An Interview with Amir Kia: Ideas on Beauty & Affordability in Senior Housing

One of the people I interviewed for this project is Amir Kia, who serves on the Board of Directors for my graduate school – Starr King School for the Ministry. Amir Kia is one of the principal owners for Spirit Living Group, a company that acquires and runs senior living facilities throughout California.

Photo E Principals Page Amir

Amir came to the field of senior housing from the ground up. When first working at a small six bed board and care facility in the Richmond district of San Francisco, he was was struck by the big difference between the way elders are cared for in the US versus in his home country of Iran, where elders are the center of the family and where he had been raised by his grandparents. He felt like there could be a big shift in the US, so he combined forces with his brothers and went out to the community and got involved with more hands on care, as well as doing assessments of other facilities. “It became clear that there was so much room to be creative and make to a difference.” Although Kia’s senior housing facilities are all private pay at this point, there are some key concepts around the environmental design that he brings to the conversation that I also feel are essential.

 Spirit Living Groups’ mission statement has some bold and radically-stated ideas that I find liberating to see named as core values: 

 The mission of Spirit Living Group is to build community, value and beauty. The Company is guided by values of Self-Expression, Presence, Intuition, Relationship, Initiative, and Trust.”

 Although SLG’s communities are all private pay at this point, Kia would also love to see them handle a diverse population – specifically people with few financial resources. “The biggest challenge to senior housing and care is affordability. Amir sees that this will have to be dealt with inevitably. “It’s going to require partnership with community resources and agencies to make it happen.”

San Francisco’s “Patch” Program

Kia tells of a successful pilot program with San Francisco’s Department of Public Health to provide housing for the most impacted low income residents. “At Hayes Valley Care we set up a pilot program with Health Services where we took the most high risk elders who were typically placed in locked facilities for lack of better placement, seniors who hadn’t received the attention for proper diagnosis and treatment and had been medicated with psychotropic drugs. We took them and placed them in our community with the interns and the staff and were really able to bring them to life again.”

 These people receive a ranking with the city, and those who used the most amount of city resources were brought to the Hayes Valley community. They received their SSI of around $700 as well as a “patch” payment from the city that helped to cover their costs at the community. The patch was less money than what the city would have spent with other city-run services, so in the end it was a cost-saving plan for the city. At one point they had maybe 15-16 people. “Some of the most memorable moments I have had have been with these people…. From the moment they walk in and see how beautiful the place is, they realize that they are being cared for. There is an energy of the space caring for you, so you begin to see yourself differently and begin to take care for yourself as well. I saw people come to life over and over again.”

The DPH program started in 2000 and continues today with many senior housing communities. Eventually, budget shortfalls made it hard for Hayes Valley to compete with other senior housing projects using the patch program where their patch cost was lower for the city. Hayes Valley would have had to cut other programming to supplement the patch program. They realized that they could no longer continue in a competitive way.

Architectural Features

I asked Amir what were his dream components that he envisions for the physical space of a senior community. His list is inviting:

 Light and space are core, where you walk into a space and immediately you feel the spaciousness and the openness  – and the joy and energy that comes from light.

 Floor to ceiling windows allow you to look out into a garden as well as bring in the light

 High ceilings

 Activities areas that are connected to common spaces – i.e. being able to see into the wellness center or art studio.

 Public cafes in the building.

 Playful colors, inviting again the open feeling.

 Flooring would be radiant floor heating – good for their feet.

 • Not long, boring hallways, but niches with art and color.

 • In memory care areas having kitchens and activities areas completely open so when the resident comes out of their room they want to come out and engage.

 [This interview was held November 7, 2012]

 Home Page Picture 3 Bayside Park

Richard Louv’s Nature-Deficit Disorder

When I told Montessori teacher Emily Zola about my idea for an intergenerational care community that would feature engagement with natural life as a key element, she insisted that I read Richard Louv’s Last Child in the Woods: Saving Our Children from Nature-Deficit Disorder.

