A few weeks ago, I visited my husband’s grandmother in her retirement community. We had been there several times before, but our most recent visit made me appreciate her situation more. After having read numerous news stories about elder abuse, fraud, and deplorable living and healthcare conditions in nursing homes, I found her community to be quite the opposite.
It’s important to mention that her community offers a mix of living situations, depending on a resident’s health and preferences. There are single-family homes for people who still want some autonomy—and can afford them—but most people reside in the large, mansion-like, main building. Residents and couples have their own apartment, which they can customize and decorate according to their wishes. Visiting nurses help sick patients in their homes. However, for those who are debilitated or need physical therapy, there’s a healthcare wing of the building that essentially functions as a hospital.
Knowing that life expectancy decreases when patients enter a nursing home, I asked my husband’s grandmother about the outcomes for her community. She told me that 25% of the residents have been in the community for more than 20 years, which far exceeds what the community’s management expected when they built it in the 1990s.
As we all know, the elderly—people who are older than 65—make up one of the fastest growing populations in the US. In 2013, the elderly population numbered 44.7 million and represented 14.1% of the US population, or about one in seven Americans. By 2060, there will be about 98 million elderly people—more than twice their number in 2013. 
Clearly, this population not only represents a large proportion of the people who may make up our user base in the future, but their age and health conditions also present interesting design challenges. My discussion with my husband’s grandmother made me aware of some disconnects between what I saw in her retirement community and the services we hear about in the news. This motivated me to explore the topic further. What are the various design considerations we should be aware of when building a service or space for seniors?
Diverse Senior Residence Options
For seniors who have realized that they either cannot or do not want to live in their own home anymore, it’s helpful to outline their diverse options. Two considerations drive their choice: their health and their financial situation. Seniors who have minimal health issues can live in independent-living communities—also called retirement communities or senior apartments. The community in which my husband’s grandmother lives falls into this category of residence. These communities are usually private and, therefore, do not accept insurance such as Medicare or Medicaid.
Assisted-living communities are for seniors who cannot be as autonomous as those who are healthy, because they require nurses to administer medications and other support to take care of cleaning and other daily tasks. While these residences are still actual apartments, they typically have smaller kitchens than those in independent-living communities. These communities may accept insurance, but they are usually private, so their residents must cover the costs of living in them.
Nursing homes are for seniors who are more frail or ill and require 24-hour nursing. Residents must often share a room. The cost of living in a nursing home may be paid from private funds or by insurance. 
Evolution of Senior Care and Living Spaces
Nursing homes are the oldest of the senior-residence options in the US. Before the 1900s, if family could not care for an elderly loved one, churches and women’s homes would take in widows and single women, while almshouses, poorhouses, or poor farms were the options for everyone else. As you can imagine, a poorhouse was the last resort for someone who was dying, with dilapidated spaces and insufficient end-of-life care. In the 1930s and ’40s, the US government stepped in, passing legislation that mandated oversight and standards for these almshouses, with which they needed to comply to qualify for government funding and grants. At that point, the almshouses were renamed and became nursing homes. 
Over the years, nursing-home standards and guidelines have continually been updated, placing a strong focus on healthcare and following a hospital-based model for care and space. An article in Long-Term Living Magazine summarizes these standards: “Design professionals and long-term care providers are often confronted by codes, standards, and guidelines that may be unclear, outdated, or difficult to use because they have been adapted from and integrated with those written for more acute-care environments such as hospitals. These guidelines also tend to be far more clinical and institutional in nature.” 
For decades, these guidelines have had obvious implications for the design of the nursing-home spaces and services. Researchers at InformeDesign outlined how these nursing homes have historically felt to their residents. Based on these standards:
Buildings are organized into nursing units of approximately 40 residents, each in a shared room.
A large nursing station is situated for easy eye contact in all directions.
Hospital-like lighting controls and fixtures are affixed to the walls behind each resident’s bed.
Residents share communal bathing and shower areas.
There is often a day room at the far end of the complex.
There are large dining and activity spaces.
Commercial kitchens, laundries, and other areas are off-limits to residents.
