Household Concept of Care

Culture Change offers the promise of enhanced quality care and quality of life for residents with the creation of a home-like meaningful environment where relationships can thrive.
The Household concept is a shift from a hospital or medical-based model of care to a consumer-driven model with facility structural changes to create a more home-like environment; restructuring staffing and management patterns to empower and support direct care staff; and creating a flexible and responsive service delivery system to meet the needs and preferences of individual residents.
During the planning phase of a project it is best to focus on certain areas within the organization to better meet the needs of the residents and foster a culture in excellence and partnership in service and care with the community.

The areas of change include:
1.Eliminate many of the medical functions and tools usually seen within a skilled nursing facility
2.Through the culture change philosophy establish Households that make the resident’s home more comfortable, warm, inviting and more home-like with a modern open concept
1.Have direct care staff work more autonomously within self-directed work teams
2.Have staff take on multiple roles across traditional departments, providing some nursing care, housekeeping services, meal preparation, personal care and social activities
1.Have staff become more actively involved in the organizational decision-making
2.Eliminate the practice where direct care staff rotate across units thus empowering true resident-centered and directed care
1.Leadership needs to become more decentralized, moving toward an interdisciplinary empowering approach with emphasis on more staff and resident involvement

There will always be a need for long term, medically supervised, personal care settings. Current financing and care models dictate that these settings group individuals together for efficiency. At the same time, studies point to the positive effects resulting from social interaction. The form these settings take, depends not only upon the vision and resources that sponsoring organizations offer, but also to the approach regulatory agencies use to protect public health, safety and welfare.

For many years, the program brief for the design of nursing homes was based upon the regulatory model of an institutional based setting. This began with the publication of the original General Standards in 1947 for the implementation of the Hill –Burton requirements for health care facilities. This later became the Minimum Requirements of Construction and Equipment for Medical Facilities that set down the design requirements for nursing homes participating in Medicare and Medicaid programs (Guidelines 1996 – 1997).

The Hill-Burton requirements were a set of prescriptive regulations defining minimum standards of design and construction. Prescriptive requirements included elements such as: maximum number of residents per sleeping room; minimum square feet per patient within a sleeping room; minimum square feet of dining and activity space per patient; minimum quantities of toilet and bathing fixtures per patient; maximum travel distance from a nursing station to each patient room door; and requirements for visualization of the corridor from the nursing station. Prescriptive requirements led to a situation where architects and designers used the regulations as the basis for all planning and design decisions. Due to cost constraints, minimum requirements quickly became maximum allowable quantities and sizes of facilities, and in some jurisdictions, these maximums were mandated. Such mandates no t to exceed particular size requirements grew from a fear that the state government may need to take over and operate poorly performing facilities. It only makes common sense that a facility with more square feet per patient is more costly to operate than a smaller facility. Over time, nursing homes began to look alike, with large nursing stations, situated to provide direct view, down a series of double-loaded corridors, radiating from a central observation
point. This unintended similarity of outcomes is what I refer to as Form Follows Regulation a situation where regulations seem to dictate the ultimate form of the physical environment.

The field of Environmental Psychology is based upon the concept that the physical environment has a significant impact in shaping the actions of individuals and groups. The layout and composition of spaces can either inhibit or encourage social interaction among individuals. Similar to the way a line of chairs set in rows at a bus depot discourage int eraction, double loaded corridors, lined with adjacent bedrooms, allow little oppo rtunity to socialize. This type of spatial organization is referred to as sociofugal, space that separates people. To promote interaction one should
create sociopetal space, space that brings people together in groupings that face one another (Osmund 1957). Another important concept that must be considered in the arrangement of space is what I refer to as the Hierarchy of Space. This is a spatial concept that refers to the pr ogression of space in terms of access and activity. The progression is often defined as four different zones: Private; Semi-private; Semi-public; and Public (Howell 1980) (Figure 1). Each of these zones moves progressively from the individual control and s afety of one ’s private space to increased opportunity for interaction with others in the public realm. All zones are important and are required to live life completely.

