SAMPLE POST OCCUPANCY EVALUATION

EXECUTIVE SUMMARY:

The mission of this nursing home is to offer the best quality care to the poorest of the poor. They wish to serve more residents with their existing staff. To meet this goal, three projects are recommended. Increase the efficacy of the residents to save staff time. Remodel the carriage house and other spaces to accommodate additional residents, caring for these residents with the saved staff time. Finally, tighten admittance criteria, considering only poor residents requiring institutionalization. To expand service provision, initiate volunteer training programs with an emphasis on community outreach to poor residents not requiring institutionalization.

INTRODUCTION:

The U.S. spends more dollars per capita on healthcare than any other industrialized country. In spite of this (according to a report in the A.M.A. Journal) the U.S. is at the bottom of a comparison of healthcare quality in ten Western Industrialized nations. One of the major reasons is that nursing homes in the United States have become a "solution" to what is basically a housing problem rather than a health problem. This is an inappropriate and expensive solution at best. The same money currently spent on nursing home care will pay for home care for three times as many people.

The U.S. has the largest percentage of people in nursing homes among all developed countries in the world. The National Association of State Units on Aging reports that 20% to 40% of the elderly population in nursing homes or long term care facilities could be cared for at less intensive levels or in alternate settings including the home. Even in Oregon, one of our most progressive states in care of the elderly, it is estimated that only 7% of the Medicaid nursing home population have complex medical needs. This problem is the direct result of uneducated consumers turning the responsibility for their own healthcare over to providers who are biased towards the institutional settings in which they have been trained. Most providers have had minimum exposure to residential care and have been schooled in the disease-focused biomedical model which minimizes the role of the patient in managing their own health. The model views aging as a disease that must be "treated" in a medical facility. As a result, many well people have been placed in nursing homes simply because they are old, not for complex medical needs.

Most often, people are institutionalized because of their limitations with activities of daily living. The New Hampshire Congregate Housing Services Program found that over 90% of the people who moved out of their homes into congregate housing needed help with meal preparation, shopping, outside mobility, laundry, and housekeeping (especially "deep cleaning" like wall and window washing). Over 60% needed help with bathing and ambulation. But less than 26% needed help with medication, transfer, dressing, or telephoning, and certainly did not need institutionalization. Ten non-institutional options should be available on the continuum of care:

1. Semi-supervised apartments (without live-in managers)
2. Supervised apartments
3. Community based group homes
4. Foster homes
5. Residential treatment centers for specific problems
6. Shelters
7. Housing with live-in roommates
7. Host homes where the resident becomes part of the family
8. Boarding houses
9. Shared homes
10.Subsidized support programs where individuals receive payments to follow a plan for self sufficiency.

These choices support all ages and financial abilities, but ideally, the continuum of care should not require frequent moving from one choice to another. Each choice must be adaptable and flexible in design. The nursing home industry gives only lip service to these other options. Only 3% of residential healthcare services are provided by nursing homes. Quality of care in the home versus the need for quality institutional care can only be decided on a case by case basis. But, institutional environments are stressful to many, and we know that stress is associated with changes in immunity that make people more susceptible to infection and viruses. Quality home care often prevents the need for institutionalization and resulting illnesses.

On the other hand, eighty-five percent of elderly people needing home care are receiving no community services. The number of elderly without a significant care giver is growing because fewer of them have married, they have had fewer children, and there are more divorces. By the year 2030, there will be about 65 million people over the age of 65 and 30 million of them will be living alone. Two thirds will claim they need help with outdoor maintenance and 54% will need help with heavy housework. Eighty percent will suffer from a chronic limitation of their mobility.

The demand for quality care is growing, and the supply of services is decreasing, especially services for the elderly poor. The mission of the nursing home is critical, but the poorest of the poor will only be served if the nursing home is willing to make major policy and facility modifications.

