Panel Discussion
Satariano: We've had an opportunity today to discuss a variety of
living units for older people in various states of health and function.
I have to admit it's almost breathtaking in terms of the range and scope
of possibilities. Rather than beginning with a question I'd like to open
it for questions of our speakers.
Audience: How is the developer planning to market Three Bridges?
Will there be direct ownership? Or renting?
Hargarther: I don't know all the innuendos of marketing, but it's
a basic lifecare community system where you buy your unit to start with
at whatever level you enter, whether it's independent living or assisted
living; you pay monthly fees and you are taken care of for life so you can
move around the community and move into whatever level of care you need
over time. If you are in independent living and you break your hip, you
have the opportunity to go into the short-term rehabilitation cottage until
you return to your unit.
Diefenbach: Purchase prices are in the range of two hundred thousand
something to four hundred thousand something for the larger units and there
is a monthly fee as well.
Satariano: One of the points that came up in the course of the two
days with regard to continuing care facilities is being able to look down
the road, and see a nursing home, and say "That's where I'm going,"
and that perhaps that thought prompts some sense of dread. To what extent
was that a consideration in development of this project?
Hargarther: That was actually taken head-on on day one. We took the
very opposite approach than that we have been used to doing. The idea was
to put the skilled nursing facility at the heart of the community and make
it so special that people feel, "Gosh, I'm glad that's where I'm going
to be if it's time to be there." That's been the focus literally from
day one.
Diefenbach: We started the project with about a five-hour lecture
from our client as to his needs in that respect.
Audience: Ed Setchko is over here; he's a potential resident of this
community. I don't know, you might want to say two or three words about
why you decided to buy in?
Setchko: The thing that attracted me the most was that these people,
apparently, take seriously the future and where we're coming down in terms
of what we do with old folk like me. I see this as a place to go to continue
my life. I'll be working probably until I die. I like the idea that they
have put at the center of this community a learning council which already
has integrated itself into the whole Sonoma County and Santa Rosa. We're
hooked up with people like Diane and other outfits like the Buck Foundation
and the Center for Aging and the like. We're bringing all those nuts and
bolts kinds of things into aging, like how we take care of our skin and
things like that. To me, that would not drag me into this place. The idea
that there are new paradigms coming down, that we are beginning to think
of different ways to be after we've done our work for 50, 60 or 70 years,
is taken very seriously by these people. I was impressed that architects
are thinking this way. And John Scully, the guy who fathered this place,
has gone all over the world and pulled ideas in; these people here have
integrated all of that stuff. To me, unless you've got a vision of where
you're going, you can do the best nuts and bolts deal in the world and it's
not going to come out right. So for me to hook up with these people to form
a town, a community with a Main Street and with living quarters that are
adequate for my needs is great! I can take my library with me which is about
three or four thousand volumes. I thought, what am I going to with this
when I retire? I can take it with me and put it into the learning center
so for me that made it.
Diefenbach: I think that's part of John's reaching out into the community.
He's not only been architecturally concerned about reaching out but with
the learning center reaching out, with the childcare reaching out. He wants
the restaurants to be of a quality that others outside will want to come
into the community to enliven the community from the outside. Both ways,
people inside going out and people outside coming in; it's not a fenced,
gated community. It's part of natural life.
Satariano: That's very interesting. It addresses a point that Peter
Calthorpe makes in his book The New American Metropolis. He talks
specifically about planned communities or new towns being internally very
appealing but one disadvantage he sees is that they tend to be segregated,
both structurally and functionally, from the outside. It seems that, at
least to a certain extent, this is being addressed in this community to
try to integrate the outside with this community. One thing that I kept
thinking as we were going through this is, again, many of the particular
communities we were talking about, the Cheesecake Consortium yesterday afternoon,
I keep thinking back to Gil Kelley and
the City of Berkeley; the City of Berkeley representing the rest of the
people, so to speak. I'm wondering to what extent some of these ideas could
be integrated into the rather significant agenda Gil is having to deal with
in terms of in some cases recreating or, as he has indicated, healing the
city of Berkeley. I'm wondering how we start dealing with that. This is
actually another point that Calthorpe makes, the idea of integrating different
types of housing and integrating people at different income levels in part
to fulfill this notion of a democracy where you have people of different
classes working together. Probably one of the most distressing trends in
our society now is that the rich are getting richer and the poor are getting
poorer. What do we do as a society to start to deal with that and how do
people such as myself, in public health, and those of you in architecture
work together to deal with that rather substantial and significant issue.
