current residence for as long as possible”

86% 77% 60%

25%

MOST IMPORTANT 9.5

HAVE ACCESS TO OUTDOORS

8.8

BE ACTIVE

8.6

HAVE MEANINGFUL SOCIAL ACTIVITIES

7.8

9

BE AROUND FAMILY BE AROUND FRIENDS 8.5 LIVE IN OWN HOME 8.9

8.7

86%

22%

17% 53%

64%

32% 18-49 50+ 65+ AGE OF RESPONDENT

21%

24% 55%

69%

29%

SOMEWHAT AGREE STRONGLY AGREE

18-49 50+ 65+ AGE OF RESPONDENT

8

7.7

GO OUT DAILY LIVE IN CURRENT COMMUNITY

6.9

MAKE A DIFFERENCE

6.6

TRAVEL

5.1

WORK

7.9

PRACTICE MY RELIGION 7.5 7

Source: 2018 Home and Community Preferences Survey: A National Survey of Adults Age 18-Plus

It’s important to note that “aging in place,” while a common concept in the senior living world, is somewhat ambiguous and can refer to aging in one’s own physical dwelling, but also one’s neighborhood or community. Qualitative research involving two focus groups in New Zealand discerned that among the participants, “‘Aging in place’ was seen as an advantage in terms of a sense of attachment or connection, practical benefits of security and familiarity, and as being related to people’s sense of identity through independence and autonomy,” and attachment was not necessarily associated with a particular house, but rather 12

BE SAFE

76%

28% 52%

10

6

5

Source: 2018 Home and Community Preferences Survey: A National Survey of Adults Age 18-Plus

“operated at social and community levels” (Wiles et al., 2011).

Baby Boomer Priorities A survey published in 2019 by LeadingAge and NORC asked 1,283 60-72 year-olds about their basic daily needs.

Participants ranked the following factors most important on a scale of 1-10: safety (9.5), being around family (8.9) and friends (8.6), having access to the outdoors (8.8), being physically active (8.6), and living in one’s own home (8.5). They value their own domain and autonomy; even with a physical disability and the need for help day-today, 60% of respondents said they want to remain in their home, though that percentage dropped to 29% for those needing help due to dementia. Twenty-nine percent selected “becoming a burden on my children or other family members” as their top worry from a given list, and 21% chose “being dependent on anyone for that kind of personal help” at 21%.

Outdoor Connectivity and Destinations In addition to an increased focus on wellness comes a desire for connection to nature and the outdoors. According to AARP, one of the trends prompted by the pandemic is the inclusion of outdoor spaces in communities, particularly “outdoor areas that allow for distanced socializing and activities” (Flanigan, 2022).

“The ability to have outdoor connectivity to a small terrace... becomes really important to the sanity and the health and wellness of an individual” JOE HASSEL, PRINCIPAL AT PERKINS EASTMAN

SENIOR LIVING TRENDS Active Adult Communities In recent years, Active Adult communities have been seeing more demand, and are projected to continue to grow, partly due to seniors’ desires for more independent, active lifestyles (Active Adult Research Brief, 2021). According to Carey Levey, president of Passco Companies Development, the key draw of Active Adult communities is wellness, both physical and emotional. For developers, that translates to an emphasis on amenities, services, and common areas that offer a range of opportunities for residents to stay fit and socialize.

Santa Rita Geriatric Center designed by Manuel Ocaña, completed in 2003

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Intergenerational Cross-Over Partnerships with universities, schools, and other youthserving organizations allow for symbiotic relationships between different age groups. According to Jeffrey Davis, the chairman of Cambridge Realty Capital, a leading senior living capital provider, senior living and university partnerships will continue to increase, as “there is much to be gained on both sides of the equation” (Williams, 2018). He notes that a senior living/university partnership would not only improve seniors’ lives, but would “demonstrate a sense of valuing seniors as a vital part of the community-at-large” (Williams, 2018). Julie Higgins, principal at Hord Coplan Macht, also predicts a rise in these partnerships in order to “encourage lifelong learning and interaction between people of all ages” and “the link between the college and senior population will provide support to the younger students in the form of mentoring, tutoring, guest lecturing and other activities” (Better with Age, 2021).

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Hotel San Jose, Completed 2000 by Lake|Flato Austin, Texas

“Small House” Approach A new model for small nursing homes, called Green House Homes, is becoming more desirable for nursing care communities due to its small-scale, domestic feel and ability to operate in a self-contained way, attributes which make them more likely to fare well during a pandemic.

“The small-house model was a solution waiting for a problem, and the problem is Covid. If I’m putting my mom and dad someplace, I’d rather put them in a compartmentalized setting with 12 or 16 people than I would a gigantic wing that comes off like a hospital.”

