By: Dr. Frank W. Rees, Jr., AIA LEED AP
Chris Muder, AIA
Like so much the world, COVID-19 has had a significant impact on the operations of Senior Living Communities.
REES interviewed our clients and friends in the industry to see how they are protecting their residents and staff. We’d like to share how they are adjusting and how the design of communities will change to address these operational issues.
COVID-19 is a bigger threat to Senior Living communities than the general population because of residents’ age, pre-existing conditions and living closely together. The average resident of a senior living facility is 84 years and COVID-19 disproportionately affects people over age 75.
Due to the increased risk, Senior Living Community Operators are taking more precautions than the general population.
A major action operators have taken is restricting access to their communities. This means families of residents and vendors can no longer enter. In addition, most residents are no longer able to leave freely. Closing communities to the outside means families, staff and vendors have had to change the way they interact with their communities. Most communities only allow limited interaction between residents and families.
Another challenge is varying state and local rules. Operators have to follow different rules for each jurisdiction where they have communities. For example, the state of Texas was not allowing salons to operate in facilities until recently.
The frequency and depth of cleaning has also changed significantly. While this cleaning benefits residents and staff, it also adds to staff workloads and operational expenses.
An additional challenge is the requirement to keep residents away from each other. Most communities were designed to have residents engaging with each other. In Memory Care settings, the best practice is to avoid residents spending time alone in their living units. Now the best way to protect from COVID-19 is residents spending time socially distanced.
How Design Can Protect Communities
As we think about how design can help communities protect from COVID-19, we have three key objectives to provide a safe environment for residents and staff:
- Keep COVID-19 from Entering
- Limit Spread Within
- Reduce Operational Expenses
Keep COVID-19 Out
Preventing COVID-19 from entering a community is the first line of defense for operators. The clients we spoke with have taken significant actions to make their communities safer by keeping COVID-19 out.
Most communities are designed with entry vestibules. The operators shared with us that they needed an entry vestibule to limit access to the community. This space is 10 by 12 feet and includes a voice connection with a staff member to screen guests. This space, like all entrances, should include a hand washing station.
Communities are exploring a category of Ultraviolet lighting installed above entry points. This narrow beam UV light will kill germs and viruses without posing a danger to people.
Some of our clients we talked to are using family visitation areas. One solution is converting an existing discovery room off the entry vestibule. This room will have one entry from the vestibule and one entry from the community lobby. A divider separates the resident from their family to prevent the transmission of any viruses. This solution gives families and residents the opportunity to interact in-person without posing additional risk to the resident or the community.
Other communities prefer the visitation area to be outside. The disadvantage of this solution is weather can impact a community’s ability to hold visitation sessions. Designing a gazebo with fans for hot days and heaters for cooler days is one concept to combat this issue.
One of our clients is planning a “phased opening” in June that will allow family members who are symptom free and wearing a face mask to be guided to the resident’s living unit. The family member can spend a few hours with the resident before being guided out of the community.
Delivery Only for Vendors
Service vendors are now playing smaller roles in the operation of communities. Most communities are only allowing supplies vendors to drop off deliveries at the service entrance. They are not allowed inside the community.
This has created a need for a breakout or decontamination area for supplies where they can be delivered and decontaminated. In the past, vendors like Sysco would service a community by bringing supplies into the community at the service entrance and then placing the supplies at the point of use. This might include restocking supplies in the kitchen or other areas of the facility. Currently vendors drop off supplies and the supplies are moved to where they will be used by community staff. When these supplies are dropped off, external packaging is removed and thrown away. Some communities are exposing deliveries to Ultraviolet light or using electrostatic sprayers to kill any viruses or bacteria that many have hitched a ride into the community.
An increase in personal protective equipment and single use products has caused a need for additional storage. Communities are requesting additional storage at the point of use.
This requirement for delivery also extends to the furniture of new residents in many communities. Movers can bring the furniture to the receiving area, but it is then placed in the resident’s apartment by staff members. One operator allows movers to deliver the furniture to the resident’s apartment but first their temperature is taken and they are provided with personal protective equipment.
The inability of service vendors to enter the building has also changed the staffing of some s vervices. Vendors that interacted with residents such as salon staff, exercise instructors or art teachers are no longer able to enter most communities. This has led some communities to bring cosmetologists and exercise instructors on staff.
With vendors and resident families restricted from entering communities and most residents restricted from leaving, staff are the main entry possibility for COVID-19. The operators we talked to have implemented stricter protocols on how staff enter the building.