Diefenbach: It would be very exciting to work on a project that is
right in the city center and how different that would be from this; but
even this tries to reach out. An inner city project would not have to reach
far. The difficulty is the financial aspect and the cost of land, it just
generally doesn't happen.
Audience: What about security and gated communities?
Diefenbach: Security we have, on both the ABHOW and the Three Bridges
projects, treated more as a planning issue than as an equipment issue. ABHOW
could not be gated; the town would not allow it, yet it is in a very public
area and people do cut through it and that's okay. As a planning issue,
there are open exterior balcony areas to allow people to walk outside where
they can see across to other areas; they can see down; people can see up;
you can hear someone if they're in trouble. The general openness about it
is very important. On this project security is considerably less of an issue.
It is not in a city center nor is it near any well-populated area.
Hargarther: They very specifically did not want the gatehouse approach
where you had to pull in and show a card and go through a gatehouse. On
the site map you can see that there are small outbuildings at both of the
main entrances. They sit off to the side, one is used for an administrative
function the other has a lot of storage in it. Both of those are going to
be occupied 24 hours a day by personnel who are watching the comings in
and the goings out. So there is that security at the perimeter. And then
there is the card key system in every unit. There are medical call buttons
in every unit. There will be someone going up and down Main Street periodically
to make sure that everything is secure. So there's definitely that presence
of security but there isn't that overt look of security with gatehouses
or fences.
Audience: What about transportation?
Diefenbach: It is a very hilly site, and there are very difficult
issues with regard to transportation. Visitors do need to enter at the low
side because we wanted to avoid cars on the high side, that was the public
pedestrian Main Street. Cars can be parked nearby, the linked structure
has an elevator within it that brings people up two floors to the Main Street
level. You arrive at the lower by car, are dropped off, come up in the elevator,
then you're totally at one level. All facilities are at the same level.
Hargarther: Were you talking about the front steps? On either side
there are parking garages in the hillside so you pull into the hillside
and park within there and then there are elevators that come up into
all the different lodges.
Diefenbach: But there are all these exterior stairs, very integrated
into nature, to encourage people to use them if they can and if they want
to.
Audience: I have another question for the SMP group, the long-term
care unit that you showed, what level of care is that?
Hargarther: That is skilled nursing.
Audience: Then how was the 90 foot rule dealt with?
Hargarther: It was very difficult. There is a nursing station on
both floors. The open area that we showed with the amoeba table and chairs,
much like the Swedish and Japanese examples, has a wall unit behind it that
has everything in it to qualify for the OSHPOD nursing station. We spent
a lot of time with the fire marshall trying to establish that the fixed
table out there is not furniture in a corridor but can be considered part
of that nursing station. From that fixed table in your wall unit of the
nursing station, you can get to all seven of those rooms within 90 feet.
Then when you go back up the stairs or the elevator to the other seven,
there is another nursing station. Right now they will have to staff both
of those nursing stations 24 hours a day with licensed people. The chief
executive officer is working to put an operational program together where
nurses use open radios; there are different kinds of call systems and warning
systems in each cottage so that one staffed nursing station is open to both
floors at night. If she is successful in doing that then it can be much
more cost-effective. If not, we at least have the plan in place and it can
operate the other way.
Graeff: One thing I'd like to add to your question and to the question
about security, at the Mary Conrad Center in Alaska we decided to make the
smartest building we could think to make at the time. That was in 1984.
We had a grant from the State of Alaska for $450,000 to see if a smart building
could be constructed using computers; we had no takers. Three M and Burroughs
thought maybe they could do something with the $450,000 to use computers
in a nursing setting. Ultimately they refused the grant because they didn't
think the technology was going anywhere in this respect.
Hargarther: We got a taker.
