Nip and tuck

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Nip and tuck
Nip and tuck
There are some basic rules of thumb in nursing home design today. In summary: Bathing schedules – out. Resident choice – in. Dining rooms for the masses – out. Small eating areas – in. And first and foremost: Hospital look – out. Comfy homelike look – in, so in.

These changes – crystallized in a movement called culture change – are leading to major improvements in the look and feel of new nursing homes. Construction of facilities today nearly always involves private rooms, as well as smaller, more intimate eating areas and living rooms with features such as fireplaces and other creature comforts.
But culture change does not have to begin with the laying of bricks and mortar. Older facilities with even the most obsolete (and, let's be honest, tacky) interiors can make design improvements in their facilities that can create an atmosphere that evokes the ever-important concept: home. 
Smaller scale changes can include, but are not limited to, new carpeting, freshly painted walls, and some creative repositioning of space. Without a lot of capital and with a little bit of imagination, a facility can be on the way to meaningful change.
“Small changes make a big difference,” says Gregory Scott, senior partner with architecture firm Reese, Lower, Patrick & Scott Ltd. of Lancaster, PA. “I think it makes a difference in the way people perceive their environment.”
Case study
It's pretty safe to say that if Minneapolis Good Samaritan Center in Minneapolis, KS, can incorporate culture change, any nursing home can.
“We've got your typical old building,” summed up Administrator Dana Rice, referring to the H-shaped, 68-bed facility built, common for the 1960s and 70s.
A few years ago Rice, who had been keen on the Eden Alternative and other innovative concepts, decided that some refurbishments were in order. Among the improvements: She decided to turn each wing of the “H” into a neighborhood, complete with its own small eating area; and she dismantled the med carts and nurses' station. Perhaps the biggest change: she broke down the former dining hall (which was in the crossbar of the “H”) into a small faux town square with a library, ice cream shop and park area with a waterfall. A winding red brick-looking path that dissects the area makes for the walkway of the little village.
“We've just made a lot of little changes to get as much away from the institutional look as much as possible,” she said.
The total cost for the project was not exorbitant, she added, especially because the project took place over about two years. The town square tallied about $15,000, an amount the facility found in its budget and through fundraising.
While she acknowledges the changes are “a drop in the bucket compared to what others have spent,” Rice said it has had a huge impact on people's impressions.
“We hear all the time that people say it doesn't look like a nursing home,” she notes.
Starting small
Even the most minor culture change-oriented improvements at a facility are worth the effort, according to experts.
“Anything you can do to freshen it up and make it nice and attractive and improve the curb appeal is important,” according to Eric Huebert, a research specialist with the Aging Research Institute.
Renovating a facility can range from cosmetic changes – such as changing the lighting and carpeting and introducing color to the walls – to more substantial structural transformations, he notes. Costs can range from $55 per square foot for lighter changes to more than $95 per square foot when you are talking about physical modifications to the building.
When thinking of even a small remodeling project, start with your floor, experts say. A good floor not only is important for aesthetic reasons but also for way-finding for residents and to absorb acoustics, according to Gail Nash, vice president of healthcare strategy for InterfaceFLOR Commercial, a carpet tile company.
“The ability to keep a facility looking homelike, inviting and clean is less expensive and easy with a carpeted surface,” she said. “It's also emotionally safer. A hard, shiny surface can make someone feel insecure.”
When changing carpeting, it is important to consider the investment. Nash said that carpet tile can last 12 to 15 years, and is not difficult to clean. A high quality carpet can cost anywhere from $25 to $32 a yard.
When buying a carpet, pay attention to color and patterns. The importance of contrast is now well known among designers for long-term care.
White – the trademark of the stereotypical nursing home - is now taboo because it is disorienting, explains Jane Rohde, principal of design firm JSR Associates Inc. of Ellicott City, MD.
“If you can use color and space and simple detail with color, that works a lot,” said Rohde, who also is on the national board of regents for the American Academy of Healthcare Interior Designers.
Sprucing up the walls with color can be a great moderately priced way to change a look.
“Adding fresh paint with splashes of color and simple borders can give even the most outdated facility an instant face lift,” said Caroline Berns, director of marketing communications for Joerns Healthcare Inc. 
Another important place to use color contrast is the bathroom. For clarity, it is vital to have a color that differs on the wall behind the toilet from that of the floor, according to Jane Daley, interior designer consultant and senior living director on the national board of regents for AAHID. Also, never use a high-gloss finish on a floor because of the confusion factor, she adds.
Sitting pretty
Furniture is another way to make a culture change statement without breaking the bank. Like walls, furniture should incorporate color that is both current and clear to residents' aging eyes. Chairs should match a certain room with vibrant blues, reds and greens, said Edith Clamen, president of Primarily Seating Inc. Quality seating, involving comfort, proportion and balance, also are important when choosing chairs, she said.
The variety of materials to choose from can help save on costs. There is a substantial savings in a dining chair that is upholstered with vinyl seating and a fabric back versus one completely upholstered in Krypton, according to Martha Wadsworth of American of Martinsville, a furniture manufacturer. Likewise, it is less expensive to completely upholster a chair in vinyl compared with all fabric, she said.
Lighting is another area where facilities can make significant changes for residents. Too much or too little can be hard on residents' eyes. Installing standard metal gutters on the top of a doorway can offer  ambient lighting, said Margaret Calkins, president of I.D.E.A.S. Inc., an education and consulting organization.
To save on costs, use fluorescent or compact bulbs. They last longer than incandescent bulbs, Daley said. Be sure to use a higher wattage bulb for the maximum amount of light. 
Saving best for last
The last part of a redesign, involving décor, is perhaps the most enjoyable – and least expensive – stage of culture change design.
That, at least, is how Beth Kuzbek, business development manager for Eldercare Interiors, feels about the process. Décor includes everything from draperies and bedspreads, wall art, plants and other tchotchkes in a room. Most facilities overlook decor in their redesigns, she said.
“The majority of facilities have an idea of what it should look like when it's done but they can't figure out the missing piece, which is decor,” she said.   
Knickknacks can make or break the look of a facility, she and others agreed. And like other aspects of culture change, it is not just about the look.
“The nice thing about décor is that it serves multiple functions,” she said. “You can do it for way-finding, for memory triggering. It's not that you are spending money to make it prettier. Do it for multitasking.”
One example of décor for way-finding is placing a grandfather clock at the end of a hallway or a painting of a bathtub near the bathroom. These would help to signal to residents where they are.  
Unfortunately, many facilities do not save enough in the budget for the décor. Facilities should receive 10% of the project's budget for the décor, Kuzbek advises.
Sometimes, finding the best décor is just a matter of rummaging in your attic. Placing a row of your mother's china on display is a great way to make a living space a living room. Also, something as simple as a magazine holder on the floor offers the perfect final touch. There also is nothing criminal about going to   the Salvation Army for an antique armoire.

