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Reimagining Long Term Care Facilities in the Wake of COVID-19

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Barry Plunkett, Healthcare Operations Consultant, Horne, LLP, speaks with Roy Decker, Founding Partner, Duvall Decker Architects, about the impacts of COVID-19 on long term care (LTC) facilities. The podcast discusses how COVID-19 is spreading in LTC facilities and what can be done to stem the spread, including designing new and separate visitor and resident spaces and revisiting interior finishes and building materials, such as using more impervious materials, which are easier to clean and maintain. Sponsored by Horne, LLP.

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Speaker 1:

Support for A H L A. And the following message comes from Horn, a different kind of accounting and advisory firm. The clients trust for industry focus, insights, straight talk and collaboration. Horns healthcare team is composed of financial professionals, former healthcare executives, and IT experts, 100% dedicated to healthcare. For more information, visit horn l l p.com.

Speaker 2:

Hello, I'm Barry Plunkett, and I am a healthcare operations consultant with Horn. I have been in the healthcare arena over 35 years with a great passion for senior living and long-term care, and I'm excited to have joined me, not just a professional with whom I work periodically, but a friend of mine and a neighbor. And that is Roy Decker, who is an architect with Duval Decker Architects. And rather than give a long list, uh, about Roy and his accomplishments and awards, et cetera, you can always check him out@duvaldecker.com. But one of the things that Roy and I have in common is that we both have a strong sense of community. And that's what his firm does especially well, is they don't just create buildings, but they create communities always in mind, enhancing the quality of lives of those people who live in that community. And they don't just build, build big buildings, they build all sorts of buildings and they always have sustainability in mind. And so it's gonna be sort of interesting and fun today to talk about long-term care and senior living after Covid. So thank you Roy, for being here. And I'm going to sort of ask you a few questions and see if we can't create some conversations.

Speaker 3:

Thank you, Barry. Glad to be here.

Speaker 2:

One of the things just in conversation that you and I had several weeks ago, and it really just took my breath after you made a comment, and that was, we were talking about getting back to normal and long-term care after Covid, and when we got back to normal. And you said, we won't be back to normal.

Speaker 3:

No, we are f we're, we're gonna find out what a new normal is. A new normal is going to be constantly either under the threat of a virus of some kind, contagion of some kind, or, um, just protecting ourselves from the possibilities of spread of viruses. Um, you know, in the last 20 or 30 years, we've seen more of these kinds of viruses than we have maybe in the hundred or 200 years prior. And a, a lot of scientists attribute the change in the, the, the, the variety and the types of viruses we're seeing and, and their contagion contagious, um, to the loss of habitats and the loss of biodiversity across the, around the world. So we're seeing species, uh, come, different species come closer together, bats and pigs, dogs and, and bats. We're seeing these species in the same markets in terms of, uh, this, this, this virus in China, or even in zoos or even in, uh, uh, uh, neighborhoods in suburbs where these, these animals never existed ne next to each other. And they, they call it spillover when a virus jumps from one species to another and virus is mutated, of course, every two weeks. So that mutation then, when it starts to spill over into another species, potentially risks being able to spill over into the human population.

Speaker 2:

Wow.

Speaker 3:

So, yeah. So I think, um, our sense of space, our sense of distance, our sense of, uh, health and, and hygiene, um, is gonna, we have to find a new normal.

Speaker 2:

Absolutely. And, uh, that poses not only problems for internally operations, but as you build for the future facilities and physically, what do you do differently? How do you think in long-term care facilities, especially assisted living in nursing homes, the, the virus is spreading? Well,

Speaker 3:

Y you know, for a long time, um, the economic model that drove that, that has driven nursing homes, assisted living complexes, and, and even independent living complexes or memory carry units, the, the, the model that makes economic sense is to make the buildings as small as possible, make the units as small as possible, which is always a stress for an elderly person cuz they collect a lot of stuff. And what do you do with it? You know, that's a, that's a side stress, but the model works when you get to a certain level of scale, number of units and an operator can make a living and pay the bills and provide good care. So, um, uh, we are, we are, we're working on an assisted living complex right now under construction, and we're about to start the interiors. Um, all the contracts have been led, all the dimensions, all the plans are finished and, um, now we're trying to figure out how does the, how do the interiors change by virtue of the virus threat? Um, if we were starting a new complex right now, we'd be looking at trying to make different arrangements of space. You know, how do we, how does a caregiver come into a, a unit but not completely come into the unit? How do do they, so the, the notion that you might have a threshold in a unit before you're actually in someone's kitchen or living room. Right. And there may even be a, a, you know, a a a different, um, H V A C vent right there to, you know, to collect air. So, um, so the spatial changes within the units, the dimensions will get larger, which, which changes the economic formula by which we can make these businesses actually operate. So

Speaker 2:

I recently read an article that, um, suggested that the big mega complexes were not as safe as creating a smaller, not necessarily personal smaller units right. But smaller facilities, uh, to create just less congestion under one roof.

Speaker 3:

Yeah. And of course, this virus is a, is a aerosol spread. So we know now that, you know, just breathing and talking and the aerosols that weit from our body are, are, are how the contagion spreads much to, you know, of course we, we, this is all coming about now after months and months of, uh, understanding the virus. Um, but that would suggest that we, uh, have different dimensions and different kinds of spaces, um, as we talked about larger dimensions. But, um, the larger complexes, um, with more residents and close contact with each other, uh, obviously are more, more dangerous for the spread of the virus and more threatening to all the residents. And, you know, in any senior facility you have a mixture of health, um, the health, the quality of health of any of the individuals. Some might, might have asthma, some might have colds. They might be more susceptible to colds. And so they are spreading the virus actively, potentially if they, if someone gets it. Um, and then you add to that, um, the number of visitors that come into a large complex, right? Family members and caregivers and food deliveries and all of the, all of the exposure is amplified with a larger facility. The problem with a smaller facility is how do you make the economics work, right? A smaller facility with less population, but bigger spaces more expensive to build. So the, the the, the dynamics of the formula that are related to both care and financial stability of the operation are, are now. And we have to remake everything in a way. We have to find the new, the new normal.

Speaker 2:

Are you starting to rethink how one can welcome visitors into facilities like this? Because during this time it's been so stressful both for family members and for residents to have this separation and the sense of isolation. Yeah. Um, are there any thought processes of what, what did you do about that?

Speaker 3:

There's been some terrible stories, you know, about family members not being able to visit their, their, their, their, their fathers and grandfathers and mothers. And, um, and, uh, in the course of the pandemic, of course we've even lost some of those residents. So that, um, I actually, we, we actually lost my father without having, being able to see him for Mm. So we couldn't see him for two months.

Speaker 2:

Wow.

Speaker 3:

And then we lost him to the virus. So, I mean, I have personal connection to the problem of the disconnection of families and the loss of social sociability, sociability, um, with within families. So, um, you know, the, the, the threat of the contagion is amplified by the number of people that are exposed to each other. So we are thinking, uh, the, the project we're working on right now, we're thinking about a visitation room, which has got a hundred percent air changes, you know, um, a separate H V A C system. So if residents and friends come in, a a resident can come down and visit and then go back to their room. So it limits the amount of people that penetrate into the complex. So that takes a, it's a little bit more management oriented, you know, but it is a way to isolate the exposure of the whole complex by family members that, that they have no control over. So,

Speaker 2:

Absolutely. Well, we're sitting in a conference room with a container of sanitizing wipes and then there's a aerosol spray container available. And what is that type of stringent cleaning doing to the products we build with?

