Attachment 5 - Small House Model Design Guide.pdf

Small House (SH) Model

January 2017 rev. March 2019

(Replaces the Community Living Center Design Guide - dated June 2011)

Small House (SH) Model Design Guide March 2019

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Small House (SH) Model Design Guide March 2019

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Small House (SH) Model Design Guide March 2019

TABLE OF CONTENTS

1.0 GENERAL

1.1. Foreword

1.2. Acknowledgments 1-5

1.3. Introduction 1-9

1.4. Definitions 1-11

1.5. Abbreviations 1-15

2.0 FUNCTIONAL CONCEPT 2-1

2.1. Defining the Small House (SH) Model 2-5

2.1.1. Types of VA Programs 2-5

2.1.2. Small House (SH) Components 2-7

2.1.3. Industry Trends 2-8

2.1.4. VA Trends 2-10

2.2. VA Values and Goals of the Small House (SH) Model Program and Design Guide 2-11

2.2.1. VA Values 2-11

2.2.2. VA Goals 2-12

2.2.2.1. Environment of Care 2-12

2.2.2.2. Principles of Small House (SH) Design 2-12

2.3. Operational Criteria 2-15

2.3.1. Residents 2-15

2.3.2. Staff 2-16

2.3.3. Food and Nutritional Services 2-17

2.4. Planning and Design 2-19

2.4.1. New Construction 2-19

2.4.1.1. Site 2-19

2.4.1.4. Community Center 2-61

2.4.2. Renovation 2-75

2.4.2.1. Renovation Project Priorities 2-75

2.4.3. Interior Architecture and Finishes 2-79

2.4.3.1. Overall Selection Criteria 2-79

2.4.3.2. Design Language 2-82

2.4.3.3. Design Elements 2-84

2.4.3.4. Interior Finish Schedule 2-95

3.0 TECHNICAL CONSIDERATIONS 3-1

3.1. Codes, Standards, and Executive Orders 3-3

3.1.1. Local Codes and References 3-3

3.1.2. Other Recommended References 3-3

3.1.3. Life Safety 3-4

3.1.4. Evacuation Standards 3-5

3.1.5. Disaster Planning 3-5

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TABLE OF CONTENTS

3.2. Systems Criteria 3-6

3.2.1. Heating, Ventilating and Air Conditioning (HVAC) 3-6

3.2.2. Plumbing 3-7

3.2.3. Electrical 3-8

3.2.4. Security 3-9

3.2.7. Seismic Requirements 3-9

3.2.8. Waste Management 3-10

3.2.9. Transportation 3-10

3.2.10. Energy Conservation 3-11

4.0 ROOM TEMPLATES 4-1

4.1. Introduction 4-3

4.2. Architectural Notes 4-4

4.3. Legend of Symbols 4-5

4.4. Typical Resident Furniture and Equipment 4-9

4.5. Typical Resident Clearances 4-10

4.6. Programming and Space Criteria 4-11

4.7. Room Templates: FA 3: House Resident Area 4-13

4.11. Room Templates: FA 9: Community Center Reception Area 4-100

9.3 Concierge Station (RCCS3) 4-101

4.12. Room Templates: FA 10: Community Center Resident Area 4-100

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TABLE OF CONTENTS

APPENDIX 5-3

5.1. Index of Figures and Tables 5-5

5.2. Photo and Image Credits 5-13

5.3. Site Visits 5-15

5.3.1. Introduction 5-15

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1.0 GENERAL

DESIGN GUIDE

S M A L L H O U S E ( S H ) M O D E L

1.1. FOREWORD 1-3

1.2. ACKNOWLEDGMENTS 1-5

1.3. INTRODUCTION 1-9

1.4. DEFINITIONS 1-11

1.5. ABBREVIATIONS 1-15

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1.1. Foreword

The material contained in the Small House (SH) Model Design Guide is the culmination of a coordinated effort among the Department of Veterans Affairs (VA), Veterans Health Administration (VHA), the Office of Construction & Facilities Management (CFM), and SmithgroupJJR, the prime consultant to this effort. The goal of this Design Guide is to maximize the effectiveness and efficiency of the design process for VA facilities and ensure a high level of design, while controlling construction and operating costs.

This document shall be used as a guide to the standards for the planning and design of VA facilities based on the Small House (SH) Model as well as for State Veterans Homes (SVH) and is supplementary to current technical manuals, building codes, and other VA criteria in planning healthcare facilities. The Design Guide, while representing a standard for functionality and organization does not preclude the need for the functional and physical design for a specific project.

This Small House (SH) Model Design Guide is also a tool to assist VA medical center staff and clinicians in better understanding the choices that project designers ask them to make during the design process. This Design Guide will also serve the VA’s design consultants in understanding the planning and design direction preferred by VA.

While this Guide contains information for key rooms / space types it is not possible to foresee all future requirements of these residential facilities. It is also important to note the Room Templates are graphic representations intended as illustrations of VA’s furniture, equipment, and personnel needs within these key rooms / spaces. Design consultants shall use these Design Standards as close as possible to this context and intent. It is the responsibility of the Project Architects and Project Engineers to develop a complete and accurate project design that best meets the users’ needs and applicable code requirements.

Disclaimer: products and material indicated are for illustration only and do not constitute endorsement for any specific product / manufacturer.

Lloyd H. Siegel, FAIA

Associate Executive Director

Office of Facilities Planning (003C2)

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1.2. Acknowledgments

Credit is due to the following individuals whose leadership, knowledge, skills, and ability made this document possible.