METHOD OF POST OCCUPANCY EVALUATION:

EASY ACCESS TO HEALTH, LLC began a three day in-house post occupancy evaluation of the nursing home. Cynthia Leibrock spent four nights in the nursing home, experiencing the environment from the perspective of the residents. All team members were present at the final meeting when the evaluation was presented.

Cynthia arrived at the facility on a Sunday night. She was housed in a pleasant guest suite and given full access to the facility. During the three day visit, meals were taken with the residents, and several were interviewed at this time. One resident described the nursing home as a "resort hotel without the tipping". The residents were extremely satisfied with their level or care, but generally did not participate in facility maintenance, food preparation, or care of their fellow residents.

Interviews were also conduced with staff, maintenance, and administration. Staff and maintenance are basically at the "beckon call" of the residents. Administration would like to see more residents served, but at existing service levels, this will not be possible. It is also difficult to find additional staff, and additional nuns are simply not available. Considering that many of the existing services could be completed by the residents themselves, the evaluation recommends program and design modifications to allow them to do so, retaining their skills in the process. Ideas to save staff time and empower residents are indicated in bold type.

RESULTS OF POST OCCUPANCY EVALUATION:

I. RECOMMENDED PROGRAM MODIFICATIONS:

A. Introduce a program to train residents to care for each other. Today, nearly 90% of elderly people living in the community already receive help from an unpaid care giver. Over 50% of the care givers are over 60 years old, and 18% are over 70. Many of the nursing home residents are capable of
helping and would view this an opportunity to serve others while maintaining their skills.

B. A research institute could be located on the campus, perhaps in the carriage house, offering innovative technological options to residents and outpatients including computer training to encourage communication and discourage isolation. With this system, residents can maintain contact with others without leaving their homes. Besides word processing, they also have access to community services, course work like language tutoring, and a senior newsletter. Checkbook balancing, banking, shopping, games, and travel services are also available.

In addition, computer training may allow residents (and outpatients) to research their own diseases and disabilities. The Planetree Project of San Jose, California, has been a leader in the movement to return the responsibility to the healthcare consumer. Through this project, health resource libraries are constructed adjacent to many medical centers in the U.S. Consumers are encouraged to learn about medical technology and services, perhaps finding solutions to their own healthcare problems. The libraries provide a free community service with understandable medical information, classes, and support groups. Book delivery service and health research services are also available.

The research center could provide a model kitchen, bathroom, and a high technology apartment allowing residents and care givers "hands on" access to education and information on self-care. The center could also provide portable "try before you buy" products which can be borrowed. A team of volunteer professionals including an O.T., social worker, architect and interior designer could offer turn-key design including assessment, modification, and specification of assisting devices.

C. Introduce a volunteer program for non-professionals to care for residents at home. An interesting system has been established in a number of U.S. cities to compensate volunteer care givers. These volunteers accumulate "time dollars" they can exchange for services they may need at a later date. These volunteer service credits can be spent for rides to get groceries, cleaning services, or even just friendly visits. Medicaid will not pay for most of these services. In this system, even the frail elderly can accumulate credits by telephone "visiting" or phone work for others, allowing them the dignity of earning the credits to pay for the help they need at home.

D. A questionnaire should be developed to measure the resident's ability to self-treat medical problems, maintain personal hygiene, and take care of business affairs. The needs assessment may also be used to screen applicants for residence, evaluating their ability to live independently.

E. The continuum of care should not require moving from one wing to another. As we age, each change can represent a loss of territory and possessions. We move from our home into an apartment, an assisted living facility, and, for some, a nursing home or hospital. With each move, possessions must be eliminated and physical territory must be shared.