DAVID DILLARD, PRINCIPAL AT D2 ARCHITECTURE

Approach The variety of options available to seniors has been broadening at an unprecedented pace. For this reason, there are many different approaches for categorizing senior housing options. For the sake of clarity, this white paper utilizes the categorization strategy employed by CBRE’s quarterly market analyses (Q3 2019 Senior Housing Market Insights, 2019) (Q3 Senior Housing Market Insights, 2020). Additional classifications and categorizations are defined within the glossary for reference.

MULTIFAMILY

LATE 60S MID 70S

ACTIVE ADULT

LATE 60S MID 70S

INDEPENDENT LIVING

MID 70S

Senior Housing Types A typical progression of housing types as a senior ages include multi-family, Active Adult, independent living, assisted living, memory care, and nursing care. The two defining amenities that differentiate housing types are bundled services and healthcare services. Bundled services include prepared meals, cleaning, laundry, dog walking services, etc. These basic services are offered to relieve the residents of responsibilities that become more difficult with age. Healthcare services address changing health, care, and daily assistance needs, and tend to become more time intensive and expensive as one ages. Healthcare services require a greater financial investment by the operator and/or resident.

ASSISTED LIVING MID 80S+

Conventional Multifamily At a certain age, seniors often want to“downsize” and move into a smaller unit. Multifamily housing offers a cost -effective solution that may or may not be age restricted. While multifamily is a generic term that may apply to any type of senior housing, for the purpose of this paper, it applies housing options that do not include the option of bundled or healthcare services, contributing

MEMORY CARE

MID 80S+

NURSING CARE

MID 80S+

CONTINUING CARE RETIREMENT COMMUNITY (CCRC)

THE SENIOR HOUSING MARKET

Figure B. The typical housing and care progression for aging seniors. Based on information from Continuing Care Retirement Communities, 2018.

to their affordability. Multifamily options do not support aging in place, so residents typically have to relocate as needs change (Q3 2019 Senior Housing Market Insight, 2019).

Active Adult Active Adult communities emerged over the last five to ten years targeting the healthiest, youngest segment of seniors by providing a broad range of amenities and recreational facilities 15

to accommodate active, independent lifestyles (Active Adult Research Brief, 2021). It has emerged as the preferred option for the baby boomer generation. Active Adult housing does not typically offer bundled or healthcare services. CBRE defines Active Adult housing as “purpose-built multifamily rental housing for younger seniors. It has a heavy emphasis on community space and activities. It can almost be thought of as independent living “unbundled” (Active Adult Research Brief, 2021).

Due to the variety of amenities provided, Active Adult housing costs more than basic multifamily, but may afford greater freedom and a higher quality of life for residents.

Independent Living As one ages and everyday responsibilities become more difficult, independent living becomes a more feasible option.

Independent living offers a variety of amenities as well as “bundled” services, to support residents as their level of independence declines. Due to the addition of bundled services, independent living is more expensive than Active Adult housing, but typically accommodate seniors for a longer span of time.

Assisted Living Assisted living serves individuals needing regular healthcare support. Typically the shift to assisted living is coupled with a shift from larger condos, apartments, townhouses, or single family homes to a smaller sleeping and living unit with shared cooking and living spaces. Bundled services are typically offered as well as amenities that are intended to accommodate shifts in physical or mental abilities. The combination of bundled and healthcare services once again 16

requires an increase in overall cost.

Memory Care Memory care is offered to residents who struggle with neurological diseases such as Alzheimer’s. Trained oneon-one care addresses residents’ new physical and mental needs. Meanwhile, bundled services are maintained. Similar to assisted living, amenities are offered, but limited to activities that residents may benefit from given their health limitations. Since memory care typically requires more oneon-one attention than assisted living, it tends cost more than assisted living facilities.

Nursing Care Nursing care is the most intensive level of care that can be provided to a senior resident. Typically, nursing care residents have more physical limitations and needs than memory care residents, and one-on-one care is holistic.

Similar to memory care, nursing care residents have access to fewer amenities than in less healthcare-intensive senior housing options. Living accommodations are smaller in scale, but accompanied by shared living and amenity spaces. Requiring the highest level of healthcare support, the cost of nursing care is the highest among senior housing options.

Continuing Care Retirement Communities (CCRCs) Some communities include more than one of these housing options. These are called continuing care retirement communities (CCRCs). CCRCs are designed to accommodate new needs that develop as a resident ages by providing convertible units or by offering multiple housing types within the same complex to accommodate evolving health/

care needs. This concept, also known as aging in place, allows residents to remain within the same community or residence in order to retain familiarity and comfort. CCRCs are the most common way that existing senior housing accommodates aging in place (Continuing Care Retirement Communities, 2018).

CCRCs may capture all five senior housing options, but it is far more common for a CCRC to accommodate only two to three housing types. Ultimately, this means that seniors are likely to relocate multiple times. To accommodate aging in place over the latter stage of the aging process, CCRCs will need to begin capturing a fuller range of housing types.