Speaker 3:

Well, you know, um, we, we love, you know, making a senior living facility, making a nursing home, making, um, a place where someone might feel like they're at home means that we wanna make them as warm, as comfortable as possible. We want the furniture and fabrics to be friendly. We want wood, we want natural wood, we want, um, and, and the products that we use to clean and disinfect surfaces destroys those more common and friendly materials. I can, I can tell you that, you know, the, the sprays we use to clean and disinfect tables, wood tables, just takes the finish right off of them and destroys them.

Speaker 2:

And is this different than it was this time last year? Our cleaning processes?

Speaker 3:

Yeah. Yeah. Cuz we are no longer just using, you know, um, uh, you know, pub polishes and deter dust, and now we're, now we're using, uh, you know, alcohol based products that are, uh, taking the finishes off materials. So yeah, so rethinking materials and surfaces to be still be friendly, but now to be antiseptic and to be resistant to alcohol-based, uh, cleaners is a, is a whole new, is a whole, they are more expensive, you know, that's the other thing. It adds to the question of, of cost and, and, uh, durability.

Speaker 2:

What's an example of some of those materials?

Speaker 3:

Uh, the table we have right in front of us is plastic, although it's, it's got a wood grain on it. So I mean, you, so you start, you're gonna start to see more simulated materials that are more durable. It's a common kind of, uh, trade, trade over, although you can feel the difference and you know the difference, you know, it's not wood. Yeah. It's a picture of wood, so it's not gonna be quite the same. But, um, yeah, I think, uh, you're gonna see much more, uh, use of those kinds of products.

Speaker 2:

Um, you, in a conversation we had at one point, you talked about how technology itself is changing so that some things are even self-cleaning or self-protecting. Yeah. What are some of those?

Speaker 3:

I, and I don't know a lot about this, but, um, I see now immediately, you know, we're architects, so we are, we're consumers of building products. We, we specify them, we put them, you know, everything you look at in a, in a space that's somehow specified and, and chosen by an architect to be in a space or interior designer. So we're, we are seeing all sorts of new products come on the market for, um, covers over elevator buttons that are disposable and that they have, um, they, they're like a gel. So when you press on'em, they have, um, they have very, very small little, um, micro openings then that, then that lets the cleaning surf the cleaning material come through the surface. So when you press on it, you get a disinfectant or a, you know, a, a a, an alcohol based surface on your, on your finger. So it's killing the germs as you touch it. So we're seeing more and more of these kinds of things on the market. Then an interesting thing about, um, some products automatically kill viruses.

Speaker 2:

Like what?

Speaker 3:

A copper,

Speaker 2:

Really

Speaker 3:

Copper as a metal and brass, uh, viruses do not live on the surfaces. So, you know, we've gone, uh, you know, we, we go, we we see hardware, for instance, you know, everybody who has stainless steel or brush stainless steel. Well, if we had more brass hardware, we would have safer handles to, to touch.

Speaker 2:

I'm not saying copper countertops in the future.

Speaker 3:

Maybe, maybe interesting again, you know, a a price increased, but, uh, that would help keep surfaces more hygienic.

Speaker 2:

You know, when we talk about these things, uh, years ago and a couple of the science fiction movies and television series, it was very much like this because when they were outta space, they had all these unknown viruses. Yeah. And you, you went into airlocks Yeah. And you were spritzed and then you went into to mix with the rest of the people. But, uh, it's probably not that far away.

Speaker 3:

Oh, it's not at all. In fact, um, you know, one of the reasons they say the airplanes have not been places to spread the virus is because the air conditioning system and air air conditioning systems in, in airplanes have a, a, I think a one or two minute complete complete air change. So every minute or two, all the air in the space is exchanged for new air and they've got, you know, they've got high level hepa HEPA filters and they've got ultraviolet light filters. So they are exchanging that air every minute and cleaning the air as it, as it comes into your, comes into the cabin. So I think we're gonna see those kinds of H V A C systems in vestibule isolated for family rooms and even, uh, elevated, um, filtering for u for units, for, for apartments and, and rooms.

