Dealing with the code masters: how two facilities built for the future - nursing homes Michigan Masonic Home and Clark Retirement Community - Editorial

Nursing Homes, Sept, 1994 by Roger Myers, Richard Perl

The Michigan Masonic Home and the Clark Retirement Community had both decided to take resident-centered approaches to master planning for renovation and expansion of their health centers. Old buildings, once serving residents in the manner dictated by the times, they were becoming obsolete. People wanted more space, greater privacy, and a residential environment. What's more, all indications were that these preferences would continue to drive facility design for many years to come.

Doing something about this required that both facilities challenge some long-standing regulations. Some aspects of each development process worked extremely well; others involved unforeseen difficulties. These organizations believe that by sharing their experiences--good and bad--with other potential facility development sponsors, they might better avoid certain pitfalls and create genuinely improved settings.

With this in mind, they both contributed their observations to the American Association of Homes and Services for the Aging (AASHA) Design & Code Exchange, a project created with funding by the Retirement Research Foundation. The Exchange facilitates networking and efforts to bring change to the design code process so that more appropriate settings for older persons can be built. The issues they documented for the AAHSA Design & Code Exchange are the subject of this article.

The Michigan Masonic Home

Located in Alma, Michigan and founded in 1891, this facility began its planning in the mid-1980s. A development team was set up ensuring active participation by board, staff, residents, and others involved with the Masonic Home.

During the five-year development process that followed, there was a fair amount of turnover on the board and among key members of the design and development team. Obviously, this can create awkward situations when trying to bring a project to completion; it is critical to maintain thorough documentation regarding all decisions. Much input and participation was solicited from residents, families and staff at all levels, as well as regulators, people from academia, and volunteers. During the process the planners learned that one thing that could have been improved upon was establishing at the onset realistic expectations. Nevertheless, the wish lists were challenging, and enabled the planners to more clearly identify what participants wanted. For example, the Masonic Home found the original certificate of need was too modest, compared to what was wanted. Because it was easier to apply for a new certificate of need rather than amend the first one for more space, a second one was applied for and granted.

They also found that risk-taking was essential. One risk involved planning for more square footage than the state allowed for nursing homes. Knowing that the state was considering increasing the square footage allowance, the Masonic Home was dedicated to building according to the newer, larger standards.

The corridors expand by two feet at each resident room doorway so that resident room doors recess by two feet. That gives residents a "front porch," and by enabling the doors to swing out instead of into the room, residents gain additional living space since they can use all floor space in their room up to the doorway. Even though this particular doorway design greatly enhances resident living space, it is frequently lost in states which set rigid square footage and cost limits for nursing homes. Unfortunately, those limits consider only start-up costs, and not the lifetime costs of the facility.

Most states want to contain costs in terms of cost per bed at startup. For example, a less expensive HVAC will yield cheaper startup costs, but will actually cost more money over the long run than a more expensive and efficient one with a longer life. Re-shaping bathrooms in the design process so that residents can get a wheelchair into the bathroom may add cost, but will make residents more independent and less reliant on staff help. Adding a little more space to keep supplies closer for staff makes staff more efficient. These costs often aren't factored into a cost-per-bed equation.

The Masonic Home was also committed to offering a high ratio of private rooms to semi-private rooms: 100 private rooms and 52 semi-private rooms were built for nursing care. However, the units were smaller than traditional units, each housing only 45 residents, with the area further divided into two sections of 23 and 22 residents. This meant corridors could be short and and thus more negotiable by frail elderly.

Fortunately, state authorities proved to be flexible in this case. The planners met often to consult with Michigan Department of Public Health staff and the Fire Marshall's representatives. Masonic Home staff were encouraged when they first saw the licensing officer from the Department of Public Health debating with the Fire Marshall's representative, the licensing officer taking on the role of advocate for the nursing home, knowing that its plans were in the best interest of the residents.