The Challenge of Aging In Place While the aging in place approach is strongly preferred by the “baby boomer” generation, market trends reflect a rush to enter amenity-filled, independent, Active Adult communities that do not offer healthcare support or aging in place. In part, this is due to the stigma associated with aging and, by association, facilities that provide care for the aging. However, higher upfront costs required to provide flexible accommodations to promote aging in place may also pose a significant barrier.

caregiver should also be considered. This approach presents a challenging financial model because it requires significant up-front investment. Technology and healthcare infrastructure must also be flexible enough to accommodate needs for the lifetime of the building. If changing technologies cannot be accommodated, future renovations will be necessary to update the units. However, if done successfully, unit conversion allows the resident to remain in their home indefinitely and eliminates the upheaval of displacement entirely.

PATH 2. PROVIDE A VARIETY OF UNIT TYPES The second approach is to provide a variety of unit types within the same community. This approach eliminates the need to over-engineer each unit and predict the future. Consequently, this is a much more cost-effective strategy. This path does not eliminate the need for relocation entirely since it requires residents to change units within the larger community as their needs change. However, the larger community, physical surroundings, routines, weather, and relationships may be maintained throughout their transition. This approach balances the need for affordability with the desire to age in place and, as a result, is employed more frequently in newly constructed CCRCs.

Aging in place can be accommodated in one of two ways: PATH 1. CONVERTIBLE UNITS The first path is to provide convertible units. Convertible units require significant infrastructural investment during construction or renovation to provide the full spectrum of care that may be necessary throughout the remainder of the resident’s life. Units must be fully compliant with the Americans with Disabilities Act, and accommodations for a 17

MULTIFAMILY

LAUNDRY

SHELTER ACTIVITIES

LAUNDRY

SHELTER

SHELTER AMENITIES

MULTIFAMILY

SHELTER

LAUNDRY

AMENITIES

ACTIVITIES

SHELTER

SHELTER TRANSPORTATION

TRANSPORTATION

MEALS

AMENITIES DAILY LIVING ASSISTANCE

ACTIVITIES SHELTER

LAUNDRY

LAUNDRY

SHELTER

MEALS

ASSISTED LIVING ACTIVITIES

INDEPENDENT LIVING

ACTIVE ADULT

LAUNDRY

SHELTER

TRANSPORTATION

ACTIVE ADULT

MULTIFAMILY AMENITIES

Multifamily

Active AdultSHELTER

+ avg. monthly rent = $1,416 SHELTER + housing TRANSPORTATION ACTIVITIES

AMENITIES + ACTIVITIES

ACTIVE ADULT ACTIVITIES

ACTIVITIES

DAILY LIVING ASSISTANCE AMENITIES

SHELTER

ACTIVITIES

LAUNDRY

SERVICES

ASSISTED LIVING

AMENITIES DAILY LIVING ASSISTANCE

TRANSPORTATION

LAUNDRY

DAILY LIVING ASSISTANCE

MEALS AMENITIES + ACTIVITIES

Independent Living

DAILY LIVING

LAUNDRY ASSISTANCE SHELTER + avg. monthly rent = $3,400 + large variety of amenities + activities BASIC CARE SPECIALIZED TRANSPORTATION MEALS + bundled services MEMORY CARE AMENITIES + SERVICES ACTIVITIES MEMORY CARE + housing

AMENITIES

LAUNDRY

SHELTER

MEALS

TRANSPORTATION

INDEPENDENT LIVING

AMENITIES + ACTIVITIES

AMENITIES

INDEPENDENT LIVING

DAILY LIVING ASSISTANCE

LAUNDRY

SHELTER

ACTIVE ADULT

SHELTER

LAUNDRY

+ avg. monthly rent = $1,200-4,000 + large variety of amenities + activities + TRANSPORTATION housing BASIC CARE MEALS

