Most Australians prefer to live independently as they age for as long as possible.

The reality, however, is that some need to go into aged care.

When that happens, best possible outcomes are needed. Along with factors such as management approaches and staff skills, this depends largely upon the physical environment in which they are placed.

This raises questions about how built environments in aged care impact residents’ outcomes and whether Australia is building the most suitable type of facilities. Such questions will grow in importance as an aging and expanding population sees both the number of people in care and the amount of money going into supporting them increase.

Already, around 180,000 Australians live in residential aged care, 52 per cent of whom have a form of dementia. Each year, the Australian government spends around $11.5 billion supporting them.

Furthermore, there appears to be a mismatch between the type of facilities being provided and those which deliver optimal outcomes.

Data produced by the the Australian Institute of Health and Welfare indicated that as of 2010/11, 54 per cent of residential aged care facilities in Australia contained more than 60 beds. Since then, the trend has moved further toward larger facilities.

Yet a recent study by Flinders University researcher Dr Suzanne Dyer suggests that better outcomes are achieved in smaller, clustered facilities.

Dyer and her team compared patient reported outcomes and resource use for 541 residents across 17 aged care facilities covering four states. Results were compared for those offering a ‘clustered care’ model involving smaller and more intimate residential-like settings (15 or fewer residents) with larger facilities offering a ‘standard Australian’ model of care.

After adjusting for differences in complexity associated with the residents concerned, smaller facilities were shown to deliver better outcomes at a comparable cost. Compared with their counterparts in larger facilities, residents in home-like environments reported having a better quality of life overall (as rated by residents or their family members), a 68 per cent lower rate of hospital admissions and a 73 per cent lower rate of emergency department presentations. This is in addition to previous research which demonstrated that residents who lived in home-like models were 52 per cent less likely to be exposed to potentially inappropriate medications.

Furthermore, this appears to be happening at comparable or lower cost. Courtesy of greater space requirements for each resident, (along with the need to construct separate facilities such as kitchens and laundries for individual units), report authors acknowledge that the smaller clustered units will generally cost more on a per resident basis during the initial build. Nevertheless, after adjusting for differences in participant and facility level characteristics, they estimated that the annual ongoing costs of care was lower under the clustered model by a predicted $12,962 per resident.

Cautioning that the building structure itself is not the only factor behind the better outcomes for smaller facilities, Dyer says more intimate physical settings are supportive of greater quality of life for residents. Smaller complexes, she said, provide a less institutionalised and more home-like environment, and provide less confusion and greater ability for residents to see their way to kitchens, social spaces and outdoor spaces. They are also most likely deliver lower levels of disruption and noise, house fewer people with whom residents share their living space and are more conducive to enabling staff to deliver flexible models of care.

“We know that a move to residential care, particularly for people with dementia, is likely to be disorienting and unfamiliar and associated with a loss of quality of life – most likely due to a loss of independence and purpose,” Dyer said.

“If facilities can be built in a manner which is more home-like – perhaps by being smaller and having better access to outdoor and kitchen areas, they are going to feel more familiar (to residents).

“Also, the physical design – for example, by increasing safe and independent access to outdoors – can help them maintain a greater level of independence.”

The study builds on earlier evidence. In 2014, a study led by clinical psychologist Professor Richard Fleming examined data from 275 residents of 35 aged care homes. It found that greater quality of life was associated with buildings that facilitate engagement with a variety of activities both inside and outside, are familiar, provide a range of private and community spaces along with amenities and opportunities to take part in domestic activities.

It also comes as some providers eschew larger environments in favour of smaller spaces.

The Synovum Care Group, for example, has adopted a ‘small scale living model’ in which six or seven people live in house-like accommodations complete with separate rooms and ensuite bathrooms for each resident and kitchen, dining, living and laundry spaces. Rather than being woken up at 6 a.m. for showering or pain medication before breakfast, meal times are chosen by each individual resident and residents have options for involvement in planning and preparing their own meals.

In another example, non-for-profit provider HammondCare offers homes designed specifically for people with dementia which are built as domestic cottages. As far as possible, these function as homes rather than institutions and are designed around an open plan, domestic kitchen and living area.

To foster independence, the homes have visual cues to aid legibility for those with dementia. ‘Memory boxes’ filled with personal effects are installed outside bedrooms to help residents remember which room is theirs. Interior space design strategies are used to show different functions and highlight entrances. Different styles of timber panelling serve as visual cues to denote doors and hallways, and different types of flooring are used to mark various common areas in the cottage.

(A backyard and garden as well as a parlour, sunroom, main bathroom (in addition to privae ensuites) and a fully functioning domestic kitchen/open plan lounge and dining area are part of life for residents in this small-scale, cottage like settings provided by HammondCare at its Erina facility. Source: HammmondCare)

HammondCare chief executive officer Dr Stephen Judd agrees about the importance of the physical environment and says this sits alongside the social environment and staffing structure and training in terms of attributes needed to generate positive outcomes.

In terms of the physical environment, Judd says there are several important attributes.

First, there is size itself. Even for younger people, Judd says large environments such as airports, shopping centres or hospitals can be frustrating and difficult to navigate. Overlay that with diminished cognition, he said, and larger environments are especially distressing for those with dementia.

Also, smaller environments also enable aged care providers to tailor service provision according to individual resident preferences (as shown through the Synovum example above). Smaller environments with a kitchen and intimate setting might enable meals to be served at varying times of the day. This could enable, for instance, those accustomed to waking up at 4 a.m. and making coffee and toast to continue to do so. Likewise, those accustomed to waking up later and having breakfast later can also be more easily accommodated.

By contrast, such flexibility is difficult to achieve in larger environments, where practical considerations such as meals being either delivered or prepared in centralised kitchens dictate requirements from a management perspective for meals to be served at given times and for washing or showering to be done at given times. Where this happens, decisions about aspects of daily resident lives become subject to the behest of others.

For those who prefer meals at regular times, smaller environments also enable the kitchen to become a hub of activity as the smell of cooking serves as a prompt for residents about times for meals and precipitates social contact as residents arrive for meals simultaneously.

Finally, Judd says many smaller environments imbue a sense of domesticity and create a feeling of comfort and homeliness. Environments with ambulance entry points out front, by contrast, create a sense more akin to that of a hospital.

Beyond the physical environment, Judd says there are other considerations such as the social environment and staffing structures. Residents in facilities where staffing arrangements resemble those of a boarding school, for instance, will not experience optimal outcomes even where they are in a physically beautiful setting. The physical building, he said, is one aspect of a larger puzzle.

In terms of strategies, Judd talks both about remodelling existing facilities and construction of new facilities.

On the former point, he says services in a large ‘brick chicken house’ do suffer from inherent limitations but still have options in regard to furniture and fittings and improving matters such as wayfinding and queuing. Alterations in these areas, he said, could make the environment more responsive to resident preferences.

On new builds, Judd says these should be small and accessible. Outdoor access is critical – possible even in a multi-storey environment by virtue of terraces. It was also important to create ‘total visual access’ whereby residents are clearly able to see where they are and where they want to go. Finally, corridors should be short. Not only does this enhance wayfinding, it also reduces the distance which potentially frail and cognitively impaired residents need to travel in order to access where they want to go.

As our population ages, Australia faces a challenge to deliver positive outcomes in residential aged care.

Smaller and more intimate facilities, it seems, are more conducive to achieving this.