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Small House; One Size Does NOT Fit All

Posted by: Steve Leone

"Right-sizing". Since the Great Recession of 2009, we’ve become all too familiar if not forever, re-defined the term. In the senior living sphere, rightsizing has alternative meaning though not divorced from the pressures of our global economy. The trend towards small house design, more specific to the long-term care segment, is not new but has gained traction and is commonly debated these days.

Since the early days of neighborhood design, grouping residents (and staff) in more intimate and personalized subsets living within a larger population, we’ve been preoccupied with the concept of small. Akin to research on smaller classroom size and student/teacher ratios, studies have shown that outcomes are more positive within smaller groupings in long-term care environments. Research that dates back to the early 90’s, noted more positive outcomes within smaller groupings that include reduced anxiety, reduction in medication usage, greater resident, family and staff satisfaction and greater socialization among residents.

The small house concept is still young in its development and currently comes in many sizes and shapes. Overall, the concept aims to deinstitutionalize long term care by creating more “homelike” environments for a limited number of residents. This environment can be best illustrated as a grouping of private bedrooms and bathrooms around an open and fully accessible, living room/kitchen not too dissimilar to a two or three bedroom flat or apartment. Perhaps the most recognizable version of the small house concept is the trademarked, Green House ProjectTM which limits the home size to 10-12.

While the small house concept continues to gain momentum, many aspects of the model have been at times, hotly contested. Supporters mostly agree on value proposition and potential beneficial outcomes. What is arguably the most debated aspect of the concept is number of residents to serve. The Green House Project serves 10-12 residents at most which has certainly pushed the range to its lowest extreme. Whether or not the same or better services can be provided and sustained financially however is at the core of the debate. What we’ve found is that there is no conclusive evidence or data that supports or dispels the financial piece of the model.

One of the most progressive long-term care providers in the country, Francis E. Parker Memorial Home (www.franciseparker.com) has landed on the number 16. A detailed modeling of staff time drove the “right sizing” for operations and appearance. Parker’s focus is on healthcare, it does not dilute its services by offering independent living. In each of its homes, Parker had implemented household concepts that provided exactly the type of baseline data needed to inform the development of its new prototype. By studying the staff experience across its households of 12, 16 and 20, Parker’s planning team arrived at its optimal size.

Parker’s Evergreen household had all the desired physical characteristics except that it housed only 12 residents. It included two distinct living rooms onto which, resident bedrooms opened. In the center separating the living rooms, are the kitchen and dining room. Four bedrooms were added during an expansion project that ultimately reached the desired ratios of 1:8 for nurse’s assistants and 1:16 for licensed staff.

When Parker embarked on the design of its newest campus, it included all the data and research gained during Evergreen’s expansion. Parker at Monroe, a new long-term care campus, will feature 6 households of 16 residents each. The households are further connected by shared amenity space allowing for greater socialization for residents and greater staff efficiencies.

Based on evidence and data Parker collected, they were able to validate 16 (residents) as the right size household. Having worked with the team at Parker for over a dozen years, one outcome is certain, they will continue to test their model to gage its success.  What will the right number be once this model is tested? Stay tuned.

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