MEALS

INDEPENDENT LIVING

AMENITIES + ACTIVITIES

BASIC CARE SERVICES

DAILY LIVING ASSISTANCE MEALS

ASSISTED LIVING

LONG-TERM CHRONIC CARE BASIC CARE SERVICES AMENITIES + ACTIVITIES

AMENITIES + ACTIVITIES SHELTER

LAUNDRY

DAILY LIVING ASSISTANCE

SHELTER

LAUNDRY

DAILY LIVING ASSISTANCE

AMENITIES

ACTIVITIES TRANSPORTATION

MEALS

ASSISTED LIVING LAUNDRY MEALS Assisted Living

TRANSPORTATION SHELTER

BASIC CARE SERVICES

TRANSPORTATION

BASIC CARE SERVICES

MEALS

AMENITIES + SPECIALIZED ACTIVITIES MEMORY CARE

TRANSPORTATION

DAILY LIVING ASSISTANCE

Memory Care

DAILY LIVING

MEALS

BASIC CARE SERVICES

SPECIALIZED MEMORY CARE

SKILLED NURSING CARE

MEMORY CARE

LONG-TERM

AMENITIES + ACTIVITIES

Nursing Care

LAUNDRY ASSISTANCE CHRONIC CARE SHELTER LIVING +INDEPENDENT avg. monthly rent = $5,200 + avg. monthly rent = $6,800 + avg. monthly rent = $10,300 BASIC CARE TRANSPORTATION MEALS BASIC CARE TRANSPORTATION MEALS SERVICES SERVICES ASSISTED LIVING + basic amenities + activities provided + basic amenities + activities provided + basic amenities +activities provided MEMORY CARE LIVING AMENITIES + + bundled servicesLAUNDRY DAILY + bundled services + bundled services SHELTER ASSISTANCE ACTIVITIES AMENITIES + ACTIVITIES DAILY LIVING + daily living assistance + daily living assistance + daily living assistance LAUNDRY ASSISTANCE SHELTER DAILY LIVING LAUNDRY ASSISTANCE + basic care services SHELTER + basic care services + basic care services AMENITIES + + housing + specialized memory care + specialized memory care ACTIVITIES AMENITIES + + housing + long-term chronic care BASIC CARE SPECIALIZED TRANSPORTATION MEALS ACTIVITIES MEMORY CARE SERVICES BASIC CARE SPECIALIZED TRANSPORTATION MEALS + housing MEMORY CARE SERVICES MEMORY CARE

SPECIALIZED MEMORY CARE

LONG-TERM CHRONIC CARE

AMENITIES + ACTIVITIES

SKILLED NURSING CARE

Figure C. Senior Housing BASICLIVING CARE MEALS Types DAILY

TRANSPORTATION Senior activity icons SHELTER

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LONG-TERM

LAUNDRY SERVICES referenced fromASSISTANCE source: https://www.myagedcare.gov.au/ CHRONIC CARE ASSISTED LIVING BASIC CARE TRANSPORTATION Multifamily average monthly rent data source: RealPage® Reports Rising Occupancy and Rents in the U.S.MEALS Apartment Sector | News. SPECIALIZED (n.d.).

MEMORY CARE SERVICES Active Adult average monthly rent source: A Guide to Active Adult Community Rentals | 55places. (n.d.). A Guide to Active Adult Community Rentals | 55places.

MEMORY CARE Average monthly rent data source: NIC MAP Data & Analysis Service; Q3 2020 Supply Report, All Markets.

DAILY LIVING SHELTER

LAUNDRY

ASSISTANCE

AMENITIES + ACTIVITIES SHELTER

LAUNDRY

DAILY LIVING ASSISTANCE

LONG-TERM CHRONIC CARE

TRANSPORTATION

MEALS

SKILLED NURSING CARE

BASIC CARE SERVICES

SPECIALIZED MEMORY CARE

Biophilic Strategies Shifts in physical and mental abilities are a natural part of the aging process, the most common being loss of physical mobility, diminished hearing, and loss of cognition and memory (Wan & Larson, 2014). These changes can limit an individual’s ability to take advantage of certain types of biophilic elements, so should be considered to differentiate design approaches for differing senior housing types. For example, strategies that benefit active adults may not be as meaningful to memory care patients.

As seniors age and their level of care and dependence increases, the frequency and duration of opportunities to directly engage with nature, or to be in shared amenity spaces, may diminish. Furthermore, individuals often have less control over their immediate indoor environment (temperature, air flow, lighting, etc). Despite these limitations, with assistance, aging residents requiring high levels of care typically still have access, albeit more limited in quantity and duration, to the outdoors and their community. A study by Brown, Barton, and Gladwell demonstrates that the positive emotional and mental restoration derived from immersion in nature can occur in as little as 5 to 20 minutes (2013). When longer durations of exposure are not possible, as may be the case for many aging adults, “micro-restorative experiences -- brief sensory interactions with nature that promote a sense of well-being” may contribute to a compounded restoration response (Browning, et al., 2014). When access to the outdoors and amenity spaces are limited, micro-restorative experiences can still be implemented at the scale of the unit.

In 2008, Stephen Kellert compiled a document identifying more than seventy mechanisms for incorporating biophilic experiences into the design of the built environment.

Contributing authors Browning and Seal-Cramer categorized these mechanisms into three types: “nature in the space”, “natural analogues”, and “nature of the space1.” “Nature in the space” refers to the direct, physical and ephemeral presence of nature in a space or place such as views to natural elements, the presence of water, or olfactory stimuli that engender a positive reference to nature. “Natural analogues” refer to organic, non-living, and indirect evocations of nature such as the use of biomorphic forms, patterns, and natural materials. Finally, “nature of the space” refers to the presence of spatial configurations as perceived in nature such as unimpeded views over long distance or obscured views that encourage exploration (Browning, et al., 2014). Strategies that fall within the category of “nature in the space” have been most consistently tied to stress reduction, whereas “natural analogues” and “nature of the space” categories have been most consistently tied to improvements in emotion, mood, and preferences (Brown et al., 2013)(Tsunetsugu et al., 2007) (Herzog & Bryce, 2007).