But Kuzbek offers a sobering note about décor: It's only one part of the total culture change transformation.
“Look at the walls and floors first, and the décor second,” she said. “Décor is not an instant fix for a bad floor. Tchotchkes will not solve the world's problems.”
Be creative
When trying to save money in culture change renovations, creativity can play a key role. 
One low-cost way to make a facility more homelike is to do away with med carts – like nurses' stations, a glaring institutional representation.  Solving this dilemma can be relatively painless financially – install a central cardboard that looks like a hutch from home or placing cabinets in residents rooms.
Also, it is important to use the space intelligently. At the Minneapolis, KS, facility, Administrator Rice found a way to offer semiprivate rooms. She took four old ward rooms, each with beds, and decertified two of them so there is one room on each side of the bathroom. The upshot? There is now a waiting list for each of these rooms.
Scale is key in creating a more homelike space. That might involve using built-in case works that vary room dimensions, Rohde said.
To save money and lend a feeling of home, let residents bring in some of their own furniture for their rooms, like their favorite chair.
One of the most exciting parts about designing with culture change in mind is the freedom built into it. Nursing homes can make a choice that works for them.
“That is key,” noted Debra Zehr of the Kansas Association of Homes and Services for the Aging. “What works for one place may not work best for another place.” 


Operationally speaking

Designing from the inside out

As fun as it is to redecorate, any designer will say that culture change is about more than buying a few chairs and hanging some pretty paintings. 

Culture change first involves a change in mindset, which involves an operational transformation. That involves engaging frontline caregiving staff and educating management. That takes time, funding and effort, designers say. 

“If you don't set up the process of an integrated team that will change operationally, making it look like culture change will not make it culture change,” explains Jane Rohde, principal of JSR Associates Inc. and vice president of the board of regents for AAHID.

Gregory Scott, senior partner with Reese, Lower, Patrick & Scott Ltd., of Lancaster, PA, noted that his firm has in some, cases made dramatic changes to facilities. But the changes didn't have the maximum impact because the staff was not up to speed on the movement. 

“The first thing about getting the biggest bang for your dollar is attitude,” he said. 
“The environmental changes are, quite honestly, relatively easy.” 

Thankfully, for facilities operating on a shoestring, many culture change initiatives 
cost virtually nothing. Changing around schedules in the facility so that residents can choose when they want to eat, bathe or wake up are some aspects of the culture change movement. Also, eliminating cafeteria service and meals and adapting to buffet-style dining is also a relatively simple adjustment. 

Doreen Gregory, president of D & V Midwest Design Inc., in Overland Park, KS, who helped renovate the Minneapolis Good Samaritan Center in Minneapolis, KS, said that meaningful change does not have to bust the bank – and, in fact, is accessible to all facilities. She believes the most important ingredient in culture change is choice. 

“Choice doesn't cost at all,” said Gregory, who recently won an award from the American Society of Interior Designers. “It just gives someone dignity when you offer them choices and selection. That's the way you and I would want it to be.”

Take another look

Some interior design changes to consider for your next renovation:
(*Prices are experts' estimates.)

Piece of wall art: $100 to $200

For town center:
New bench: $150
Laminated awnings: $1,500

Carpeting: $25 to 35 per yard

Vinyl flooring $4.50 per square foot

Renovation of nurses' station: $10,000+

25 dining room tables: $500 per table, $1,500 for a table and four chairs

Window treatment: $1,000 for each window

Interior designer: Retainer of $500 to $1,000