Speaker 2:

You know, as we talk about this, it sounds all fairly somewhat sterile and mechanical. Are there thought processes of how do you keep from taking away the quality of your life as you have known it, especially in an older generation who has lived in wood product homes and those kinds of things? How do you account for psychologically what it's doing to you?

Speaker 3:

Yeah. So, um, uh, you know, that's a, that's a, an issue and a question for seniors. It's also an issue and a question for all of us because, you know, we find ourselves after nine months of being isolated, uh, looking at computer screens, communicating with family members as a, you know, virtually, um, conducting meetings, virtually you, I think we'll see an increase in all of those kinds of technologies for seniors. Um, for my father, we finally got an iPad to him that he could see my mom and they could talk once a day, but it was, you know, we couldn't even deliver an iPad to him. So we, you know, we were isolated from even bringing a product for a while. Wow. So she was able to get him an iPad and we were able to talk to him. So we're gonna see, I think we're gonna see standard equipment and, and, um, and, and technology really in every room so family members can talk. So that's one thing that's, that's really, uh, making sure we can keep people connected minimally. Um, the question about the social and the, the social life within a assisted living within a nursing home, I mean, how do the resident, the residents gather, how do they play cards? You know, what porches do, do they have access to, to, to, to watch other people? Are they in neighborhoods where they can see, um, you know, parks or, or children playing or, you know, the, the things that we take for granted as, as quality of life issues, which is as we get older sometimes it's really observing life.

Speaker 2:

Yes.

Speaker 3:

And having access to those views will become part of the architecture again, and will become part of the way in which we cite facilities. We're gonna, we, we, we, we will be looking for circumstances where, um, somebody, uh, in a senior living facility might be on the edge of a street. They, they, they don't have to interact with it, but they can see it from the room. The windows might be bigger units, might actually have small porches that are, you know, so, so they can actually minimally interact and, and then with each other, internal to buildings and, and, and, uh, the community of buildings, we might see, um, you know, porches inside the building. Yes. So, so if we have, so imagine there's a threshold that allows a caregiver to minimally come into a, a unit from, say, a hallway. That threshold might be large enough to also hold a rocking chair so a resident can sit there and open up the doors and sit on the edge of a court orders mm-hmm.<affirmative>. So that becomes, that space becomes a kind of a margin of safety between the resident's unit and the larger complex, but also affords a, a kind of social sociability to come back. So,

Speaker 2:

You know, so often, um, and I guess it's sort of a, um, field of dreams mentality. We build it and they will come. And sometimes we do that without the input of those we're serving.

Speaker 3:

Right.

Speaker 2:

Is there a way you're familiar with that? Um, you gather that input of those you're going to be serving?

Speaker 3:

It's a really good question, Barry, and it is one of the great failings of architectural practices around the country. I think, um, when you introduced me, you said something about our commitment to making community. The fundamental foundation of that commitment is that we listen to our clients. We, we talk to the residents that we're serving, we go into the communities and we try not to, um, make that a transactional conversation. In other words, we're not just look looking for an answer, and then we take it and we're, we're looking for a sense of the quality of life and the complexity of life that they live with so that we can translate those, um, which are, which are really broader dimensions of understanding to seniors. And what, and, you know, what, what are they thinking about in the morning? How do they make their breakfast? You know, do they get together with somebody else in the complex? What kind of romances, emerg in senior complexes, right? I think people are always thinking, well, there's a room and there's a resident, you know, well, it's, it's a complete community. So how do, how do we as caregivers and how do we as planners and architects, um, uh, learn the full sense of life of that community? We have to listen. We really have to talk to, to the residents. We have to cultivate the stories. Um, and there are many, um, to help make a, a real community. And that, and you know, I sometimes say it's important to listen to the people that will talk to you, which is usually operators and administrators and Right. And sometimes you'll get a resident who's a, you know, one that's interested. But, um, the truth of the matter is you have to hear the quiet voices, which are the residents themselves.