“The children and nature movement is fueled by this fundamental idea: the child in nature is an endangered species, and the health of children and the health of the Earth are inseparable.”

-Richard Louv

This book presents a compelling and pressing argument about the shift that is happening in our children as a result of societal changes such as our obsession with media technology and a litigious mania to the degree that Girl scouts can no longer climb trees at camp. He discusses at length the growing studies that point to correlations between improvement in child health issues such as ADHD, obesity, depression and the engagement in the out of doors.

Stephen and Rachel Kaplan have done numerous studies in what they call “attention-restoration theory” such as a nine year study of participants in wilderness retreat programs. It’s not surprising that they discovered that the subjects reported “experiencing a sense of peace and an ability to think more clearly”. More interestingly, they began to find that “just being in nature was more restorative than the physically challenging activities.” In other words, they were finding that having all of our activities structured and challenging leads to “directed-attention fatigue which leads to impulsive behavior, agitation, irritation, and an inability to concentrate.” In our helicopter age of parenting, we need to learn to back off, or as Louv quotes Deborah Churchman, associate editor for the children’s magazine Ranger Rick:

“Your job isn’t to hit them with another Fine Educational Opportunity, but to turn them on to what a neat world we live in.”

Of added note, the Kaplans found in a survey of twelve hundred corporations that “those with a window view of trees, bushes or large lawns experienced significantly less frustration and more work than enthusiasm than those employees without such a view.”

Just being outside with free time to play and explore and imagine is key to the developing mind and spirit and body of a child. This is how a child develops their own intimate connection with the earth and its creations. By contrast, Louv talks about how school education curriculum on nature is increasingly geared now towards catastrophic problems of the environment, to the degree that children are numbing to nature. This phenomenon is developed by David Sobel who terms it “ecophobia”.

Lacking direct experience with nature, children begin to associate it with fear and apocalypse. He (Sobel) offers this analogy of dissociation: In response to physical and sexual abuse, children learn to cut themselves off from pain. Emotionally, they turn off. ‘ My fear is that our environmentally correct curriculum ends up distancing children from, rather than connecting them with, the natural world. The natural world is being abused and they just don’t want to have to deal with it.”

The garden and outdoor areas of the Mister Woods Intergenerational Care Community will have space to play and get muddy and sit quietly next to a bed of comfrey or climb a tree (waivers!) It won’t be asphalt and perfectly groomed beds of annuals. Louv says that even an empty, scruffy lot on a city block can be a place for a deep encounter with nature. The key is to have the experience be of the child’s own encounter, imagination and creation.

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“Soft Fascinations”

From a New York Times article (1/31/10)…

“Imperiled Environment Creates an Imperiled Mind”

“SUPPORT FOR ecopsychology’s premise that an imperiled environment creates an imperiled mind can be found in more established branches of psychology. In a recent study, Marc Berman, a researcher in cognitive psychology and industrial engineering at the University of Michigan, assigned 38 students to take a nearly three-mile walk — half in the Nichols Arboretum in Ann Arbor and half along a busy street. His purpose was to validate attention-restoration theory (A.R.T.), a 20-year-old idea that posits a stark difference in the ability of natural and urban settings to improve cognition. Nature, A.R.T. holds, increases focus and memory because it is filled with “soft fascinations” (rustling trees, bubbling water) that give those high-level functions the leisure to replenish, whereas urban life is filled with harsh stimuli (car horns, billboards) that can cause a kind of cognitive overload. In Berman’s study, the nature-walkers showed a dramatic improvement while the city-walkers did not, demonstrating nature’s significant restorative effects on cognition.”

Theological Reflection on the Project’s Intentions

At the start of this new website blog, I would like to state up front that my orientation to this project is unabashedly spiritual. The ideas for Mister Woods come from transcendent moments in providing spiritual care for elders, in struggling with my despair and frustration and wanting to see change happen, and from visions and messages. Guiding me is the question I can ask myself: “What would I want for myself when/if I am unable to care for myself and have no financial resources to do so?” In other words, application of the Golden Rule. Another question guiding me also is one I often ask myself: “What is my most beautiful intention here?”