F. Initiate a wellness program. There is a growing movement in the U.S. encouraging citizens to take responsibility for their own healthcare. One skilled nursing facility has set a tremendous example of the power of education. Stevens Square rewards wellness rather than giving love and attention only to those who complain of illness. They use a three-part program to implement this philosophy: the teaching of self responsibility, the development of community instead of isolation, and resident involvement with meaningful activity. Residents begin by learning a list of acclamations offered by the American Psychological Association:

1.We are responsible for our own health.
2.Illness is a communication from within.
3.Most healing comes from within.
4.Treatment must involve body, mind, and spirit.
5.The care-giver is a consultant, not a miracle worker or authority figure.
6.Our positive attitude along with a personalized caring staff is essential to change and healing.
7.Our physical and social environments greatly affect health.
8.Nutrition and exercise are the cornerstones of good health.
9.We are uniquely individual and services should be individually tailored with maximum choice.

Since implementation of this wellness program, patient hospital days were reduced from 568 in 1980 to 161 in 1986. As an added benefit, the average length of stay of staff increased from 16.1 months in 1980 to 63.43 months in 1986. This wellness philosophy can also be extrapolated to home care to prevent hospitalization.

G. Expand the senior day care program. A 1982 California study found that 87% of the elderly people who participated in adult day care programs maintained or improved their level of functioning. Sixty-three percent had been Medicaid eligible for institutionalization before entering the program. In the last twenty years the number of U.S. Adult Day Care programs has jumped from 15 to 2200 programs. A respite program could also be considered offering lodging and senior care from a few days to several months.

II. RECOMMENDED DESIGN MODIFICATIONS:

A. Exterior Planning:

1. Level sidewalks, removing changes in elevation that form tripping hazards and limit wheelchair access.

2.Consider additional privacy from the street, perhaps through additional foliage along the fence. Residents seldom use the property in front of the home because of the lack of privacy.

3.In back of the home, consider handrails on the paths and stairs. Residents expressed a fear of falling if they use these paths and frequently require staff assistance. Paths are not accessible to wheelchairs, and the slopes cannot easily be reduced to accommodate them. Perhaps the back yard can be secured for wandering.

4.Although the patios are seldom used, they greatly contribute to the quality and quantity of light in the residents rooms. They are occasionally used for parties and also function as gardening areas for the residents. Residents need to remain connected with others, but through windows, doorways, and porches which allow the choice of privacy. Designs can encourage "chance" encounters and excuses to meet people. Too much privacy can be dangerous to your health. Use of the patios may increase if the patio doors were accessible. An elevated garden would help both standing and seated users.

5.Consider the addition of a small pool for water therapy (note: this was a low priority to administration).

B. Electrical, Mechanical, Acoustical:

1. Lighting: Evaluate the hallways to consider increased lighting levels in some areas, even during the day. In the hallways, the skylighted alcoves are used more frequently than those alcoves without sky lighting. At night, wall sconces in the halls create an eerie effect. In the resident rooms, eliminate existing institutional lighting and consider cove lighting on a rheostat to increase ambient light levels without glare. Some staff spaces also need increased ambient lighting (eg. activity room).

2. HVAC: Individual controls in resident rooms are difficult to adjust and require staff assistance.

C. Ceiling and Wall Finishes:

1. Color changes in the hallways have been very helpful for spacial differentiation. Warmer and lighter colors may be considered, however. Blues and greens are perceived as grey through the yellowing lenses of the residents, and contrast is more difficult to perceive between these cooler colors. Lighter colors will increase the ambient light levels.

2. Consider wall fabric in resident rooms to absorb ambient noise and allow residents to personalize their spaces.

D. Windows and Doors:

1. The manual exterior doors are all difficult to manage and may require staff assistance. Many bathroom door closers require over 5 lbs. of force and are unusable by residents. Consider additional automatic doors or replace door closers to reduce the force required for use.

2. Sliding glass doors to patios are particularly difficult for elderly users and require staff assistance. The hardware on these doors requires tight grasping and pinching, and the force required for use may exceed 20 lbs. in some locations.

3. Many doors still have knobs including doors to rest rooms (marked accessible) and doors to resident rooms. Replace with levers and add extra length door stops to protect the walls from the levers.

4. Exterior thresholds prevent wheelchair access and may be a tripping hazard. Consider replacement with a mortise system.