Graeff: I tell that story, among the many other stories, when you're
on the leading edge as they are. We think electronics will become very critical
in the next 10 to 15 years for humanizing the environment by freeing up
skilled people, and other concerned people, from the menial tasks that we
have all been subject to for the last 40 years. It's going to change physically
the kinds of planning that you do. For instance, at Mary Conrad we eliminated
the nursing station; it's located remotely from where the residents live,
and we were able to keep surveillance of the facility through the use of
electronics that are benignly located like little spots in the ceiling.
We had a lot of problems when we did it; there was a lot of protest about
"Big Brother" watching. It's the reverse when you come to the
actual folks who come to your facility; they like the security of knowing
there is continuous monitoring even if it's electronic monitoring. We think
that's going to go a long, long way. There are some new geographical information
systems; you can locate a pin anywhere you wish to within a one millimeter
grid. When we hired our security consultant for the Mary Conrad Center he
asked us how exactly we wanted to know where our people were. Is one millimeter
close enough? Does it matter
if you know where your people are within one millimeter? We don't know the
answers to those questions yet but knowing where your people are is a problem
with wandering Electronics will tell you more than you need to know, thus
eliminating the need for long corridors with nursing stations at the intersections.
Hargarther: We're at a very awkward moment right now of pushing technology
and yet having codes and regulations that are truly impediments to doing
that. How can we start to bring one in line with the other is going to be
one of our biggest challenges. I hope that at one of these conferences someday
we can spend a whole portion on being advocates and getting to the State
and to the regulators to get them to understand these contradictions . On
the Three Bridges project we caused such a stir, had so much interest from
OSHPOD and the State Fire Marshall. We literally had OSHPOD, the State Fire
mMarshall, Department of Health Services, and the Department of Social Services
all coming to the site physically to see what was going on. We were saying
technology can do it and they were saying, "Well, what do you mean?
We don't believe it." They wanted to touch the dirt to believe it.
Audience: I have two questions. The first one is for Karen or Bill:
Can you give us some sense of what that project is going to cost to live
in? Is that something the average architect can look forward to retiring
in?
Hargarther: We're trying to set up a deal as the architects.
Diefenbach: We each get a unit included in our fees so we're all
set. I think I mentioned it's in the range of a couple of hundred to four
hundred thousand to buy in and monthly fees. We're not privy to those numbers.
The client does do financial pro formas at great length, has done many,
many of them. Some of it relates to his financing options. Financing potential
from Japan through his contacts there is at a much more opportune rate than
we could imagine here and with the value of the yen to the dollar today
it's very timely. He's hoping he'll be able to afford much more on this
project than many other locally funded organizations could.
Hargarther: He's pushing the limits of the American marketplace and
what our market is ready to take. He has, I believe at last count, a list
of 180 people who have given all their information and signed on the bottom
line that they're ready to give the deposit the day that they're able to.
Audience: During the last couple of days we spent time talking about
life-care, we really haven't touched on the issue of Title 22 versus Title
24.
Fey: I can't comment specifically on Title 22 or Title 24; I haven't
done enough work in California to understand the specifics. I know that
we spent a lot of time in Washington, Alaska, and Oregon taking a look at
the issue of changing things particularly because the Providence model of
assisted living is basically going to be a replacement for the skilled nursing
facility anticipating every level of care. We took a project to Alaska (this
was after Mary Conrad) and tried to explain to the local building officials
that we were going to move nursing home eligible people in, but we wanted
to build the home under 40-home license and an R1 type of occupancy. We
also tried to explain that the reason it was so appealing to us was that
we didn't have to staff it as heavily as a skilled nursing facility. There
is a lot of education that has to occur. What we found, typically, wherever
we've gone is that it's the local building official that's been the problem.
We've always had far more success
with state officials in terms of enabling us to work and actually getting
the state fire marshall to act on our behalf on projects particularly if
it's a problem related to locking doors and being able to use the wander-guard
type of systems. Local building officials simply can't understand or really
struggle with that particular concept. I think there's a lot of education
that needs to occur and it's going to happen because of the growth of that
particular industry. People are going to push that limit.