First, staff must enter and exit through an identified staff entrance. While this was common so staff can clock in and out, it has taken on new importance. Communities have hand washing stations at all entrances. Some operators require locker rooms next to their staff entrance and are requiring staff to change shoes and clothes when entering the facility. Other communities are requesting that employees put on clean clothes at home and then not make any stops when commuting to the community.
Before entering the community, operators are screening employees for fever and other COVID-19 symptoms. Employees are also asked to fill out a questionnaire about any activities that may place them at higher risk of contracting COVID-19.
One question included in the questionnaire is if the employee has worked at any other senior living community. Before the pandemic started, many staff members worked at two communities to earn extra income. Staff members would typically work full-time for one community and then 20 or more hours a week at a second community. Since the outbreak and operating companies are requiring employees to work in a single community. This prevents an outbreak at another community from spreading to their community through a shared employee.
Limiting the Spread
Unfortunately, even with precautions to keep COVID-19 out, infections can still enter communities. Coronavirus is particularly tricky since residents or staff can be infectious without showing symptoms. Operators are actively working to limit the spread of the virus in numerous ways beyond simply keeping people six feet apart.
The CDC believes the most common way the Coronavirus is transmitted is through the air. This means having clean air is vital for limiting the spread of any virus that does make it into the community. Communities have three main ways to remove viruses from the air.
The first option is to increase the amount of outside air as much as possible to dilute contaminates. This is expensive because it requires cooling and dehumidifying the additional outside air.
The second option is to clean the air with high performance filtration or germicidal ultraviolet filtration at the air handler. Ultraviolet air purifiers use the properties of ultraviolet light to kill any viruses or bacteria that may be circulating in your air condition system. In addition, filterless cold plasma air purifiers provide similar benefits using a different technology. These devices are typically easy to install in an existing system. For higher risk areas, air scrubbers that combine filtration and ultraviolet light can be installed. By being so close to the source of viral particles it is able to remove them from the air more quickly than a filter in the central air handler.
The third option is to treat the air. Solutions to treat the air, work by killing the virus in an occupied room. The air doesn’t have to pass through a filter, instead these solutions permeate the in-place air. Examples of this include dry hydrogen peroxide gas and using germicidal ultraviolet light to treat the upper air volume.
No Touch Technology
While the CDC believes surface transmission is not the primary way COVID-19 spreads, it is an important consideration for other bateria and viruses. A technology many communities have in place that can leverage to limit the impact of infections are RFID key fobs. It can be combined with automated doors and elevators to eliminate contact with high touch surfaces.
These key fobs can be used to trigger resident apartment doors to open, as payment within the community and open exterior doors. The key fobs can also work with exercise machines that track a resident’s exercise habits and automatically set the machines to the resident’s ability level. Some communities are using the fobs to automatically send elevators to the resident’s apartment level.
In addition to access, RFID key fobs can be used to track residents and staff. This can be critical to tracking the spread of an infection outbreak in the community. It can also help communities know exactly which residents need to be quarantined.
Several communities are also using no-touch fixtures in common restrooms. This eliminates high-touch areas where viruses can spread.
With the increase in cleaning, communities are finding that surfaces need to be easily cleaned and the finishes need to be able to stand up to stronger cleaners. Carpet is often difficult to disinfect so some communities are using HEPA vacuum cleaners. In the future communities may limit the use of carpet in renovated or new buildings. In addition, communities where Ultraviolet lighting is used for cleaning need to ensure they have selected finishes that are Ultraviolet resistant to prevent fading and breakdown of the surfaces.
Many modern finishes have the option of additional antimicrobial coatings. These can be placed on floors, walls and furniture to prevent the spread of bacteria, providing residents extra peace of mind.
Different Ways to Dine
Community dining regularly brings large portions of the residents together at one time for social interaction. However, this presents a significant risk for spreading infections. In many communities, residents are eating in their apartment rather than the community dining room.
When residents do come to their dining area, they are being seated at least six feet apart which results in one person or couple per table. By replacing large tables with smaller tables, communities can increase the number of residents who can be served in the dining area. Tables that are 3 feet deep by 2 feet wide allow a single resident or a resident couple to eat comfortably. As restrictions are lifted, these small tables could attach together to create larger seating arrangements.
In many communities, residents can no longer serve themselves in bistros due to concerns over spreading infection. Instead, staff bring food to their table and serve drinks. In addition, tables are not being set until a resident arrives and is ready to be seated. When setting the table, communities are using pre-wrapped utensils. Tables are disinfected before the next resident is served.