This progression of the physical environment is of particular importance to older people who are increasingly vulnerable to abrupt changes in environmental stimuli. They may no longer possess the resiliency to moderate this environmental press, or impact that the physical environment can impose. Unfortunately, within the typical nursing home the hierarchy of space is truncated into only two zones, private and semi -public. There is
little opportunity for life that is not either confined to the private zone of one ’s bedroom (if one considers a shared bedroom private), or as a lonely bystander within the semi -public zone of large, undifferentiated dining rooms, dayrooms and corridors. An early concept for improving the hierarchy of space within nursing homes was proposed in Designing the Open Nursing Home (Koncelik 1976). This design took the typical lounge or
dayroom of the institutional model, often found at the end of the corridor, divided it into smaller areas and relocated the space as a “front porch” between the private resident bedroom and the public corridor space. These transitional semi -public/semi -private spaces provided a zone referred to as the “corridor neighborhood” offering opportunities for personalization and a variety of visual stimuli, reducing the typical repetition of corridors.

Until the Omnibus Reconciliation Act (OBRA) of 1987 little progress was made in the advancement of designs for nursing home environments beyond the traditional hospital -based institution. Even today, radial wings of double -loaded corridors with a majority of side -by-side semi-private bedrooms are still being constructed. But with the advent of OBRA 1987, nursing home operators were required to consider resident rights, autonomy,
choice, control and dignity. Many forward -thinking oper ators saw this also as a mandate to significantly change the institutional design model of the physical environment. Enhancing Quality of Life for residents has become a requirement.Yet little research or guidance exists to help facility operators and designers understand what it means to provide a life of quality. Some organizations have conducted resident, family and staff satisfaction surveys to help understand how they are performing in the eyes of their constituents. Though helpful to some extent, these surveys provide little new information with regard to the physical environment. Regulators, architects and designers are not the only groups that are unable to break away from the institutional model that has been the standard for so many years. Residents, families and staff can only know the types of nursing home environments they have experienced. The CMS State Operations Manual speaks in detail to many of the psycho-social aspects related to Quality of Life such as Dignity, Self -Determination and Participation, Participation in Activities and Activities. But when it comes to
direction with regard to the physical Environment, it offers only that “The facility must provide a safe, clean, comfortable and homelike envi ronment.” And goes further to indicate that the environment must be “sanitary and orderly”, provide “private closet space”, “adequate and
comfortable lighting”, comfortable and safe temperature levels” and finally “comfortable sound levels”. Only the last five requirements have any direct relationship to the design of the physical environment and provide very little guidance indeed. Yet it is understandable that such requirements be performance -based rather than prescriptive in nature. It is extremely difficult to define what is, or is not “homelike,” or
how one might actually create “home” within institutional settings.

The American Institute of Architects ( AIA) Guidelines for the Design of Healthcare Facilities is a cons ensus-based standard that provides much greater detail in its design guidance. Developed as both a regulatory document for adoption by legislative authorities, and as a guide to best practices, the document provides both minimum standards and educational g uidance. Through the use of appendix material that sits adjacent to the regulatory language, designers and regulators are able to directly compare minimum requirements with newer design concepts. The appendices
often serve as an introduction for new materi al that, in subsequent editions of the document, is adopted as requirements. The AIA Guidelines are a building design guide that works to avoid definition of operational requirements. To Live in Fullness Wikipedia defines Quality of Life as “the degree of well-being felt by an individual or group of people” ( Though not tangible or measurable, quality of life may be thought of as being comprised of two components: the physical and the psychological. Physical definitions of well -being would include ones level of health and safety. These are the aspects that have traditionally been heavily regulated within the long -term care environment, often to the detriment of psychological well -being. It is the psychological aspect s of well-being that offer the greatest potential to inform the way that physical environments for long-term care are conceived and constructed.

