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Is Assisted Living


Industry Insiders Share Problems and Solutions

By Richard and Carol Meier

This book is dedicated to our beloved parents, Howard and Bernadine Clapp and Frank and Eileen Meier.

Acknowledgements: This handbook could not have been written without the indispensible assistance of those who contributed to its creation. Many thanks to Helen and Troy Hellenbrand, Joan Kettner, Jim Salter and Dave Gillespie of Gillespie Design Group for their valuable input and support.

Note: This handbook is presented with the understanding that the authors, publisher and any distributor do not render any legal, medical, healthcare, accounting, or other professional service or advice. The information contained herein is intended as an educational aid only. The authors present the information herein as a service to our readers. While the information in this handbook discusses legal and medical issues, it is not legal or medical advice. Moreover, due to the rapidly changing nature of the industry, and our reliance on information provided by outside sources, the authors make no warranty or guarantee concerning the accuracy or reliability of the contents of this handbook.

Copyright 2012 Richard and Carol Meier

Table of Contents

A Brief Assisted Living Design Retrospective
Richard and Carol Meier are pioneers in assisted living. They entered the field in 1987 as they started to explore and understand the assisted living portion of senior housing. Carol and Rick had health care experience in nursing homes and hospitals, and were thrilled with new and developing options to provide care and assistance to the elderly. They were pleased with efforts to increase the quality of life for seniors, to provide a safer environment for them to live in and to help them with the activities of daily living. The goal of assisted living that Rick and Carol found to be most attractive was to allow the senior to live in the most independent, least restrictive home setting as long as possible, and to keep them out of hospitals and nursing homes. Rick and Carol have developed and operated assisted living/Alzheimers homes for hundreds of residents for over a decade, and have developed other senior housing projects for more independent seniors. They were Founders of the Wisconsin Assisted Living Association WALA.

Generation 1 Homes the 1980s

When the Meiers initially reviewed the assisted living profession in the late 1980s, there were 52 total homes in Madison, WI. Over 94% of these homes were 8 beds or less in resident capacity. Most of these homes were converted from being single family residences, where 2 residents shared a bedroom. The early home conversions were most commonly ranch style homes with 4, 5 or more bedrooms. The residents would likely share a bathroom with 4 or more other residents. The homes would vary from 2,500 to 5,000 square feet. Few early assisted living residences were new and designed specifically to serve the elderly. Few homes specialized in care if the senior suffering from Alzheimers or other dementia. The majority of operators of assisted living in the 1980s were the owners of the home providing the residential services. Many lived in the home with the residents. They were often relatively short 4

on skilled business development and operations, but were long in effectively caring for their residents. More sophisticated business participants, such as corporate owners from nursing homes and hospitals were also entering the field in the late 1980s. Their design efforts reflected their skilled care orientation with long halls and centralized services. They built what they knew.

The Mature Phase of Assisted Living

Generation 2 Homes the 1990s to the Present
Companies specifically organized to develop and operate assisted living residences started forming in the early 1990s, with multifamily residential builders being a strong participant. These entrants built what they knew too apartment building like projects again with long hallways and centralized services. The builders seemed to leave the field after their first project as the provision of services to the elderly was underestimated by them. Other developers picked up these properties. In the 1990s residences changed significantly as purpose built assisted living and Alzheimers homes were developed. Developers were now offering private bedrooms and baths, and afforded the residents more room and privacy. Homes became larger during this period, with 15 and 20 bed residences being a more common size in the 1990s and 2000s. It was not uncommon to have projects of 50-75 or more residents. In 1990 the Meiers entered the DeForest, WI. market with a home that offered 20 private bedroom and bath living units. The project was very well received by the market. Residents were clearly looking for more room and more privacy. In 1991, the Meiers opened a 29 unit home, in Stoughton, WI. with 27 private bedroom and bath units, and 2 apartment units with kitchens, living rooms, baths and separate bedrooms. Again the project was extremely well accepted by the public who appreciated the choices becoming available in assisted living. Later in 1994, the Meiers opened a home with all apartment units. The mix in this project was 28 studio apartments and 6, 1 bedroom apartments. In 1994, were added 34 studio and 1 bedroom apartment units were added to the Madison, WI. residence. In 1999 the Meiers 5

opened a 95 bed residence in Appleton, WI. serving both assisted living and Alzheimers residents. This phase of assisted living continued to be designed around the apartment building model, however. Resident living units continued to be accessed via long hallways which took them to and from activities, dining, religious services, hair and medical appointments and exits. Often the number of residents in the home determined the length of the hallways. When resident capacity increased, the longer the hallways became. Obviously, residents needed to negotiate these hallways as a part of actively and satisfyingly living in that home. These new homes were gorgeous, more efficient to operate and certainly an improvement of the smaller shared bedroom homes of an earlier phase of assisted living. However the resident was not always well served by these new designs.

