July 8, 2020

Designing Senior Housing for Safe Interaction
The Role of Architecture in Fighting COVID-19

Being able to share space together, to affirm ourhumanity as well as our safety is critical to theprotection and wellbeing of older adults.
Early on in the COVID-19 pandemic, it became clear that the virus was disproportionately
affecting older adults. In the US, as of June 10th, people 65 years or older represented 45% of
COVID-19 hospitalizations, 53% of intensive care unit admissions and 80% of all deaths fromCOVID-19. Statistics show that 45% of deaths are from people living in nursing homes or assisted
living centers.

How do wedesign for safeinteraction, notsocial isolation?

For seniors, mitigating the risks of COVID-19 has much to do with where they live. A small share,
3%, live in nursing homes with round-the-clock care; people living in this institutional model
have been particularly affected by COVID-19 because of their greater susceptibility to the illness
and contagion risks in shared spaces. The vast majority of older people (age 65 and over) live
in independent homes in the community. Of these older adults, 73% live in single family homes
and the remainder in apartments, mobile homes, and other housing types. The type of housing,its location, household configuration, and the extent of interactions with people from outside
the household, such as with those who come into the home to provide support or care, are allimportant to understanding and mitigating risk.
Yet in addition to managing contagion risk, older adults also need to balance another threat totheir health – social isolation. Research has linked social isolation and loneliness to higher risks
for a variety of physical and mental conditions: high blood pressure, heart disease, obesity, an
immune system, anxiety, depression, cognitive decline, and even death. Before the pandemic,
studies reported that nearly a quarter of older people were considered to be socially isolated.
Indeed, the desire for connection leads many older adults to live in independent housingthat offers supportive services such as meals or transportation as well as a ready communityof neighbors. There are nearly 700,000 units of this type of housing in the US, much of itaffordable to those with low incomes, ranging from small to large scale facilities and offering
town homes or apartment models, some on full campuses. In these senior housing models,
communal spaces and the thresholds between public and private spaces are critical tomanaging contagion risk of COVID-19: these are the spaces through which residents, family, andcaregivers pass, and through which groceries, packages, and other goods come in and out of
the buildings and individual apartments. Yet it is also vital that older adults living in this type of
housing continue to be able to connect with one another.
As the current strategy to prevent the spread of COVID-19, social distancing, further exacerbates
these risks, we need to seek solutions in this model of housing that ensure seniors do not haveto choose between safety and quality of life. Being able to share space together, to affirm ourhumanity, as well as our safety is critical to the protection and wellbeing of older adults. How
can we better assess the risks posed in these different types of housing to allow older adults togain control over their spaces? How do we design for safe interaction, not social isolation?

Shares of Older
Individuals by Housing
Type

3% live in group quarters(majority nursing home)
6% live in mobile homes
or other
16% live in apartments

75% live in single family
homes

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July 8, 2020

Designing Senior Housing for Safe Interaction
The Role of Architecture in Fighting COVID-19

About This Document

The following design strategies are meant to guidesenior housing developers and operators as they
adapt existing buildings to balance infection control
and social interaction.
MASS Design Group was founded ten years ago in response to an epidemic disease — extremely
drug resistant tuberculosis — whose airborne transmission was exacerbated by spatialconditions of hospital wards and waiting areas. Over the past decade we have partnered withorganizations working on the front-lines of the world’s major health challenges, from responding
to acute epidemics of Ebola in Liberia and cholera in Haiti, to addressing the chronic injusticesof structural health inequities in the US and around the world.
The senior population is rapidly expanding and providing high quality, accessible housing withsupportive services will be a national imperative. We have chosen to focus on affordable, rental
housing for seniors in this guide because older renters, many with a fixed income and limited
savings, are the most vulnerable to the social, environmental, economic and health challenges.
We also believe that many mission driven non-profit senior housing providers will lead the way toprovide high quality experiences for residents, and all senior housing can learn from their efforts.
This document draws upon COVID-19 infection control guidelines we co-developed withhealthcare practitioners; our experience designing affordable housing; as well as conversations
with industry experts, researchers, and community development corporations. Whereas otherguides focus on how to keep people distanced from each other; this guide is aimed at achieving
infection control principles while offering solutions that allow people to safely come together.
This guide and its design principles were developed through research and focusedconversations with leaders in affordable housing development, operation, and design. We are
grateful to Jennifer Molinsky of the Joint Center for Housing Studies; Emi Kiyota, founder of
IBASHO, for their partnership and to Alma Balonon-Rosen, Massachusetts Housing Partnership;
Susan Gittelman, B’nai B’rith; Carrie Niemy, Enterprise Community Partners; Jane Rohde, JSR
Associates; and Enterprise Rose Fellows Peter Aeschbacher, Sam Beall, Nick Guertin, Yuko
Okabe, Kelsey Oesmann, and Jason Wheeler for their experience, consultation and review.
As more research emerges regarding the virus, federal and state guidelines are updated andreleased, and additional case studies are completed, this document will be updated.