DEPARTMENT OF VETERANS AFFAIRS - VETERANS HEALTH ADMINISTRATION

OFFICE OF GERIATRICS AND EXTENDED CARE

Marianne Shaughnessy, Ph.D., Director, Facility-Based Program Policy

AGPCNP-BC

Lisa Minor, RN, MSSL Director, Facility-Based Programs, Geriatric and Extended Care Operations

Edward A. Litvin, PE, CHFM Director, Office of Capital Asset Management Engineering and Support

Aubrey Weekes Director, Environmental Programs Service

Christine Emanuelson Johnson, NCIDQ Program Manager, Interior Design, Environmental Programs Service

STATE HOME CONSTRUCTION PROGRAM

Anna Gaug Program Manager, State Construction Grant Program

Kelley J. Kash, Colonel, USAF, MSC Maine Veterans’ Homes CEO (Retired)

Van F. Moore WESTCARE Heath Care Management Services Senior Vice President

OFFICE OF CONSTRUCTION & FACILITIES MANAGEMENT

Lloyd Siegel, FAIA Associate Executive, Office of Facilities Planning

Gary Fischer, RA Project Manager, Senior Healthcare Architect

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1.2. Acknowledgments

OFFICE OF CONSTRUCTION & FACILITIES MANAGEMENT

Kayvan Madani Nejad, Ph.D., AIA Architect

Linda Chan

Don Myers, AIA

John Bulick

Orest Burdiak

Lam Vu, PE

Mahmut Nazli, PE

Michael Taylor, PE

David Treece, AIA

Facility Planner

Director, Facilities Standards Service

Director, Facilities Development Service

Interior Design Leader

Electrical Engineer

Mechanical Engineer

Plumbing Engineer

Architect

CONSULTANTS - SMITHGROUPJJR

Bill Kline, AIA, ACHA, EDAC, LEED AP, CAA

Shary Adams, AIA, ACHA, EDAC, LEED

AP

Principal in Charge

Project Manager

Alexis Denton, AIA

Laura Babinski, RA, LEED AP BD+C

Senior Living Planner

Technical Architect

Hyewon Sun

Keri Firebaugh, LEED AP BD+C

Technical Architect

Interior Designer

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1.2. Acknowledgments

SUB-CONSULTANTS - THE INNOVA GROUP

Chris Phillips

Gail Cisneros, RN

Lee Pettit, AIA, LEED GA

Project Manager

Equipment Planner

Consultant

SUB-CONSULTANTS - URS CORPORATION

Troy Metz, PE, LEEP AP Mechanical Engineer Project Manager

William Hoffman, PE, LEEP AP Mechanical Engineer

Danny Reyno, PE Electrical Engineer

CONSULTANT (SPACE PLANNING CRITERIA & SEPS) 2019 REVISION- HDR

Ronald Villasante, RA, CAP, MRCP, MArch Director of Federal Healthcare Planning

Cynthia Adams Healthcare Planner

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1.3. Introduction

We are pleased to present this edition of the VHA Small House (SH) Model Design Guide, formerly known as the Community Living Centers Design Guide. This design guide provides enhanced, expanded guidance for creating an environment in which residents that require extended care services are at the literal and figurative center of the household. The model of care is resident-centered, where care is driven by the resident and involves the resident and family, when available, in decisions regarding care. This commitment to cultural transformation was made by VHA in 2005, in keeping with shifting standards in the nursing home industry.

The transformation away from the medical / institutional model of care that serves the needs of the institution and changes the focus to the needs and preferences of the resident is at the heart of the HATCh (Holistic Approach to Transformational Change) Model, and our nation’s Veterans deserve no less. The HATCh Model, designed by the Centers for Medicare and Medicaid Services, places the resident at the center of Work Practices, Care Practices and the Environment of Care. Care practices such as individualized meals, snacks and daily activity planning are central to the model. Work practices including consistent staffing, horizontal leadership and professional staff development give staff autonomy and responsibility to manage care delivery according to the preferences of the Veterans they serve. This guide addresses the environment of care with facility design, decor and elements in the home that support the transformed care and work practices. Private bedrooms with full baths allow each Veteran/resident a place of their own in addition to large communal spaces that encourage socialization and interaction. Smaller conversational spaces facilitate visits with family and friends.

A small house is an intentional community of 10, 12 or 14 residents and a staff of highly trained workers who live and work in a well-designed environment organized and operated around the guiding principles of autonomy and dignity. When successfully implemented, the Small House (SH) Model provides exceptional rehabilitative and hospice care and chronic disease management, with sufficient staff and equipment to support all personal care and assistance needs. While comprehensive data on outcomes is limited, the currently available evidence suggests that implementation of the Small House (SH) Model leads to better resident outcomes and higher resident satisfaction at comparable or lower overall cost. VHA is committed to use of the Small House (SH) Model of care in all of its facility-based settings, including Community Living Centers and State Veterans Homes.

We are proud to share this new version of the VHA Small House (SH) Model Design Guide that now includes designs for building vertical households for spaces where land for individual homes is not available, and specific suggestions for renovations within existing footprints and space.

Delivering high-quality, high-value care to our nation’s Veterans in a resident-centered environment is our shared mission. This guide for the development of therapeutic environments of care is a critical step in the cultural transformation journey.

