Every designer who has worked in the long-term care or assisted living arena has an opinion on the correct number of residents a senior care household should have. The original Greenhouse® in Tupelo, Mississippi was pegged at 10 residents. The flurry of design activity following that introduction provided households ranging from 10 to 20 and generally proved to be experiments in balancing number of residents, staffing requirements, siting constraints and returns on investments. Unfortunately, designs of households are too often driven by the construction budget and convenience of resident room layout determined by the designer. This is not to say that these parameters are not important because they are. However, in the life cycle of the building being designed, the initial capital costs are overshadowed by operational costs. Thus, balancing the number of residents in a household with the staff (on each shift) must be a prime consideration addressed early in the design process. In addition, the connectivity between adjacent households can have a profound effect on shared staffing, particularly on the evening or night shifts.
For example, if the sponsor is attempting to achieve about 5 hours of direct care per resident per day, this can be accomplished with two CNAs plus one nurse on both the first and second shifts of the day and one CNA and a shared (1/2) nurse on the night shift if the household is 12 residents. With the same staffing it translates to 4.2 hours if the household is 14 residents and 3.75 hours if the household is 16 residents. One can quickly see that it is more difficult, and more expensive, to try to staff at this care level as an increase in residents within a household occurs.
In addition to the effect that staffing may have on the design of a household, the creation of a household size that accommodates a sense of “family” should enter the design mix. While there are certainly large nuclear families, most of us have been a part of families that are populated with less than 20 individuals and, for that matter, less than 10 to 12. When entering a congregate living situation, most of us can more easily assimilate into that group when it is a smaller one. In addition, it becomes somewhat more intuitive and comfortable in that process of assimilation when the physical environment is smaller and approaches replication of a single-family home or apartment size.
In the end, a well-designed household does not result from a set formula nor is it the result of a proscriptive process. A good household design utilizes the client’s marketing requirements, their occupancy requirements and their ability to appropriately staff the households. Embracing a resident-oriented model of care means designing household size, staffing and physical environment that provides a sense of space, place and belonging, giving residents an enhanced sense of dignity and independence. It is not a magic number, but good, solid understanding, as well as arduous work by the designer that results in an appropriate size of household for each individual application.