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Among the most vulnerable in the pandemic have been the elderly who reside in assisted living or skilled “lifecare” communities. These senior facilities have been designed to eliminate isolation and loneliness. However, residents in these group settings have proven highly susceptible to contracting the novel coronavirus, as it’s able to rapidly spread among people in close quarters.
But changes are in the works—some already being implemented and others requiring more time and money.
The U.S. Green Building Council recently released new LEED guidelines for best sustainable practices for the COVID-19 era. The changes focus on cleaning and disinfecting, indoor air quality, water systems, and reoccupancy practices and human behavior within spaces. And the American Institute of Architects just published a report, Reopening America: Strategies for Safer Buildings, with a section dedicated to senior living communities.
© Xenex
At some point, the safety of a facility may be measured by a health care–associated infection score, which is currently used in hospitals, says Sarah Simmons, epidemiologist and senior director of science at San Antonio-based Xenex, a manufacturer of germ-zapping robotic solutions.
“A lot of diseases we worry about in elder care settings are spread through coughing, but a substantial proportion are from a dirty environment and cause recurrent infections,” she says.
For the most part, the suggested changes fall into five categories that aid physical and emotional health while making infection control a priority. Real estate professionals should take note of these recommendations and share them with clients who are weighing elder care for themselves or family members.
1. Layouts
© Green House Project
Facilities that have adequate space and available funds may decide to renovate to create more single-occupancy rooms. Some buildings may want to reorganize so there are fewer rooms in a single wing and residents are better isolated in the event of an outbreak, says Nick Steele, senior interior project manager at AECOM—San Jose, an architecture, engineering, and design firm. He is also vice president of advocacy for the International Interior Design Association’s Northern California chapter, which works to help make better decisions for elder care facilities.
At the same time, there must be a balance between health safety and the negative effects of isolation among the elderly. “Flexible layouts can address these challenges holistically without adding square footage,” says Patrick McCurdy, a principal and leader of the health care practice at Hoefer Wysocki, in Leawood, Kan. “Future facilities should be designed for maximum flexibility and adaptation to the unknown—this includes infrastructure for minimizing cross-contamination and technology for contactless care, such as telehealth.”
Drew Roskos, housing studio leader at HED, an architecture, planning, and design firm in Chicago, says that using movable furnishings can help make adjustments. Having access to the outdoors for fresh air and natural light will also benefit everyone, including the patients themselves and visitors (when permitted). Outdoor space can also be used for dining when the weather is good, the AIA report recommends. However, Simmons offers the caveat of excluding outdoor water features that can transmit bacteria and the potential for Legionnaires’ disease.
Steele recommends having multipurpose rooms where staff could stay overnight if an outbreak occurs, which would help them avoid traveling home and spreading pathogens.
Bathrooms should also be reworked. Poor ventilation systems can pose risks because bacteria can harbor on surfaces and in the air unless a toilet is used quickly and the lid closed, Simmons says. Communal and private bathrooms could be outfitted with touchless faucets and valves, say Joseph G. Allen and John D. Macomber, authors of Healthy Buildings: How Indoor Spaces Drive Performance and Productivity (Harvard University Press, 2020), which cites nine ways to improve buildings without expensive technology and capital improvements.
2. Materials
To reduce the spread of bacteria, viruses, and fungi, design professionals are using materials that have a natural ability to kill harmful microbes relatively quickly. A favorite is copper alloys for doorknobs, drawer pulls, IV poles, bed rails, and other surfaces, because it has a higher antimicrobial factor, McCurdy says. Steele advises leaving off the clear coating that covers the alloys since it makes the copper ineffective at killing bacteria. When well-maintained and regularly cleaned, this choice can kill more than 99% of bacteria that come into contact.
Switching from curtain partitions to glass or plexiglass panels will protect against the spread of germs and ease sanitizing. The use of antimicrobial fabrics can also hinder or eradicate the growth of unwanted bacteria, McCurdy says. For disinfection purposes, hard surfaces are best constructed from nonporous materials, like quartz and Corian, rather than more porous marble and laminates, Simmons says. For flooring, she recommends porcelain tiles, vinyl, and wood rather than carpet for similar reasons. For walls, paint has advantages over wallpaper. Roskos recommends avoiding upholstery with folds, seams, piping, and buttons that impede fast cleaning.
3. Air Quality
Clean air is the most emphasized factor in the WELL Building Standard, a certification for buildings that measures the impact on human health, says Steele. One key to meet the WELL standard is to keep the interior of the HVAC system clean, particularly in older buildings where ductwork can be hard to reach, Steele says.
The U.S. Green Building Council guidelines suggest adjusting ventilation and air filtration. Other options are to use UV lights that sterilize surfaces and kill viruses and bacteria or to add portable air purifiers.
