E10 – Designing Care Spaces with Our Future Selves in Mind: Jane Rohde 

Introduction

Jane Rohde is affectionately known in FGI circles as “the mother of the Residential Guidelines.” Her passion for residential health care facility design and advocacy for the aging and vulnerable populations led to the inclusion of residential health, care, and support facilities in the Guidelines documents beginning with the 2018 edition. In this episode, Jane explains how nursing homes, initially intended for short-term care, evolved into a care model that often widens the gap between “those who have and those who have not.” Jane further emphasizes the need for community-centric design, pointing to common design mistakes including poor acoustics in large spaces, inappropriate lighting disrupting circadian rhythms, and lack of contrast in colors leading to falls. Jane also shares why a detailed functional programming process, engaging community stakeholders to identify service gaps and needs, is “the nitty gritty” that she loves the most.” 

About Jane Rohde

Jane Rohde is the principal of JSR Associates, Inc. and founder of Live Together, Inc., a nonprofit focusing on intergenerational care models and demonstration projects combined with workforce development opportunities to improve quality of life for residents of all ages. Her consulting focus includes vulnerable populations with the goal of achieving equitable access to housing, care, and services. She sits on various health care and sustainability committees supporting research, advocacy, and humanistic approaches to community development, and until 2022 was the chair of the Residential Document Group for FGI’s Health Guidelines Revision Committee. Jane has received the Changemaker Award for Environments for Aging (from The Center for Health Design), the ASID Design for Humanity Award, and the Pioneer Award from the Facility Guidelines Institute. 

 

 

Acronyms Mentioned 

ADL: activities of daily living 

SNF: skilled nursing facility 

P.A.C.E.: The Program of All-Inclusive Care for the Elderly 

IRC: International Residential Code 

IBC: International Building Code 

AHJ: authority having jurisdiction 

ADA: Americans with Disabilities Act 

 

Mentioned in this episode

Medicare: Federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions 

Medicaid: Joint federal and state program that gives health coverage to some people with limited income and resources 

Georgia Tech: Public research university in Atlanta, Georgia 

Jon Sanford, M.Arch.: Associate professor in industrial design at Georgia Tech and the director of the Center for Assistive Technology and Environmental Access (CATEA) 

Maggie Calkins, PhD, CAPS, EDAC: Board chair of IDEAS Institute, an independent research institute dedicated to exploring the therapeutic potential of the environment, particularly as it relates to frail and impaired older adults  

Greenhouse Project: A nonprofit organization founded in 2003 on the belief that everyone has the right to age with dignity 

 

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Show notes (download transcript)

 

Guest Intro

This episode’s guest is Jane Rohde, who is known as the mother of the Residential Guidelines document. Jane was the tri-chair for the residential document group until 2022 and participated in the creation, if not the birthing of, the residential document. She is principal and founder of JSR Associates, and she has over 30 years of senior living, health care, and sustainability consulting and design experience. Jane is a key figure in the FGI world. She received the Pioneer Award from FGI in 2020 for all of her efforts in being a visionary in leading us into this residential space.

 

What facilities are covered in the residential Guidelines document?

Nursing homes

Nursing homes would be your long-term care. Sometimes we also see rehab as part of that because nursing homes are usually licensed for both. The care population is usually a certain number of ADLs that cannot be handled or maintained through assisted living.

Nursing homes [as opposed to skilled nursing facilities] was the most generic terminology that we could use. Most states do license to the skilled nursing facility level, but the criteria is the same, so if somebody adopts the Guidelines to use it as code and licensing code in their state, we would say that the skilled nursing facilities would fall under nursing home.

Hospice facilities

Hospice care is really for those who are terminally ill and working through the process of passing to the next world. It’s basically to allow someone to pass with ease, and you want that to be in the most comfortable, amazing setting possible. Services can come to your home, services can come to assisted living, but then there’s also dedicated hospice facilities. Those are usually licensed under nursing homes, depending on the jurisdiction.

 

Other facilities covered in the residential Guidelines document

• assisted living settings
• independent living settings
• long-term residential substance abuse treatment facilities
• settings for individuals for intellectual and/or developmental disabilities
• adult day care/adult day health care facilities
• wellness centers
• outpatient rehabilitation therapy facilities

 

Non-residential support facilities

So, how we evaluated it was to look at the continuum of care, putting together the different pieces and parts. So, that’s why we have nonresidential support facilities that are also included. That’s things like adult daycare, adult day health care, what we call P.A.C.E.—programs for all-inclusive care of the elderly, and why we also evaluate, outpatient rehab.

 

Look at needs by demographic; not by diagnosis

I think that there’s a thought missing: usually we look at it by diagnosis, not by demographic. So, we try to encourage people to look at it from a demographic perspective because who’s using most health care? Older adults and older staff. When you start to get into the 45 to 65 is your average age for a nurse, you also start having some of the same issues, whether those are mobility issues, those are site issues, acoustics, or hearing issues.

 

Long-term substance abuse and treatment, settings for individuals with intellectual or developmental disabilities

We realized that any age can have these issues, but it’s really considered a long-term setting because it’s longer than even a week, or three days, or two days, or whatever. We worked on that using different protocols in different states, and it’s the same with settings for individuals with intellectual or developmental disabilities. Typically the terminology used state-wise is group home, but a lot of times we use that for older adults too, because it fits the criteria better.

 

An á la carte approach to designing

You’ve given us almost an á la carte approach to say here are all the different types of communities that exist and understanding that many of them can be on one particular campus. So, you might have a skilled nursing facility along with a[n] assisted living-type community along with an independent community and how do those coexist and sort of play together on that same campus? And how do we calibrate requirements and minimum safety kind of considerations to each of those different communities?