Table of Contents

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Principles for Safe Interaction

p. 3

Defining Thresholds

p. 4

Case Study: Senior Affordable Housing

p. 5

For Future Developments

p. 9

Principles for Safe Interaction
The Role of Architecture in Fighting COVID-19

July 8, 2020

Creating safe space for interaction in housing can be challenging. Here are someprinciples that are applicable across many situations.
Make spaces breathe better.

As COVID-19 can by transmitted through airborne particles, proper
quantities of fresh air must be delivered to residents. HVAC systems
play a large part in creating well ventilated spaces and should undergo
frequent maintenance. Operable openings can supplement air dilution.
Special care should be taken in high risk scenarios where population
density is high or residents may be ill. UV disinfection lights and air
filters can also be used, and fans can help create negative air pressure
environments.

Sequence flows through aspace.

Strong way-finding will help visitors and service providers navigate
semi-public and semi-private spaces and limit unnecessary mixing. A
clear threshold of sanitary protocols for both people and goods will
additionally reinforce the inside of the building as a clean zone.

Reduce pressure on high trafficplaces.

Social distancing measures must be implemented with sensitivity
to mobility difficulties common amongst older adults. Common
areas of risk are elevators, hallways, and shared amenities. Consider
how residents can pass each other while maintaining a 6ft distance,increasing queue spacing and adding seating for extended waits, anddistributing amenities throughout the building or home.

Encourage people to get
outdoors.

Group residents into “villages.”

Created by Estevão Sarcinellifrom the Noun Project3

Risk of infection transmission is lower outdoors where there is accessto fresh air. Increase the quantity and accessibility of outdoor spaces
where possible, and include a diversity of spaces through scale andprogram. Exercise can also be encouraged with looped walking paths
and frequent points of interest along them.
Small adjacent clusters can form a happy medium between complete
isolation and complete exposure to the rest of the building. Smallgroups of neighbors (8-10 units) can not only be a peer support group,
they can also share common amenities without relying on higher risk
multi-purpose rooms or shared dining spaces.

Increase cleaning protocols forhigh-touch surfaces.

Clear cleaning protocols will not only improve the safety of a space,
they will also increase trust and comfort levels. Make high-touch
surfaces obvious with brightly colored non-porous materials such as
paint, tape, or signage. Provide cleansing methods such as an open
sink or hand sanitizer adjacent to high-touch surfaces.

Expand the threshold of theunit.

As more goods and services are brought to the doorstep, the unit
or house entry must adapt to spatial and behavioral needs. Signage
identifying the residence should be clear to reduce delivery mistakes.
Designating a space off the floor for packages and deliveries will help
keep narrow circulation paths free of tripping hazards.

Embed technology.

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Communications technology not only allows for critical information
to be shared immediately, it can also safely foster necessary services
such as wellness checks and reduce isolation. Having a standardized
technology baseline creates equitable access to communication andinformation.

July 8, 2020

Defining Thresholds
The Role of Architecture in Fighting COVID-19

While senior housing varies widely, all homes encompass the private and public.
The space between public and private is often conceived of as a two dimensionalline when it is in reality a series of thresholds that will change based on theresident’s living and care situation. The following prompts will help residents,
property managers, and visitors determine where each threshold lies and key
factors to be aware of to maintain infection control.

The Importance of Thresholds
Prior to COVID-19, most housing types had weakly
defined thresholds for the transition to public
and private. The threshold between “clean” and“dirty” can, in the context of COVID-19, become an
undefined no man’s land.

With the introduction of protocols for cleaning,
donning and doffing, and other principles in
infection control, this threshold can occur atdifferent points along the spectrum expanding
areas that are deemed “clean” or “dirty” to allow forincreased social interaction and autonomy.