Diefenbach: In California there's a task force that works with OSHPOD,
is anybody here a member of that task force? How is that going?
Audience: It's slow going.
Hargarther: But it's interesting that task force even exists because
what happens is you're calling OSHPOD on many antiquated codes and regulations.
What I always point out is that these planning regulations have us planning
the old Florence Nightingale wing and here we are trying to design hospice-like
care centers and we're forced into, you know, "well, you've got to
have room so many feet from this and that," and everything's lined
up so strictly that it almost forces you to design an old module immediately.
Diefenbach: Sometimes you resort to solutions to get by these regulations
and we do here as well; the roll-down coil door to shut off a two-story
space, for example, isn't necessarily the safest option for other reasons
but there's no other way to do it.
Noell: I have one point to add. There are different organizations
around the country that are springing up essentially to fight the variety
of rules in many jurisdictions. One of them is the National Coalition of
Nursing Home Reform. Another was recently formed in Wisconsin, its initials
are SAGE. I don't know what the "A" stands for, something like
Society for Gerontological Environments. There are a number of conferences
and gatherings, you know, the natives are restless, we're tired of it.
Audience: Could you say something about bringing furniture to Three
Bridges?
Hargarther: The life-care communities in Japan are almost exactly
what we're proposing to do at Three Bridges. A lot of the common spaces
will be designed, the interior design will be done. In all the private,
independent units you bring everything that you want. You also can participate,
in particular the early residents, in selecting finishes in each of their
units. In the assisted living and skilled nursing facilities we are going
to be providing beds, the window treatments, the floor coverings, and the
wall coverings. In skilled nursing we'll be doing the love seat and the
hutch next to it but in every one of the assisted living and skilled nursing
rooms we are providing a space that individuals can bring a significant
piece of furniture that is special to them. In Japan they always hadI call
them altars, that's probably not the right worda shrine to their deceased
spouses, something that was very important to them, something they had in
their homes which they brought to theie room, and they would bring their
favorite piece of furniture as well. That's what the intent is here. You
obviously can't bring a whole household to a single room, but there are
definitely accommodations being made to bring some belongings.
Audience: You could bring in a lighting fixture?
Diefenbach: I would think so.
Hargarther: Yeah, I think you would be able to.
Diefenbach: A lighting fixture but certainly not a bed. That's the
one element they don't allow us.
Hargarther: And that's back to licensing.
Audience: I just wanted to go to the issue that was raised, I would
love to see a conference built around identifying the issues which many
of us are aware of. I've worked in Washington and the State of California
as an advocate for some of these issues. There are organizations, it's possible
to put together coalitions. I'm not saying that's a short-term solution;
anybody that's worked in this arena knows that it's not, but I think it
is timely. I think we have the community behind us to identify the issues
and to start applying pressure. We have case studies and we could make some
good strong cases now for some of these issues. We're not getting what we
say we want from the regulations; they're not working and, in fact, in many
cases they work against us. I think secured rooms and perimeters for wandering
or dementia, that sort of thing is an excellent example. We want not to
have people killed in fires and, yet, when you put fire doors on rooms of
frail elderly who can't get out of the room you're going to get exactly
what you say you don't want. I would love to see a conference built around
attacking this issue.
Audience: Are you aware of how the staffing ratios of the facilities
you visited in Japan compare with the ones here?
Diefenbach: There are much higher ratios of staff to occupants. Primarily
because of the 100% employment situation in Japan. It's just a cultural
thing; everyone is employed in Japan. There isn't unemployment and therefore
a lot of young people are used, at a very low salary, to support the nursing
staff.
Audience: Were these publicly financed facilities in Japan?
Diefenbach: No, all six of the projects we showed to you are privately
developed and privately financed by two individuals, Koji Muriyama and Hasa
Galason, one with an interest in architecture, the other with an interest
in public health. They joined together 25 years ago to start the first development
in Japan.
Hargarther: They are all set up as not-for-profit.
Audience: But the residents pay with private payments?
Diefenbach: Yes.