Loss of mobility and/or cognition and increased reliance on others for care, which are common for residents in assisted living, memory care, and nursing care environments, may lead to less direct contact with the outdoors and community members, and more time spent in one’s personal residence or unit. Some strategies that fall within the “nature in the space” category can be difficult or expensive to apply at the scale of the unit, such as water features or circadian lighting.

1 Several different categorizations and frameworks have been created to utilize Kellert’s mechanisms. Within this chapter, we have opted to focus on the framework provided by Terrapin Bight Green’s 14 Patterns of Biophilic Design because of it’s method of organization, which is primarily intended to differentiate between authentic natural elements and non-natural elements (which correspond to changes in seniors quality of life/access to authentic natural elements as they experience shifts in physical mobility and mental acuity) and because of the particularly detailed descriptions and examples of applied elements, which is more applicable to the scale of the residential unit and allows us to make our evaluation of each element more objective.

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However, others can be implemented relatively cost effectively. These include windows with views to nature, operable windows, diffuse artificial lighting, and natural imagery and décor.

Strategies that fall within “nature of the space” are commonly encountered in both indoor and outdoor environments. Cost effective applications at the scale of the unit include unimpeded views over 20 ft. distances, balconies, and warm lighting. However, at the scale of the unit, several of these strategies can again be challenging and costly to implement, including sectional variation, auditory stimulation, or operable partitions. However, the residence is itself a space of security and comfort, and in this way fully satisfies Pattern 12, Refuge.

Strategies that fall within the category of “natural analogues”, which make indirect references to nature through fractal patterns, the use of colors, materials and forms found in nature, and the simultaneous representation of visual complexity and order, are especially useful because they can be implemented cost-effectively at all scales, including within the unit. Many can even be incorporated within building materials already present on the project, including patterned fabrics, carpet tile, natural paint color selections, or wallpaper. Figure D. summarizes the way all 15 Patterns of Biophilic Design can be implemented across senior housing types, with physical and mental limitations considered.

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Naples Botanical Garden, Completed 2014 by Lake|Flato Naples, Florida

Multifamily

Active Adult

Independent Living

Assisted Living

Memory Care

Nursing Care

X X X X X X X

X X X X X X X

X X

X X

X X

X

X

X

X

X

X

VII. Connection with Natural Systems

X X X X X X X

VIII. Biomorphic Forms & Patterns

X

X

X

X

X

X

IX. Material Connection with Nature

X X X X X

X X X X X

X X X X X

X X

X X

X X

X X

X X

X X

X X

X X

X X

NATURAL ANALOGUES

NATURE IN THE SPACE

I. Visual Connection with Nature II. Non-Visual Connection with Nature III. Non-Rhythmic Sensory Stimuli IV. Thermal & Airflow Variability V. Presence of Water VI. Dynamic & Diffuse Light

X.Complexity & Order

NATURE OF THE SPACE

XI.Prospect XII. Refuge XIII. Mystery XIV. Risk/Peril XV. Awe

Figure D. Biophilic category and element application by housing type Biophilic categories and patterns from Terrapin Bright Green’s 14 Pattern’s of Biophilic Design (Browning, W.D., Ryan, C.O., & Clancy, J.O., 2014), (Supplement. 2021, Awe).

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MARKET DATA + FUNDING STRUCTURES The Existing And Future Market Approximately 42% of senior housing communities within the US are classified as Continuing Care Retirement Communities (Figure F.) This high percentage of CCRCs is a promising indicator of the nation’s ability to accommodate aging in place. However, classification as a CCRC does not necessarily guarantee equitable distribution of housing types. CCRCs may provide two or more senior housing options, in any mix of quantities preferred. Nationally, nursing care composes nearly 50% of the available senior housing units, while only 7% provide specialized memory care (Q3 Senior Housing Market Insight, 2020). These numbers highlight the need for greater diversity in senior housing offerings at a national scale.

Another market challenge is the high cost of joining a senior community. According to data collected by the NIC MAP Data & Analysis Service from the third quarter of 2020, the least healthcare-intensive senior housing option, independent living, rented for an average of approximately $3,000 per month. The most healthcare-intensive senior housing option, nursing care, rented for over 3 times that for an average of approximately $10,000 per month.

The Active Adult market sector, still in its infancy, has been lumped in with either multifamily or other traditional senior housing types within the following data sets. Over time, as Active Adult begins to compose a larger portion of senior housing, sector specific data should become available.

