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BOOK REVIEW |
Professor of Architecture School of Architecture and Planning University at Buffalo, State University of New York Buffalo, NY 14214
Design for Assisted Living: Guidelines for Housing the Physically and Mentally Frail, by Victor Regnier. John Wiley & Sons, New York, 2002, 344 pp., $74.00 (cloth).
Design for Assisted Living: Guidelines for Housing the Physically and Mentally Frail by Victor Regnier presents an agenda for the design and management of assisted living facilities. It is both an extensive compendium of information about design and an insider's reflection on the nature of the industry. In addition, it includes an illuminating critique of long-term care in the United States. The book is based on research, conducted both by the author and others, and on many years of practical experience in the field. Victor Regnier is one of the world's premier authorities on assisted living and, more generally, housing for older people. He is an architect and gerontologist who has authored many articles and books. Professionally, he has consulted on more than 250 building projects in the United States, Canada, the United Kingdom, and Germany. He is a former Fulbright Scholar and has received numerous awards for his work.
A Wealth of Information and Ideas
Weighing in with 344 pages and more than 200 illustrations (23 in color), the book has a wealth of information. There are four main parts to the volume: "Assisted Living Defined," "100 Critical Design Considerations," "Case Studies," and "Conclusions and Directives." The book is intended as a resource for architects, planners, interior designers, landscape architects, housing providers, gerontologists, nursing home administrators, housing managers, and policy makers. Although it sounds like a tall order to write for such a diverse audience, the organization and style of writing make it work. The most notable feature of the content is the focus on "best practices" and the case study method of research. Although Part III has 14 detailed case studies of entire projects, Part II makes extensive use of examples from many buildings. Every "design consideration" is illustrated with a photograph from an actual building.
One of the unique features of Design for Assisted Living is the inclusion of extensive information and commentary on developments in this field in northern Europe. In the early 1990s the author did a study tour of assisted living facilities in five European countries, visiting more than 100 facilities. He wrote two books that documented the European experience in this field. In 1999 he completed a second study tour, this time visiting 95 new projects in the same five countries. In between he became very familiar with the assisted living movement in the United States through his consulting work on more than 100 projects and a series of one-day "post occupancy evaluations" he completed each quarter of the year. Regnier writes in the Preface: "This book, for me, is like an evaluation. It is about taking stock of what we have learned and what needs to be explored further" (p. x).
The author himself puts great emphasis on communicating the extent of his experience and the depth to which he has investigated this building type. His presentation is definitely convincing. I was daunted by reading that in his trips to northern Europe Regnier had visited so many facilities. I would certainly be burned out by a tour even one quarter in scope! It is a tribute to his commitment to this subject that he would take on such an extensive investigation.
In this book one can find "9 features of assisted living," "8 conceptual frameworks," "100 critical design considerations," "20 lessons learned," "20 most important design issues and consideration," and "6 concluding issues." At first, this obsession with lists may be off-putting, but it is a technique that my colleagues and I have also used quite effectively when communicating with designers. Practical people want the answers. They don't want to wade through a lot of verbiage and discussion before getting to the golden nuggets. This book makes it easy to find the information that you need to do your work better.
Design for Assisted Living is far more than a book of lists, however. The first chapter is a good review of the defining characteristics of the building type. Rather than relying on the broad definition from the Assisted Living Federation of America (ALFA), a trade association for the industry, Regnier defines assisted living by identifying a set of qualities and characteristics that all projects should strive to include. He presents these as a normative standard, knowing full well that "even excellent projects are not likely to include all nine of these features." In other words, he is not content to create a building code or licensing definition. To the author, a house is not necessarily a home. His standards are higher. This utopian spirit challenges the field to reach further than formula-driven design. He exhorts the practitioners of assisted living to create an environment that has certain qualities, not merely a limited set of physical and service characteristics.
Assisted living, Regnier writes, can be defined by projects that meet these criteria (p. 4):
He ends the first chapter by introducing a critique of the hospital-based care model and institutionalization. The decentralization of care services provided by home care networks and improvements in technology allow older people to "age in place" for a longer period of time. At the point where they can no longer care for themselves, he argues, assisted living is increasingly a better fit than a nursing home. Both the regulatory and corporate communities are responding to this reality and examples from northern Europe have demonstrated the feasibility of the residential care model for all but the most disabled persons.
Two chapters provide overviews of key research in the field. Chapter 2 reviews the findings of a study of the assisted living industry that was conducted by ALFA. This study defines the nature of facilities today and identifies trends in the industry. Included are demographic statistics, extent of services provided in facilities, characteristics of buildings, and cost information. This information is particularly useful to developers and managers of facilities. Chapter 3 provides a review of "conceptual frameworks for assisted living environments and services." This chapter is particularly useful to researchers and scholars because it brings together in one place the ideas of other researchers and leading practitioners. It also demonstrates a consensus in how experts conceive of this building and service type.
