Recording - Murphy Partner's Rotem Yaniv's Presentation at the University of Toronto Institute of Health Policy, Management and Evaluation
Last November I gave a presentation at The University of Toronto Institute of Health Policy. This was part of the Health Services Systems and Policy Research 2023-2024 Seminar Series themed: Advances in Aging Environments Research & Practice: What We Know & Don’t Know About the Influences of Psychosocial & Physical Work Environments on Workers and Their Work.
The presentation includes:
the state of the seniors housing market
financial comparison of different types of seniors housing
experiences of seniors living in Long Term Care Homes
The Salutogenic and Pathogenic design approaches
Case studies demonstrating salutogenic design principles
The cost and cost escalation of building seniors housing
Ministry of LTC minimum standards compared with CSA evidence based design recommendation comparison
Personal professional experience - we can still have better design
I hope you will enjoy the video below. For your convenience, I am also including a transcript of the presentation below. I aim to turn this presentation into a blog post in the future.
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Own a site? Operate a Long Term Care Home? Have a plan to create Seniors Housing? Want to learn more about salutogenic design? Let’s talk.
Transcript
Peggy Chi:
We are pleased to have Rotem Yaniv with us today. He is a project Architect and Murphy Partners Seniors Housing Architects with over 11 years of experience designing Long Term Care, life Lease, & retirement homes. Rotem is part of the Design and Dementia Community of Practice of The Brain Exchange Network in Ontario.
During his training, he explored the design for Continuum of Care campus in an urban context. Rotem believes senior housing should provide the right balance of fresh air, daylight, planting, and colour, and offer safe, secure and homelike environments for both residents and staff. Welcome Rotem. We're very excited for your presentation.
Rotem Yaniv:
I'd like to thank the IHPME at U of T for inviting me. And special thanks to Peggy Chi for making this happen. Thanks, Peggy.
Hey, my name is Rotem Yaniv. I'm a Project Architect at Murphy Partners Seniors Housing Architects. I'm here today to share some of my experience designing a variety of types of senior housing since I started working 11 years ago. What I hope to do today is provide the context in which I design housing for seniors.
I don't think it controversial to suggest that there is a housing crisis in the GTA. In the next slide, I will show a few recent headlines that relate to how the housing crisis is impacting seniors in particular.
So we have seniors who are having trouble paying rent. On the other hand, we have seniors who are home owners and they have a hard time downsizing. They do not like the available options, so they stay in their larger homes. Their larger homes are harder to maintain and they are less likely to be barrier free. For example, they have front steps and they have stairs to the second floor.
We know that the number of people over 85 is only going up. We're not sure who's going to take care of them in the future or where they will live. We know that currently there are nearly 40,000 people waiting for long term care bed on the waiting list. And on the other hand, many of the long term care homes are outdated and they need to be renovated to meet current standards. And sometimes it's so costly that the operators choose to exit the market, selling their homes to condo developers, thereby reducing the number of long term care units on the market.
This is how we end up with stories about seniors living in their cars.
I'm going to very briefly talk about the types of senior housing. I can do an entire presentation just about types. So if you have any questions, please ask me at the end.
Very high level. The first type is Age at Home or Age in Place, people stay where they currently live. A lot of times there are some home retrofits like ramps, non slip flooring, barrier free showers and the likes. The second type is very similar to condos. It's called Life Lease and it's for independent living. Usually you see a dining room on the ground floor of such buildings. The third type is a retirement home. This one includes a lot of subtypes like Independent living, independent supportive living, assisted living and memory care.
And finally, we have long term care. Long term care homes stand out because while they are mostly run by private corporations, their funding models are strictly governed by the Ministry of Long Term Care. My next slide is going to show how the different types compare from an economic point of view.
In terms of services provided, the person aging in place needs to outsource all services like meals, laundry and PSW (Personal Support Workers). For Life Lease, meals and other low level of care services may be provided a la carte. For Retirement Homes, a variety of services are offered, and in long term care, all services are included.