Marianne Shaughnessy, PhD, AGPCNP-BC Lisa Minor, RN, MSSL

Director, Facility-Based Program Policy Director, Facility-Based Program Operations

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1.4. Definitions

DEFINITIONS

ADL Activities of Daily Living: Basic activities individuals need to perform to live independently and include bathing, mobility, grooming, dressing, eating, and toileting.

Alzheimer’s Dementia of the Alzheimer’s type is the most common form of dementia (accounting for at least 50 percent of cases) and is characterized by a gradual onset of symptoms, with progressive intellectual deterioration and decline in ability for self-care over a period of time.

Bariatric (As defined per VA TIL) a bariatric patient is anyone who has limitations in health due to physical size, health, mobility, and environmental access (Bushard, 2002). For using VA assessment form and bariatric algorithms, VA defines bariatric as individuals exceeding standard capacity equipment (300 lbs) with a BMI of 50.

Bathroom A room containing a toilet, handwashing sink, and some facilities for bathing. This could be either a bath tub or a roll-in shower.

Circulation Area Entrances, vestibules, corridors, passages, elevators, escalators, stairs, etc; included in gross areas and excluded in net areas.

Common Space Spaces in the House that are intended for socializing and/or activities for residents, visitors, and their families.

Community All the Houses, Neighborhoods and Community Center at a site comprise a Community.

Community Center: A facility supporting no more than twelve (12) houses that provides various common use areas for residents and support areas required by the operational model of the Neighborhood.

Community Living The Small House (SH) Model replaces what was formerly called Center (CLC) Commuity Living Centers (CLC).

Dementia Dementia is a symptom complex characterized by intellectual deterioration (including disturbances in memory as well as impulse control, language, spatial abilities, judgment, etc.) severe enough to interfere with social or occupational functioning.

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1.4. Definitions

DEFINITIONS

Gross Square Feet Total building area measured from outside face of exterior walls.

(GSF)

House Staff Office A staff work area.

House A unit comprised of ten, twelve or fourteen single occupancy resident bedrooms, with toilets and showers, and all the common areas necessary to accommodate the residents in a residential environment.

Hospice Care for the terminally ill that focuses on comfort and quality of life.

Leadership in Energy A rating system for building design as well as professional accreditation and Environmental for people working in the design building industry.

Design (LEEDTM)

Mechanical Area Main boiler room and other mechanical and electrical areas;

included in gross areas and excluded in net areas.

Memory Care Specially-designed spaces and supportive environments for residents with dementia.

National Fire Produces a code used in many jurisdictions to define fire protection Protection requirements of building codes. VA uses several of the NFPA codes Association (NFPA) including NFPA 101, Life Safety Code.

Neighborhood A grouping of three Houses and a Neighborhood Center.

Net Area / Net The area of rooms or spaces as measured from the inside wall to inside Square Feet (NSF) wall and assigned to functional use by occupants.

/ Net Square Meters

(NSM)

Rehabilitation Retraining of residents to highest level of function using physical, occupational, and speech therapy.

Resident A veteran residing in a house planned and designed based on the Small House (SH) Model or a State Veterans Home (SVH).

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1.4. Definitions

DEFINITIONS

Resident Centered Care

Care delivery model that focuses care resources around the individual resident. Essential services are near or are brought to the resident.

Residential Model Design philosophy based on incorporating elements of home and minimizing institutional aspects.

Small House (SH) Model

Skilled Nursing care provided in a non-institutional, residential scale setting in small groupings of resident, common spaces, and support spaces.

Staff Spaces Spaces where nursing and administrative staff work.

State Veterans Homes (SVH)

A program that includes nursing homes, domiciliary, and adult day health care which are owned and operated by the states.

Support Space Spaces that support the day to day operations of the Houses in a Small House (SH) Model facility.

United States Green Building Council

(USGBC)

The United States Green Building Council is a national coalition of leaders in the building industry that developed the LEED™ system.

VA-SEPS Acronym for Space and Equipment Planning System, a digital tool developed by the Department of Defense (DoD) and the Department of Veterans Affairs to generate a Program for Design (PFD) and an Equipment List for a VA healthcare project based on specific information entered in response to Input Data Statements. SEPS 3, the current version, incorporates the propositions set forth in all VA space planning criteria chapters. SEPS 3 is designed to aid healthcare planners in creating a Program for Design (PFD) and Program Room Contents (PRC) based on a standardized set of criteria parameters.

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1.5. Abbreviations

ABBREVIATIONS

A Amps/Amperes

ABA Architectural Barriers Act

AC/HR Air Changes per Hour

ACT Acoustical Ceiling Tile

ADA Americans with Disabilities Act

ADAAG ADA Accessibility Guidelines

A/E Architectural / Engineering Firm

AFF Above Finished Floor

AHJ Authority Having Jurisdiction

AIA American Institute of Architects

ANSI American National Standards Institute

ASHRAE American Society of Heating, Refrigerating & Air Conditioning Engineers

AR As Required

AT Acoustical Ceiling Tile

BC Base Cabinet

C Celsius Degrees

CC Contractor Furnished, Contractor Installed

CFM Cubic Feet per Minute

CLC Community Living Center

CV Control Valve

VA-CFM Department of Veterans Affairs, Office of Construction & Facilities Management

CLG Ceiling

CO2 Carbon Dioxide

CP Carpet (without cushion broadloom)

CRS Corrosion Resisting Steel (SS)

