Costly Design Features Can Pay Off for Skilled Nursing

Last month, the Centers for Disease Control and Prevention issued a warning to skilled nursing operators and other health care providers about the dangers of Legionnaires’ disease, an airborne illness that can claim lives — and costs operators hundreds of millions of dollars annually.

Advances in skilled nursing facility design have made disease prevention easier for providers to manage, but SNF operators work in the oldest physical plants in the long-term care space. Many of these facilities were built long before anyone knew about bacteria-fighting copper fixtures, negative airflow systems, or screens that subliminally signal staff to wash their hands. And upgrading an existing facility to mitigate shared disease risks could prove costly.

“Maybe it could cost as much as a new building,” Perkins Eastman President and COO David Hoglund told Skilled Nursing News.


Like many architects and contractors asked to put a ballpark estimate on a project with so many variables, Hoglund — who helps lead the architecture firm’s senior living practice — laughed while attempting to put a dollar figure on average SNF upgrades, citing the wide variety of differences and challenges that operators face from facility to facility.

“The variables are so big,” he said. “Are you doing it empty or occupied? Are you redoing the mechanical systems — or are you just taking a person out of each room? That’s why people kind of chuckle when you ask that.”

But even in cases where it doesn’t cost quite as much as a whole new building — for instance, if a contractor could take advantage of existing water, sewer, and gas infrastructure to save some cash — a complete SNF overhaul to meet newer standards of disease prevention and design could come in at 70% of the cost of a new building, Hoglund said.


Still, he and other architects agree that when it comes to weighing the costs and benefits, it’s often wise to make these investments.

Single and Not Ready to Mingle

One of the most basic ways to prevent the spread of disease in SNFs, Hoglund noted, is the introduction of single-person rooms instead of the shared, hospital-style rooms that had prevailed in past years. It’s also a pleasant side effect of a general trend toward single-person units amid growing demand for a less institutional, more residential feel.

“Almost everything we’re doing in long-term care is private rooms” Hoglund said, “and we haven’t designed a traditional side-by-side semi-private room in probably over 25 years.”

Not only do private rooms minimize residents’ exposure to others in large group settings, but they also allow for single-user bathrooms, greatly reducing the chances of bacteria spreading.

“There’s no towel racks, grabbing the wrong counter. There’s no touching the same handles that somebody else did. That’s their room, and there isn’t anybody touching it other than the staff,” Hoglund said.

Making private rooms feel like home — and not a hospital suite — while still maintaining proper disease control protocols can be difficult. Melinda Avila-Torio, managing interior designer at THW Design, noted that instead of including medical-grade hand-washing sinks for staff to use in each room, a facility could employ corridor units to make the resident’s quarters less like a clinical setting.

“We keep emphasizing the residential appeal,” Avila-Torio said. “They don’t want it to look like a hospital.”

Subliminal Signals

That logic even extends to completely eliminating clinical reminders for staff members through a novel kind of subliminal messaging. Some facilities use screens near sinks that display different calming images — such as trees blowing in the breeze, or a view of a waterfront. Operators can then train their employees to wash their hands every time these images change, eliminating the need for hospital-style placards or verbal cues, said Carlos Moreno, a managing director at the senior housing- and health care-focused THW.

“You don’t want to see a sign that says: ‘Alright, 20 minutes ago, you washed hands, now it’s time to wash hands again,’” Moreno said. “These are subliminal messages that indicate change, forcing you to think through your day, making you think: ‘What did I just do, and what did I have to do next?’”

Of course, these fancy upgrades come with a price tag, but THW senior designer Alejandro Giraldo said that some operators phase in disease-fighting design elements gradually to save money and test new ideas.

“You can have three or four units that could have specific infection control components built in, and that’s something you can manage in a project instead of the whole project,” Giraldo said.

And Avila-Torio noted that some operators could look at it as an insurance policy against the costs associated with a serious disease outbreak.

“Every time you get hit with these costs of care, and remediate or eliminate an occurrence, it probably costs a lot,” she said. “It would have cost less money if they had implemented that safeguard from the beginning.”

Written by Alex Spanko

(Pictured: The lobby at Wilson Health Care Center, a post-acute skilled nursing and rehabilitation facility in Montgomery County, Md. Credit: Thomas Watkins Photography.)

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