In terms of the (housing) costs to a resident aging in place, it's a homeowner. It could also be a renter, although that might make renovation a little complicated. With life lease you pay lump sums similar to condos at slightly reduced prices compared to condos. Retirement homes have rental models that could be between $3,000 and $7,000 a month. In some cases it may be more depending on the level of services the person receives. And in long term care, again a rental model, but it's fixed by the government between $2,500-$3,000 monthly from residents and the operators get a top up from the government which means that it's subsidized.
Construction funding. You don't need them for aging in place (the home is already built). For Life Lease, 85% of suites need to be pre-sold to get a construction loan. For Retirement Homes, construction loans are harder to get with rental projects because the time to recuperate construction costs is much longer. Over a decade. Usually. For Long-Term Care, it must be supported by government funds as rental income is fixed by the government.
So private models allow market conditions to dictate the desired level of investment but create unaffordable condition as there is a severe shortage in supply. Regulated or public models like long-term care control affordability but require government funding and are usually controlled by government. This means design standards which may increase operator costs further, which in turn demands more government funding, but it also leads to more affordable housing products.
People living with severe mobility, cognitive or vision impairments may not be able to safely stay at home, at least not without a dedicated caregiver. On one hand, the housing market is unaffordable. On the other, it takes at least six months to get into a long term care home. Some people wait 2 1/2 years.
And this is from the Ontario Long Term Care Association: most people want to age at home, yet one in five seniors over the age of 80 have complex care needs that can only be safely met in long term care.
In the next slide, I will again show a few recent headlines that describe experiences of seniors living mostly in long term care, but not only.
The most known thing about long term care is what happened during COVID: high number of deaths. We also know that many residents are given antipsychotic drugs without a diagnosis. We know that older people feel more lonely compared to younger people. This is not limited to long term care, and it's especially worse for immigrants. We also know there are issues in long term care with residents falling, being physically restrained, and having depression as per data from Health Quality Ontario. I think that we, designers, policymakers, developers, and operators should consider how much of these headlines are caused by buildings and their design. I'm not saying that it is only the architecture, but is it possible that architecture plays a role in these headlines?
To try to answer this, to try to answer the question about architecture and experiences in long term care and seniors housing in general, I will talk briefly about the Salutogenesis and Pathogenesis approaches to design and then use them as lenses to examine Seniors Housing architecture.
The Pathogenesis approach focuses on causes of disease and applying external interventions to eliminate the pathogenic factors. Salutogenesis, on the other hand, looks at environmental factors that cause global well-being.
Salutogenic architecture looks to create and maintain good health by fostering personal confidence through the built environment. Let's use De Hogeweyk as an example. De Hogeweyk is a known case study for what is called the Dementia Village model. It is located in Holland.
De Hogeweyk is allowing seniors access to risk in ways that are not generally acceptable in Canada. For example, you can see in this image, what's preventing these seniors from jumping into the water fountain? The De Hogeweyk promotes independence and agency for its residents. According to studies, this in turn increases health and well-being for those residents. This is done while sacrificing pathogenic standards that aim to reduce risk and I can tell you from my experience, some operators will not allow any kind of water features in their long term care homes.
Now, I am not here to promote increasing risk to seniors. I am, however, interested in what we are losing when we focus only on risk prevention. I think that sometimes it leads to unintended consequences.
There are many aspects to Salutogenic design. I will focus on three of them. Sense of Comprehensibility, Sense of Meaningfulness, and Sense of Manageability.
Let's start with Sense of Comprehensibility. This is a cognitive component. It's the ability to make sense of the environment. In the case of architecture - makes sense of the external physical environment. For example, have you ever been in buildings that look the same no matter where you are in the building? Compare that to a building where you knew exactly where you are, where you want to go, and how to get there because the building was easily comprehensible.
