National Assisted Living Week Profile: The Forest at Duke

When The Forest at Duke decided to revamp its skilled nursing, assisted living, and memory care accommodations, its leadership team had a decision to make: Renovate the existing long-term care building on its Durham, NC, campus or start over. They turned to Perkins Eastman for help. The firm’s senior living team conducted several planning workshops with the client and its resident stakeholders, where it became clear that the community’s values required a new approach. Whereas the existing 30-year-old, 92-bed building was “thematically” home-like in the way its hallways and common areas were designed, it wasn’t a true household in the sense that small groups of residents had their own kitchen and dining room, living room, and den like a family would, CEO Anita Holt says. “We really wanted something where our architecture and our programming were not in conflict.”

As a result, The Forest at Duke decided to build anew, replacing 14 cottages on its campus with the new Small House healthcare center, which opened in February.

The main entrance, with its variety of natural materials and open porches, looks anything but institutional.

Once its assisted living and long-term-care residents moved in, the existing building came down to make way for a new independent living tower, which Perkins Eastman is also designing. The community center will also be expanded to strengthen the connections between each part of the campus. “In every continuing-care community, people always assume that the move to a health center is such a tremendous loss,” Holt says. “We believe that just because you need more care, the quality of your environment should not be diminished.”

Porches on every level allow residents easy access to the outdoors.

The Forest at Duke deserves a spotlight in recognition of National Assisted Living Week. The annual observance, honored through celebrations at assisted living communities across the nation this week, seeks to emphasize “the special relationships and bonds created within assisted living communities.”

The Forest’s five-story Small House healthcare center stacks nine, 10-person households across two wings that are linked by a central core containing amenity spaces, administrative offices, and vertical circulation. Each neighborhood of two households has a permanently assigned staff, and the personal residences orbit around a full-service kitchen, dining area, living room, den, and screened porch.

Like at home, residents have a lot more food choices that are easily and readily available than they might at other healthcare communities.

Living rooms aren’t just huge central spaces for programming in a small-home environment, says Anita Holt, the CEO of The Forest at Duke. “It’s just your space.” Likewise, a nearby den serves as a TV room.

It’s the realization of The Forest’s evolving philosophy, says Perkins Eastman Associate Principal Greg Gauthreaux, the project’s lead architect. “They had already bought into the importance of resident-centered care. They just needed the bricks and mortar to support their commitment to providing the best care,” he says. With a dedicated staff within each small living environment, he adds, “they form relationships with the residents. It’s a more personal experience for both staff and residents.”

But the new model required adjustments. Before, operations were siloed between roles such as housekeeping, dining, nursing, and support services. Now, each household’s staff works as a team, sharing responsibilities. The Forest’s leadership pitched in to deliver a seamless transition. On one day, Gauthreaux explains, you’d see the director of facilities pushing a linen cart, while Holt would be helping cook dinner in one of the kitchens. “It’s a one-for-all, all-for-one mentality. They were willing to do whatever was necessary to make this succeed,” he says.

Small-home models have become a lot more popular in the wake of the pandemic, according to Senior Housing News. A study of these communities in 2021 concluded that this building type saw fewer Covid-19 cases and deaths than traditional settings where staffing is shared among dozens or even hundreds of units. The segmented small-house design allows for better infection control and a stronger sense of community, the report said.

Multi-purpose rooms in The Forest’s central core are open to anyone on the campus.

At The Forest, Gauthreaux’s team infused a sense of community throughout its design. The amenity spaces, for one, are open to the entire campus. And once the independent living tower is complete, it will serve as a connector between the Small House and the campus’ large central community center. “It’s a literal connection between independent living and healthcare,” Gauthreaux says. “No one wants to be put away in a facility. They want to continue those relationships they’ve built while living on campus.” The design integration also makes it easier for independent living residents to regularly help out in the Small House and form relationships with their neighbors under the community’s volunteer program, Holt says. That also includes the leadership: Holt volunteered early on to organize its library and arrange all the books by genre. And for managers who are there on weekends, they make a point of interacting with every Small House resident—even for just a minute or two—at least once, as well as giving time to the staff who are working there.

The V-shaped Small House (center left) will bridge across to a new independent living tower, which in turn connects to the campus’ large central community center. “It connects and expands the commons areas from one side of the center to the other,” Holt says. Site plan Copyright Perkins Eastman

Outside, abundant gardens and terraces, walking trails, operable windows in each household, and screened porches on every floor maintain a constant connection to nature – one of the client’s overriding goals. “There was such a deep intent to make sure that you had sufficient amounts of sunlight, no matter where you were,” Holt says.

Each household features wide window seats that allow for a sunny respite while also sending daylight through the interior hallways.

The design team went further, nestling the building into a hill and organizing its layout to symbolize the campus’ verdant surroundings. The core “trunk,” for example, contains staffing spaces and amenities, while the “canopy” branching off of it contains the individual households, with lively color palettes and plentiful windows that send dappled sunlight throughout, just as the leaves of a tree would do.

A ground-floor memory-care garden allows residents to walk about freely. Raised beds allow them to do a bit of gardening from a seat or wheelchair.

In all, Gauthreaux says, the Small House is designed to promote inclusion and belonging among a population that is too often removed from the daily patterns of life. The programming also gives residents a choice: where they want to go and with whom, what they want to do and when, and even what they want to eat from day to day. “Everyone wants to feel like they belong,” he says. And though there are sections dedicated to skilled nursing and memory care, “every household looks like every other household,” Holt adds, noting especially that the screened porches on each level give residents access to the outdoors without supervision. A memory-care garden on the ground level extends that access further. Here, she says, “we’re able to provide the same continuum of care [as other communities] but in a much more flexible way.”