Definitions and Key Characteristics

Questions to help guide residents
and housing operators indetermining where their public,
semi-public, semi-private, andprivate thresholds are.

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PublicE.g. Street, Outdoor
SpacesSemi-Public
E.g. Lobby, Lawn

Semi-Private
E.g. Corridors, Porch

PrivateE.g. Unit interiors,
Bedroom

dirty

clean

dirty

clean

In the public domain,
risk of infection ishigher. The individual
has minimal control
over the cleanlinessand relies on the local
government, authorities
or policy makers toestablish infection
control norms.

In a semi-public realm
there is typically ashared agreement for
behavioral norms but thequantity of people andproximity to the “public”
zone make it difficult for
an individual to enforceor have control overnorms.

Semi-private zones aredefined by their scale as
they typically limit the
number of individuals.
Typically users of thespace are known, giving
individuals greater
control and knowledgeof potential risks.

Do I have control over my personal safety?
Do I have control over my interaction with others?
With whom do I share control over this space?
How large is that group of people?

Private zones are thosewhere individuals havethe greatest amount of
infection control andwhere risks are lowest.
This can vary basedon how many people
the residence is sharedwith, the relationshipbetween residents tothem, and the levelof exposure of eachindividual.

July 8, 2020

Case Study: Senior Affordable Housing
The Role of Architecture in Fighting COVID-19

Senior affordable housing comes in many forms. As a case study to apply lessons learned andguidelines for infection control we have selected a multi-family affordable housing project for
older adults. This example building is multi-storied with a double loaded corridor located in theeastern United States. The study assumes that some basic services are provided to residents
but most care is delivered through home health aides or other vendors. We will break downeach zone of the public to private spectrum and identify specific applications of each of theprinciples.

Case Study: Senior
Affordable Housing

PublicCurb to entry

Visitors, Caretakers, Vendors

Building Staff

Support Program Staff, Mail Delivery
Transportation

Strategies for the Public
Realm
For most multi-family housing for older adults,
the primary access to the outside is via car,whether this is caretakers visiting, deliveries
being made, or residents taking trips
elsewhere. The buffer zone between the entryof the building and the curb is an opportunity
to not only establish clear way-finding to help
those unfamiliar with the building, programs
usually housed inside can be redirected here.
Create designated entries with clear
and distinct areas for staff, vendors,
residents, and packages entering thebuilding. Build capacity for spatial
literacy of clean and dirty areas.
Take advantage of outdoor space tocreate waiting areas. This is not only
safer for limiting disease transmission,
but it may also be one of a resident’s
few chances to be outdoors.
Introduce touch-less entry doors
to reduce surface transmission.
Alternatively, install foot-pedal operated
door openers to reduce surface contact.
Provide clear signage for visitors ofdifferent types, indicating building
protocols. If there is a designated entry,
indicate it here.
Establish a ritual of washing hands onbuilding entry by placing hand sanitizer
and/or a hand washing sink at the entrance.
Making this highly visible will help residents
build trust with each other and encourageadherence through social norms.
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Semi-Private
Shared circulation,
resident social spaces

PrivateUnit interiors

Residents

Stakeholders

These diagrams depict thethresholds of public and private
or “clean” and “dirty” that exist in
housing that need to be reexamined
to improve infection control andsocial interaction for residents.

Semi-Public
Lobby and sharedamenities

Entry

Case Study: Senior Affordable Housing
The Role of Architecture in Fighting COVID-19

July 8, 2020

Strategies for theSemi-Public Realm
The ground floor lobby is typically where
shared services and amenities are located.
While it is dedicated to residents, there
is a higher exposure risk as members of
the public will frequently enter the space.
Building management should make cleaning
protocols visible and enforceable wherever
possible. Flows of movement should also
be demarcated clearly to ensure safe
distribution of traffic.
Decorate each mail box foreasy identification. This not
only allows the resident
to extend their sense ofownership, it also reduces
the likelihood that theirmailbox will be touched by
accident.

Created by Estevão Sarcinellifrom the Noun Project

Provide spacefor cleaning of
packages. Thisshould occur
within the lobby toavoid unnecessary
exposure withintight circulation
paths such as
hallways andelevators.