Over the last 20 years, nursing homes have added aquariums, aviaries, and plants to make these settings more appealing to residents. However, the overall feel of nursing homes remains sub-par because the model emphasizes streamlined healthcare rather than quality of life. “The basic, sterile, amenity-poor, one-size-fits-all model, the sparseness of individual spaces, and the large institutional nature of shared spaces remained largely unchanged. Besides cost considerations, regulatory constraints that emphasize infection control and smooth delivery of care to very sick people are often blamed for consigning older people to living in an institution.” 
Transforming the Nursing-Home Model
To transform the nursing-home model that the government instituted decades ago, several forces have needed to unite:
private versus public—The two other categories of senior living that I mentioned earlier—independent-living communities and assisted-living communities—emerged in the private senior-residence space. Thus, they do not need to comply with antiquated guidelines that are still mandatory for facilities that want government funding. Moreover, seniors often prefer them to nursing homes By giving nursing homes some competition, they also ensure that seniors have more options.
people-focused care—A new emphasis on individualized, person-centered care has taken hold—in contrast to the historical, one-size-fits-all approach.
quality of life—While quality of care is still important, it will no longer be acceptable as an excuse for a diminished lifestyle. Medicaid and Medicare Services are also pushing for an emphasis on quality of life, as well as “outcomes such as comfort, security, meaningful activity, relationships, autonomy, individuality, privacy, dignity, functional capacity.” 
As experience and service designers, we see the attributes that need to be in place for the transformation of nursing homes as universally relevant and applicable. If we reflect on the transformation efforts organizations are pursuing relative to leveraging digital or being more customer focused, the following insights surface:
Nursing homes realize the negative business impact if they don’t transform. There is always a bottom-line business impact of transforming an existing business model—whether it’s increased loyalty or staving off the competition, as in the nursing-home example.
They understand the importance of people to their transformation efforts. Whether focusing on employees or customers, the human side of a service is key.
They emphasize experience-based outcomes. As designers, we appreciate how people feel about an experience, but this is new territory for many organizations. During transformation efforts, there’s a shift of emphasis to less tangible outcomes—in addition to the more tangible ones such as medical care in the nursing-home example.
Once the right levers are in place to start a transformation effort, as designers, we have the opportunity to reinvent what we do. For nursing homes, green-field opportunities are anchored in the movement often referred to as “people-centered culture and design” and focus on the “values of choice, dignity, respect, self-determination, and purposeful living.” 
Atul Gawande, author of Being Mortal, explains: “Making lives meaningful in old age is new…. [It] requires more imagination and invention than making them merely safe does.” He encourages family members who are selecting a home for their loved ones to “choose a place of residence that will also respect someone’s individual choices, preferences, and freedoms. Instead of selecting a facility that will force an older man who has fallen recently to use a wheelchair, for example, pick a place where a staff member will ask him how much being able to walk—even with the help of a cane or walker—means to him. Preserving that ability could mean all the difference in his life, even if it means he’s more at risk of a slip.” He continues to advise family, “instead of making healthcare decisions based on how they make us feel—[that is], Is my loved one safe? make those decisions based on how they'll affect our family member’s quality of life.” 
As nursing homes transform and adopt a people-centered model, the impact of this shift has huge implications for designers. Both interior designers and architects need to rethink the physical spaces of nursing homes. Service designers need to rethink the interactions between nursing-home staff and residents. User experience designers and technologists need to rethink how technology can best support this new people-centered model.
Design Trends for Physical Spaces in Nursing Homes
As Long-Term Living indicates, “Transformation to a person-centered culture requires the creation of built environments where both elders and their caregivers are able to express choice and practice self-determination in meaningful ways at every level of daily life.”
A European project called Wel-Hops—welfare housing policies for senior citizens—in which Italy, Spain, Hungary, Sweden, and the United Kingdom collaborated, created a set of guidelines for use by anyone overseeing the planning of new senior housing to help them design a more elderly-centered space,  as follows:
Sleeping in a peaceful place transforms a physiological need into a pleasure. For example, provide a discreet bedroom—not a studio—that is large enough for a bed and wardrobe and has sufficient space for navigating around the room in a wheelchair.
Feeling autonomous and safe while taking care of oneself increases self-esteem. Here are some examples: Use toilet-flushing buttons that residents can activate with the whole hand and require little force. Install mirrors at a height that allows a seated person to see himself or herself.
