Many ideas were explored to create a product which responded to the changes in the way healthcare and the regulations which govern it have impacted this industry. Lifestyles have changed and there are many choices for care. Our newest facility is 87,000 square feet containing 124 guest suites.
New HIPAA regulations strictly control the privacy of an individual's medical history, status, and require a secure environment for case management.
Our aging population is living much longer, healthcare costs are very high, and there is significant pressure for reform that has created a segregation in an attempt to deliver the required care at the least cost by paying for services performed, not the infrastructure they are performed in. Until recently, the size of these facilities was restricted to 367 square feet per resident. We can now build a facility that can accommodate the need for the additional staffing, rehabilitation areas, physicians' offices, charting rooms, and make the facilities more accessible from an ingress/egress standpoint unlike a conventional skilled nursing facility, nursing home, or long-term care facility built in the past. A simple fix such as more parking and a thoughtful traffic circulation plan also makes visitation easier and more conducive.
The departure from the former payment reimbursement system also brings into focus utilities and other variable costs requiring the deployment of energy efficiency initiatives to save operating costs.
An estimated 12 billion dollars is spent by Medicare annually paying the costs of re-hospitalization resulting in a readmission from an improperly managed post-acute experience, viewed as an abuse. Hospitals are being held responsible, and must create a network of accountability for post-acute care to avoid the extreme penalties that will be assessed in order to contain these abuses. As such, it is more important to foster partnerships between acute and post-acute providers like never before. Future payment bundling is also on the horizon for these services.
We started our design using 100 percent private guest rooms integrated with an enhanced family visitation environment. Studies show that residents and staff are more comfortable with this program.
Ironically, four major hospital systems in our area have built new facilities in the last two years, all private rooms as well. Recovery times are improved and, in addition to being part of the holistic healing, family members can actually reduce patient care loads and help improve outcomes by observing patients and providing some assistance such as help with toileting & dining, while encouraging their loved ones and caring for them.
CMS, the intermediary for Medicare, has discussed a test pilot in Texas at Remington Medical Resorts, where there is a significant focus on the rehabilitation regime. The goal is simply a desire to better manage the process to rehabilitate and get guests back home. Results reflect an average length of stay of 11 days, well below the national average, and significant enough to attractive insurance companies who currently are the payer source for 60 percent of Remington's guests. The pilot proposes rewards in rate enhancement by way of accelerated or special RUG rates for the success while reducing unplanned discharges or re-hospitalization.
The building is a use group I-2, and construction type 2A, which is fully protected, non-combustible. It is constructed with a light gauge steel framing system incorporating a "Hambro" structural floor system. The exterior facade consists of a decorative combination of manufactured stone, brick and stucco.
There are 62 guest suites on each floor, resulting from the maximum allowable distance to the central nurses' station. Behind that station are physician, pharmacy, nursing offices and related support areas. The guest suites are equipped with medical gases, and physicians can perform examinations or discuss care plans and have regular interactive dialogue with the family in the room. For the ease of communications, the entire building is Wi-Fi capable with secure communications for accessing resident medical records which are available to medical staff by way of specially equipped iPads." Eleven of the rooms have an additional 36 square feet for the use of guests with special needs. Each suite has a defined guest area where sofa beds are able to be used for overnight stays. The guest floors are 29,000 square feet each. The main floor is driven by the size of the floors above and includes a 12,000 square foot rehabilitation area for inpatient use, an outpatient rehabilitation area, regional training facility, administrative offices, food service, salon, laundry, and back of the house miscellaneous spaces.
Most ceiling areas in guest and common spaces exceed 10 feet which enables us to use architectural mouldings to enhance the area creating soffits and coffers highlighting the additional area. The interior doors are all laminate finish and 8 feet tall to support the extra ceiling height.
Studies indicate the importance of natural light and sound control. We have selected the largest window the exterior wall will allow giving us a 6 foot square unobstructed vision panel consisting of two panes of glass about one inch in total thickness, and coated with Solarban 60 and Solarcool 60. These are Pittsburgh Plate Glass products which provide an efficiency that eliminates the transmission of heat or cold through the glass.
The walls between the guest rooms and corridors are insulated with sound absorbent insulation to promote a calm and quiet atmosphere for the healing environment.
A system of ground water using 400-foot deep wells is used to provide system water to support the most energy efficient geothermal heat pumps manufactured by Climate Master, which provide the heating and cooling for the facility. The well water circulates through the building and returns to the earth. Condensers for the kitchen walk-in units, the pool heater, domestic hot water generation, and the computer room unit are all geothermal capable compressors, as well.
Rainwater is captured and stored in underground tanks to create a non-potable water loop capable of flushing toilets throughout the facility. Our engineers have determined there is a 4 to 6 days of supply with the 10,000 gallon storage. Sensing this would not provide the full impact of savings; we have interrupted the return line for our ground water system to "top off" the rainwater tanks insuring an uninterrupted supply of water.