Create a changing
and storage area toprovide space forstaff to don and doff
PPE separate fromresidents.
Have a rigorous system of checking invisitors. This will aid in contact-tracing
if an infection is discovered in thebuilding.
Air cleansing strategies, such as
Germicidal Ultraviolet (GUV) air
disinfection units or high efficiency
particulate air (HEPA) filters, can beused to purify potentially contaminated
air in shared areas like lobbies andelevators.

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Encourage use of stairs where possible
as an alternative to elevators. An ideal
stair is both easy to use and pleasant towalk – this can be achieved by opening
the stair to daylight, improving lighting,or adding music. Introducing seatingby the stair will provide a moment ofrest especially needed by lower mobility
residents.
Look for ways to reduce use of hightouch areas, such as elevators, bysetting limits on the number of people
able to use the elevator at the sametime and improving existing stairs
to encourage use of other means ofegress.
Create buffer zones
where people may bequeuing – for sharedrestrooms, mail boxes,
elevators to allow for
distancing.
Use signage on the
ground to indicate
directionality incirculation.
Research states theelevator buttons
require enhanced
cleaning protocols.
Install hand sanitizer
at elevator lobbies
and where possible
make elevator buttons
larger and moreaccessible so they
can be pressed with
an elbow or cane.
Elevator functions
such as “destination
dispatching”, wherea key card or fob
is used to indicate
destination, reduceor eliminate use of
buttons.

Adapt space
where possible
to accommodate
additional services
and provide basic
amenities such as asmall grocer or healthscreening station
within the building.

July 8, 2020

Case Study: Senior Affordable Housing
The Role of Architecture in Fighting COVID-19

Strategies for theSemi-Private Realm
Within multi-family housing for older adults,
the semi-private realm is typically made upof circulation and resident-only amenities.
These are often minimally sized due to anemphasis on maximizing the unit countfor efficiency. As a result, social distancing
measures require spatial adaptations to be
implemented in many cases.
Please note: the recommendations on this pageuse the example of a floor with double loaded
corridor. While not ideal for many reasons,
including infection control measures, thistypology was chosen as the example due to its
proliferation in affordable housing developments
today.
Providing access to the outdoors oneach floor helps residents accessnature, fresh air and sunlight without
having to take the elevator or stairs.
Shared balconies for 8 - 10 units or
establishing protocols on times ofuse can help mitigate overcrowding.

Implement systems for timed usage
for outdoor space based on floor,age, or other factors. This will reducerisk of transmission, as well as allow
residents to expect a degree of crowd
management. Additionally, limitedgroups will aid in contact tracing.
Claim additional outdoor space as
programmed space. Opportunities forexercise are especially important, as
residents have limited time outside.
This can be in the form of exercise orplay equipment, as well as walking
paths. Walking loops make it easy forresidents to use without getting lost or
ending up too far from their units.
Give definition and variety to outdoor
spaces, such as active areas, porch, or
meditation areas. This will help not only
cater to a variety of residents, it will
also give residents a reason to exploreand visit different locations. This canhelp reduce the traffic load on any one
location.

Widen hallways where possible.
This strategy originates from
hospital design by eliminating
double loaded corridors
and instead thickening thecirculation space to operate as
an interior public realm.
Make hallways one way if
circulation allows. Corridorsthat have elevator cores at eachend can become unidirectional.
This is a simple method of
maintaining distance between
residents.
Bring amenities closer toresidential units. This not
only allows residents to staycloser to home, it reduces therisk of lengthy queues whereresidents may need to standfor periods of time.

Televise community events to bringprogramming and familiar activities
into the unit or more localized common
spaces. This allows residents to beconnected to the community withoutcompromising safety.

If the hallway is lessthan 6ft wide, introduce
pause points so residents
can have room to safely
pass one another in longcorridors or circulatory
paths. This doubles as arest point as long double
loaded corridors are
difficult to navigate forolder adults.

Insert common spaces at each floor toallow people to gather and participate
in community programming (shared
kitchen, living, laundry). Used outside
the peak of an outbreak, these spaces
can help reduce social isolation, whilestill reducing degree of exposure andallowing for easy contact tracing where
necessary.

Hallway Pause Point

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Use furniture that can be appropriately
spaced for social distancing, withupholstery that is easily sanitized.