How do we do that? The following image and text is from Arch Daily: Architects can design spaces to accentuate more intuitive paths through master planning and design of wayfinding systems. Healthcare design can also bolster the sense of comprehensibility through colours, landmarks and views of nature. This is an image of New Lady Cilento Children's Hospital in Brisbane, Australia, by Lyons + Conrad Gargett.
The second component of Salutogenesis that I will speak to is the sense of manageability. This one is an instrumental or behavioral component. It means one has access to resources. If a resident feels stuffy, can they open a window? If they feel lonely, do they have access to family and friends? Can they manage or are they being managed by someone else? Do they have some level of agency and independence?
Again from Archdaily: By providing operable windows or access to facilities and older adult feels capable of making decisions for their health and acting upon them. And this isan image of Sayanomoto Clinic in Saga, Japan, by Yamazaki Kentaro Design Workshop.
The last component I'll speak to is the sense of meaningfulness. Meaningfulness is about motivation. What do we do every day to keep us going? We read, we listen to music. We workout. We go for a walk in the park. When we work, we are more motivated if we believe our work leads to something that we think is positive. When we design housing for seniors, we need to think about what it means for people to live there.
(From Arch Daily): Through this Salutogenic approach, health centres can incorporate art installations, spaces from music and social support, and recreational spaces like libraries or gyms. Hospitals may incorporate nature and animals in their facilities to inspire patients. Views of landscapes serve as positive distraction and have a proven effect on boosting patient recovery. The image is of Santa Rita Geriatric Centre in Menorca, Spain, by Manuel Ocana.
And just a personal note about animals if you ever happen to visit Nisbet Lodge, which is right across from Pape Station [in Toronto]. The last time I visited they had a cat that was just hanging out in the party room in the Long term care home.
I'm going to present 4 case studies from Scandinavia and the US. To some extent these are experimentations. I am not in a position to say how much of the concepts I'm going to present operators should embrace. Research as defined by a paper called Salutogenesis, A Bona Fide Guide Towards Health Preservation, published in the Journal of Family Medicine and Primary Care Health, provided evidence that this salutogenic approach to design can benefit residents in terms of health and well-being.
Let's get to it. The first case study is from Copenhagen, Denmark. The project is called Future Sølund Urban Nursing Home and it features intergenerational mixing and mixed-use, and by that I mean retail. Housing and institutional uses are located on the same site as well as access to green space. These renderings are from a winning entry to an architecture competition. The building is currently under construction. It's scheduled to complete in 2026. It includes nursing home units, homes for young people, homes for special needs, daycare centre, shops, cafes and workshops.
So in this equivalent of a long term care project, you have shops and cafes that invite the general public to enter the senior housing, to enter the nursing home and participate in the lives of the people living there. The pathogenic approach limits the interaction between residents and the outside world to reduce the risk of harm. The salutogenic approach promotes community and intergenerational mixing, sense of manageability, access to family and friends.
Here is a quote from the architects: In the competition we had a wish to create the framework for a vigorous community between generations bursting of lushness and passion.
This project also includes 3 courtyards. One of them is called Generation Square. This is what the judges of the competition had to say: Generation Square is very convincing by showcasing a place where all people, people of all ages meet and draw in the life of the city. Art, music and green spaces promote the sense of meaningfulness and provide motivation.
The second case study is again, De Hogeweyk Dementia Village in West Holland. The home employs a small household model of 12 beds per resident home area. A cost saving measure is the notion that residents must walk from place to place by themselves, reducing the need for physiotherapy spaces.
So this is an intuitive path comprehensibility, and you can see in the image how verandas and elevated walkways around courtyards provide that sense of comprehensibility.
De Hogeweyk, is funded similarly to other nursing homes in Holland. I recommend listening to a 99% Invisible podcast episode about De Hogeweyk.
This is from the De Hogeweyk website: In De Hogeweyk, you will find houses where people live together based on similar lifestyle. They can visit the pub, restaurant, theatre, the supermarket or one of the many offered clubs. The concept supports unique needs, lifestyles and personal preferences.