Problems with Generation 2 Homes

As the Meiers studied the market since 2008, it became clear that something was wrong. Surprisingly and disappointingly wrong. Richards review of several homes was a sad surprise to him. There were many problems in assisted living. Some homes were not well maintained. Some homes were designed for more mobile residents and were now having difficulty serving the increased number of residents who required wheelchairs. Many homes had narrow hallways, confusing and complex layouts or additions, and poor area lighting. The number of homes that served 30, 40 or more residents had increased over the years. When, in 1987, 94% of the assisted living homes were 8 beds or less. In 2011, according to WALA, only 50% were 8 beds or less. The average size of CBRF assisted living in Wisconsin is now about 20 residents. However, as the size of homes had increased, the distance residents had to travel within the home increased too, generally to the disadvantage of the residents. Falls and problems with resident confusion and getting lost in the hallways were, and still are, far too prevalent.

While the Generation 2 Homes were a welcome improvement over Generation 1 Homes with more privacy, more amenities and more space; residents of Generation 2 Homes are still suffering from one problem that remained as prevalent and devastating as ever. Resident hallway issues, such as not being in the sight of staff, falling, getting lost, assisting residents who are unable to move with confidence within the home, forcing staff to leave residents they were working with to find, care for, assist and redirect residents lost or having problems in the hallways. Falls remain the largest cause of the relocation of loved ones from their home into assisted living, and from assisted living into hospitals and nursing homes. Falls cause broken bones, concussions and other injuries which very often force the resident into more restrictive living conditions such as skilled care. No other factor contributes as much to serious health problems for seniors than falls. A study by the Alzheimers Association in 2012 titled Alzheimers Disease Facts and Figures stated the following are reasons that Alzheimers stricken residents are hospitalized (some from home, some from assisted living): 1. 2. 3. 4. 5. Falls and Syncope (light headedness) Heart Problems Gastro problems Pneumonia Mental 27% 17% 9% 6% 5%

Falls are over 5 times more likely to be a cause of hospitalization as mental issues, over 4 times more likely than pneumonia, over 3 times more likely than gastrointestinal and 50% more likely than heart problems. How can we go on not addressing this issue? Through the first 2 generations of assisted living home designs, falls are still the biggest cause of injury, relocations and hospitalizations. Little progress has been made. Reliance on wheelchairs and walkers has not been the answer. Assisted living designs of Generation 2 Homes are still based on the apartment building design criteria. The basic architectural design paradigm of assisted living has not changed for 25 years!

Resident falls have not been addressed in the design of Generation 2 Homes. Many homes are beautiful and attractive, but they remain unnecessarily unsafe for their residents unsafe in ways that needlessly shorten the residents length of stay in assisted living, degrades their quality of life while they live there and then sadly forces them to live the remaining days in skilled care facilities from which they never leave. Long and complex routes of travel in Generation 2 Homes still confuse and frustrate residents who become lost in them. Residents often live in dread of having to travel in certain (or all) hallways. It is time for a new paradigm that truly helps these residents. Long and complex routes of travel in Generation 2 Homes bring additional danger to both the assisted living frail senior and the Alzheimers sufferer. When residents are out of the sight of staff, they are out of reach of immediate assistance. If they become injured while out of sight, they may wait a long time for help. As with strokes, the longer one has to wait for help after suffering an injury the worse things become fast.

The Safety Paradigm

Generation 3 Homes 2012 and beyond
In 2008, Rick and Carol agreed that they wanted to open new types of assisted living/Alzheimers homes. The criteria for these new homes were that they must become a major step forward in assisted living/Alzheimers design and operation. The Meiers researched literature and the Internet to find what new designs were now being developed. Those designs are bringing forward new assumptions and ideas, while questioning the status quo. New ideas are badly needed. These new designs took different approaches to serve the needs of todays assisted living/Alzheimers residents. Outside the Box thinking was what mattered. Rick has put these ideas together to look at what Generation 3 homes should provide to residents and operators.

In 2009, Rick recognized that his mother, Eileen, was showing signs that she would soon be no longer able to have a safe and satisfactory quality of life without constant supervision, assistance and support. Richard and Carol, and Richards sister Marge, had been assisting Richards mother for 3 decades, as she lived alone in her own home until she was 93 years old. The journey of finding the best assisted living home for Eileen dictated that Richard visit many assisted living/Alzheimers care homes in Madison to find the best match of services and accommodations for her. He, of course, included homes that he had previously built and operated in the Madison area, as well as others. It became clear that most homes (including the ones Rick had designed previously) were not well suited for the healthcare needs of todays resident. The design of the building itself was often presenting problems to the safety, satisfaction and retention of the residents. Long hallways and centrally provided services were causing problems for the resident of today. It was maddening for Rick to see that the basic design of the new homes in the Madison area was no different than the assisted living homes Rick built in 1990. The new homes Rick visited were still built and designed like apartment buildings. That design worked better in the 1990s with a healthier resident, but is no longer appropriate or even safe for the resident of today. People are now less mobile, less coherent and frailer than 10, or even 5 years ago. Generation 2 designs do not work well for this population. A Generation 3 design is the solution. This book will discuss Generation 3 Homes, why they offer advantages to everyone involved, how to find one, and what to avoid, if you are helping your loved one into assisted living.