5.Drapery cords in the resident rooms are difficult to use and require staff assistance.

E. Floor Covering:

1. Hallway glare is caused by the windows at the end of the halls. These windows are an attractive design feature which would not cause glare if carpet is installed. Carpet may also be considered in the resident rooms to reduce glare, increase traction, and to cushion falls. Carpet will also absorb the ambient noise which makes hearing difficult. Most activities taking place in resident rooms can be heard in the halls, including conversation, toilets flushing, television, etc. Consider carpet in the therapy areas as well. Therapy areas offer little privacy, especially acoustical privacy for painful treatments.

2. Floor covering is the dining room is dark and glaring.

3. Stripes in the upstairs halls may be perceived as a change in elevation.

4. Water seeps under the ground floor causing the VCT tile to buckle. It may be possible to cover the buckled tile with carpeting but technical assistance from the manufacturer will be required.

5. Loose mats in the entry may be a tripping hazard.

F. Furniture:

1. Sharp corners on counters, planters and bedroom furniture may cause injury.


2. Bedroom furniture needs "C" grips to reduce the need for staff assistance.

3. Nightstands should have a gallery rail or edge around the top to prevent items from being accidentally pushed to the floor.


4. Closet rods in wardrobes should be lowered to reduce staff assistance. Upper shelves should be wire or acrylic to allow the resident to see the contents.


5. The existing mattress cover doesn't breathe and may be uncomfortable. The mattress also buckles when the bed is elevated. Vertical spindles on the headboard will aid in transfer to bed and reduce staff assistance. The foot board is too low to provide support to a walking user, and the bed is very institutional in appearance. Controls should also be evaluated.

6. Library bookcases should be attached to the walls in case of an earthquake.

7. Nurses stations are not accessible. A section at each station should be lowered to wheelchair height (30" H) if the nurses stations are needed at all (see Goal II below). Surfaces of the nurses stations are cluttered indicating a need for additional storage. This may be solved by the new computer system which should save staff time by reducing paperwork.

8. Chairs and sofas in the public spaces are too soft for easy exit.

9. Recliners in the residents rooms are difficult to operate.

10.Furniture placement in the resident rooms makes space difficult for wheelchair access requiring additional assistance from staff.

11.None of the furniture has been evaluated for California 133 compliance.

G. Accessories and Equipment:

1. Handrails at interior and exterior stairs do not have the necessary extensions.

2. Elevator doors are not adjusted to remain open for twenty seconds upon re-opening.

3. No mailbox is available on the second floor. Residents complained about the amount of energy wasted to take the elevator to the ground floor to mail a letter. But the real reason may be that as we age, we loose possessions. The value of those few possessions which remain increases dramatically. Symbols of life like flower boxes, mail boxes, clothes lines, and holiday displays become increasingly important.

4. Evaluate the call system-the existing system is often out of reach in the resident rooms, and the perimeters of the building are not secure to prevent wandering from the premises. Wandering is dangerous for the residents and increases staff time. When the call system is used, a very loud and distracting alarm sounds at the nurses station, disturbing all the residents but especially those with dementia. A personal response system should be considered, perhaps with a computer chip notifying staff if a resident with dementia leaves the building.

5. Metal lamps do not have touch converters and squeeze controls are not available on the cords of other lamps.

6. Signage should be removed from the back of doors and reinstalled so that it can be read when the door is open.

7. Labeling the halls by fire zone is an institutional cliche. Wayfinding and orientation are very difficult with existing signage. Personal collections could also be securely displayed to serve as cues for wayfinding.

8. Drinking fountain controls are protruding hazards and have caused bruises.

9. Exposed therapy equipment looks threatening.


10.Laundry equipment and sinks are not accessible requiring staff assistance. Replace with shallow sinks and front loading machines with controls on the front. Take a hands off approach, encouraging residents to do their own maintenance and even help with the care of other residents. This will save staff time and help residents to retain their skills.

11.Public telephones are not accessible or amplified requiring staff assistance.