CT Ceramic Tile

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1.5. Abbreviations

ABBREVIATIONS

DG Design Guide

DOE Department of Energy

DS Door Switch

EDM Electrical Design Manual

EMER Emergency

F Fahrenheit Degrees

FC Foot-candle

FD Floor Drain

FIXT Fixture

FLUOR Fluorescent

FPS Fire Protection System

GFI Ground Fault Circuit Interrupter

GSF Gross Square Feet

GSM Gross Square Meters

GWB Gypsum Wallboard

HAC Housekeeping Aides Closet

HATC Holistic Approach to Transformational Change

HIPAA Health Insurance Portability and Accountability Act of 1996

HVAC Heating, Ventilating and Air Conditioning

HP Horsepower

HR Hour

IES Illuminating Engineering Society

IESNA Illuminating Engineering Society of North America

JSN Joint Schedule Number kW Kilowatt

LED Light Emitting Diode

LEED Leadership in Energy and Environmental Design

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1.5. Abbreviations

ABBREVIATIONS

LB Pound/Pounds

MCS Master Construction Specifications

MTD Mounted

NEC National Electrical Code

NFPA National Fire Protection Association

NHRA Nursing Home Reform Act of 1987

NSF Net Square Feet

NSM Net Square Meters

O Oxygen

OBRA Omnibus Budget Reconciliation Act of 1987

OCFM Office of Construction & Facilities Management

OIT Office of Information & Technology

PG Program Guide

PH Phase

PFD Program for Design

PSDM Physical Security Design Manual

RB Resilient Base

RCP Reflected Ceiling Plan

RF Radio Frequency

RPS Radio Paging System

RSF Resilient Sheet Flooring

SC High Build Glazed Coating (Special Coating)

SCI/D Spinal Cord Injury/Disorders

SD Standard Detail

SF Square Feet, Square Foot

SFPE Society of Fire Protection Engineers

SP Special Faced

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1.5. Abbreviations

ABBREVIATIONS

STC Sound Transmission Class

SVH State Veterans Home

TIL Department of Veterans Affairs, Office of Construction and Facilities Management Technical Information Library http://www.cfm.va.gov/TIL/

TJC The Joint Commission

UPS Uninterruptible Power Supply

USGBC United States Green Building Council

V Volts

VA Department of Veterans Affairs

VAMC Veterans Affairs Medical Center

VAV Variable Air Volume

VC VA Furnished, Contractor Installed

VHA Veterans Health Administration

VISN Veterans Integrated Health Network

VOC Volatile Organic Compound

VSO Veterans Service Organizations

VTEL Video Teleconferencing

VV VA Furnished, VA Installed

W Watts

W/SF Watts per Square Foot

Department of Veterans Affairs Office of Construction & Facilities Management 1-18 http://www.cfm.va.gov/TIL/

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2.0 FUNCTIONAL CONCEPT

DESIGN GUIDE

S M A L L H O U S E ( S H ) M O D E L

2.1. DEFINING THE SMALL HOUSE (SH) MODEL 2-5

2.1.1. Types of VA Programs 2-5

2.1.2. Small House (SH) Model Components 2-7

2.1.3. Industry Trends 2-8

2.1.4. VA Trends 2-10

2.2. VA VALUES AND GOALS OF THE SMALL HOUSE (SH) MODEL PROGRAM AND DESIGN

GUIDE 2-11

2.2.1. VA Values 2-11

2.2.2. VA Goals 2-12

2.2.2.1. Environment of Care 2-12

2.2.2.2. Principles of Small House (SH) Design 2-12

2.3. OPERATIONAL CRITERIA 2-15

2.3.1. Residents 2-15

2.3.2. Staff 2-16

2.3.3. Food and Nutritional Services 2-17

2.3.4. Medication 2-18

2.3.5. Linen and Materials Management 2-18

2.4. PLANNING AND DESIGN 2-19

2.4.1. New Construction 2-19

2.4.1.1. Site 2-19

1. Overall Site Layout and Planning 2-19

2. Stand Alone Facility vs. Attached to Existing Medical Center 2-23

3. Horizontal vs. Vertical 2-23

4. Site Circulation and Access 2-25

5. Parking 2-25

6. Emergency Access 2-26

7. Main Entry 2-26

8. Site Wayfinding and Signage 2-26

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Table of Contents (continued)