That’s right.

 

The origin of nursing homes and current issues

Nursing homes were never designed for someone to live for 10 or 15 years in a nursing home bed, in 80 square feet, right? Nobody was ever intended for that. It was really meant to be an extension of the acute care setting where someone went for a short period of time and then generally passed away. It gave them a transitional place or a step down. And what has happened over time is that that didn’t work anymore. So, people who couldn’t afford assisted living when the assisted living market came in, just as context, when that became something that was viable, it was really meant to just assist people who were living independently a little bit. Then assisted living became a business, and then assisted living became a facility, and then it became licensed. And so, when that happened, it meant that people who had means could stay in assisted living longer; people who had no means ended up in a nursing home.

 

Reimbursement challenges

You used to have private pay, you used to have your Medicare public pay, and then you used it for rehab, and then you had Medicaid. So, it was a balance. It was kind of a rob Peter to pay Paul, but you could balance it out to give the higher level of care for everybody. That no longer exists. Nursing homes right now are struggling and they’re struggling desperately, and COVID didn’t help that. The pandemic didn’t help that.

 

Asking the right questions during the functional program process

We believe that unless you understand the services that are provided in the community at large, you have no way of understanding what should be programmed. So, if we want to talk to people, we would call the local senior center; we would talk to the area agency on aging; we might talk to the state; we may talk to the local home health care provider. Who has physical therapy available? Is one of the colleges involved? Who is the health system? How does a health system work? And what are they providing? What we look for is commonalities and then gaps.

 

Understanding the operational flow

When we get into the specific functional program, that’s my nitty gritty that I love the most, and that’s how we structured the one in the Guidelines. That’s why we do the who, what, where, when, and how throughout, and that is to understand every operational flow that comes in and out of the building. So, if I have food delivery, where is it being delivered? I don’t want it at my front doors. Particularly if I’m doing a smaller model; I want it to come into the side kitchen door or I want it to come into the back door where my loading dock is. So, am I going to do a loading dock? Am I going to do personal laundry for my residents because that makes them feel more like at home and family members can participate or am I going to send all that out?

 

Getting the staff on board when change happens

When we do functional program, we meet with every department group. It’s all about a matter of what they understand and what they don’t understand and then how that applies. And then when they see it, they’re like, it’s best to go do a journey—we call it learning journeys—but taking somebody off to the learning journey to go, this is what it would work like.

 

The mobility and transfer risk assessment

The resident mobility and transfer risk assessment is really evaluating your care population; who are you caring for and what does that look like if you’re aging over time.

Grab bars

Grab bars for transfer and mobility were designed for veterans returning from Vietnam. So, the dimensions are too high, and the placement isn’t right…it was meant for people who have upper body strength to do a side transfer out of their wheelchair, and older ladies, we’re not positioned to be able to do any kind of transfer that would actually take that kind of upper body strength. What we were able to do is provide an alternative grab bar scheduling, so even if your local authority is going to require certain ADA compliance in a certain number of rooms or whatever it might be, the rest of the rooms could all go along toward the resident mobility.

Fall risk in showers

Where we really see it is when people don’t have the vertical grab bar coming out of the shower because that’s the one that they hang on to as they step out and reach for their towel. And so, if you put a hook there, then they’re reaching for the hook, or they’re reaching for the towel, and then they use the towel as the grab bar, and then they go down. So, it’s like a fall process. So, the reason that’s important is that it really tells you about the care population, how much mobility issues you have, and it forces people to actually look at it.

 

The resident dementia and behavioral health risk assessment

When we look at resident dementia and evaluating it, we did it as an overlay. The idea of the overlay is that you can have dementia and be in any setting. Independent living, for example. So, if you have two spouses living in one apartment and one has dementia and the other does not, what are some of the features or factors that you may want to consider? So, do you have a[n] elopement risk? Do you have things that happen in terms of getting lost in queuing? Those are things that help people stay independent longer. So, those are different pieces and parts that you want to look at.

 

Common errors when designing and building residential health, care, and support spaces

Lofty, big spaces

The one I see a lot is the architectural need to be lofty and big and tall because most people need to be in smaller spaces where there’s some decent acoustics so that you can hear each other.

Improper lighting  

Also, the lighting. So, you’re in your community spaces, people are starting to tone down for the day. So, you start to tone down from blue lights into amber lights. Then they go out into the corridor and it’s all blue light. So, by the time they get back to their nice little resident unit, whether it’s an apartment or their room, and it’s all calm light again, they’re all wound up again because the circadian lighting got, you know, it kicked them back up to daytime instead of going down towards sleepy time.

Lack of color and/or contrast

If you don’t know a handrail’s there, because the handrails white and the walls white, [residents] don’t use it because they don’t know it’s there. We also perceive space by the edges. Say you use a dark border and then a really light middle. People think the middle is either a hole or a step-up or something else, and can be perceived—again, you stop, and in that pause of not being sure is when often falls can happen.

 

The importance of mock-ups

Sometimes we’ll do mock-ups where we actually lay it out. And then the staff will run a wheelchair through it because they can’t necessarily picture what it means on a drawing. Drawings don’t mean anything to someone who doesn’t read architectural drawings.

 

The heart of this work

Typically, when we do culture change processes about 95 percent of the people who you work with are all for it because they’re only there—it’s their heart. I mean, who else works in long term care unless you have a heart, you know what I mean? It’s just like, it’s so heartfelt.

 

Wrap-up

The work that the Guidelines committees do and the volunteers and the amazing passion and strength behind all those volunteers and all the calls and the amazing staff and everybody else that’s involved in it, I couldn’t match it in any way, shape, or form.