Strive to integrate assisted living into care continuum at retirement communities

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Robert C. Pfauth
Robert C. Pfauth

My father-in-law (let's call him Dick) lives in a retirement community. It's an upscale continuing care retirement community built within the last decade and managed by a respected not-for-profit sponsor.  He occupies one half of an independent living duplex, which he and his late wife moved into when she began to show signs of Alzheimer's. 

My mother-in-law's disease subsequently progressed such that she moved into a secure assisted living unit in the “health center” on campus. Before long, she had to move again, this time to the nursing unit on another floor in the same building, before finally passing away from the tragically memory-depleting disorder.

Now in his late eighties, Dick soldiers on in the same patio home, spending hours in front of the TV or computer, often asleep in his chair. Meanwhile, his gait has worsened, and he is beginning to show evidence of memory loss himself. After a cooking mishap, he no longer fixes himself proper meals and usually scrounges around for whatever can be eaten right out of the package.

Nevertheless, his relative physical and cognitive health permit him to stay in his solitary domicile. And although he visits the “club house” regularly to get his mail, have Sunday dinner in the elegantly appointed dining room and attend scheduled programs, his social life also leaves much to be desired, exacerbating his isolation and decline.

Dick's adult children, scattered across the country, know that he needs more attentive care.  They all realize that it's only a matter of time until he stumbles and falls, with potentially life-threatening consequences.

“He really belongs in assisted living,” is the oft-heard refrain at family gatherings.  But after having been rebuked with words like, “You've got to be kidding!  I'll never go into assisted living!” no one dares broach the subject anymore.

So why this obstinate stance? Why this stubborn refusal to consider what is clearly in his own best interest? It's not as though they were “putting him in a nursing home.” Or is it? Could it be that his perception of such a move is that it will rob him of the last vestiges of his independence and dignity? Has assisted living become the new nursing home? Or is that the wrong question?

You see, at Dick's community, the “health center” houses all levels of care beyond independent living, including assisted living, memory support and skilled nursing. Moreover, these are all accessed through a shared main entrance. Perhaps we should be asking ourselves instead, “How should assisted living, as one element of the continuum of care and services for elders, be integrated into the continuum in a campus setting and be related to other levels of care?”

If we agree that “aging-in-place” with minimal or no relocation constitutes an ideal senior-living scenario, it would seem that to the extent practicable, care and services should be delivered to the individual rather than the other way around. When this model runs afoul of state regulations, as is often the case, one could argue that the next logical alternative is to locate contiguous levels of care directly adjacent to one another, and to make them appear relatively seamless in terms of design and ambience to minimize the trauma of moving. Additionally, from a planning and operational standpoint, this would permit services such as dietary and laundry to be conveniently consolidated.

While these goals may seem laudable, does that mean that they should co-exist under one roof and with one front door? I would argue that they should not. Rather, I believe that as long as assisted living and skilled nursing are required by regulations to occupy distinct portions of a physical structure and their populations thus kept segregated, they should be appreciably distinct. Certainly they should be comparable in terms of comfort, amenities, and design quality, but nevertheless separate and even to some extent dissimilar.

This is not to say that they each need to be housed in a freestanding structure, but rather greater architectural finesse is required to ensure that each level of care occupies an attractive yet discrete building element, including a clearly defined and separate entrance.  (Note that this does not mean a “front door” for AL and a “back door” for SN.)  And for heaven's sake, don't let anyone label them as the “health center!”

Now, granted that some seniors may never want to budge from their homes—no matter how acute their need or how attractive the alternative. This is to be expected and is, in fact, quite common. But it would seem unlikely that such a person would voluntarily want to take up residence in a CCRC. For them, there are home- and community-based alternatives available to address their increasing needs.

For those who do wish to avail themselves of the “safety net” offered by a continuum however, the perceived chasm between independent living and assisted living must be reduced and the distinction between assisted living and skilled nursing clarified so that when the need eventually arises, this transition becomes a non-threatening one.

Since the concept of assisted living as a less institutional alternative to skilled nursing first emerged in the early 1980s, it has been widely embraced for its lower construction and operating costs, more “homelike” environment and relative lack of regulatory strictures.  While the level of agency oversight (with its exasperatingly divergent manifestations from state to state) has increased since then, new models such as the household and “small house” have emerged, and concepts including person-centered care and negotiated risk have begun to gain currency.

Let's harness this innovative way of thinking to create a new paradigm for assisted living in a campus setting that keeps the continuum intact, and ensures operational efficiency while also providing a more comfortable segue from independent living. Unless and until “aging-in-place” can practically and legally occur in one place, let's make each of those places as inviting and enjoyable as possible for those who choose campus-style living.

Robert C. Pfauth, AIA, NCARB, is an architect who specializes in the design of environments for older adults.


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