9. Gardens and Landscaping 2-26

2.4.1.2. House 2-28

1. Guidelines for Support and Staff Area Layout 2-31

2. Flexibility and Inclusiveness of Houses 2-31

3. Designing for Social Engagement 2-32

4. Room by Room Descriptions: House Resident Area 2-36

a. Resident Bedroom (see Room Template 3.1) 2-36

b. Resident Bathroom (see Room Template 3.2) 2-37

c. Living Room (see Room Template 3.8) 2-38

d. Dining Room (see Room Template 3.9) 2-39

e. Kitchen (see Room Template 3.10) 2-40

f. Den (see Room Template 3.13) 2-41

g. Laundry Room (see Room Template 3.14) 2-42

h. Bathing Room (see Room Template 3.6) 2-43

i. Vestibule / Foyer (see FA 2.2 & 2.3) 2-44

j. Sitting Alcove 2-44

k. Home Entry / Front Porch (see FA 2.1) 2-45

l. Balcony and Patio 2-46

m. Garden 2-47

5. Room by Room Descriptions: House Support Area 2-48

a. Pantry (see Room Template 3.11) 2-48

b. Kitchen Housekeeping Closet (see FA 3.12) 2-48

c. Housekeeping Aides Closet 2-49

d. Clean Utility Room 2-49

e. Soiled Utility Room 2-49

f. Clean Linen Storage 2-50

g. Medication Room 2-50

h. Visitor Toilet (see FA 2.4) 2-51

i. General Storage 2-51

j. Specialty Storage 2-51

k. Equipment Storage (see Room Template Test Fit 4.8) 2-52

l. Garage / Receiving (see Room Template Test Fit 4.10) 2-52

m. Gas Manifold Room 2-53

n. Crash Cart Alcove 2-53

6. Room by Room Descriptions: House Staff and Administrative Area 2-54

2.4.1.3. Neighborhood Center 2-55

1. Overall Layout and Planning 2-55

2. Room by Room Descriptions: Neighborhood Center Resident Area 2-56

a. Neighborhood Center Lobby (see FA 6.2) 2-56

b. Multipurpose Activity Room (see Room Template 7.1) 2-57

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Table of Contents (continued)

3. Room by Room Descriptions: Neighborhood Center Support Area 2-58

c. Conference Room (see FA 8: Rm 7) 2-58

d. Multipurpose Activity Storage Room (see Room Template 7.3) 2-58

e. Public and Family Toilet (see FA 6.5 & 6.6) 2-58

f. Housekeeping Aides Closet 2-59

f. Crash Cart Alcove 2-59

h. Receiving / Breakdown Room 2-59

i. Clean Linen Storage 2-60

j. Soiled Linen Storage 2-60

2.4.1.4. Community Center 2-61

1. Overall Layout and Planning 2-61

2. Room by Room Descriptions: Community Center Resident Area 2-62

a. Community Center Lobby (see FA 9.2) 2-62

b. Concierge Station (see Room Template 9.3) 2-63

c. Security Station (see FA 9.4) 2-63

d. Consult Room 2-63

e. Great Room (see Room Template 10.4) 2-64

f. Retail Store 2-65

g. Post Office 2-65

h. Theater (see Room Template 10.5) 2-65

i. Library (see Room Template 10.6) 2-66

j. Hair Care Salon / Shop (see Room Template 10.7) 2-67

k. Meditation Chapel (see Room Template 10.8) 2-68

l. PT / OT Exercise Gym (see Room Template 10.3) 2-69

m. Exam Room 2-70

n. Public and Family Toilet (see FA 9.8 & 9.9) 2-70

o. Covered Entry 2-70

4. Room by Room Descriptions: Community Center Support Area 2-71

a. Hair Care Salon / Shop Storage 2-71

b. Maintenance Storage 2-71

c. Housekeeping Aides Closet 2-71

d. Crash Cart Alcove (FA 10.11) 2-72

e. Receiving / Loading 2-72

b. Copy Room 2-73

c. Team Workroom 2-73

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2.0 FUNCTIONAL CONCEPT

Table of Contents (continued)

2.4.2. Renovation

2.4.2.1. Renovation Project Priorities 2-75

2.4.3. Interior Architecture and Finishes 2-79

2.4.3.1. Overall Selection Criteria

2.4.3.2. Design Language 2-82

1. Color 2-82

2. Textures and Patterns 2-83

2.4.3.3. Design Elements 2-84

1. Flooring Finishes 2-84

a. Carpet 2-84

b. Sheet Vinyl 2-85

c. Luxury Vinyl Tile 2-85

d. Linoleum 2-86

e. Tile (Porcelain, Ceramic) 2-86

f. Rubber 2-87

Wood 2-87 g.

h. Epoxy 2-88

i. Stone 2-88

2. Walls Finishes 2-88

a. Paint 2-89

b. Wallcovering 2-89

c. Wood 2-89

d. Tile 2-90

3. Acoustics / Sound Control 2-90

4. Wall Protection and Accessories 2-90

5. Ceilings 2-91

6. Lighting 2-91

7. Window Coverings 2-91

8. Interior Furnishings 2-92

9. Art 2-93

10. Wayfinding and Signage 2-94

2.4.3.4. Interior Finish Schedule 2-95

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2.1. Defining the Small House (SH) Model

The information in this document applies to all Department of Veterans Affairs (VA) facilities based on the Small House (SH) Model whether they are new construction or renovation of an existing VA facility;

it also applies to State Veterans Homes (SVHs) built or renovated through the State Home Grant program.

2.1.1. Types of VA Programs

The Department of Veterans Affairs provides either skilled nursing care or funding for three types of programs:

1. Small House (SH) Model facilities: Owned and operated by the Department of Veterans Affairs. These facilities provide long and short term skilled nursing care and rehabilitation.

2. State Veterans Homes: The State Veterans Home (SVH) Program is a grant program whereby the VA funds a portion of construction and per diem costs. SVHs are owned and operated by the states. Oversight for meeting standards is provided by the VA. These facilities provide long and short term skilled nursing care and rehabilitation.

3. Community Nursing Home Program: The VA Contract Community Nursing Home Program consists of VA contracts with community based facilities owned and operated by private enterprises. These facilities provide all levels of skilled nursing care with a focus on long term care.

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2.1. Defining the Small House (SH) Model

The following image is a diagrammatic layout and shows key adjacency attributes for the model of care provided by the VA in a Small House (SH) Model.