Projections for future senior housing demand growth indicate that if the senior housing market continues to grow at the current rate, “supply additions cannot keep up with the forecasted growth in demand.” This forecast is particularly 22

salient for independent living, assisted living, and memory care unit types, which collectively make up approximately half of all unit types, with the remainder being nursing care units (Q3 Senior Housing Market Insight, 2020).

Developers have taken notice of these projections, which indicate investment potential. Senior housing has become an increasingly attractive market sector for investors. In a survey of developers conducted in 2020, “most respondents reported that the most attractive investment opportunities are in assisted living followed by independent living (Q3 Senior Housing Market Insight, 2020).” For these two housing types, location appears to have a significant impact on expected returns, particularly Class B and C properties.

When compared to other market sectors, senior housing generally outperforms multifamily and is more resilient to market fluctuations. “Over a five-year period, senior housing returns have outperformed the National Property Index and multifamily in total returns and income returns. The senior housing sector’s stronger performance may reflect the fact that senior housing has experienced continuous demand growth despite significant fluctuations in the general economy (Q3 Senior Housing Market Insight, 2020).” In 2020, the average national cost per square foot to develop senior housing was $317. In the same year, hard costs alone averaged $206.50 /sf, an increase of 4.8% from 2019 (2020 Seniors Housing Development Costs, 2020).

Funding Structures Funding structures for senior housing projects may have a significant impact on a projects ability to prioritize aging in place and employ biophilic strategies to improve the resident experience. Generally, there are three different funding structures (Figure H.):

6 Senior Housing Supply

Independent Living

Assisted Living

Memory Care

Nursing Care

Total Supply

AVERAGE MONTHLY RENT BY SEGMENT (DAILY FOR NURSING CARE)

NUMBER OF COMMUNITIES BY MAJORITY TYPE

Majority NC, 8%

Majority IL, 12%

CCRCs, 42%

NUMBER OF UNITS BY SEGMENT TYPE

350

7,000

340

6,000

330

5,000

320

4,000

310

3,000

300

2,000

Majority IL, 23%

Majority NC, 47%

8,000

Average Daily Rate

Average Monthly Rent

Majority MC, 6%

Majority AL, 32%

290

1,000

280

Majority AL, 23%

Majority MC, 7%

Independent Living

Assisted Living

Memory Care

Nursing Care

Source: NIC MAP Data & Analysis Service; Q3 2020 Supply Report, All Markets.

Source: NIC MAP® Data Service, Q3 2020. All Markets.

Figure F. in the top 100 NIC MAP MetroFigure Community Location Markets

G.

Although the 85+ plus population is predicted to increase by 177% the next years to2more thanS18.5 are 1metro 5 over |areas, C of B RQ3E302020 Q 3Supply 0 2Report, 0 HAllMmillion, Inursingthere Figure F. and institutional Figure G. Source: NIC MAPinData & Analysis Service; Markets. less than 2.0 million quality units/beds the major which nearly 1.0 million is skilled supply.

The past and certainly the current rate of new supply additions cannot keep up with this forecasted growth in demand.

Total No. of Communities

Region Northeast

3,318

480,078

Southeast

3,685

460,781

North Central South Central

I. DEVELOPER/ 3,272 402,906 OPERATOR: 2,235 261,052

West Top 100 Metro Market Totals

LOCATION MIX (UNITS/BEDS)

Total No. of Units/Beds

3,413

385,031

15,923

1,989,848

DEVELOPER / OPERATOR

West, 19.2%

Northeast, 24.6%

II. NON-PROFIT/ DEVELOPER PARTNERSHIP: South Central, 13.2%

NorthNON-PROFIT / OPERATOR Central, 20.2%

Note: Northeast – CT, DE, ME, MA, NH, NJ, NY, PA, RI, VT Southeast – AL, DC, FL, GA, KY, MD, NC, SC, TN, VA, WV North Central – IA, IL, IN, MI, MN, NE, ND, OH, SD, WI South Central – AR, KS, LA, OK, TX, MO, MS West – AK, AZ, CA, CO, HI, ID, MT, NM, NV, OR, UT, WA, WY

CBRE Q3 2020 SHMI

VISION

VISION

VISION

OPERATIONS

OPERATIONS

OPERATIONS

CONSTRUCTION

TYPE 2.

FUNDING

CONSTRUCTION FUNDING

FUNDING

NON-PROFIT / DEVELOPER

MORTGAGE REIT DEVELOPER

FUNDING

EQUITY REIT

Southeast, 22.8%

TYPE 1.

Source: NIC MAP Data & Analysis Service; Q3 2020 Supply Report, All Markets.

6 |

III. REAL ESTATE INVESTMENT TRUST (REIT):

CONSTRUCTION

VISION

OPERATIONS

CONSTRUCTION

HYBRID REIT

TYPE 3.