Studies investigating the psychological concept of Flow provide much information. Flow describes a state of being where one is completely immersed
in an activity to the extent that one loses track of time. It is often associated with sporting activities where the concentration and effort required are closely matched to the challenge. In sports it may be know n as being in the groove. In religious settings, as a state of ecstasy.
Flow is the experience of “being in harmony with what we Wish, Think, and Feel” (Csyikszentmihalyi 1997) being at one with the moment, so much so, that we lose ourselves to the task at hand as well as the sense of time. We have all heard the saying: “Time flies when you’re having fun.” The satisfaction that results from Flow experiences provides a true measure of the Quality of Life. What is most helpful are studies that looked at the Flow potential of everyday activities (Csyikszentmihalyi 1997). In these studies, people were asked to document their activities, whether alone or
in groups, and their feelings about the activities. Unlike many studies that rely upon the memories of individual s entering their daily activities into a diary at the end of the day these studies required extemporaneous documentation at random intervals throughout the day. This methodology provides remarkable insight into the activities, feelings and participants inv olved in everyday living.

Within the studies, daily activities are broken into three categories that each occupy approximately one third of our waking hours. These activities include Productive Activities, Maintenance Activities, and Leisure Activities. The Quality of Experience in Everyday Activities
Based on daytime activities reported by representative adults and teenagers in recent U.S. studies , the typical quality of experience in various activities is indicated as follows:
– negative; — very negative; • average or neutral; + positive; ++ very positive
Productive Activities:
Happiness Motivation Concentration Flow
Working at work or studying – — ++ +
Maintenance Activities:
Housework – – • –
Eating ++ ++ – •
Grooming • • • •
Driving, transportation • • + +
Leisure Activities:
Media (TV and reading) • ++ – –
Hobbies, sports, movies+ ++ + ++
Talking, socializing, sex ++ ++ • +
Idling, resting • + – —
Sources: Csikszentmihalyi and Csikszentmihalyi 1988; Csikszentmihalyi and Graef 1980; Csikszentmihalyi and LeFevre 1989; Csikszentmihalyi, Rathunde, and Whalen 1993; Kubey and Csikszentmihalyi 1990; and Larson and Richards 1994.

From this analysis it was found that those daily activities that produce the greatest potential to generate an experience of Flow include: Working, Studying, Driving, Hobbies, Sports, Movies, Talking, Socializing, and Sex. Life is What we do, How we feel about it, and Who we do it with
(Csyikszentmihalyi 1997). The chart above tracks the first two elements, but it is the third, with whom we participate with in these activities, that adds a dimension to further enhance the experience. Though a solitary engaged mind and body can provide much satisfaction, Csyikszentmihalyi finds that “we depend upon the company of others” to live a life of fullness. “Over and over again, findings suggest that people get depressed when they are alone and they revive when they rejoin the company of others.” He goes on to say, “The importance of friendships on well -being is
difficult to overestimate. The quality of life improves immensely when there is at least one other person willing to listen to our troubles and support us emotionally.” Much of what the study found is that, “a typical day is full of anxiety and boredom. Flow experiences provide the flashes of intense living against thi s dull background.” This points to the notion that in order to improve quality of life, one must engineer one’s daily life to maximize participation in high Flow potential activities. Or as care providers, we must provide the opportunities to participate in activities that are engaging and challenging within a setting that enables the development of relationships. At the Walden School in Vermont, students follow the philosophy of Henry David Thoreau by continually asking themselves three questions: What is my relationship to myself? What is my relationship to culture? What is my relationship to the natural world? ( In a similar fashion, it is helpful in the design of long -term care environments within a culture change milieu to think in terms of relationships. Focusing solely on the person or resident, as in resident-centered care or person directed care, limits our thinking. Quality of life is enhanced when we consider the totality of experience within Relationship-Enabling Environments.