While there’s no way yet to stop the coronavirus completely, its spread can be hindered by adding bipolar ionization indoor air quality devices into HVAC systems, says Tony Abate, vice president and chief technical officer at Fairfield, Conn.–based AtmosAir Solutions, who’s an expert on the airborne transmission of viruses. “Bipolar ionization is a proactive technology similar in concept to the Pac-Man game. It attacks, mitigates, and curtails the spread of deadly viruses,” he says.
Macomber warns against the potential for facilities looking to cut costs by using cheap products or not changing a dirty filter. “If people get sick, they are less productive, and that is worth a lot of money,” he says. "We need to look at the whole picture, not just the energy budget.”
4. Smart Technology
Buildings may incorporate more smart technology, such as automatic doors, touchless hand-washing stations, disinfectant chambers at entrances, and voice-activated systems that control lights and the temperature, says Steele.
The AIA report suggests implementing regular temperature checks on residents, workers, and visitors by using infrared scanners. Mark Francis, vice president of special projects, team, and family experience for Schonberg Care, a long-term care company headquartered in New Orleans, anticipates the possibility of a room equipped for virtual doctor visits so staff can perform exams and relay results to off-site medical personnel. “This is already happening around the country, but it’s not as prevalent as it could be with situations like COVID-19,” he says.
© Xenex
Xenex’s portable disinfection machines can move through spaces, rapidly pulsing UV light to deactivate pathogens that are frequently left on surfaces, Simmons says. Pulsed xenon UV light does not damage surfaces, which some UV mercury vapors do, she adds.
Real-time locating systems embedded into badges or other devices, can track interactions as people move throughout a facility, says Peter O’Connor, principal, clinical technology solutions at Hoefer Wyosocki. “This can help encourage crucial functions such as hand-washing or facilitate locating medical equipment and care team members,” he says. “Technology will also offer patients greater control over tasks, from raising and lowering shades to ordering food and controlling temperatures.”
There should also be a good supply of laptops and smartphones that are cleaned regularly so residents can maintain relationships virtually if in-person visits aren’t possible, the AIA report advises.
Also on the horizon could be 3D-printed food that can repurpose food waste and mix ingredients in new ways to compensate for food shortages, Roskos says.
5. Design
© OZ Architecture
While health and safety are the motivating factor for elder care facility updates, architects at Denver-based OZ Architecture also believe that design can uplift residents’ spirits. One method is to reduce the scale of a community into smaller hubs. That also makes it easier to minimize residents’ contact in an emergency and curtail the circulation of poor air or pathogens throughout a building. “It may cost more to incorporate more mechanical units on a roof, but there would be advantages in case of a pandemic,” says OZ principal Jami S. Mohlenkamp.
Natural light and views are key, too, he says, and artwork, residential-style window treatments, and accessories can enhance the look.
© Green House Project
Some of his ideas stem from working with Dr. William H. Thomas, a geriatrician and co-founder of the Green House Project, a Baltimore-based nonprofit organization focused on designing alternatives to institutional-style nursing homes. The concept places 10 to 12 residents per home, with private bedrooms and bathrooms and an abundance of natural light.
“In a skilled nursing or memory care environment, that’s important since residents don’t tend to go outside,” Mohlenkamp says. “We wanted everyone to see clouds in the sky and stars at night.”
The Green House Project’s model offers the benefit of “human connectedness with social distancing,” says Senior Director Susan Ryan, which works well during the pandemic. While many updates may increase the cost of construction, prices should eventually decrease once these design methods become more widespread, Steele says. And the anticipated benefit is priceless: healthier living.
Two Emerging COVID-19–Era Trends
Evaluate first. Engineers John Bilotta and Tony Gonzalez of New York City–based Syska Hennessy Group advise owners, managers, and designers of elder care facilities on what diseases and viruses pose risks and how to evaluate buildings’ existing systems. They consider what kind of HVAC system each building has, whether it has independent temperature controls, how much fresh air comes into each building, and, if there’s an outbreak, whether the system can be adjusted, says Gonzalez.
In the case of COVID-19, the question is whether to increase the outside air supply to dilute what’s inside, he says. And if that’s the recommendation, does the system have the heating and cooling capacity to maintain the space’s temperature? “We also have to design according to the facility’s budget and state and local codes,” he adds.
To weigh all the possibilities and be able to provide the best solutions, time is required to make the best designs, says Bilotta. “Yet, nobody wants to hear in a crisis that you need time. They need a solution quickly,” he says. “We must rely on our best design practices, which includes different types of air handling systems and air distribution or different types of air filtration.”
Rethink location. While it’s often been less costly to build in suburban and rural areas versus denser urban sites, Chicago architect Drew Roskos thinks the denser areas offer the advantage of connecting residents to a larger public community outside their limits, which presents greater chance of success and good health.
“The most significant attribute of placing communities in denser areas is the greater access to people and activities, which can improve mental and physical health. A weak social life can lead to depression and amplify the impacts of chronic disease,” he says. “It’s my opinion that multigenerational neighborhoods also reduce the negative effects of ageism.”