Preparing one’s own meals—and those of others—proves self-sufficiency and increases self-esteem. Examples include: Provide a single large work area that is accessible to wheelchairs, has rounded corners, is strong enough to lean on, and can be lowered. Allow sufficient space for a table and chairs, ideally with a clear view of the TV and other spaces.
Taking control of one’s home helps maintain good self-esteem. For example, allow residents to select different options for their home’s layout, use their own furniture, and choose the finishes.
A cozy, hospitable space stimulates socializing. For example, provide areas in the home for guests—such as a sofa bed. 
Such guidelines for physical spaces reflect the shift to patient-centered care. But the person-to-person interactions among residents and staff are equally important and must be designed as well.
Design Trends in Person-to-Person Interactions
As I mentioned earlier, private senior-living options—which are often preferred—have caused the publicly funded nursing homes to take a hard look at themselves and make improvements. In turn, Medicare and Medicaid began mirroring the patient-centered care movement in the private sector. They updated their guidelines to integrate softer elements into their regulations and instituted reviews of nursing homes to ensure compliance.  These updated guidelines include the following:
Provide 24-hour access to approved visitors—not only family members. Moreover, nursing homes have to prove that visitors are aware of this policy—that is, it is encouraged rather than kept hidden.
Encourage residents to dress in their own clothes and assist them in dressing rather than requiring hospital gowns.
Avoid staff’s interacting and conversing only among themselves rather than with residents.
Groom residents as they wish to be groomed, maintaining their personal style.
Allow residents to choose their daily schedules, consistent with their interests and plans of care.
Limit the use of audible chair and bed alarms, which can startle residents. 
Equally important as the guidelines themselves is how reviewers prepare to assess a nursing home’s compliance with the guidelines. Here is a synopsis of how the Medicare and Medicaid agencies now train their employees to evaluate a nursing home for compliance with these new people-centered guidelines:
Rely on resident and family interviews to ensure you consider the resident’s former lifestyle and personal choices.
Observe whether staff shows respect for residents. When staff interacts with residents, do they pay attention to them as individuals? Do staff respond in a timely manner to residents’ requests for assistance? Do they explain to a resident what care they are administering or where they are taking them?
Observe whether staff members appear distracted when they interact with residents. For example, do they continue to talk with each other while doing a task for a resident as if the resident were not present?
During resident and family interviews, determine what time the resident awakens and goes to sleep and bathes or showers and determine whether this is the resident’s preferred time. If residents are unaware of their right to make such choices, determine whether the facility has actively tried to obtain information regarding residents’ preferences from them—or from family members for residents who are unable to express their preferences—and whether caregivers are aware of their choices. 
The methods a reviewer uses to assess compliance are very familiar to experience designers—surveys, interviews, observations, and collating of personal artifacts. Essentially, the reviewer needs to get a sense of a resident’s persona and preferences, determine whether the resident’s experience with the nursing home supports that persona’s preferences, then determine whether there are any gaps that the nursing home needs to address.
As should be obvious, staff interactions with residents are critical to the quality of service a nursing home provides. But, unfortunately, nursing-home staff retention continues to be a problem: “The turnover rate in long-term care is a significant problem, with rates ranging from 55% to 75% for nurses and aides and sometimes over 100% for aides alone.” 
Interestingly, the attributes of a nursing home that relate to retention and keeping nursing staff happy are actually very similar to those for the residents:
Provide opportunities for professional growth.
Encourage employee involvement in decision making.
Allow staff participation in care planning.
Clearly communicate work expectations and performance against objectives.
Build teams and increase coworker support.
Minimize the time they spend on activities other than direct resident care.
Call aides by name. 
The spirit of these recommendations for retaining nursing-home staff centers on growth, participation and inclusion, personal preferences, clear communication, and respect—all of which are attributes that are associated with quality of service and care for seniors. Moreover, these guidelines for retaining staff and caring for residents reciprocally support each other. For example, aides could recommend activities that they believe the residents would enjoy to management. This, in turn, would help residents feel that the nursing-home experience is personalized for them, as well as help aides feel ownership in their role.
Before you try to picture your own grandparents using a VCR, let alone social media, let’s look at some data from a 2012 report by Forrester, “91% percent of seniors use email, 49% have a Facebook account, and 44% play solo games online…. Many expect to continue these activities as they transition to assisted-living arrangements.” The expectation that nursing-home residents will want to continue using these technologies has prompted nursing homes to add IT amenities to their overall service. A 2012 survey of Chief Financial Officers of senior-living organizations “found that 90% had invested in wireless technology in general, and 36% had Internet access and social networking for residents and clients specifically.” 