Speaker 2:

Yeah. You talk about what goes on in the community that you would never think about. Uh, I was involved in the development of a con, um, complete retirement community from independent living to assisted living nursing home and an Alzheimer's unit, and it had a chapel mm-hmm.<affirmative>, and it just had routine services on Sundays and Fridays and Saturdays, but it also had weddings Yep. That occurred from romances within, in naturally head funerals. Yep. And even had a couple of christenings now that was not of children born at the retirement center, but it was grandchildren. Right. And so, uh, just the whole circle of life is, uh, had happens within there. I have something that I need to share with you that I haven't even told you about. Horn has created, um, high along with a couple team members, a survey that we did specifically to seniors and specific geographic areas about what long-term care looked like to them mm-hmm.<affirmative>, And we've developed that to share with potential clients who are looking to develop long-term care facility because it's what they want in what they need. Right. And, um, it's, it's a good sample. It's 500 people. And so we have a little, little validity in it, and we have been able to divide it geographically. So if you're building Mississippi or Alabama or, or what Tennessee you can say, and it does change Yeah. Uh, uh, geography changes, uh, because a lot of it's based on your previous culture mm-hmm.<affirmative>, and you have to take that into consideration of who's coming to live in this new culture Yeah. In this new community. Yeah.

Speaker 3:

So people think culture is, um, one thing, or they think, you know, the whole country where the whole south as a culture. And, and the reality is culture is very local. So, you know, and all you have to do is, is, is think about the difference between, uh, Memphis, Tennessee and, and Jackson, Mississippi and everything that the economy, uh, the, the culture, the arts, the, you know, what people do for recreation changes from just one city to another. And that, and you're absolutely right. So the, the way people grow up, the way they raise children, the way they grow old is all within a very local culture that does change. And you have to be really sensitive to those differences to make a successful, um, senior living or actually any living circumstance, uh, our project. Yeah,

Speaker 2:

Sure. Well, anything else about long-term care in general? Uh, and the future, especially in respect to Covid that comes to mind?

Speaker 3:

I think we don't know yet how to make healthy facilities. I think we know and apply our medical, uh, um, lessons and principles. Um, but the way we fight and protect ourselves from these kinds of the viruses, uh, are more behaviorally oriented. I mean, how do we create spaces that support healthy, healthy interactions between residents, between caregivers and residents? Um, how do we make the mechanical system safer? How do we filter air? Um, how do we, how do we, um, uh, accommodate families? All those kinds of things that we talked about. Um, but a lot of the changes I think we'll see in terms of making, um, healthy spaces is now gonna be equally shared by behavioral changes, awareness, even wearing masks, even safe distancing, you know, um, washing our hands. Um, I can't tell you how lax my children were about washing their hands until we got this virus, you know? Right. And now I watch'em, it's just now it's part of their behavior. They've changed their behavior as a way to protect themselves and to protect us.

Speaker 2:

And a lot of that behavior we probably should have had anyway.

Speaker 3:

That's exactly right. That's why, that's my, my thing was, oh my gosh, my kids' hands were dirty. Yeah. You know,

Speaker 2:

And our houses probably were.

Speaker 3:

And our houses too. Yeah. So, um, you know, the products we use everything about, um, this kind of pandemic kind of virus, um, that spread socially and, and you know, I think we have to think about our behaviors differently and it'll affect everything. That's why I think there's no going back.

Speaker 2:

Yeah. There again, that's the little scary part, Roy. It's always, it's been great to sit here and talk with you, and I hope we have pulled some thoughts out that, uh, we can share and make a difference with somebody.

Speaker 3:

Well, happy to be here and happy to have this conversation as, as you know, the, all of these things we're learning on the go right now. We're, yeah. You know, we're trying to, as quickly as we can make safe, healthy spaces for people to live in at all ages,

Speaker 2:

And we need to pay attention

Speaker 3:

And we need to pay attention, and we all need to work together.

Speaker 2:

Yeah. Thanks Roy.

Speaker 3:

Thank you. Thank you, Barry.