What is my most beautiful intention?

Checking in with myself to see what is my most beautiful intention in any given moment of choice is one of the ways that I can align myself with that “Place of the Greater Good”, or God, or the Spirit of Life (the list goes on…) Well, often that might first require digging around to find what your hidden intention is (hidden to yourself, that is), assessing what your need is, and then adjusting the dial so that it becomes your most beautiful intention. When you “hit” the inner knowing of your most beautiful intention it feels “right”. There can be a warm glow, a sudden flow of energy, a sense of creativity opening up, a sense that you are coming from your best self. For me, this felt sense that I experience marks that I am on the right path, the Red Road. There is wind in my sails. Proceed this way.

As we move forward with manifesting a new creation, we stay on course by being directed by this intention and we stay on course by holding before us our “high resolve”. One of the co-founding ministers of the church I belong to – The Church for the Fellowship of All Peoples – was Howard Thurman (1899-1981) . Thurman was a prolific writer in the mystical tradition, one of the top 12 ministers of his era according to Life magazine, and the spiritual advisor to Martin Luther King Jr. and many others in the Civil Rights Movement. Thurman bolsters us with these words in those times when our spirits are flagging:

 “In the quietness of this place, surrounded by the all-pervading Presence of God, my heart whispers: Keep fresh before me the moments of my High Resolve, that in fair weather or in foul, in good times or in tempests, in the days when the darkness and the foe are nameless or familiar, I may not forget that to which my life is committed.

Keep fresh before me the moments of my high resolve.” 

(Meditations of the Heart, Beacon Press, 1953, p. 210)

Howard Thurman

So what are my most beautiful intentions? I want to see a community like this for several reasons: to serve the social and human needs of people – especially those who have no/low resources, to keep alive a vital and responsible connection to the earth, and to nourish the spirits of our children, our infirm and our elders. As this project discussion unfolds, I hope to bring in the voices of some of the clergy members who I have had the good fortune to interview as well as insights from other theologians and fellow seminarians from various schools affiliated with the Graduate Theological Union. I hope that many of you will share your reflections as well.

Some of the upcoming areas of discussion from me will be around these ideas:

• The Mister Woods intergenerational care community as a reflection of our interdependent nature (Buddhist, quantum, defying isolation), our need for interconnectedness, Relationality theology.

• Presence in nature provides opportunity for inner spaciousness, transcendent experiences.

• Ritualizing our life passages

• Ideas on spirituality in the late stages of life, (Lars Tornstam’s Gerotranscendence, i.e.)

• Children, Nature and Spirituality ( Edward Hoffman and others)

• Spiritual connections between children and seniors.

• The elders: Wisdom keepers

• Nature as scripture: what the plant nation can teach us.

Re-purposing and Infill Site Ideas

In my dream vision I would build an entirely new facility based on Frank Lloyd Wright’s economical usonian architecture. May this someday be so, and good for another blog discussion down the road. In the meantime, I suspect a realistic approach would be to convert existing skilled nursing facilities (SNF) or to convert just about any large inner city building that has the needed elements and has an undeveloped area that can be worked into the garden.

“Keep listening to what the space wants and do it. Don’t keep whittling it away or else nobody is happy.”

– Don Houston

Conversion Example #1: A converted SNF might be developed from an existing large (100+ occupancy) for-profit facility that gets sold to the NNN Non-profit. In this instance, some of the building would be vacated and converted into the children’s nursery school. More common areas would be part of the remodeling. Since the staff would be reduced and therefore the parking needs reduced, some of the parking lot would be torn-up and re-landscaped for the garden.