Of course, nursing homes do see the value of these technology trends to their residents’ health and well-being. “13% to 25% of nursing-home residents have been diagnosed with depression. Social isolation is a major contributing factor to depression, and technology that helps residents stay socially connected and active can help prevent the onset of the illness…. Installing Internet access and wireless technology also can get patients moving and learning…. Several nursing homes [have] Nintendo Wii gaming units that residents use to play active games with each other and residents of other facilities.” 
While adopting more consumer-oriented technology is the big trend, the use of extensive healthcare IT systems such as electronic medical records is more complex and expensive.  In a long-term study with funding from Medicare and Medicaid, the University of Missouri found that “all the nursing homes used technology to support patient care, whether through tracking dietary needs and medications or to complete other administrative activities…. [They used] technology to complete tasks such as keeping track of patients’ medications or scheduling appointments…. However, most of the technology was used to communicate patients’ information within the nursing home rather than to communicate with external units such as hospitals or off-site pharmacies.” 
One of the biggest areas of opportunity for technology to improve nursing-home care, therefore, is improving the exchange of information across multiple healthcare stakeholders to prevent hospitalization and rehospitalization. “Previous research has shown that every time patients move from nursing homes to hospitals and back to nursing facilities, their conditions deteriorate…. Transitioning between hospitals and nursing homes is a complicated process because the exchange of accurate, complete, and timely information often is convoluted…. Research suggests that nearly half of hospitalizations among nursing-home residents enrolled in Medicare or Medicaid could have been avoided. These potentially avoidable hospitalizations amounted to more than $7 billion in 2011.” [11, 12]
Home as the Ideal Senior-Living Space
While nursing homes have begun to transform themselves—including their physical spaces, relationships between staff and residents, and technology—for both a better resident experience and improved healthcare outcomes, the reality is that the ideal place in which seniors would live out there final chapter is at home. Not only do almost 90% of seniors prefer to stay at home rather than move into a nursing home, the cost to the US government of supporting nursing homes is considerably higher than the cost of supporting in-home services.  Home health technology is the key to allowing seniors to continue to live at home. InformationWeek outlined the top eight home health and IoT technologies that are emerging:
sensors that can be placed anywhere in the home to alert caregivers of issues such as a senior’s missing a meal or falling
GPS that lets others know where a senior is at all times, even specifically in what room inside the home
mobile apps that can remind seniors to take their medicines and provide easy access if they need to call for help
remote monitoring tools—for things such as glucose level, heart rate, and blood pressure—and numerous other wellness tools that are now on the market minimize the number of doctor visits that are necessary
big data and analytics are making the field smarter and more proactive in responding to seniors’ conditions
household gadgets such as Roomba for cleaning and wearable technologies that translate doorbells or telephone rings into a visual alert help with daily activities
social media enables seniors to connect with others through games, chat rooms, and message boards
telehealth leverages phones and videoconferencing systems to eliminate numerous doctor appointments by connecting all of a patient’s relevant medical professionals at the same time 
While these technologies may seemingly be the panacea for senior living, obvious simplifications usually involve some hidden complications as well. We must carefully plan and orchestrate all interactions for seniors—from making these devices easy for seniors to use to ensuring that all healthcare stakeholders can interact remotely with seniors. Our role as experience designers is key to the successful use of home healthcare technologies.
Director of Strategy & Experience Design at NTT Data
Woodbridge, New Jersey, USA
Laura’s 10 years of experience have focused on representing the human element in any interaction with a brand through actionable, business-impacting insight gathering and design. At NTT Data, Laura leads cross-channel experience design strategy engagements for clients. Clients have included AstraZeneca, Hachette Book Group, GlaxoSmithKline, Prostate Cancer Foundation, Honeywell, and the NBA. In addition to her Service Design column for UXmatters, Laura has written articles for the Service Design Network’s Touchpoint: The Journal of Service Design, User Experience Magazine, Communication Arts, and Johnny Holland. She has presented on service design at SDN’s Global Service Design Conference, the Usability Professionals’ Association International Conference, IxDA New York City, and IxDA New Jersey. Read More