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The mission of the AIA Design for Aging (DFA) Knowledge Community is to foster design innovation and disseminate knowledge necessary to enhance the built environment and quality of life for an aging society. This includes relevant research on characteristics, planning and costs associated with innovative design for aging. In addition, DFA provides outcome data on the value of these design solutions and environments. 

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Bringing long-term care back into community

By Isabella Rosse posted 10-24-2016 02:19 PM


By Rudy P. Friesen, FRAIC, Hon FAIA, LEED AP / Blueprints for Senior Living newsletter, October 2016

As an architect I have poured my heart and soul into creating better environments for elders, especially those in long-term care (LTC). More than 15 years ago, when my first household-type care facility opened, I was elated. Recently, I have begun to see the limitations of the household model.

Let me back up. For a while now, many of us have been reclaiming long-term care from the medical profession and from hospital-like facilities with their nurses’ stations, long corridors, shared rooms, rigid schedules, and suppressants. We have championed more humanistic approaches such as the household model.

The household model is resident-centered. Residents are ensconced in environments that try to be home-like. They seem happier and need fewer costly drugs for managing their health or behaviours. It’s been proven that, compared to the medicalized model of LTC, residents receive a higher quality of care at a lower cost. This model’s uptake has been slow. Still, it is at the leading edge of LTC today.

But now, after advocating for the household model and visiting facilities all over the world, I see its limitations. The scale of even a 10-resident household just doesn’t have the feel or familiarity of home. And I’ve seen some strange, cartoon-like versions of this model, from themed villages to retro designs. Such environmental dishonesty can only breed distrust among residents. And while this model is much superior to its medicalized predecessor, it is essentially paternalistic. The saddest part is that residents are usually incarcerated and ghettoized in their own little communities, not integrated into the larger community.

So, I’ve been searching for a better system. What I have found encourages me. Namely, two systems—Buurtwonen in the Netherlands and Nuka in Alaska. Both systems forgo separate eldercare facilities and integrate elders into the community.

Buurtwonen is the newly created housing arm of the very successful Buurtzorg homecare organization in the Netherlands. Buurtzorg, a non-profit homecare organization, was founded by Jos de Blok 10 years ago. Since then, it has grown from a small team of nurses to over 10,000 nurses working in 850 self-managed teams of 10-12. These teams work in an environment of high trust and autonomy. They are supported by 15 coaches and about 50 administrative staff, so overhead is low. The result is a higher quality of care at a significantly lower cost.

Buurtzorg is the fastest growing organization in the Netherlands where clients have the right to choose their care provider. It has the highest client satisfaction rate and has received the award for best employer for a number of years. Its services cost 65% less than its competitors, thanks to greater prevention, shorter periods of care, and less overhead. Its reach is global.

Buurtzorg treats clients as whole people with physical, emotional, relational, and spiritual needs. Nurses bring their whole selves to work. They are encouraged to shape the organization. More than 100 projects have been initiated by team members, including a boarding house for clients, a respite facility in a farmhouse, and community housing. The Buurtwonen (neighborhood living) LTC housing system is their latest innovation. Imagine this.

  • Small complexes of houses or apartments are constructed in existing communities, and as close as possible to shops, doctors & pharmacies, churches, etc. Their construction costs are lower than conventional LTC facilities.
  • The small one-bedroom homes are wheelchair accessible and have a nurse call system.
  • Housing costs are separated from care costs. Rent for the housing component is paid to a landlord (a for-profit or non-profit). Care costs are paid to Buurtzorg.
  • Buurtwonen residents receive care from Buurtzorg whose teams provide 24/7 care.
  • Residents’ care needs range across all levels, from modest to heavy. A sustainable care network is created around each resident including volunteers and family.
  • To maximize efficiency, Buurtzorg teams also provide homecare to the surrounding community as needed.

The Nuka System of Care is an integrated, non-profit health care system owned by the indigenous peoples of Alaska. Nuka (meaning a strong and extensive living structure) has achieved remarkable results and is recognized as a world leader in healthcare redesign. There are no separate LTC facilities. This is community integration at its healthiest.

Both Buurtzorg and Nuka are examples of community-based health care organizations that provide higher quality care at a lower cost.

The question is, how can we collaborate to adopt the best of the household model, ditch the worst, and leapfrog to an integrated community model of eldercare and LTC? When I look at Nuka and Buurtwonen, I glimpse a brighter future where all elders, regardless of limitations, whether dementia or frailty, are integrated into the larger community in meaningful ways.


About the author


For more than 40 years, Rudy Friesen has spearheaded innovative solutions for elder housing. He was the architect for the first Chez Nous personal care home, a forerunner of the household model. Rudy is the founder and Partner Emeritus of ft3 Architecture Landscape Interior Design, a 45-person design firm based in Winnipeg, Canada. He is Past President and Fellow of the Royal Architectural Institute of Canada (RAIC), and Honorary Fellow of the AIA. He also serves on several Boards of elder facilities, is a SAGE member, and is currently serving on the RAIC Age Friendly Housing Options Task Force. Rudy offers research, design, advocacy, and consulting services through and is a voice for change. See

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