Assisted living communities have been in lock-down mode since the Covid-19 pandemic struck the United States in mid-March — but this situation is slowly beginning to change.
Over the next weeks and months, assisted living buildings will adapt again in order to facilitate certain visitors and restart some activities. To regain a semblance of normalcy while still protecting the health and wellbeing of residents and staff, they must rely on creative and flexible operational approaches and new technologies.
From parking lots to reception areas, from activity spaces to dining rooms, from hallways to elevators and health care offices to gyms, communities will be reexamining how spaces are used and devising new practices and protocols. Some of these changes will be temporary, put in place to meet the demands of this moment in time. But some of the changes that will be seen over the next few months will stick and evolve into more permanent features as new communities are built — with this in mind, this summer could provide early glimpses into the assisted living of the future.
In some regards, assisted living providers may have no choice but to continue down the road they are headed and enact permanent changes, according to David Mammina, vice president of private sector real estate – director of healthcare and senior living practice at H2M Architects + Engineers in Melville, New York. He anticipates that regulators will begin to mandate that assisted living buildings implement or continue certain procedures and design elements that providers have developed in response to Covid-19.
In other instances, providers will voluntarily opt to continue with some of the practices they develop in the months ahead. Covid-19 is forcing a wholesale reevaluation of standard operating procedures, and providers are discovering certain efficiencies. They also may be willing to sacrifice efficiency in some areas to mitigate risk or keep up with evolving consumer expectations.
Across its portfolio of about 80 properties, Carlsbad, California-based Integral Senior Living (ISL) is examining “every policy and procedure and how we structured things before and changing to adapt to our new norm,” President and CEO Collette Gray told Senior Housing News.
While the future is uncertain, with Covid-19 threatening to spike again, here is one vision what assisted living will look like come late summer and early fall.
Outdoor living rooms
Many aspects of Covid-19 remain mysterious, but recent studies from China and Japan support the idea that transmission is more likely to occur indoors than outdoors. As senior living communities begin to allow loved ones to once again visit residents, expect outdoor meetings to be a first step.
Officials in Ohio gave assisted living communities permission to restart family visits this week, provided that the visits take place outdoors. Communities in Ohio are readying outdoor spaces to host these visits, and senior living providers in other parts of the country are also preparing to facilitate outdoor meetings. By August or September, tents or other structures used for visitation may be a common sight outside of assisted living buildings.
Aegis Living — based near Seattle in Bellevue, Washington — has already invested significant efforts into its Outdoor Living Rooms project. This is an initiative to create safe and welcoming outdoor visitation areas, Aegis’ Tom Laborde told SHN. As of June 1, Laborde transitioned from COO to a senior advisor role with Aegis. He is currently focused on Covid-19 response and infection control.
Outdoor Living Rooms came about because Aegis does not believe that facilitating outdoor visitation should simply involve setting up chairs six feet apart, Laborde said. Rather, the provider wanted to create a prototype set-up that can be customized across its 32-community portfolio, when it is appropriate for a particular building to start outdoor visitation. The company aims to have these in place this month, especially in time for Father’s Day.
The design calls for a wood-framed piece of Plexiglass to create a barrier between visitors and residents, who will wear masks. Comfortable seating for residents and up to two visitors, and the ability to provide refreshments, are also components. Often, these outdoor living rooms will be created under a roofed porch to provide shade, otherwise a tent can be used.
The design of the outdoor space is only one element to consider. A building also has to adapt its operations to support these types of visits. Staff members need to be present to pre-screen residents and visitors, ensure proper social distancing and disinfect the area between visits, Laborde said. Visitation schedules also have to be created and maintained.
The approximate cost to create a single outdoor living room is $1,000. Based on how the spaces have worked in pilot projects at a few communities, the cost is well worth it, Laborde said.
“The stories coming out of it make you want to cry,” he said, noting one example of a resident meeting her granddaughter for the first time.
Visitation tents could indeed become a more common sight outside of assisted living by the end of the summer, said Mammina. It’s possible to install lighting in tents to facilitate evening and nighttime visits, he noted, and to equip tents with misting devices to help cool the air — a key consideration in the hot and humid late summer.
While outdoor visitation tents may become less common as Covid-19 wanes, assisted living communities of the future almost certainly will place a greater emphasis on outdoor spaces as a result of the pandemic.