 Conversion Example #2: Another option would be to re-purpose an existing building that could adequately serve the needs of the intergenerational commnity. Infill projects are a way of recycling a well-built building and saving on planetary resources. A multi-floor building is an intriguing consideration, where the administration offices and nursery school could be on the upper floor(s) and the elders and nursing care on the ground floor.

A space that goes up several floors could also allow for some other very creative and potentially income-bearing uses: office spaces could be rented out to other community and non-profit organizations, making the care community even more engaged as a hub of activity. Loft-style space could be offered to artists (and gardeners/horticultural therapists) who in turn work with the elders and children for their rent. Again, if the facility was big enough or had the kitchen and dining space to support it, low-cost dining programs could be offered to the general public or at least for the children and live-in resident artists and employees.

In an interview with architect Don Houston (where we discussed the Pattern Language  approach to architecture and systems), he offered some cautions with the infill approach. He encouraged thinking of these building as “permeable membranes”. “Don’t let the structure stop you – you can do anything you want to do. In Pattern Language you always leave some of the old to give complexity, richness.” He also encouraged to “keep listening to what the space wants and do it. Don’t keep whittling it away or else nobody is happy.” And – “It may cost more.”

Interview with Clara Allen: Managing a Skilled Nursing Facility

In order to get some sense of the basic administrative structure of a skilled nursing facility, I spoke with Clara Allen in November of 2012, then the Administrator of the San Bruno Skilled Nursing Hospital in San Bruno, California. 

claraLR

It needs stating right off the bat that this institution is a for-profit model, a division of Meridian Foresight. Nevertheless, the size of this organization seems very manageable and we can learn some basic proportions of staff to patients and how the various departments break out. This five star (top rating) facility houses 45 residents, has a staff of 58 (both FT and PT plus on-call staff), and eight departments: nursing (5-6 RNs, 5-6 LVNs, 25 CNAs), social services, maintenance, dietary, activities, housekeeping, staff development and business office. They are accountable to Clara and each department (which has its own budget) gives her a spend down report on their expenses twice a month.

They have an IDT – an Interdisciplinary Team – that meets to discuss things like falls, patient weight loss or gain, new admits. Everyone works together to find solutions, see how different elements are contributing to a problem.

They have three different committees that meet monthly: Customer Service (plans big events like karaoke, bingo night, dances) and one that plans bigger outing events like picnics. The Quality Assurance Committee (lab, pharmacy, others) meets quarterly to address infections, falls, budget overviews. There are also monthly General Staff Meetings to discuss issues that concern every department, like personnel policy changes, or culture change. 

Culture change is an action-oriented collaboration that seeks to transform the institutionalized culture of a nursing home. The goal is to create a person-centered and resident-directed environment to help improve staff retention and resident care in nursing homes.  – California Culture Change Coalition 

As part of her duties, Clara is also in charge of marketing, oversees maintenance projects and does the admission paperwork with new patients and their families. She does the long and short-term planning. She is also in charge of customer care, responding to comments and complaints that are submitted on their surveys.

The big responsibility (for any SNF) is the state and federal mandated annual survey, which means a team of inspectors is in the building for 4-5 days and examines the following things:

• up to 30 patient charts are audited

• all required proper documentation is on file; compliance with forms

• activities match what the residents want

• Rx dosages are reduced as possible (not overly medicated)

• discharge planning

• hygiene

• kitchen; food has proper textures

• emergency responses and procedures in place

2567” is the name of the form that is used by the state to inform each facility what deficiencies were found during their annual survey. It’s mailed approximately one week after the survey concludes. A plan of correction (POC) must be submitted, usually within 10 days of receiving the 2567. On of the advantages of being owned by a larger corporation is that Clara has the assistance of doing a “pre-survey” to prepare for the annual survey, which helps to make sure everything is in place. Last year San Bruno had no corrections and received the top possible rating of 5! As a non-profit organization, where might we find alternative systems of support that a parent corporation provides? How does this staff structure seem to you?