The third case study is also from Holland. It's called Wiekslag Boerenstreek Nursing home. The nursing home hires 15 to 19 year old teens to help with the busy period. The home features apartments with full kitchens, which you don't see anywhere other than (some) independent living suites in retirement homes. There are not even kitchenettes in Long Term Care units. It also features a common cafe, kitchen, and living room at grade and those are accessible to visitors to promote residents, independents sense of manageability.
[From their website] The choice of the location is critical to the care organization. Preferably it must be close to shops at the centre of activities in the neighborhood and with good views of those daily activities.
The fourth and last case study is more of a design guideline. It's coming from the US. It's called the Greenhouse Project. Homes are small in scale, self-contained and self-sufficient with elders at the centre surrounded by a self managed team of care partners. Designed to reinforce the identity of elders and eliminate institutional signposts, all homes have private rooms and washrooms for everyone. (Sense of manageability). The living room with the fireplace, together with an open kitchen where all meals are prepared and served at a communal dining table, completes the home. Dedicated public, private and support spaces that are small and easily navigable support the sharing of lives and foster community engagement. So that's the sense of comprehensibility.
Let's take a look at the floor plan. Note the central space. It includes a kitchen, a dining table, and it's not restaurant style with four seaters, but it's a long dining table such as you may find in a dining area in a home. There is a fireplace at the centre. There are some lounges and everything is overlooking with very generous windows, overlooking garden and porch or patio space. The back of house services are at the back. That's the only place where you would see corridors. The bedrooms are laid out around the central core, which means that you don't even need nursing stations. Staff can simply fit in the kitchen and be able to monitor all of the bedrooms. The bedrooms door can remain open and when staff warms up baked goods in the kitchen, the smell of those muffins or cookies attracts residents out during meal times, which provides the motivation to eat, so Sense of Meaningfulness.
Here's a comparison between a courtyard design with 32 beds, which is the maximum allowed by the Ministry of Long Term Care in Ontario, and that means that usually you would find homes with 32 beds in a resident home area. So that's on the left, and the same greenhouse project with 16 beds [is on the right].
Note the long corridors in the 32 beds version, the long corridors required to reach the different parts in the building. Also note the dining room. We have 8 tables, they sit four people each. That feels more like a restaurant and we can design it to be a very nice restaurant, but it's not exactly a home dining area.
To sum up the Salutogenic Seniors Housing Concepts:
- mixed-use (retail, institutional, and housing on the same site)
- intergenerational (Student Co-Housing)
- non institutional feel/ aesthetic
- small households (home like atmosphere)
- access to outdoor areas with lush vegetation
- seniors are residents, not patients, identity and agency are reinforced
- appropriate lighting level and I didn't touch on that up until now. But that connects to daylight - versus electric light. Daylight is a lot stronger than indoor lights and let's not forget that a lot of people living in long term care homes or even in retirement homes may have vision impairment issues
- and of course barrier free design. So
How do we design homes for seniors in the GTA? It's not only about cost, but it is mostly about costs. Let's look into the cost of building senior housing. But first, one last headline. This multi year cruise around the world costs less than living in Toronto. Would retiring at sea be a better plan?
So the Altus Group releases a construction cost guide every year. The guide provides cost per square foot for different types of buildings in different regions. We're going to focus on senior housing. I'm going to show you estimated prices per square foot (hard costs) in the GTA in 20/14/2018 and 2023 from the Altus Cost Guide.
A note about hard cost: those are the costs directly related to the physical construction of a building. Soft costs, on the other hand, include consultant fees, planning and permit fees, insurance, marketing and development charges. Hard costs do not include soft costs. They do not include land cost either.
So just quickly going through these numbers, there are three categories. I'm going to focus on: Long Term Care (LTC) and Assisted Living (Retirement Homes) and not going to get too much into the numbers. The bottom line is that over the last nine years, the cost of a similarly sized long term care building rose 73% and the price of Assisted Living in Retirement Home grew 105%.
So for example, if your Long Term Care building had hard costs of 40 million in 2014, it is estimated to cost around $70 million in 2023 plus land costs plus soft costs.