The heart of the book is in Part II, "100 Critical Design Considerations." These strategic considerations for good design are organized into 10 chapters, each dealing with a different set of issues, including neighborhood and site, fostering independence, and the dwelling unit. They focus on the quality of life for residents and making the building attractive to family and friends. There is a wealth of information and ideas embedded in these strategies—everything from how the building should fit on the site to how it can engage the staff. As an architect, I particularly appreciated the introduction of basic design lore like how to make the most of corner locations and making small spaces appear bigger. Too often, books like this are focused on the unique features of a type and do not explore how common design problems intersect with the unique challenges it presents. For example, Consideration #32 is "Corridors as Rooms/Corridors with Character." Extensive corridors are a common problem in many buildings. Regnier presents six strategies to minimize their negative impacts. He explains why each strategy works in detail, giving insights and examples to illustrate his points. He introduces many basic architectural concepts such as how decorating the corridor reduces the perceived length of time it takes to traverse it and why a corridor over 40 feet long looks so long and boring and what this means for the frail older resident. These architectural insights are valuable contributions to the broader field.
The 15 case studies in Part III of the book offer a different lens into the land of assisted living. Whereas Part II provides a detailed examination of specific issues with many examples introduced from actual buildings, the case studies provide a holistic perspective on leading projects. They were selected to demonstrate a wide variety of projects, both from northern Europe and all regions of the United States. The case studies range from large to small and from urban to rural. They also include a wide variety of housing types, ranging from apartments with services to dementia care facilities and nursing homes. This diversity is particularly useful because geography and climate play an important role in design and, as a whole, the cases demonstrate how Regnier's criteria can be applied across facility types. Each project is described with plans, photographs, statistics on the project, and a description of how the buildings "operate for the older person." This last type of descriptive information provides a snapshot of what life in the facility is like.
In the last part of the book, the author makes an effort to reflect upon what he has learned from his research and experience. He uses several approaches to accomplish this. First, he identifies the key lessons of the northern European experience as a whole. Second, he examines the specifics of each country's approach to show how different ideas emerge based on the context of each culture and social policies. Third, through a chapter on the "20 Most Important Design Issues and Considerations," he synthesizes, in a more manageable form than the 100 Critical Design Considerations, what he considers to be the most important goals of design and policy using one illustrative example for each. Fourth, he identifies and discusses future trends.
This book is an excellent resource for a wide range of professionals and researchers who are interested in assisted living for older people. It presents an informed review of the state of the art in this field backed up by a wealth of information. The organization of the book is particularly useful for practitioners, including designers, administrators, and professional service staff, especially those who are contemplating or in the midst of a planning and design project. This book could also be a valuable resource for older people and families seeking to find a good assisted living facility, although the amount of information may be a bit overwhelming for this audience. I hope that the author will think about producing a shorter, more concise, guide for the consumer to use based on the information in Design for Assisted Living. That would be an excellent way to reach an even wider audience.
Philosophical Ideals
Although there are many issues presented in the book that deserve detailed discussion, I think the most important to highlight are the ideals that Regnier presents for the assisted living industry and his vision of the future.
The author views assisted living as more of a philosophy than a building type. This is a very different perspective than the common view of the concept on the street. To most consumers, assisted living facilities are viewed as one of the points on a continuum of living arrangements for older people ranging from completely independent housing to long-term care facilities with extensive medical services (e.g., nursing homes). The common belief is that assisted living provides a housing option for people who need a level of supportive services and care beyond what can be provided in supportive housing environments and stopping short of licensed long-term care. They also are a lower cost alternative to care than a long-term care facility.
Assisted living as a building type has always been hard to define precisely, however, because there are a variety of ways that this niche can be filled. For example, Regnier reports that ALFA's definition of assisted living begins: "[A] special combination of housing, supportive services, personalized assistance and healthcare" (p. 3). This ALFA definition can be applied to many service-supported, or congregate, housing types and also to many nursing homes.
Regnier discovered in northern Europe that successful assisted living models include service-supported housing, long-term care facilities, and everything in between. He argues that the definition of assisted living should not be focused on a building type, but rather on the philosophy that underlies the program, the way that philosophy is carried out in the design of the building and services, and the experience of the residents, taken as a whole. Whether this happens in a context that emphasizes more independent apartment living or a licensed long-term care facility or something in between is immaterial. The key to his vision is the emphasis on the word "living." Assisted living provides assistance for living. It helps residents continue their lifelong development as individuals as part of a social network rather than treating them as if they have no future as people and no connection to the community.