NEIGHBOR-

HOOD

CENTER

HOUSE

HOUSE HOUSE

COMMUNITY

CENTER

HOUSE

HOUSE

HOUSE

HOUSE

HOUSE

HOUSE

NEIGHBOR-

HOOD

CENTER

NEIGHBOR-

HOOD

CENTER

HOUSE

HO USE

HOUSE

NEIGHBOR-

HOOD

CENTER

NEIGHBOR-

HOOD

CENTER

HOUSE

HOUSE

Figure 2.1 The Three Components of the Small House (SH) Model: House, Neighborhood Center, Community Center

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2.1. Defining the Small House (SH) Model

2.1.2. Small House (SH) Components

The Small House (SH) Model consists of three major components: the Houses, the Neighborhood Center(s), and the Community Center. Provision of these components is dependent on the number of residents. See Figure 2.1. A facility planned and designed following the Small House (SH) Model may function either “stand-alone” or as part of an existing “campus” site.

1. The House

The House is a residence for 10, 12 to 14 veterans. The number of residents is determined by demand;

the minimum number of residents is 10 and the maximum is 14. For purposes of this design guide, 12 residents per Home is used as a base model. The House is based on the “small house” model of care which is defined as intimate, small scale, and residential to accomplish the goal of skilled care in a home setting. The “Home” implies a nurturing, familial environment. The purpose of the House design is to foster a feeling of family and to help support mutually beneficial relationships between residents and staff. The House functions as a household while providing added safety and security for the resident veterans.

2. The Neighborhood Center:

The demand for a Neighborhood Center is generated when the programmatic need has projected three Houses. Each Center provides a setting where residents and staff can come together for programs and activities on a scheduled or non-scheduled basis. The Neighborhood Center also supports the Homes from a materials management standpoint by providing storage for clean supplies and holding space for soiled items. Neighborhood Centers shall be located immediately adjacent to the Homes that they serve with climate-controlled, accessible connections.

3. The Community Center (if authorized):

The demand for a Community Center is generated when the programmatic need has been projected.

The Community Center functions as the heart, “town center”, and front door for the Community. While the House and Neighborhood Center contain all daily activity and support spaces, the Community Center provides destination spaces or services where Veterans can come together for special occasions and large group events. Support, administrative services, and wellness programs are among the functions accommodated in the Community Center. The purpose of the Center is to provide the space to meet daily needs of wellness for the residents and facilitate social interaction whether planned or spontaneous. This includes being readily accessible from the Houses and Neighborhood Centers in order to bring together Veterans, staff, family, and visitors.

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2.1. Defining the Small House (SH) Model

2.1.3. Industry Trends

The VA examined industry-wide trends that are affecting providers of skilled nursing, assisted living, and memory care. In these types of care, the “small house” model, adopted by the VA in 2010, is now commonplace. The success of this model is supported by empirical research that shows better care outcomes for residents and higher satisfaction of staff. Beyond the fundamentals of the small house model of care, current trends include the following key elements:

1. The Kitchen functions as the heart of the House. It is the center of activity and the main focal point. (See Figure 2.2). It is also used as a space for cooking, occupational therapy, and resident socializing activities. When the kitchen is active throughout the day it becomes the true heart of the House.

2. Work space for administrative needs is integrated into the kitchen so that staff spend more time in the common spaces with residents.

3. Resident bedrooms are single occupancy with a private bathroom that includes a toilet and shower.

Figure 2.2 The Home kitchen in the Cottages at Hearthstone is the hub of activity. Note: ledge above upper cabinets should be enclosed because it is difficult to clean.

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2.1. Defining the Small House (SH) Model

(2.1.3 Industry Trends cont’d)

4. Resident room access door shall not open directly to dining or living areas for privacy. The resident rooms can be adjacent to, not around, the common spaces, with easy access to the House’s public spaces. See Figure 2.3. Alternatively, there can be a buffer between the living/ dining rooms and resident rooms, such as a partial-height wall, casework, or a sitting alcove.

See Figure 2.21 for a functional diagram of a House program.

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Figure 2.3 The Arkansas CLC groups common spaces in the public zone and residents rooms in the private zones.

5. A variety of spaces, in terms of type and scale, are provided. In addition to the dining and living room that are very public and function for all residents in the House, there are common spaces that are more intimate in scale and allow for smaller group or private activities and passive observation, see Figure 2.4. This builds in the opportunity to respect personal preferences or routines of residents in the design of the House by giving them the choice of participating in different types of activities.

6. Additional spaces are provided in the Neighborhood Center for social activities, such as a Multipurpose Activity room, beyond the boundaries of the House so that residents from two or more Houses can easily interact with one another.

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2.1. Defining the Small House (SH) Model

(2.1.3 Industry Trends cont’d)

Figure 2.4 Small scale seating areas like those in Lambeth House allow for spontaneous interactions.

2.1.4. VA Trends

The Veterans Health Administration, Office of Geriatrics and Extended Care, forecasts that the future acuity and demographics of residents will change in the following ways:

1. Acuity: There will be an increase in resident acuity levels; acuity is defined as an increase in the intensity of care required by the resident.

2. Age: There will be an increasing number of younger residents.

3. Gender: An increase in gender diversity of residents will require a greater emphasis on privacy and security.

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2.2. VA Values and Goals of the Small House (SH) Model Program and Design Guide

2.2.1. VA Values

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Figure 2.5 HATCh Model

The core values of the VA are described in the “I CARE” model:

1. Integrity: Act with high moral principle. Adhere to the highest professional standards. Maintain the trust and confidence of all with whom I engage.

2. Commitment: Work diligently to serve Veterans and other beneficiaries. Be driven by an earnest belief in VA’s mission. Fulfill individual responsibilities and organizational responsibilities.

3. Advocacy: Be truly Veteran-centric by identifying, fully considering, and appropriately advancing the interests of Veterans and other beneficiaries.