To reduce costs while maintaining the original scope of work (e.g the number of units) and quality (like market standards, operator standards or ministry standards), projects commonly undergo value engineering. Value Engineering may include:
reduction in growth construction area,
simplification of building form
reduction of interior and exterior finishes
review of building systems like mechanical, electrical, structural and others, and replacement with cheaper systems if available
review of funding strategy. Is it possible to get more money to offset construction costs? For example, increased the number of units without significantly impacting the growth floor area.
Less regulated markets like Life Lease and retirement homes can roll costs onto buyers or renters (within market limits). Long term care projects, where funding and income is controlled by the government, are at a higher risk of stopping the work.
When projects are too expensive to build, they get paused inn the best case; they get cancelled in the worst.
Let's put costs aside for a moment and look at the minimum standards for LTC and how they compare to evidence based design recommendations. The Ministry of Long Term Care sets the minimum standards. It's the law along with the Ontario Building Code. We have to meet the 2015 design manual.
On the other hand, last year CSA came out with recommendation for Long Term Care operation and design. They have a chapter on design. It was written by researchers and that is what I mean by evidence based design.
When conducting value engineering, the minimum MLTC and Ontario Building Code requirements, the law must be met. Long term care operator standards and evidence based design recommendations are under discussion. In other words, to ensure a specific standard, it must be part of legislation and also it must be funded appropriately by the government.
I'm going to do a comparison between the two. Above is the MLTC Design Manual and below are the CSA recommendations. The current MLTC design and funding paradigm makes it difficult for operators to consider small households, the MLTC allows for 32 beds. The CSA recommends no more than 12 beds per household.
We did a design exercise with an operator in Alberta to design a home and we found out that the Alberta equivalent of the Long Term Care Home Design Manual only allows up to 14 units. That is, Alberta decided to go with the small household model. As a result, what we found out is that the floor area per bed turns out to be 30% more than in Ontario, so it needs 30% more money to build. It also needs 30% more space (land).
It is important to note that small households can be achieved by allowing certain spaces to be shared between households. This must be clearly defined in the Ministry’s Design Manual before such design can be considered.
Reducing household sizes will allow for home like environment, promoting identity and reducing the institutional hospital like feel of spaces which is the salutogenic approach. At the same time, it may also improve infection prevention and control (IPAC) as there are less transmission vectors for disease in the household which is the pathogenic approach. So this recommendation benefit both from salutogenic and pathogenic appraoches. They're not always in tension with each other. Sometimes we can achieve both of them together by following a better standard. However, I have to stress funding. Money is where this starts and end.
Next up the maximum number of bids per suite or per washroom. The current Ministry of Long Term Care funding model promotes 60% of the units to be private and or singles and 40% semi-private or basic. Those are two different types of two bed suites. The CSA notes that having private beds only have been shown to reduce the potential for transmission of organisms and therefore decrease the risk of infection, decrease medication errors, and improve overall safety for both residents and staff (pathogenic). There is also an argument that private beds provide increase privacy and thus promote individuality and agency (salutogenic). I would like to note that private beds are more expensive to the residents. In the current MLTC model, private beds cost $3000 a month, whereas basic beds cost only to $2500.
There's also a question regarding the number of beds per washroom, this is just a small anecdote. Interestingly, De Hogeweyk has households of 12 private suites but the washroom is outside and 12 suites share only two washrooms between them to cut on construction cost. If anyone has any opinion about washrooms I would love to hear it at the end.
Last point of comparison - ensuite washroom components, the Ministry of Long Term Care allows a toilet and sink only while the CSA recommends a private shower in every suite. The ability of some residents to shower in their own bedroom ensuite instead of a shared facility promotes independence and dignity.