Clearly, the traditional institutional model of the nursing home falls far short of providing an environment that enables a fulfilling quality of life. The physical environment of institutions are sociofugal in nature, l acking in the appropriate hierarchy of spaces and provide little to enhance quality of life in resident’ relationships with themselves, the community, or nature. Early concepts toward improving the physical environment provided only modest steps forward. R egulatory hurdles including health care design guidelines, building codes, life safety codes,
food safety regulations, and a plethora of overlapping state and local health and safety requirements are all focused upon maintaining the institutional model of nursing home construction. This institutional bias proved a difficult obstacle to overcome. As the image of nursing homes became less desirable to residents and families, alternatives such as assisted living began to appear in the marketplace. These alter natives provide an attractive image to residents and families, in many cases advertising themselves as nursing home alternatives” through the provision of home health care and visiting nursing services. Conformance to less restrictive residential codes an d regulations help to achieve the desired “homelike” feel by allowing narrower corridors, elimination of the central nurse station and creation of smaller more intimate settings. Many in the long -term care industry predicted the end of nursing homes. At the same time, many operators and designers were embarking on
an alternative approach, not to supplant, but to reform the vision of the nursing home. Designs appeared with high proportions of private rooms, and shared rooms providing enhanced environments where each resident received separate sleeping areas with each their own window and furnishings, sharing only the room entry and toilet facilities. Corridors were shortened, nursing stations became less pronounced within nursing units of 36 -45 residents as opposed to the traditional 60 beds. Smaller decentralized clusters or pods that provided small -scale social settings closer to
resident rooms were created. Staff support areas, including small work desks were also decentralized to increase staff efficiency by
locating direct -care staff closer to resident bedrooms. Most of these newer cluster concepts, however, are still corridor-based schemes with inconsistent or incorrect hierarchies of space where semi-public corridors pass directly outside of private bedrooms with little or no transition zone. Still, the institutional bias prevails due to requirements that all rooms open onto corridors that are physically separated from spaces as
protection from smoke and fire, and that allow direct visual supervision of staff on a 24 -hour basis. These requirements and many others conspire against the creation of a true home for residents.

The Household model can be described as a living arrangement where all activities of daily living occur within a small-scaled environment, reminiscent of a large family home. This type of living arrangement has been used for many years as group home settings for developmentally disabled populations. The first use of the term household in a skilled nursing home setting described Evergreen Manor in Oshkosh, Wisconsin as “two neighborhoods with dining and bathing facilities shared by three “households” of six private rooms which in turn share family rooms and kitchenettes” (Architectural Record, April 1988).
The initial concept (Figure 4), designed by this author in 1987, was developed ten years later into the fully formed household model by taking the crucial step of including the di ning room within its nine resident household environment as a country kitchen. Opened in 1997, the fully operational Creekview at Evergreen Retirement Community is described as “a creative effort to rethink the nature of skilled care organizationally as well as architecturally” (DESIGN ’98, 1998). Subsequent refinement of the household/neighborhood model resulted in the 2005 addition at
Evergreen Retirement Community of Creekview South utilizing households of eleven residents each. The household model provides an environment that is immediately understandable to residents and visitors as a setting that has been a natural part of everyday life. Individuals intrinsically
know how to act within a household. All activities of daily living occur within closely related private or semi-private zones that
are discrete from other portions of the facility. In addition to private or shared resident sleeping rooms with their own bath room with toilet (and sometimes shower), households typically contain a living room, dining room, kitchen, and common bathing facilities. Often an additional, flexible activity space is included for use as a quiet room or small conference/work space. Open access to a secure bac kyard directly available to
residents, enables a continuing relationship to the natural environment. Support areas for staff include a workspace used for storage of medicine and supplies as well as necessary paperwork, asoiled utility room, storage of cle an and soiled items and equipment for laundering personal clothing. The small scale of the household, with its open floor plan, virtually eliminates corridors and allows orientation and easy access for residents to all daily activities. The households at Creekview South are each part of a larger nursing unit known as a Neighborhood. Four hous eholds of eleven residents each are connected together through a Neighborhood Center. This organization provides clearly defined geographic zones of responsibility for resident assistants within each household and the team manager for the entire neighborhood. Support is provided to each neighborhood and household from the adjoining CCRC campus through central services including procurement, housekeeping, commercial laundry (not resident clothing), and food service that provides prepared bulk food for individual plating from steam wells at each country kitchen.

