The Small House Model for Memory Care
What would you give to insure you lived each day of your life happy?
There is a growing understanding of what makes a successful environment for seniors living with memory impairment. The elements that can make a difference in the lives of those with dementia are not that complicated and can be encapsulated in two words – connectedness and a sense of home. The small house or cottage model has been found to be the most successful environment in providing that sense of home, connectedness, and ultimately, happiness. Juniper Communities has served as an innovator in pioneering the small house model within their memory care communities. Juniper continues to believe that this model remains the gold standard in memory care.
Maslow’s hierarchy says that to be fulfilled—happy—we need to have not only our physiological and safety needs met but also be able to feel like we belong, are accepted and can contribute.
At Juniper we have long subscribed to the belief that the keys to healthy aging include staying physically active and socially connected. For some of us, doing one or both can be more difficult over time. This is particularly true of some individuals who are living with memory loss. Our job as caregivers and partners in caring is to facilitate new ways of helping residents to be connected to the community – their home – while at the same time fostering a sense of independence.
Environmental features are key in both keeping people physically active and connected with others. A 2011 study by Dr. Margaret Calkins, Ph.D., an internationally recognized leader in the field of environments for the elderly, especially those with Alzheimer’s or dementia, found that people who lived in small group or cottage settings had less disruptive behaviors and greater socialization. They (and their families and the staff who cared for them) were also more satisfied—happy.
Another study done in 2011 in the Netherlands by Hilde Verbeek titled Redesigning Dementia Care concurred. Her research indicated that residents in small-scale living communities were significantly more socially engaged and displayed fewer physically non-aggressive behaviors, such as wandering, than residents in larger, traditional settings. They experienced greater wellbeing and less stress—they were happier. The study also found that residents in this “person-environment model” developed an individually meaningful experience of choice, mastery and relationship. They developed a feeling of “at-homeness” or happiness!
Understanding the Small House Model
Caroline Cantley in her 2002 book Put Yourself in My Place stated that there is broad agreement that desirable dementia care homes be small scale, which she defined as 6-14 residents. Getting much larger, she and her colleagues said, is a distinct move away from a “family feel” towards something more institutional. Different research provides other specific numbers, Dr. Calkins suggests between 9 and 24 residents, but they all are within this general range. Larger communities may mitigate their size with their layout, such as linking several smaller houses together to achieve economies of scale.
Juniper has been well ahead of the trend as we have owned and operated two types of small house models for more than a decade. Two of our small house models, Aurora and Louisville, both in Colorado, were purpose built by Juniper in 1999 and 2000 respectively, as part of our initiative to provide leading-edge care to residents living with memory impairments. These two communities include four small houses, each with 12 or 13 rooms, virtually all private, surrounding a town hall area. Each town hall provides destination locations consisting of multiple familiar spaces such as an office suite, game room, library, country store, and gymnasium, where residents from all houses can go for additional services or programs. In this model, where the houses are linked, all staff are readily available to assist if needed.
Juniper’s other three memory communities although not purpose built by Juniper, were acquired between 2006 and 2014, in part based on their similar design. All three are based on a small house or cottage model. For instance our community in Naples, Florida is a campus with six small cottages, each home to 15 residents in a combination of private and semi-private rooms, spread across lovely grounds connected by walking paths and gardens. Another, acquired around the same time, has three neighborhoods of 12 residents each in a combination of private and semi-private rooms, which open onto a central common area.
In both models, residents at Juniper’s communities live within a short walk to the living room, kitchen and dining areas. The environment is homelike; there are no nurses’ stations and no medication carts that block the hallways. Staff wear polo shirts, not scrubs, and are trained to engage residents in activities of daily living, as well as social and recreational activities. In both models, there are large, accessible and safe outdoor spaces surrounding the community.
Design Aspects that Matter
Small scale is of course critical, as are several other design elements including:
• High visibility of features that are most important to residents from the location where they spend the most time such as being able to see the toilet from the bed, the kitchen from the living room, the activity space from the dining room, and so forth.
• Unobtrusive security measures like disguised doors to inhibit exit-seeking behavior, and decorative fencing to provide a secure environment that is aesthetically pleasing.
• Separate bedroom suites, furnished with the resident’s own belongings.
• Adequate and time appropriate levels of illumination such as brighter lighting during awake hours and dimmer lighter in the evening.
• Accessible outdoor space to offer opportunities for residents to enjoy nature while satisfying needs to walk and wander safely.
• Sense of movement through different types of spaces, for instance personal bedroom space to family living and dining space, to community activity spaces in our Town Hall concept.
In addition to these items, a 2010 study, Long-term Care for people with Dementia: Environmental Design Guidelines, by Richard Fleming and Nitin Purandare maintained that “it is desirable that the facility be small, have a homelike appearance and provide opportunities for engagement in the ordinary activities of daily living….”
For us this means:
• Life Skill Stations that create small vignettes such as sewing, gardening, or a work bench that help spark old memories and foster normal daily activities that encourage interest, movement, and interaction.
• Consistent staff assignments with the same staff assigned to the same house at the same time as often as absolutely possible, in order to foster a sense of familiarity, an ability to truly know each individual and cater to their particular wants and needs.
• A personalized, custom experience for each resident, through use of My Life Story, Music Assessments, and other tools that help us know each resident as an individual.
• Individualized daily connections activities that include assisting with ordinary activities of life, Music & Memories program, art and pet therapy, intergenerational experiences, outings, and events.
• Family and friends come to visit – just like at home! This can be spontaneous, drop in visits or community planned events that foster a sense of tradition and belonging.
Ultimately it is all about relationships. The small-house model of care becomes a true community for a group of seniors and staff. It focuses on nurturing the spirit of life, and its heart is found in the relationships that thrive there. Juniper’s goal via the small house model has always been and continues to be to serve as a place where seniors can receive assistance and support with activities of daily living and care, without the assistance and care becoming the focus of their life. And ultimately to provide the key elements to successful memory care – connectedness, home, and happiness!