Social SpaceJuly 8, 2020

Case Study: Senior Affordable Housing
The Role of Architecture in Fighting COVID-19

Strategies for thePrivate Realm

Embed technology and communication
devices in the base design of the unit.
This will allow residents to not only
receive contact-free notifications, it
provides the platform for contact-freesocial connection.

While the primary point of PPE donningand doffing would occur at the entry of thebuilding, donning and doffing at the unit
entry is still important between interactions
with neighbors, such as when using sharedamenities.

Contaminated air can be diluted byadding fresh outside air via open
windows, balconies, or doors. Ensure
operable portions are at appropriate
and accessible heights for operation by
those with mobility limitations.

Neither standard 250 sf single room
occupancies or 900 sf two-bedrooms
currently allow for proper areas of donningor doffing at the unit entry or for separationof residents who may have different levelsof personal risk. Developing space forproper storage of PPE and hygiene practices
and delineation between interior spaces will
give greater control for residents to manage
their personal needs and needs of theirspouse or roommates.

Connect a shared bathroom
directly to a bedroom by adding adoor. This will allow one memberof the household to self-isolate if
necessary, while maintaining accessto the bathroom.

Balconies are a design hero infighting the COVID-19 pandemic.
Stories range from entire
communities gathering on theirbalconies to applaud healthworkers or listen to a neighbor’s
serenade. Balconies allow
people to open their homes forincreased amounts of fresh air
and to socialize and interact withothers with safe distances.

Create negative pressure in high riskrooms to ensure directional flow of
air. This can be achieved by putting a
fan in a window. Examples of high risk
locations include residents suspectedof being ill or rooms that have a highdegree of shared use.
Identify the resident through thebuilding. Beyond relying on theapartment number, a distinct design
can help create a sense of personal
identity and aid in effective wayfinding for deliveries.

Created by Estevão Sarcinellifrom the Noun Project

Designate space inthe unit to don or doff
PPE, or clean supplies,
packages, or groceries
before they enter further
into the home. Use theclosest surface as asanitizing station andhave a trash receptaclefor discarded packaging
and PPE.

Recess the entryway to the unit tocreate space off of the corridor andthe path of travel to accommodate
additional supplies (medicine,groceries, laundry) being delivered toresidents.

Created by Estevão Sarcinellifrom the Noun Project

Accommodate these materials withadditional shelves, hooks to keepthem at an accessible height and offof the floor.
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Unit Entry Exterior

Unit Entry Interior

July 8, 2020

Designing Senior Housing for Safe Interactions
The Role of Architecture in Fighting COVID-19

For Future Developments

Good designfor the mostvulnerable isgood design foreveryone.

The lessons from COVID-19 provide a window into a new way of prioritizing and evaluating thedesign of affordable housing. Designing for the “new normal” changes the way we think aboutcertain design elements in housing. Corridors for example, have been highlighted as one of
the elements in hospital design where infections have spread. In housing, efficiency in design
has led us to rely on the 6ft double and single loaded corridor as given in the design. However,6ft corridors do not allow for social distancing and perhaps there is greater opportunity fordramatically changing the layout of senior housing entirely. Options include reducing thescale of buildings to “villages,” and eliminating or rethinking hallways to help provide accessto services. The greenhouse movement, in assisted living design, provides a model for how
this type of layout may support and provide safer social interaction and more meaningful
relationships as a set number of residents share basic spaces such as a kitchen, living room, oroutdoor space.
New housing developments would also benefit from solutions to provide services for residents
without them having to leave the building. Bringing in additional amenities and developing
creative partnerships with other businesses such as a health clinic, grocery store, pharmacy,salon, or a resale shop within the boundary of the site allow residents to gain independence overbasic necessities without being exposed to potential risk of infection.
Previously, balconies, equal access to outdoor space, generous entryways, open stairways,
and telecommunication devices built into the base unit were seen as luxury items. These sameelements during the pandemic are proving to be essential in maintaining physical, mental, andemotional health and should be included in future projects as essential. Less-institutional spacesthat have been intentionally designed for people’s well-being are better for infection control.
All of these suggestions will of course mandate a cultural shift in the way we fund and financeaffordable housing. However, as COVID-19 continues to show the devastating connection
between the design of housing and its negative impacts on health, we have the opportunity toprove that good design matters and that everyone deserves a safe, dignified, and healthy home.

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