After witnessing residents enduring long periods of isolation, providers and architects have spoken on the need to include balconies, patios or other outdoor access from individual living units. And courtyards and other outdoor spaces where multiple residents gather will be designed to accommodate social distancing, Mammina believes. For example, benches or other seating areas will be positioned at strategic distances and fixed to the ground.
Entryways: The first line of defense
While much activity will be concentrated outside the front door, those who do enter an assisted living building in the next months can expect to go through a careful screening process.
Lobbies or reception areas may become similar in some ways to to airport security zones, Mammina said. In other words, visitors should expect to undergo varied screening measures, some of which may be done via new technologies and devices that providers will implement.
A primary goal in entryways and throughout buildings will be to limit the amount of surfaces that visitors touch; to achieve this, existing communities will be installing certain solutions, and future communities will be designed to be as “touchless” as possible. One simple example is that many older facilities still have paddle-style doors, Mammina noted, which can be replaced with automatic entrances.
Touchless temperature screening devices will become commonplace, he believes, but he also urges providers to have disposable thermometers available, particularly in the summer months when visitors can appear to have a fever when they first come in out of the hot weather. Providers may also have visitors step on mats that can be filled each day with a disinfecting solution, to clear shoes of the virus. A personal protective equipment (PPE) station may also become a feature of entryways, where visitors will sanitize their hands, don gloves and potentially put on a fresh mask — assuming that they are wearing a mask of their own when they enter the building.
Aegis Living is planning to incorporate several of the elements that Mammina described. By August or September, Laborde anticipates that communities will have an infrared thermometer system that will take a visitor’s temperature. Aegis has been using a kiosk check-in, and is exploring making this a touchless system. A concierge will be present to make sure that all visitors sanitize their hands and are issued a mask if needed.
Questionnaires have been an important part of the visitor screening process since the pandemic began; these will continue in the months ahead, but the questions themselves may change. For example, as antibody testing advances, providers will likely ask whether a visitor has had an antibody test and what the result was, ISL’s Gray said. A rapid Covid-19 test, administered on-site in the reception area, would of course be the ultimate tool in safeguarding a building.
“I think that might very well be an option,” Gray said. “I think it’s going to depend on availability, where the tests are sourced to — whether or not we are seen as a venue in which we should have that additional testing.”
Up to this point, senior living providers have not been prioritized for tests to the same extent as skilled nursing facilities and other health care settings, she noted.
Senior living providers across the country are increasingly cash-strapped, as Covid-19 has driven up expenses while choking off revenue. Adapting buildings for the next phase of the pandemic will also come with costs, and companies will have to make strategic decisions about where to invest. The top priority should be making building entryways both welcoming and secure from an infection control standpoint, in Mammina’s view.
“That’s the first line of defense,” he said.
Hallways and elevators
Visitors and residents alike will have a different experience moving through buildings’ hallways and elevators for the foreseeable future.
In terms of hallways, options are limited for controlling the flow of foot traffic. Some grocery stores and other retail locations have used footprint decals and other visual cues to encourage one-way traffic down aisles, but a similar approach is probably not feasible in senior living hallways, Gray believes.
“If we start getting into, you could only walk this way down the hallway, at some point that’s a residents’ rights issue,” she said.
But staff and residents can and should make efforts to maintain social distancing in hallways, she added.
Hallways could also be transformed by the addition of nurses’ stations, according to Mammina. This could mark a lasting change from the assisted living status quo.
“In any state I’ve worked in, there are no requirements for nurse stations in an assisted living build, because it’s not intended for someone with the acuity to need a nurse station,” he observed.
He believes this will change for a few reasons. For one, medication management sometimes occurs out of a central health care office within an assisted living community, which becomes a hub of activity and can lead to lines of people waiting for their meds. Basing medication management out of nurse stations throughout a building alleviate this crowding and the associated infection control risks. In addition, lines are more likely to form close to elevators, which will become limited to one or two people at a time. A caregiver at a nurse station could help oversee and assist residents waiting in line.
Future assisted living communities probably will be built with more elevators than in the past, Mammina said, but buildings that are already operational have a few options for how to manage these small spaces to support social distancing and mitigate infection risks.
Buildings that are only a few stories tall could program their elevators to stop automatically at every floor on every trip, eliminating the need for anyone to touch buttons. Technology also has a potential role to play here — ultraviolet lighting systems are available that could be used to disinfect elevators, for example, Mammina said. And the plastic laminate that is commonly used in elevators could be replaced with materials, such as copper or other metals, that are less hospitable to viruses.