+

Figure H. Funding Structures FUNDING

NON-PROFIT / DEVELOPER VISION

OPERATIONS

CONSTRUCTION

23

I. Developer/Operator In this funding structure, the developer funds and directs the design and construction of the project. They are responsible for developing the goals and vision of the project and ensuring that the design aligns with this vision and all funding constraints. When construction is complete, the developer maintains control of operations and maintenance for the senior community. Furthermore, they retain all project risk and profit for the lifetime of the project.

II. Non-Profit/Developer Partnership In this funding structure, a non-profit organization and a development company partner and divide responsibilities.

Typically, the non-profit group brings a vision for the project to a developer, seeking funding. If the vision is compelling and the pro-forma can be balanced, a developer will agree to fund the design and construction of the project. The non-profit and developer teams collaborate throughout the design and construction process to ensure that the vision is maintained and the project stays within budget. In this funding structure, the non-profit is reliant on the developer for project realization. Thus, when budget challenges are encountered, it is likely that aspects of the original vision will be sacrificed before budget changes are enacted. Following construction, operational responsibilities are carried by the non-profit organization.

III. Real Estate Investment Trust (REIT) REITs generally fill the role of the developer by providing equity. The primary difference between developer/operator, non-profit/developer partnerships, and REIT funded projects is that REITs are publicly traded. Developers invest private equity, while REITs collect smaller pots of money from many individuals through major stock exchanges to generate the equity required for the project. This financial structure makes 24

it possible for those able to invest even modest amounts of money in the stock market to benefit financially from real-estate investments. Similar to developer partnerships, REITs may own, operate, or finance properties. Listed below are three of the most common funding structures for REITs (Office of Investor Education and Advocacy, 2011).

Type IIIA. Equity REIT An Equity REIT is responsible for creating a vision for the project, funding and overseeing design and construction, and for operations once the project is complete. The REIT retains all risk and profit for the lifetime of the community.

Type IIIB. Mortgage REIT Mortgage REITs are a partnership between a REIT and a second party (non-profit or developer) where the REIT provides the funds required for design and construction and retains the risk and profit for the mortgage and related assets. However, vision development, design and construction oversight, and operations are carried out by the partner organization. The partner organization is solely responsible for decision-making and ensuring profitability.

Type IIIC. Hybrid REIT Hybrid REITs are a partnership between a REIT and a second party (non-profit or developer) where the REIT provides funds for the design and construction process, but also takes on more responsibility by dividing responsibility for vision development, oversight of design and construction, and operations responsibilities with the second party. The REIT retains risk and profit for the mortgage and related assets, but also carries influence in decision-making and shares responsibility

for making a project profitable.

Challenges + Opportunities While senior housing is a quickly growing market, it still suffers from enormous challenges associated with shoestring budgets and complex health and care requirements that can make it difficult to balance a pro forma. Project components that prioritize resident health and wellbeing, fitness, interaction with nature, and engagement with the larger community yield benefits that are much more tangible when the financier also plays a role in the operation of the project and hence, benefits financially from the happiness and health of residents, and a rich social community where many want to join and none want to leave. Biophilia is a mechanism that contributes to these outcomes in significant ways. However, if the investor remains independent of everyday operations, the value and benefits of biophilic design elements can easily go unrecognized.

In scenarios where the developer or REIT is solely the investor and is not in support of the cost premium that is sometimes associated with biophilic strategies, there are still many low-cost opportunities for the operator to cultivate a biophilic atmosphere during the design process or retroactively. Some of these strategies include painting walls with natural tones, selecting carpet, fabrics, tiles, imagery, wallpapers, and decor that incorporate natural textures and patterns, and indoor potted plants.

While the former scenario is more ideal, it is important to recognize that there are exceptional projects that fall within all of these financial structures that are model projects for incorporating biophilia within senior housing. While financial structure may present a challenge, it is not a limitation.

Hardberger Park Urban Ecology Center, Completed 2013

by Lake|Flato

25

Naples Botanical Garden, Completed 2014 by Lake|Flato Naples, Florida 26

CONCLUSION Amid a skyrocketing demand for senior housing as the baby boomer generation begins entering retirement, there is a question we should be asking -- are there ways in the design of this new wave of senior housing should look different than those that preceded it? How can we leverage the design of this typology to improve residents’ quality of life and transform the perception of aging into something that generates excitement and anticipation?

And how can we sustain these elements throughout all stages of aging?

There is increased awareness in the scientific community that spending time outdoors or in spaces with natural elements can improve mood, reduce stress, and improve cognitive performance.

Additionally, accommodations for aging in place can limit physical and emotional distress and prevent feelings of displacement from one’s community.

The upcoming generation of seniors is increasingly gravitating towards environments that make us feel good, make us healthy, and help us live longer more fulfilling lives through a closer attachment to our surroundings, environment and community.