Audience: That's another good thing about Three Bridges; it is a
non-profit corporation and that's been very sticky for the State, the County,
and the City because they've never dealt with a non-profit corporation for
life-care before. Also, the way you go into this there's an equity level
you buy into, and a non-equity
level, that you don't buy into. That makes a huge difference. So you can
go anywhere from two hundred thousand to six hundred thousand.
Diefenbach: If you don't have an equity buy-in, I think the monthly
rates are higher than if you have an equity buy-in.
Audience: How much will it cost to build this?
Hargarther: Independent living, design estimates are at about $85
a square foot. Assisted living and the Main Street components are up at
about $140 a square foot. The skilled nursing is pushing $175 a square foot.
There is definitely money being put in up front that is returned to the
investors but long-term they do have 501C-3 status as a non-profit entity.
So in the future any money coming into the community has to be put back
into the community; it can't be used for profit.
Audience: I wonder what the profit is for the developer?
Diefenbach: None, it's a non-profit organization; he's not doing
it for profit.
Audience: What the corporation does is set it aside because what
we guarantee to the residents in exchange for that is life-care for life.
So, if you die the next day, you don't get the money back. But if you live
for 40 years and in the last thirty years of your life you need very costly
care, 24 hours a day, because you suffer from Alzheimer's then, you know,
we need that money to help give that care.
Hargarther: And it's very heavily monitored; I mean, they're watching
profits.
Satariano: Let me just make some final comments. This refers to some
things I said yesterday morning. I think one of the facts in aging research
is the tremendous variability that exists among people in a particular age
group. We tend to focus on the similarities. Someone who is 65 is more likely
to have health problems than someone who's 45 and that's certainly the case
but it's not very interesting. The most interesting fact in aging research
is the tremendous variability. We know this from our own experiences that
some people who are 75 are very happy and other people who are 75 are not
happy. The most important question is, why is that the case? Why do some
people do well while other people do not? That really is the goal of research.
My field is epidemiology and we're very interested in the epidemiology of
aging to understand these things. And not only to understand about the people
who have problems but also to understand more about the people who seem
to do so well. The idea is that if we can understand more about those people
who are well, perhaps we can mimic in some way what makes them well, and
design interventions to help those people who are not doing so well. The
ultimate goal of the research and programs for older people is to postpone
limitations and disability. Probably, when all is said and done, there's
very little we can do to extend a lifespan. Obviously some people are working
in that area but there's maybe five to ten years you can extend a lifespan.
What we can do is postpone the time the person spends with limitation or
disability that's pushed toward the end; so the period of limitation and
disability occupies fewer years toward the end of life. That really is the
goal.
I think as we begin to do research in this area, particularly as we begin
to talk to people in other fields beyond epidemiology and public health,
the more we realize that those factors that determine why some people do
well and others do not are not solely based on the individual and that
individual's capacity. You
can have two people who have the same functional capacity if you measure
it in terms of cardiac reserve and pulmonary function but, yet, you find
that one person does much better than the other. It may be, and often is,
that one person may live in a single-story house and the other person lives
in a two-story house and as they both get older, it's more difficult for
the person in the two-story house to get up and down stairs. So one person
is able to function and lead a fuller life while the other person is not.
Those of us in public health find it very exciting when we think of what
we can do to help people postpone limitations and disability. What we are
learning from conferences like this is that we don't only have to focus
on issues like diet or exercise intervention, as important as those things
are, but we now can think about the environment itself and the type of work
that most of you are doing in terms of design. I remember in the late sixties,
Marshall McCluhan talking about technology as being the extension of our
senses, that technology really can extend vision and hearing and other senses.
I think of housing design as being in that category, as well. So, when we
think about ways to improve the lives of older people and to postpone limitations
and disability we can think about the environment that people live in. It
means that we have a much more comprehensive agenda to deal with. That's
what I find to be exciting.
I've been at Berkeley since 1989; I remember talking to Diane shortly after
I arrived about trying to do something in this area and finally we got around
to doing it. It's taken a while. That's how things work at the University.
But I hope this is really the first step and I would like to have future
conferences in which we do have the opportunity to focus on particular areas.
Return to Blueprint for Aging Table of Contents
Return to Center on Aging Main Menu
Return to UC Berkeley Home Page