The Home Trap
by Debajyoti Pati
It could be argued that the most beloved family members are the grandmas and grandpas. The current Covid-19 pandemic is depleting this most valuable family resource at an astronomical rate. More than a third of all Covid deaths in the United States are occurring in nursing homes and long-term care facilities. Living in an old-age facility has become extremely unsafe. However, Covid-19 is not the first sad thing to affect American nursing home residents. For the past several years, studies in the press and scientific journals have highlighted the existence of another epidemic – loneliness. That loneliness accounts for more deaths than lack of medical care came as a surprise to many.
If nursing homes are unsafe, what is the alternative? Study after academic study have shown that a vast majority of people are reluctant to move to a long-term care facility, and prefer to stay at home till the very end (https://assets.aarp.org/rgcenter/general/home-community-services-10.pdf). Numerous factors force their decision to relocate, albeit unwillingly. Over the past years home healthcare is gaining grounds in the United States to tackle the high healthcare cost, encouraging people to stay out of hospitals unless acutely needed. Indeed, with a pandemic like Covid-19, ramping up hospital bed availability in response to an unpredictable surge in census essentially means people with less acute conditions need alternative care settings. If hospitals become the last resort owing to the cost of care or occasional pandemic/epidemic, and nursing homes become unsafe places, what is the alternative? Home healthcare? While we debate extensively and heatedly about how to reopen the economy and safety protocols for people to return to their workplaces, there is a palpable silence on the topic of safe care for lesser acuity. The key question is whether our home environments are suitable for safe home healthcare. If not, we are, by negligence, creating yet another unsafe care setting for many elderly.
Even before the Covid-19 pandemic rendered hospital beds out of bound and nursing homes as unsafe places, the question of home healthcare was gaining traction, because of growing healthcare costs as well as the physiological and psychological pathologies associated with loneliness. So, in the fall of 2018, I asked my class of graduate students in acute care design to examine the specific spatial needs for home healthcare and develop a list of physical design provisions needing attention. They identified a typical middle class, single family, detached home in Lubbock, TX, as a case study. Clinical experts from Covenant Health, a large tertiary care health system in Lubbock, which has also instituted home healthcare program in the region, joined in the examination.
It should be noted that the examination was not about independent living or universal access, on which numerous thought leaders have already produced exemplary work (the work of Cynthia Leibrock comes to mind). We were specifically looking for spatial support in situations when elderly people, sometimes attached to an intravenous pole, may be treated at home. We identified nine spatial attributes/elements lacking in the home environment, which could affect safety of care delivery. Those include (1) clear, wide, and unobstructed access for ambulance and emergency personnel to the main door; (2) sufficiently wide corridor width from main door to master bedroom for stretcher/bed access, and reducing turns and corners; (3) sufficient space in the master bedroom to accommodate one hospital bed and a second bed for the spouse; (4) infection control in the master bathroom; (5) space in the bedroom for clinical equipment such as IV pole and patient lift; (6) sufficient door width for safe navigation through doorways when attached to an IV pole; (7) bathroom doors opening out to enable access inside in case of obstructions originating from falls or other emergent situations; (8) clear and visible location for medications and living will; and (9) visibility of the hospital bed from other locations in the house for monitoring. There were fourteen other missing attributes/elements, which were not directly related to safe healthcare, but were factors of independent living not widely considered. These were presented in details at the 2019 Healthcare Design Expo and Conference in New Orleans, Louisiana. With the unique demands of self-quarantine or isolation originating from the pandemic, these factors assume even greater importance since in such situations people are expected to be independent for an extended period of time. Further, we did not audit the environment for physical design factors contributing to patient falls, on which we have conducted two phases of experimental studies funded by the National Institutes of Health and the National Patient Safety Foundation.
The lack of the above spatial attributes raise several questions as we begin to plan the post-pandemic response. Since the pandemic started, there have been frequent discussions on responses to design of hospitals, work places, shopping establishments, restaurants, salons, etc. Home design should be part of this discussion. Homes, once built, are difficult and expensive to change. Loneliness is not going to vanish, and some other epidemic or pandemic may strike again. Home healthcare offers a viable and psychologically suitable option during all times. How would a design response to the above problem look like? How can we ensure safe care in all types of home environments – apartments, low-income housing, high-rise residential buildings, etc.? This offers a potent area for deeper multidisciplinary examination at the Swiss Center for Design and Health.
Debajyoti Pati is Professor and Rockwell Endowment Chair at the Texas Tech University, the Director of the North America Chapter of the International Academy for Design and Health and a member of the International Advisory Board of the Swiss Center for Design and Health.