They are seeking spaces and communities that help restore, maintain, and strengthen enjoyment in everyday experiences and interactions.

understanding limitations and opportunities of biophilic design throughout the various stages of aging, as mental and mobility challenges are encountered. Such a focus can help designers and decision-makers prioritize at the scale of the unit.

This data will be an essential tool for promoting the incorporation of biophilic strategies within new projects that will be largely development-driven over the next 25 years. The financial structure of current projects often creates a disconnect between those who are operating the facility and those financing the project. While the benefits of aging in place and interaction with biophilic elements may be observed by the operator, who interfaces directly with residents on a regular basis, it can be difficult for those who are not directly involved in everyday operations to fully understand their impacts. Increased research can help attribute a clear marketable value to these biophilic elements and improve the likelihood of their being prioritized and sustained throughout the design process.

Altogether, the next 25 years offer an opportunity to transform the senior housing sector. A significant amount of research needs to be compiled and conducted to highlight the design elements that may impart the biggest positive impact on residents and create communities and environments we can all look forward to becoming a part of one day.

While there is a body of research supporting the benefits of biophilia on the general population, there is a dearth of research focusing specifically on the intersection of senior populations and the impact of biophilic strategies on physical and mental health and well-being. This research should include a focus on 27

GLOSSARY

28

Active lifestyle, active living

Terms often used in marketing. May include any type of lifestyle housing promoting physical and mental activity and cater to younger seniors. It’s one way to avoid the term “seniors” in marketing.

Active Adult

A community geared toward independent seniors who desire an active lifestyle; typically feature amenities supporting this lifestyle (Active Adult Research Brief, 2021)

Aging in place

The concept of remaining in ones’ residence of choice and retaining access to necessary care, services and preferred amenities as one ages

Assisted living community

A community that provides nursing care, housekeeping, and prepared meals

Age-qualified, Age-restricted, Age-targeted

Terms used broadly to represent a wide-array of senior lifestyle housing. Usually refers to multifamily, but sometimes, used for single-family communities.

Continuing care retirement community (CCRC)

A community that accommodates a variety of healthcare needs with an amenity-rich lifestyle. Also known as a “life plan community (LPCs).” They are well-positioned for growth in the seniors housing marketplace over the next decade (Continuing Care Retirement Communities, 2018).

Continuum of Care

Spectrum encompassing the levels of care from independent living up to and including skilled care/skilled nursing care. Retirement communities with a complete continuum of care allow a person to transition from one form of care to another depending on their needs without displacement.

Independent living “light”

An informal term sometimes used for Active Adult (Q3 2019 Senior Housing Market Insight, 2019).

Memory care

Specialized form of care for seniors struggling with memory loss due to dementia, Alzheimer’s disease, or other cognitive impairments (Active Adult Market Analysis, 2014).

Real estate investment trust (REIT)

Company that owns, operates, or finances income-generating real estate; REITs pool the capital of numerous investors (Office of Investor Education and Advocacy, 2011).

Senior apartments

Generic term for any rental multifamily housing catering to or restricted to seniors; not necessarily purpose-built for seniors.

Skilled nursing community

A community that provides 24/7 skilled nursing care for individuals requiring specialized medical care or daily therapy services in a skilled-care setting. Although sometimes temporary, a stay in a skilled nursing community could be likened to a long-term hospital stay. Sometimes provided for short-term stays following hospitalization, surgery, injury or significant decline in health (Witt, 2021).

University-based retirement community (UBRC)

A community in which 55+ individuals have primary access to advanced educational opportunities; promotes lifelong learning and inter-generational communities .

55+

Descriptor for a variety of senior housing types, but most commonly applied to for-sale single-family housing communities intended for but not restricted to seniors; can also refer to manufactured home communities (typically home owned, land leased).

62+

Descriptor used predominantly in reference to communities that require occupants be 62 or older.

29

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Wave of Diversity Heading Toward Seniors Housing, Says Love & Co. Report.

(2018, July 24). Seniors Housing Business. https://seniorshousingbusiness. com/wave-of-diversity-heading-toward-seniors-housing-says-love-coreport/ Wiles, J. L., Leibing, A., Guberman, N., Reeve, J., & Allen, R. E. (2011). The meaning of “AGING in place” to older people. The Gerontologist, 52(3), 357– 366. https://doi.org/10.1093/geront/gnr098

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Williams, E. (2018, February 14). Senior living/university partnerships may be the way of the future, says Cambridge founder Davis. Cambridge Realty Capital. https://www.cambridgecap.com/blog/senior-living-universitypartnerships-may-way-future-says-cambridge-founder-davis/ Welfare facilities [Share Kanazawa] (2014). Good Design Award. Japan Institute of Design Promotion. https://www.g-mark.org/award/ describe/41886?token=y53E1jOKoy.org Zen-Inspired Senior Living (2021). Enso Village, The Kendal Corporation. https://enso.kendal.org/

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