12. Elevators are not sufficiently vented.

H. Kitchens:

1. Increase accessibility to allow residents to prepare their own snacks, even from a wheelchair. Consider adjustable height counters cleared for wheelchair access, cabinets on locking casters below, side by side refrigerators (with low freezer space), lowered upper cabinets, etc.


2. In the resident's kitchens, chairs with arms would encourage use.

3. Tables should provide contrast edging for use by residents with vision limitations.

4. Kitchen appliances are accessible to residents with dementia requiring staff time for supervision. Perhaps a circuit breaker should be considered.

I. Bathrooms and Utility Spaces:


1. None of the bathrooms in and adjacent to the resident rooms are accessible. Showers and toilets cannot be used from a shower wheelchair, requiring many hours of staff time to help the residents with personal hygiene. An inaccessible lip is on the floor of the roll-in shower. Bathtubs have insufficient grab bars for use and no seat for transfer. None of the toilets provide sufficient room for transfer (3'6" to the side). The only toilet planned for a parallel transfer has this space blocked by permanent arms on the toilet.

2. None of the bathrooms in the public spaces are accessible. The public bathrooms have exposed hot water pipes, controlled flow tissue dispensers, flush valves requiring more than 5 lbs. of force to operate, and toilet seat covers and paper towels mounted over the toilets above the 44"H maximum.

3. Many of the showers and bathrooms are used for storage of wheelchairs, scales, and furniture (probably because these spaces cannot be used by the residents).


4. Wheelchairs are currently being stored in the halls. Add additional utility spaces for storage.

J. Carriage House and Space Planning:


1. The carriage house is used for maintenance and storage by the auxiliary. This is valuable space located with the most desirable view on the property and would be ideal for independent living. It could be used for resident care, relocating maintenance to the main building and renting space in another location for storage. (Note: maintenance would prefer to be located in the main building and is willing to move).

2. Consider adding an office space for resident use to reinforce long term memory.

3. Consider using one existing guest room as housing for an additional resident.

4. The nurses stations are not used in the independent living wing, and some residents rooms are being used as offices. If the nurses stations were used as offices, more residents could be housed.



References
Bane, Gresham. (1988, July). A mobile emergency room; a new option in comprehensive home care. Caring, p. 25-27.

Beasley, Kim. (1990, June). Design lines: the cost of accessibility. Paraplegia News, p. 42.

Beck-Friis, Barbro. (1989). Physical dependence of cancer patients at home. Palliative Medicine, 3, 281-286.

Boise, Linda. (1991, February). Family care of the aged in Sweden. Viewpoint Sweden, 2.

Casady, Dan. (1991). Fact sheet on personal care attendant (PCA) services in Flordia. Self Reliance, Inc. Center for Independent Living. (Available from Self Reliance, Inc. Center for Independent Living, 12310 N. Nebraska Ave., Tampa, Flordia.)

Coates, Gary and Susanne Siepl-Coates. 1989. Vidarkliniken: A Study of the Anthroposophical Healing Center in Jarna, Sweden. Paper read at the Built Form and Culture Research Conference, November 1989 at Arizona State University, Tempe, Arizona. (Available from Gary Coates, Department of Architecture, Kansas State University, 211 Seaton Hall, Manhattan, Kansas).

Committee on an Aging Society. (1988). Cross-national perspectives on environments for the aged.

America's aging: The social and built environment in an older society. Washington, DC: National Academy Press.

Cox, A. and Groves, P. (1990). Hospitals and Health-Care Facilities. London: Butterworth Architecture.

Crooks, Salle R. (1991, July 25). Rising costs will force more hospitals to close. U.S.A. Today, p. 1D.

Dewolf, Maxi (1990, March 1). Healthcare on wheels: retired doctors come to aid of elderly. U.S.A. Today,4D.

Emergency room crisis. (1991, August 28). U.S.A. Today, p. 8A.

Farnsworth, Alexander. (1990, December). Metropolis, p. 21-23.