The Green House ® and Small House models of the household offer a complete break with the institutional nature of traditional nursing homes. “Intended to be a self -contained home for a group of 7-10 elders…a Green House ® blends architecturally with other homes in its neighborhood” (The Gerontologist, Vol. 46, No. 4, pg.538). It is envisioned that eventually these types of small, self-contained facilities could be developed as parts of typical residential neighborhoods with one or more “houses” integrated into the community. The Green House ® concept was developed by Dr. Bill Thomas. He states: “We wanted there to be a heart, a center , a focus of the house. So you know, what you have in the hearth is sort of food on one end, fire on the other, and a place to share convivium or the pleasure of a good meal sort of in the middle.” He continues
“We’ve always insisted in the Green House ® that there be one big table, because that’s how – that makes a meal into a community
experience.” (PBS Lehrer NewsHour, 01/23/08). Similar in organization to the Creekview households, ten private resident bedrooms surround a large semi -private living space called “The Hearth” which includes a fireplace, living room, dining table, and open kitchen. Residents are encouraged to
participate in household activities including meal planning and preparation, clean up and other activities. As a self -contained house, all resident and staff support areas are provided Personal care services are provided by specially trained staff dedicated to each house, while nursing services are provided by visiting nurses who are responsible for multiple houses. Although the Green House ® model envisions stand alone, self –
sufficient homes, in practice, the first Green Houses® in Tupelo, Mississippi rely upon the support of the adjacent traditional nursing home for services such as hou sekeeping, central supplies and food purchasing, including some of the food preparation already accomplished (The Gerontologist, Vol. 46, No. 4, pg. 538).

While Creekview and the Green House ® demonstrate a household plan layout where private resident bedrooms open directly toward the semi-private living spaces, other organizational approaches are also in use. Household organizations that locate reside nt bedrooms along corridors used only for accessing the bedrooms can provide an environment more closely related to a single family home, where one typically finds bedrooms separated down a short hallway from living, dining and kitchen areas. This concept was used at Meadowlark Hills and can be seen in the Chapman Shalom Home East nursing homes design currently under construction in Saint Paul, MN. Within this alternative organization of the environment, the corridor serves as an additional transition zone between the semi-private living areas and the private bedrooms. It is important when using this organizational technique that entrance to the household from semi -public areas occurs first into the semi-private social areas of the household. As in our homes, the front door does not enter into the bedroom hallway.

The scale of the environment is one of the most significant aspects to determine whether it is perceived as institutional or homelike in nature. In the case of the household model there are three major factors that influence the size and scale of the environment: the number of residents that make up the household grouping, the physical size of the environment, a nd the staff ratios necessary to provide the desired levels of care.
Recently constructed households tend to consist of between eight and twelve residents. This size of social grouping appears to be small enough to eliminate the potential disruption caused by excessive numbers of social interactions associated with larger group size, while also providing the desired critical mass needed to foster personal relationships. “ In any group we tend to see one-third of residents who participate in all offered activities, one-third who almost never participate and one-third who may or may not join in”. Using this observation, with a household size of 8 -12, between three and eight residents will be available as part of the social environment. This size of social group also provides enough
diversity to assure some level of common interest within the group. This is important as it is highly unlikely that all residents of what are often random groupings of individuals, whose only commonality is their need for skilled nursing care, will be in harmony with what they wish, think, and feel. The dimensional size of the physical environment should be matched to the activities and group size being accommodated. If the physical environment is too small, overcrowding occurs. Too large, and the group may be overwhelmed by the space, therefore losing the intimacy and comfort associated within residentially scaled environments. The influence of geometry cannot be underestimated as a factor in creating appropriate scaled environments. Resident bedroom spaces require a given area (approximately 13 feet by 20 feet), a means of access into the space and enough exterior wall for placement of a window. When arranging more than ten or twelve resident bedrooms in a plan, one of two things occurs. Either the social areas around which the bedrooms are arranged become oversized, or resident rooms must be located along corridors leading to and from the semi -private, social areas of the household. Shared bedrooms alter the geometry somewhat, as these rooms only require a single entry door and bathroom for two sleeping spaces. But use of shared rooms provides only marginal advantages in th e geometry of the arrangement. Examples of designs that are described as households or sometimes neighborhoods that accommodate from 16 to 24 residents are inconsistent with the concept of a true household. Primary groupings of living and dining areas for this magnitude of group size may be far better than the 40 -60 resident groupings they
replace, but once the quantity of twelve residents is exceeded, it appears that the positive potential of the household model is diminished and confused. One exception however, may be in the case of short-term stay populations. This population group often is comprised of younger “patients” residing within a short-term stay nursing home to receive intensive physical or occupational rehabilitation therapy after a hospital s tay. These patients have no desire or inclination to remain as residents of the facility. Short-term rehabilitation facilities offer a high -tech, high -touch
environment reminiscent of a hotel or spa experience. In this situation, larger scale social areas and patient rooms located along corridors may be a reasonable response to a transient population concentrating upon “graduating” out of the program. The third factor that influences household size is the ratio of direct care staff to the number of residen ts being served. Ideally, the residents of a household would be served by at least
one dedicated resident assistant during each of the day, evening, and night shifts. Additional staff would then be added during the heavier care day and evening to assure that residents receive the assistance needed. This can be a difficult balancing act since required assistance can vary considerably depending upon the acuity level of the residents being served, or even from one day to the next, as resident well being change s due to short term episodes of sickness.