Only Caregivers Interact with Residents
Communities have also restricted which staff can interact with residents to limit exposure. Caregivers serve residents their meals instead of kitchen staff. If maintenance staff need to access a resident’s room, the resident moves to a different area of the community while the maintenance staff perform any needed repairs.
Self Contained Neighborhoods
Several of the communities are using the neighborhood concept which limits the possible spread of coronavirus. Neighborhoods are groups of residents within a community whose apartments are physically close to each other including group living and dining areas. Operators are making these neighborhood’s self-contained by assigning care giving staff to a single neighborhood. In addition, the neighborhood will participate in activities with only residents from their neighborhood while still social distancing. For example, only residents from a single neighborhood will use the fitness center on a given day. Once each resident leaves, the exercise equipment is cleaned before another resident uses it. Other neighborhoods have different scheduled times to use the equipment or open exercise areas.
Neighborhood communities have a common living room area for each neighborhood. During times of increased risk, these living rooms may be converted to dining areas for the neighborhood to facilitate social distancing. To prepare for this possibility, high voltage outlets could be installed that would allow food warming carts to be used for serving food that is prepared in the kitchen.
Reduce Operational Expenses
Many of the tasks communities are taking on to limit COVID-19 are also increasing the workload on staff. This is placing a significant expense on operators. Below are a few suggestions for reducing the impact on staff.
As a result of the pandemic, many regulators and insurance companies have relaxed their restrictions on telemedicine. By embracing telemedicine, a community can save staff time that would previously be used to take residents to medical appointments. This has the added benefit of keeping residents within the community, avoiding potential exposure. Existing exam rooms can be adapted to create specialized exam rooms for virtual doctor visits. Large screen displays and high-resolution cameras will help overcome resident resistance to the idea of a remote doctor directing their care.
Digital Activities and Entertainment
One operator we spoke with told us they’ve stopped hiring entertainers to come to their communities. Instead, they are bringing entertainers to a studio and then streaming the entertainment to residents at multiple communities. Centralizing this type of entertainment is less expensive than live performances and can increase the quality at each location.
Salons as new revenue
Salons may see a spike in usage because residents can no longer travel to the external salons they used before living in the community. This may result in the need for larger in-house salons, presenting an opportunity for communities to capture additional revenue. Increased internal demand may offset decreases for salons that served outside customers as part of a marketing program.
Before COVID-19 most communities delivered mail to Assisted Living and Memory Care Residents. Independent Living resident mail was delivered to mailboxes by the Postal Service.
Currently, many communities sort and deliver mail directly to all of their residents. Those communities with a central mail hub for residents benefit from the mail carrier placing mail in resident boxes. Companies delivering packages can utilize lockers. Many communities are now holding mail for 24-48 hours to allow time for any viruses or bacteria on the outside to die before delivering to residents.
REES is assisting clients making changes to existing communities and designing new communities to help the operator achieve a COVID-19 free environment.
We anticipate many of the changes implemented as a result of COVID becoming part of operators’ tool kit for managing risk even once there is an effective vaccine. Controlled entry and exit from the community will be used to control infections during flu season. Air purification systems will become part of the standard equipment for common areas and corridors. Some communities will choose to extend their use to living units. Ease of cleaning and disinfecting surfaces will play a larger role in selecting finishes. No touch technology will see a continued increase in use. We believe more communities will adopt neighborhood operations as operators find it increases safety and efficiency.
Other items are likely to revert to their previous state once the threat of COVID-19 passes. Dining, movies and activities spaces requiring additional space now may return to similar pre-pandemic sized spaces.
About the Authors
Dr. Frank W. Rees, Jr., AIA, LEED AP
Dr. Frank W. Rees, Jr. is the founder of REES, an Architecture, Interior Design and Planning firm. Dr. Rees has served as Principal Architect or Planner on more than 200 projects in 31 states and 12 foreign countries. He is licensed to practice architecture in 39 states, is LEED accredited, a registered Interior Designer and NCARB Certified. Dr. Rees served as CEO of REES for more than 37 years. He stepped away from management in 2012 to work on select projects. As the author of 1 book and more than 60 articles, Dr. Rees has spoken to many professional organizations and his current work is focused on Senior Living communities.
Chris Muder, AIA
Chris Muder is a Project Manager and Senior Living Leader at REES. Chris has nearly 15 years experience designing with Senior Living Communities. Chris is a regular speaker on the challenges and opportunities facing Senior Living Communities. He brings a unique, user–focused perspective to senior living.