4. Respect: Treat all those I serve and with whom I work with dignity and respect. Show respect to earn it.

5. Excellence: Strive to the highest quality and continuous improvement. Be thoughtful and decisive in leadership, accountable for my actions, willing to admit mistakes, and rigorous in correcting them.

These values are the basis of the VA’s focus on resident-centered care. The HATCh Model (Holistic Approach to Transformational Change, see Figure 2.5) describes the fundamental principles and context for the VA’s shift from an institutional model of care to one that is resident centered. The core elements of the model are: Care Practices, Work Practices, and the Environment of Care. The resident is at the point of intersection of these three elements. The Care and Work Practices include how and what care is provided, while the Environment of Care is the physical realm of where that care takes place. HATCh assumes the equal importance of these three fundamental elements. Refer to https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC4421880/ for additional information.

Department of Veterans Affairs Office of Construction & Facilities Management 2-11 www.ncbi.nlm.nih.gov/pmc/articles/PMC4421880

2.2. VA Values and Goals of the SH Program and Design Guide

2.2.2. VA Goals

2.2.2.1. Environment of Care

The overarching goal of the Small House (SH) Model environment is to provide a home where veterans can have the highest possible quality of life and receive the best quality care. This environment is a place that supports care-giving that is administered with integrity, commitment, and respect. Overall, the environment provides veterans with the following:

• Independence: the resident has choices and control over their day.

• Dignity: the resident is honored, treated with respect, and allowed to have privacy and express his/her identity.

• Engagement: the resident has opportunities for social interaction and activities that help maintain or improve activities of daily living.

• Family involvement: the resident’s family is part of the care and well-being of the resident and has access to dedicated family space.

2.2.2.2. Principles of Small House (SH) Model Design

The VA’s commitment to resident-centered care is exemplified in the Small House (SH) Model, the 10, 12 or 14 bed area that is the resident house and center of daily life. The purpose of the Small House (SH) Model design is to:

• Foster a sense of family among residents and staff.

• Provide a variety of opportunities for engagement in social spaces, both large and small, including space for families.

• Give the resident a sense of ownership of the house as their personal space.

• Increase physical activity and restore function.

The basic design princliples of the Small House (SH) Model:

• The house is designed around a central gathering area, or focal point: the kitchen. While there may still be a fireplace in the living room, the kitchen is the focal point of the house because it is the hub of activity.

• Common areas such as living and dining rooms are easily accessible from resident rooms so that residents are encouraged to participate in communal activities.

• There is an on-stage/off-stage approach to support space. Support space is “off-stage” and seen as little as possible. Common spaces such as living and dining rooms are the “on-stage” visible spaces to encourage resident use.

• There is some decentralized supply such as linen and medicine cabinets so that they are close to resident rooms.

• Resident activity and interaction is supported by locating recreation storage in common areas so that it is easily accessible.

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HOME 3

2.0 FUNCTIONAL CONCEPT

2.2. VA Values and Goals of the SH Program and Design Guide

(2.2.2.2 Principles of Small House Model Design cont’d)

• Efficiencies related to the House and the Neighborhood include the use of common resources to limit duplications which may also serve to encourage social interaction with the residents.

Examples include but are not limited to:

◦ Shared access to amenities

◦ Common walkways to the Community Center

◦ Grouping of homes for types of care

RESIDENT

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Figure 2.6 The floor plan of Lebanon, OR State Veterans Home exemplifies principles of the Small House Model design, such as locating the kitchen in the center of the house and separating on-stage and off-stage spaces.

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Office of Construction & Facilities Management 2-14

2.3. Operational Criteria

The design of the House has a direct effect on the quality and efficiency of care that can be provided.

The buildings must operate to support the needs of the resident. Examples include:

• Sufficient space is allocated for staff use in spaces which do not conflict with resident circulation and living areas.

• Open plan layouts are utilized with visibility to all areas of the House.

• Security will be both active and passive for residents and the facility in general, including but not limited to electronic security at exterior doors and alignment with security measures, procedures and systems of the local VA facility, where applicable.

• Universal design concepts and full accessibility must be provided by application of VA PG 18- 13 Guidelines.

• The Kitchen serves as the central staff work space which allows staff to remain in close contact with residents.

2.3.1. Residents

Understanding the types of residents will help define the operational needs of the individual House as well as the Neighborhood and Community Centers. Variations could include length of stay, demographics and acuity levels. The following are the types of residents which may be admitted/ accepted to a House.

1. Short-term residents:

a. Short term residents are those that stay at the House 90 days or less while recovering from an acute trauma or illness. They often require rehabilitative services such as physical and occupational therapy.

2. Long-term residents:

a. Long term residents stay 91 days or longer at the House. They may live at the House for many months or years.

3. Residents of any age, gender, or special needs.

4. Residents with many different kinds of physical impairments. These may stem from chronic or acute illnesses, incidents, or injuries. Acuity levels may vary greatly and fluctuate.

5. Residents with spinal cord injuries (SCI/D) or traumatic brain injuries (TBI).

a. The SCI/D resident has special needs that have been developed in the SCI/D Design

Guide. Please refer to the SCI/D Center, Long Term Care (LTC) sections in VA 104 PG-18- 9 & PG-18-12 when planning for the SCI/D resident.

6. Hospice residents:

a. Hospice may be a service brought to a House on an as-needed basis or it may function as a separate and dedicated Home. Hospice is a service that includes palliative care at the end stages of life.