I'll talk a little bit about my own experience designing long term care homes. In this example, shifting bedrooms closer to a staircase on the right allowed for a window at the end of the corridor. These photos are for illustration purposes only. You can see a a corridor with no window at the end [in one photo] and this [other photo] is what the corridor might look like with the window at the end. It provides views to the outside, giving better orientation of where you are in the building, and daylighting improving lighting levels. On the plan. You can see that this entire block of bedrooms was shifted to the right, allowing a window for people coming from this corridor.
Similarly, in this example, this is a reference project that we were given. The care desk is like a nursing station and as you can see all of the views are towards corridor walls and doors. On the buildings that I'm working on, we were able to provide a generous window providing daylighting. And it's so large, it's a feature window improving the environment next to the care desk
Operators at the design table. So operator developer organizations include both capital development or construction departments and operational departments, and they're usually separated. They usually have different budgets. Our experienced operator developers bring their Ops team to the table during the design of buildings to ensure they meet their latest operational standards. Some conversations revolve around the need for more space for certain functions, i.e. the request to increase the size of the building and increase cost. But other conversations don't have any cost associated with them.
So for example, what you see on the right, this is how some residents sit on the toilet. They need the help of staff and a mobile human lift. That lift is on wheels, and the staff maneuvers the resident through the washroom door, then onto the toilet. In this case, there was a conversation about moving the doors to be straight in front of the toilets, so the path of travel maneuvering this bulky lift will be simplified. This doesn't have any cost. Moving a door a few inches here or there doesn't cost anything, but it could result in significant time saving for staff, and we know that staff time is at a premium in long term care homes.
I'm going to talk a little bit about municipal bylaws and standards. Sometimes they can be indirectly used to facilitate better home environments. Let's start with urban design requirements. So Urban design department ask in many municipalities for shadow studies, which means that all parts of building need to be set back from property lines to minimize shadows on on neighboring sites. They also asked for imaginary 45° angular planes as you can see in this section image. What that creates is terraces. The building is set back above a certain number of floors. We could utilize such terraces to create safe and secure spaces for people living with dementia to step outdoor without supervision because they do not have any place to go. This is an example of such a space in the Walker Wing Roof Garden on the second floor of the Belmont House Long Term Care in Toronto. It was designed by Montgomery Sisam.
Urban forestry departments require a minimum number of trees planted and landscaping buffers, and those have potential for seniors appropriate garden spaces. In this example, this is again Belmont House by Montgomery Sisam, when you approach the building you see a very generous garden at the front. The building itself has generous windows in front of the nursing stations viewing this garden so residents living in the long term care home can see this garden from the nursing stations areas.
What does stormwater management have to do with Salutogenesis? You ask. So in case you don't know, we have big problems in Toronto and other municipalities with sewers. There are combined sewers - old sewers - and in general a lack of capacity of sewer infrastructure for stormwater. One of the ways that we deal with this on site (and we have to deal with this on site as part of the site plan application), one of the ways is through vegetation because the soil under the vegetation retains the water during storm events and then that water does not enter the municipal sewer system.
In Toronto, we even have a green roof act and most long term care buildings, except perhaps the smallest ones, would need a green roof on top of them. This creates a great opportunity for outdoor amenity spaces for seniors or simply for views. So the image that you're seeing here is the Via Verde in New York by Dattner Architects and Greenshaw, and the landscape architect just had so much fun with this building. You can see a variety of vegetative roofs and roof planters. I think that they also have urban agriculture happening on the roof. And note how there are stairs leading from one roof terrace to another. It's a 10 story building and they designed as cascading steps.
Last but not least - natural features. This is the Rosedale Valley Bridge Photo by Ashton Emmanuel. The GTA spreads over environmental features that are part of the urban context. For example, in Toronto we have the ravines, lush green areas running through the city with many sites overlooking natural views. Now, these natural features are protected against development, and so they should. However, the sites adjacent to them can be developed. And if we happen to work on a site adjacent such a ravine or such an environmental feature, why not provide views from windows, gathering spaces and seating areas overlooking the features?
That's it. I am very interested in what researchers and operators in the audience think about senior housing and their design. I hope this presentation can start a greater conversation.