Friend, Tim. (1991, August 14). Western European kids get better healthcare. U.S.A. Today.


Goodman, John C. (1991, November 7). Don't mess up healthcare. U.S.A. Today, p. 10A.

Honaker, Charles. (1991, March/April). Home healthcare renaissance. Group Practice Journal, 8-12.

Keenan, J. M. & Hepburn, K. W. (1991, March/April). Home care needs physician leadership. Group Practice Journal, 14-23.

Landis, David. (1991, October 23). Lifeline. U.S.A. Today, p. 1D.

Leibrock, Cynthia A. (1993). Beautiful Barrier Free: A Visual Guide to Accessibility. New York: Van Nostrand Reinhold.

Melcher, John. (1988, August). Keeping our elderly out of institutions by putting them back in their homes. American Psychologist, 8, 643-647.

Newman, S.J. (1985). Housing and long-term care: The suitability of the elderly's housing to the provision of in-home services. The Gerontologist, 25(1), 35-40.

Noelker, L. (1982). The Impact of Environmental Problems on Caring for Impaired Elders in a home setting. Paper presented at the 35th Annual Scientific Meeting of the Gerontological Society of America, Boston, Massachusetts.

O'Donnell, John M. (1983, May) The holoistic health movement: implications for consulting theory and practice. Counseling and Human Development, 15 (9), p. 1-12.

Regnier, V. & Pynoos, J. (1987). Housing the aged: design directives and policy considerations. New York: Elsevier.

Rosenthal, J. A., Motz, J. K., Edmonson, D. A., & Groze, V. (1991). A descriptive study of abuse and neglect in out-of-home placement. Child Abuse and Neglect, 15, 249-260.

Royal Danish Ministry of Foreign Affairs. (1984). Denmark Review: Disability Aids. Author: Copenhagen, Denmark.

Royal Danish Ministey of Social Affairs. (1990). The Pensioner in Denmark. Author: Copenhagen, Denmark.

Schwatrz, P.J., Blumenfield, S., Simon, E. P. (1990, May). The interim home care program: an innovative discharge planning alternative. Health and Socal Work, p. 152-160

Schwartzberg, Joanne G. (1991, March/Arpil). Reimbursement, physician case management, and home health care. Group Practice Journal, 24-26.

Simons, Janet. (1989, March). Assisted living demand outstrips supply. Senior Edition USA/Colorado, p. 9-11.

Smith, Kerri S. (1991, June 4). The nursing home dilemna. The Rocky Mountain News, Lifestyles, p. 24.

Snider, Mike. (1991, August 29). Stress may be something to sneeze about. U.S.A. Today, p. 1A.

Soldo, B. & Longino, C. (1988). Social and Physical Environments for the Vulnerable Aged. In Committee on an Aging Society. American's Aging: The Social and Built Environment in an Older Society.
Washington, DC: National Academy Press.

Stuyk, R. (1988). Current and emerging issues in housing environments for the elderly. In Committee on an Aging Society. America's Aging: the social and Built Environment in an Older Society. Washington, DC: National Academy Press.

Swift, Catherine. (1991, March/April). Group practices pursue home care. Group Practice Journal, 52-55.

Thompson, T., Robinson, J., Graff, M., & Ingenmey, R. (1990). Home-like architectural features of residential environments. American Journal of Mental Retardation, 95 (3), 328-341.

U.S. House of Representatives Select Committee on Aging. (1990). Housing for the frail elderly: hearing, May 4 and July 26, 1989. (SD cat. no. Y 4Ag 4/2:H 81/26). Washington, DC: U.S. Government Printing Office.

Vanderheiden, Gregg C. (1990). Thirty-something million: should they be exceptions? Human Factors, 32 (4), 383-396.

Ward, Bernie. (1991, September). Overcoming barriers. SKY, p. 52-61.

THE ATTITUDE
THE LIFESTYLE
LIFETIME LEARNING
GIVING BACK