None of this is possible unless the staff are continuously trained.Tom Laborde
But patience on the part of visitors, residents and staff members will likely be the real key in the short-term — anyone in an assisted living building while Covid-19 remains a threat should prepare to wait their turn to use the elevator. At Aegis, for example, elevators likely will only be used by one resident and caregiver at a time.
“We don’t have any fancy technology to deal with that,” Laborde said. “It’s going to be the human beings who work with us that help us manage, so you can imagine there’s a lot of training that is going to make all this work — none of this is going to be possible unless the staff are continually trained in how to manage residents in this environment.”
Amenity, health care spaces transformed
Covid-19 dramatically shut down common spaces within assisted living communities, as residents have largely been isolated in their living units. Now, amenities such as salons, wellness centers and dining venues are gradually beginning to reopen — but with significant precautions in place.
One common approach will likely be to limit the number of people that gather in a particular place at one time. So, residents will be asked to sign up for appointments to visit salons, gyms and use other amenity spaces, Gray said.
Within common spaces, providers will be moving furniture and taking other steps to create social distancing. Some communities will likely secure furniture to the floor in their new positions, Mammina predicted. He also thinks that communities can and should use partitions to break up larger rooms into smaller spaces, because rather than large-group activities, providers will have to offer more frequent activities and programs for smaller groups of residents.
That’s the approach that Aegis plans to take, Laborde said.
“You might, as you’re walking through the community, see a group of five residents in the living room area participating in an activity, then further down the hall in the activity room, see five people participating in an activity there, then maybe out in the courtyard, there’s five people participating in the courtyard,” he said. “We want to keep the groups small but sufficient so that residents can engage with each other.”
Securing furniture to the floor and using movable partitions can be done in a tasteful and dignified way, Mammina stressed — responding to Covid-19 does not mean that assisted living communities need to become more institutional in look and feel either in the next few months or further in the future.
For example, moveable fabric walls that conjure up “old church basements” are not the only option for partitions; providers could opt for versions that are finished with plants and mosses, perhaps with a planting box at the base.
Dining rooms in particular present challenges, but providers are beginning to conceptualize how they can begin to reopen, taking steps such as:
— Rearranging tables and chairs. Aegis could potentially remove chairs to limit each table to just a single diner, Laborde said. ISL is considering moving tables together, so that multiple residents can sit together but with plentiful space between them, Gray said.
— Plexiglass partitions might be set up on tables between diners, Mammina proposed.
— Residents will dine in shifts.
— Tablecloths, salt and pepper shakers, sugar containers, packets of coffee creamer and similar implements will be removed, to reduce or eliminate the number of objects touched by multiple diners.
Other common spaces within a building could be repurposed. For instance, because in-person tours likely will be uncommon for the foreseeable future, so-called “discovery rooms” where tours begin could be turned into visitation spaces, Gray said. In other words, rather than doing all family visits outdoors, these could be indoor spaces where residents meet with loved ones.
And while health care partners may begin to visit communities in greater numbers in the months ahead, telehealth will likely remain an important way for residents to receive services. Communities may create dedicated telehealth offices where caregivers can assist residents with appointments, if conducting the session in a living unit is not possible or appropriate, Gray said.
While it’s clear that assisted living communities will begin to operate in new ways, Gray and Laborde both emphasize that reopening of ISL and Aegis communities will be done carefully and in a phased approach, based on appropriate public health guidelines and internal company benchmarks. And, they anticipate that restrictions will in some cases have to swiftly be re-instituted, if Covid-19 reappears in a building or the potential threat of infection goes up.
For instance, Aegis has rolled out a five-phase reopening plan. In Phase 1 — which can begin only after a community is free of Covid-19 for 14 days — small group activities can commence and residents can eat one meal per day in common dining areas. This is also the phase in which Outdoor Living Rooms could be established. If any coronavirus symptoms or confirmed cases are detected in a community, the building reverts back to Phase 0.
But despite their caution, Laborde and Gray also strike an optimistic note, that by having to rise to the challenges of Covid-19, their operations will improve and their communities will ultimately be better designed, more efficient, more technologically advanced and ultimately safer and more desirable places to live.
It’s a message shared by Aegis Living CEO Dwayne Clark as well, in the company’s public announcement of its Outdoor Living Room project.
“As a company, we have stepped forward to help shape the future of the senior assisted living industry during this pandemic and beyond,” Clark said. “Things will not go back to the way they used to be so we must continue to use the latest science and medical research and our ingenuity to push new boundaries and create new ways of approaching resident care.”