A Case Study – Part 2: Cultural Transformation

This is the second post of a series dedicated to a case study of a single project—the VA Roseburg Healthcare System Community Living Center (CLC) Expansion— designed by Robertson/Sherwood/Architects. Click on “A Case Study” in the Labels list at right for the full series.

The VA Roseburg Healthcare System has provided first-rate Alzheimer’s and dementia care to veterans for many years through the Protected Care Unit (PCU) on its main campus in Roseburg, Oregon. Unfortunately, the PCU is physically deficient in many ways, particularly with respect to a recent mandate from the Department of Veterans Affairs to transform the mode of care to a more patient-centered approach. This post describes the impact of that “cultural transformation” upon our design for the new CLC Expansion, which will entirely replace the old PCU.

The transformation involves a move away from the traditional nursing home paradigm —characterized as a system that fosters dependence by keeping residents well cared for, safe and powerless— to a “regenerative” model. This innovative model is also referred to as “resident-centered” care because a goal is to increase the resident’s autonomy and sense of control. The VA is a late-adopter, only now catching up with the private sector and the trend toward this enlightened philosophy of care.

The VA has a huge suite of design guidelines for its healthcare facilities, which we’re obliged to follow. These guidelines prescribe everything from goals for energy reduction to the exact size of spaces devoted to storage of clean linens. Periodically, these guidelines become outdated and in need of renewal. For the CLC Expansion project, our design team found itself on the cusp of a major update that resulted in the current Design Guide for Community Living Centers. We initiated design of the project and meetings with the PCU staff without the benefit of the new guide. At the time, we didn’t know we would be thrust into the middle of a contentious cultural transformation debate pitting in-the-trenches caregivers against well-intentioned policy-makers in Washington, D.C.

The consequences of finding ourselves in the middle of this transformation were significant. We started, stopped, and then started again the programming and design processes.(1) Initially, the program called for separate memory-care and hospice suites totaling 22,000 gross square feet; with the changes wrought by the transformation, the VA reduced the overall project scope and abandoned plans for the 10-bed hospice. Ultimately, the program would require 20 Alzheimer’s/dementia patient beds housed within a facility totaling approximately 18,000 square feet.

Most importantly, our new charge was to focus our programming effort upon the quality of life to be provided to the patients, rather than upon achieving machine-like efficiency and maximum staff convenience. This is not to diminish the importance of functionality; rather, it reflected a desire by the VA to honor and provide its resident veterans with as dignified, de-institutionalized, and life-enhancing an environment as possible.

It’s difficult to overstate the magnitude of this shift in focus. The Roseburg VA’s excellent staff knows what works for them when it comes to delivering care to its PCU patients. The challenges the nurses face everyday—from dealing with inappropriate outbursts, paranoia, and violent behavior, to assisting with everyday tasks like eating, bathing, and dressing—cannot be ignored. It’s no surprise that their world-view is filtered through a lens that focuses upon operational efficiency. They must contend with issues that few of us outside of their profession can fully appreciate. Nevertheless, the latest research regarding Alzheimer’s disease and related dementias highlights the importance of good design as a treatment factor.

Functional Relationship Diagram from the Design Guide for Community Living Centers, June 2011

Fundamentally, the new program objective involves mitigating the realities of aging, including issues related to rehabilitative, memory, and palliative care by providing a supportive and comfortable environment. This means creating a real home for those being cared for in a house-like setting. Accordingly, our design for the CLC Expansion project will promote a culture of care that is patient-centered rather than staff-centric. This direction is supported by critical research and evidence-based observation.

Keys to this new model of care are the following principles:

• Understandable architecture
• Sensory stimulation
• Safety
• Wayfinding
• Minimizing confusion
• Settings for small groups
• Providing residents with options

The cognitively impaired patients in the CLC will likely be divided into two sub-populations:

• Those who suffer from diminished memory and flawed judgment but are active and fairly physically adept.
• Those who are profoundly physically and mentally impaired.

There are several national models of culture change in the housing of memory-care patients that our team looked to. The common thread is a philosophy that supports resident choice, the creation of individualized living spaces, and respect for each person’s individual needs. Planetree and the Green House Project are two of these models.

The new program follows both the Planetree and Green House design models by requiring a residential-style kitchen, a fireplace, and plenty of natural light through windows and skylights. The staff and patients will use the kitchen in each “house” for baking cookies, making coffee, toast, etc. The CLC staff does not envision full preparation of meals at these kitchens as this would be handled by Dietetics, located in a neighboring building on the campus. In this regard, the operation of the kitchen in each of the houses will not fully conform to some patient-centered care models because meals are not cooked on site. Regardless, meals prepared by Dietetics will be brought to the residential kitchens and served family style or consumed by patients in accordance with their own schedules.

In addition to the private bathrooms within the patient suites, the CLC Expansion will include a shared grooming room with a bath spa in each house. This will allow residents through restorative care to maintain (for as long as possible) their ability to perform basic activities, such as combing their hair and brushing their teeth.

The CLC Expansion will also feature a salon and a home for a companion dog that will have the same free access to the secure courtyard outdoors that the residents would have access to while being contained by an attractive fence.

An important consideration is the need to control unauthorized exiting from the facility. Intentionally or otherwise, residents may attempt to leave their home. Accordingly, the project will incorporate access control systems, such as proximity card readers, delayed egress at emergency exits, and a sallyport vestibule at the gatehouse entrance to the secure courtyard. Other measures will include camouflaging of doors not normally intended for use by the residents.

The design will be comprised of distinct and home-like units. These will best meet the needs of cognitively impaired residents who are mobile and energetic, and/or restless or particularly disoriented. Such a concept eliminates long corridors and makes it easy to include small, family-scaled gathering spaces.

Each unit will be staffed by a team of universal workers, known as Shahbazim, rather than registered nurses. Shahbazim will perform personal care, meal preparation, light housekeeping, and laundry tasks. The VA will provide a clinical support team, which will include nurses, therapists, physicians, dietary professionals, and pharmacists. The assigned nurses will be available to each home on a 24-hour basis. The other clinical professionals on the team will visit the houses regularly and as individual residents require.

Patients and staff will collaborate to create a daily routine that meet an individual patient’s needs. There is no predetermined routine, facilitating patients’ independence to the greatest degree possible.

Altogether, the effects of the cultural transformation mandate upon our design for the CLC Expansion have been huge. The mandate fundamentally shaped our response to the challenge of providing a respectful home for veterans tragically afflicted by the ravages of Alzheimer’s disease and dementia. Read the forthcoming posts in this series; my expectation is that you’ll easily grasp how meaningfully the VA’s paradigm shift has impacted our design solution.

Next in the Case Study series: The Tree of Life

(1)  We originally initiated programming in March of 2010, proceeding through site selection, conceptual design, schematic design, and completing design development before the VA asked us to halt work in February of 2011 because of the new mandate. Since restarting, our team has revisited the functional program and carried the project through all of the subsequent phases. We’re presently preparing the construction documents. The VA hopes to solicit bids for the project this April, with construction beginning by mid-Summer.