Mixed-Age Skilled Nursing Facilities Face Significant Barriers

When Skilled Nursing News set out to envision the nursing home of the future, one topic kept coming up over and over again: the intergenerational SNF, a place where people of all ages could recover from surgeries or receive long-term care together.

But creating such a diverse facility is easier said than done.

“For short-term rehab, some of those folks are there maybe a few days,” said Soo Im, an associate principal at the nationwide architecture firm Perkins Eastman. “They’re not necessarily interested in creating a community while they’re there.”


That kind of “self-segregation,” as Im put it, remains a top challenge for architects and providers in creating inclusive spaces for people of all ages. In general, the youngest members of any SNF population will be receiving short-term, post-acute care, with a goal of leaving as quickly as possible.

David Dillard, principal at the Dallas-based D2 Architecture, compared the problem to a business-focused hotel where guests are generally traveling alone and may keep to themselves at night.

“If you can create the right environment, you do come out of your room, you do have a glass of wine,” Dilard said. “The idea of an upscale, very friendly hotel environment is about as good as you can do.”


For a SNF, that might include dining areas, coffee shops and salons that are open both to the public and residents, to make short-term rehab patients feel like they’re in less of a clinical space. Those kinds of outward-facing ancillary services also encourage family members to visit, which could in turn bring both short-term and long-term residents out of their personal shells — while  providing a financial benefit to the operator.

“It’s a moneymaker,” Dillard said. “Even if it’s a third-party operator, it’s a moneymaker, and it’s certainly a happiness-maker.”

Perkins Eastman is currently working on a skilled nursing project in California’s Bay Area that includes a day care and kindergarten facility on campus, as a way to involve both generations in the community — and potentially provide services to employees somewhere down the line.

The company also has a continuing care retirement community (CCRC) development in Boston that has a full kindergarten-through-eighth-grade school on site, where students interact with the residents. While those partnerships primarily involve the CCRC’s independent-living program, students have also worked with the skilled nursing residents.

Small house, big potential

The “small house” model — in which SNFs are arranged into individual structures or floors with their own living and dining facilities — could present a compromise option that falls somewhere between full age integration and segregation. As nursing homes have become expected to care for increasingly higher-acuity residents with potentially lower cognitive skills, younger people could feel left out, according to Martin Siefering, partner at Perkins Eastman.

When Siefering first started designing nursing homes nearly three decades ago, most residents had physical health issues but strong cognitive faculties. Today, people in their 50s and 60s with recurring physical problems could find themselves isolated in a population that has significant mental health issues.

“I think the small house in general gives a great tool to get there — 10 to 12 residents together,” Siefering said. “You could group people who are younger and who have higher cognitive function and support them better in all ways.”

Leading a horse to water

Overall, the architects who spoke to SNN emphasized that even the most deliberately planned intergenerational SNF model could fail. The period after a surgery can be difficult and painful for younger skilled nursing residents, which isn’t necessarily conducive to forming deep community bonds.

“Some people are so pissed off that they just want to stay in their room, or they feel so bad, or they’re so shocked by the surgery,” Dillard said. “I’ll give them that. No harm, no foul.”

Siefering agreed, noting that the combination of post-surgery shock and unfamiliar medications might make residents “anti-social” during that period. But if a designer and provider can create an open, welcoming space in the front of the building, it can go a long way toward fostering the type of environment where people feel comfortable — and not so much like a patient.

“We’ve done a couple projects where we [put] cafe coffee shops at the front door to really change the image of the organization,” Siefering said. “It’s a place about socializing and gathering, rather than a place that’s about getting treatment — or, at the worst case, dying.”

Written by Alex Spanko

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