Multiple households that are interconnected, have greater flexibility in either adding staff as needs increase, or reducing staff levels during the night shift when one assistant can cover multiple households under one roof. Adjustments in staffing levels are more difficult to achieve in the case of separate detached, Green House ® or Small House models where staffing can never be reduced to less than one staff member per household.
Flexibility for a Variety of Population Groups Small clusters of residents within household scale environments provide the opportunity for operators to develop individual strategies in the grouping of resident populations. Some care providers may chose to group residents with similar “diagnoses” or care needs, together within homogenous household settings. This calls for specialized staff trained in particular interventions necessary to care for specialized populations. It may also enhance camaraderie among residents with similar backg rounds and
experiences. Other reasons for homogenous grouping may be funding and referral advantages as in the case of the Green Houses ® of Chelsea, Massachusetts where plans call for houses identified by different populations including people with Lou Gehrig’s Disease (ALS), AIDS, Hospice, or the most common special population group, those with Alzheimer’s or other dementias. Other care providers prefer to allow houses to fill organically
with the intention that, over time, staffing requirements among houses may equalize as each house gains a heterogeneous population with a mix of heavy care and lighter care residents. This philosophy reinforces the concept of home in that, once a resident moves into a room, and becomes part of a household they can remain as long as desired without the need to move again. Deinstitutionalize Clinical Resources Providing a normal living environment requires intentionally working to eliminate, or re -envision the many clinical elements found within the traditional institution al setting. Even within smaller scale environments, the need remains for staff to complete tasks such as charting, distribution of medicine, processing
soiled items, and bathing residents. Many examples of innovative, homelike solutions are currently in us e including the staff work area, medicine distribution cabinet and bathing room.

The Neighborhood – Enabling Relationships within Community The household models encompass the private and semi-private zones within the hierarchy of space. Yet in creating a quality of life that encompasses life in all its fullne ss it is necessary to maintain relationships with the greater community and culture. These types of relationships occur best within the semi-public and public realms. We all need to get out of the house on occasion to meet with others and participate in a wider range of activities than may be available within our immediate “family group.” In order to
engineer one ’s life to maximize high flow activities ( Working, Studying, Driving, Hobbies, Sports, Movies, Talking, Socializing, and Sex), a variety of opportunities must be reasonably available. Not all activities and personal encounters can be pre-planned. There is value in serendipity and chance meetings that require exposure to a larger community. A neighborhood center shared among several households also encourages participation from members of the greater community can serve this function. Large group activities, religious services, music, theater and fitness
opportunities within easy access can be made available to residents. At Creekview at Evergreen Re tirement Community, a fitness center including a warm water aquatic therapy center, providing memberships to community elders is located in the heart of the nursing home. By providing a hub of activity within the nursing home, residents’ lives a re-enhanced through greater opportunities, while at the same time demonstrating to the
community that aging is a natural part of life and the nursing home is not the last place one would like to find oneself.