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2.3. Operational Criteria

(2.3.1 Residents cont’d)

7. Dementia residents:

a. Dementia is an umbrella term that describes any kind of change in the brain that results in a cognitive impairment. Typically executive function and memory are most affected.

Dementia is most commonly caused by Alzheimer’s disease, but other neurological or vascular diseases such as Parkinson’s and Huntington’s may also be causes.

b. Symptoms of dementia can include short and long term memory loss, an increase in anxiety and confusion, obsessive behavior, challenges in spatial navigation, behavioral fluctuations, wandering, and lower thresholds for being overwhelmed by stress and or stimulation. Symptoms can vary greatly among residents.

c. For residents with dementia it is important to reinforce personal identity, enhance self-esteem, maximize independence, encourage social interaction, and create a wayfinding and orientation strategy that is easy to understand.

Features supporting enhanced design may include:

◦ Safety features that are not imposing,

◦ Reduced background noise,

◦ Enhancements of visual access,

◦ Signage and wayfinding tools or cues,

◦ Carpets that are textural and not patterned, to avoid the appearance of objects sitting on a field,

◦ Contrasting color finishes on walls to help define space,

◦ Exit doors disguised or camouflaged in some fashion (specifically for dementia residents),

◦ Floor materials and colors with complementing and limited contrast,

◦ Tactile art and life skills stations.

2.3.2. Staff

Operational efficiency is important to maximize the time staff are in direct contact with residents. To achieve this, the Small House Model uses minimal back-of-house support spaces to allow staff to spend as much time as possible in the common areas with residents. The intent is to maximize visibility from staff work areas to resident common areas and resident room entries so that staff are quickly alerted to any problems.

The Small House Model concept assumes a “universal-type” worker. The universal worker is a caregiver who provides a wide range of services, including meal planning, cooking, activity planning, laundry, light housekeeping, and personal care.

Space for staff respite, break space, is provided in the House and staff shall be considered in the design of landscaped spaces around the facility.

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2.3. Operational Criteria

2.3.3. Food and Nutritional Services

The pantry and House kitchen are designed with the flexibility to accommodate the following two options:

Option 1:

• Food is delivered in bulk to either the House or Neighborhood Center then moved to the pantry and home kitchen. Dry goods are stored in the pantry; refrigerator and freezer storage is located in the kitchen and pantry. Food is then prepared, cooked and served in the kitchen.

See Figure 2.7.

Option 2:

• Food is delivered to a central receiving/loading area in the Community Center, VA Hospital, or parent facility, where the central kitchen is located. The central kitchen is used for bulk food preparation, and storage. Food is prepared in the central kitchen and transported in bulk to the House where it is warmed or cooled and served directly from the kitchen. Even if the home kitchen is used only for serving of food cooked in bulk, it will have full cooking capabilities.

Dining is one of the most important aspects of the resident’s day-to-day experience. Resident-focused dining involves offering food choices, developing appropriate menus, and planning the production and distribution of food. It may also include allowing residents to be involved in the activity of preparing the food. The House must respond to residents’ dietary preferences and individual dining schedules as part of resident centered care. In both of the options delineated above, cooking and food preparation is a Home activity for residents that is about more than just eating, it is an essential part of their social interactions and activities of daily living. Snacks are accommodated and available to residents at all times of the day. Residents have access to a refrigerator and microwave for personal food items.

Figure 2.7 Kitchen during meal preparation in Tuscaloosa, AL Community Living Center.

Office of Construction & Facilities Management 2-17

2.3. Operational Criteria

2.3.4. Medication

Medication will be delivered directly to the medication room. Some medication storage shall be provided in lockable casework at each resident room, adjacent to the resident room entry for ease of access by staff. The use of carts will be kept to a minimum. If use of carts is required/preferred, care must be taken to reduce the impact on the home environment by utilizing non-institutional looking carts and those that create minimal noise. Cart usage will be controlled or regulated and only utilized at times of day that are least disruptive to residents, as determined by the nursing staff.

2.3.5. Linen and Materials Management

The management of linen and materials in the House operates in the background with minimal disruption to the residents as a result of the “off-stage” approach discussed in Section 2.2.2.2.

Clean linen and supplies:

• Frequency of cart use is lessened by decentralizing the storage of clean linen. Main linen and supply storage will be located in the Neighborhood Center when available, or in a clean linen room in the house. Secondary supply will be in decentralized closets in the House, and in casework in each resident room.

Soiled linen:

• Each resident bedroom will contain a soiled linen hamper. Soiled linen will be transported from the hamper to a cart housed in the soiled utility room in each House. Other biohazards and soiled linens such as those from the dining room will be transported in a closed hamper or cart directly to the soiled utility room. These hampers are then brought to a central soiled linen room in the Neighborhood Center.

Oxygen:

• If the facility chooses to have piped oxygen, it can be supplied in the following ways:

1. From the gas manifold room to headwalls in the resident bedroom.

2. If located on a VA Medical Center campus, a central oxygen tank may serve the Houses.

• Portable oxygen tanks shall be stored in the Gas Manifold Room.

Trash:

• Trash will be held in trash receptacles throughout the House and brought to the Soiled Utility Room in the House. If there is a Neighborhood Center in the facility, trash will be transferred from the Houses to the Neighborhood Center Soiled Utility Room before being moved off-site.

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2.4. Planning and Design

2.4.1. New Construction

2.4.1.1. Site

1. Overall Site Layout and Planning

As previously…