The single largest energy load in our building is the ventilation system. Basic exhaust and supply air units have been replaced by energy recovery units that capture approximately 60 percent of the heat and air conditioning from the exhaust air system saving significant energy. The humidity is also recaptured in this process. The supply and return from these units operate on variable drive fans which minimize fan speeds based on demand control ventilation. In the guest rooms and bath, the control is a carbon dioxide sensor which only runs the system to a preset level. In the kitchen, the system operated from a computer program known as Melink, gathers its data from an infrared sensor, smoke, and heat detectors located in the hood above the kitchen cooking equipment sensing steam, heat, and smoke again assisting the fans to operate at the lowest optimal speeds.
The food is prepared to order. Menu selections are broad, and most residents order room service to dine in their rooms. We have eliminated open flames and substituted the range tops with induction cooking units where the energy is transferred directly to the cookware. This is a significant departure from the way things have been done for years. In addition, we are acquiring Rationale combination electric steam ovens, and a system of cooking by Electrolux which operates on a cook/chill system. The new kitchen gives the food service directors the opportunity to develop menus that are appealing, innovative, focused on quality and presentation.
The exterior walls are insulated with an open cellular insulation providing an R-30 value. The ceilings of the top floor also use the same treatment achieving a value of R-50.
The roofing system is a Firestone TPO white reflective roof system to support the installation of a 100kw solar system on top of it. The solar power is input into the system grid through an inverter, and credit given for the power manufactured.
We have entered into an agreement with KONE elevator who provide us with energy efficient elevators which operate on 6.6 horsepower 480 volt 3 phase motors instead of the 40 horsepower typical hydraulic systems of the past. These elevators have LED lighting systems and are currently being considered as the only approved "Energy Star" program administered by the federal government.
Miele International has agreed to make us the first customer in the United States for their popular heat pump dryer widely used throughout Europe. The units have a self-contained closed air loop which eliminates the requirement for exhaust, combustion, or the tremendous amount of outside air. The savings of this system alone are approximately $ 28,000 per year. We have complimented the laundry with the addition of Miele's "G" force washers which reduce the drying time and promote a labor savings with their design.
All the facilities' lighting is LED, including the site lighting and decorative fixtures. This saves approximately 270kw of the lighting load, and the entire facility is backed up by 600kw of 480 volt 3 phase emergency standby power provided by MTU, the only company available to guarantee 85 percent performance for extended periods of time. We have had a long standing positive relationship which we consider to be the finest generator company.
The resulting facility encompassing all the above is likely as close to zero net energy it can be while considering all the requirements of the residents we serve and regulations in place that pertain to these type facilities. We continue to research better material and methods everyday to keep our company in its place as the leading provider of these type facilities.
Fundamental shifts are taking place in healthcare, but some of the more significant changes could have little to do with congressional reform.
We have spent a great deal of time developing ways to support the best practices in patient care.
With our goal of 100 percent private resident rooms integrated with a more conducive family visitation environment, studies show that residents and staff are more comfortable with this program. Recovery times are improved, and in addition to being part of the holistic healing, family members can actually reduce patient care loads by observing them and providing some general assistance needs such as rest room trips.
Natural lighting is key. The new large scale windows provide more natural light in the resident rooms than ever before. This factor also helps to showcase the rooms volume highlighted by the signature expansive ceilings we create.
Our focus on LED lighting, with enhancement in the resident rooms, provides our residents with control of their artificial lighting.
Sound abatement is achieved by using more sound absorbing materials where possible, while eliminating any overhead paging.
The pursuit of New Jersey's first net-zero skilled nursing facility, making energy efficiency affordable and worthwhile, may represent the first time construction costs are being evaluated with design solutions resulting in a clear understanding of how certain decisions will affect both energy efficiency and the bottom line of our operations.
Our strategies resulting from this goal will be:
- Increased daylight – for better indoor environmental quality and decreased electrical lighting use.
- Better solar control – to minimize peak cooling loads and increase thermal comfort.
- High performance building envelope – to balance heat loss and radiant comfort with thermal performance.
- Decentralized, decoupled systems – separates the thermal conditioning from ventilation air for better efficiencies.
- Optimized heat recovery – harvests waste heat from the HVAC systems.
- Advanced HVAC & lighting controls– variable and shutoff based upon occupancy.
- Ground source heat pump – thermal balance of heating and cooling uses the natural thermal capacity of the ground.
- LED lighting systems – reduces energy usage while providing a quality lighting source.
- TPO roofing systems – provides an efficient environmental assembly which allows the vertical capability to decentralized energy recovery systems, while maximizing solar intent.
- All patient rooms private – while private rooms are more expensive to construct especially in terms of the more robust patient room infrastructure, they are now considered requisite for any new project.