Looking to the future, Regnier takes this argument further. He argues that assisted living is a philosophy that has a growing body of adherents and will continue to expand due to a mix of consumer demand, economic realities, technological advances, regulatory adaptation, and competition in the larger framework of aging services. The growth of adult day care and improved health care and wellness programs geared toward longevity, he believes, will allow people to remain in independent housing longer with a spouse or other family members, delaying the move to assisted living. Thus, the population entering assisted living facilities will be less healthy and more dependent than it is today. More chronically ill and dependent populations will be attracted to assisted living facilities, and governments will develop policies that allow people to stay in such facilities longer. The ability of assisted living programs to address this challenge will be enhanced by advances in building design concepts, technology, and therapeutic practices.
As for the nursing home industry, it will address consumer demand and the economic disparities by moving toward a more residential model to accommodate people with higher service needs. Perhaps third-party payment programs including Medicaid will accept assisted living as a feasible alternative to skilled nursing care and force the nursing home industry to change its model. Regnier predicts that skilled nursing homes will move more and more to a single-room occupancy model, which is now almost universal in northern Europe and is a key feature of assisted living. Thus, the two "building types" will move closer together.
Regnier also believes that family participation is central to the success of assisted living. It is much more family friendly than the skilled nursing care model and thus families feel more welcome in the former. He also believes that residents move to assisted living facilities based on their environments. He reports that building design is one of the most important attributes consumers cite when describing why they moved to a particular assisted living building. The economics allow facilities to capitalize on this fact. Regnier points out that a $300,000 reduction in the cost of a building translates into only a $3 per day reduction in the overall cost and represents only a savings of 5% in a daily charge. This not enough savings, he says, to justify the impact that such a cost reduction would have on the building's appearance, given how important design is in attracting residents.
An Agenda for the Future
Regnier focuses on the lessons of northern Europe in proposing an agenda for the next generation of assisted living in the United States. Two of his recommendations are particularly astute. First, he proposes that assisted living should take on an increasing community-based orientation and become a focus of neighborhood services and family support. Assisted living facilities could capitalize on the expertise they have developed in providing individualized services in-house to bring them to the community at large. In particular, they can provide assistance to families in planning and making decisions for the later years of life. Second, he proposes that an active lifestyle should be encouraged through an emphasis on movement therapies and wellness. In the United States, he observes, contemporary facilities emphasize a passive lifestyle through an environment designed for relaxation rather than rehabilitation. While this appears benign, there are serious health consequences of a setting where everything is done for the resident. Northern European models emphasize physical and occupational therapy, and link therapy to more informal activities like access to fitness equipment and participation in food preparation.
I find Regnier's arguments and recommendations very persuasive. The examples from northern Europe demonstrate the ideals of assisted living in practice and how, with an enlightened care philosophy, these ideals can be imbued in both the facility design and the service program. However, I am not convinced that the industry in the United States will live up to the challenges and the ideals set by Regnier. How many assisted living facilities measure up well to these ideals? Certainly the facilities he uses as case studies have adopted many of the principles he proposes, but I wonder how extensive their penetration has been in the industry. My own experience selecting a facility for my father suggests that there may be great regional differences, reflecting the degree of local competition, prosperity of the region, and sophistication in planning and design. In addition, there may be a relationship between adoption of the ideals and the cost of the services provided. Perhaps Regnier will, in the future, research and report on barriers to adoption of best practices and the degree to which they are available to a broad range of income groups, to people from all walks of life, and in all geographic regions of the United States.
I think there is a challenge that the industry must face that is not discussed in Design for Assisted Living—how to serve the populations that may not be able to afford to live in the "exemplar" facilities. It is not a challenge for the industry alone, of course. The northern European countries all have national health insurance and social welfare services that evidently pay for the ideals of assisted living, although I am sure there is quite a range of quality in facilities. At least no one is denied the opportunity to live in a good facility due to income or other factors. In this country, we have not yet developed a financial support system that would pay for bringing the assisted living model to all older people. The United States has to adopt the philosophy at a high level and follow through by making it a reality on an inclusive basis. Sadly, there doesn't seem to be much movement in that direction although there are glimmers of hope. I also wonder about the willingness of long-term care insurance providers to recognize the value of the assisted living model and goals like the recommendations made by the author. Although current policies cover assisted living, when the rubber hits the road, will they pay for Regnier's definition or will they only pay for a shallow imitation? Design for Assisted Living certainly sets forth an agenda for the industry that is laudable and inspiring. Now, it is important that we find ways to make sure that this agenda can be far-reaching in its impact and inclusive in the range of older persons that it affects.
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