Skip to main content

Changing the long-term care spectrum

Our population is ageing rapidly, impacting the way we live, dwell, care, and work with each other in society. Older persons have a higher chance of developing diseases, especially related to neurodegenerative diseases such as dementia and do not only influence physical functioning but also lead to disabilities in mental and social health. Concerningly, the group older people who require intensive and continuous care is growing significantly, whilst at the same time, the group of people who are available to care for them is decreasing [5]. With labor markets for health and social care experiencing tremendous shortages and the demand for well-educated and trained staff increasing, the group of people providing the vast majority of informal care (aged 45–60) is decreasing rapidly. Furthermore, with trends of retreating governments expenditure on costs of care and service provision increasingly being paid by older people themselves [35] the demand for high-quality long-term care services sees a continued rise.

These developments highlight the need to redesign long-term care for older people dramatically. Long-term care services support people to maintain or improve their functioning in daily life and quality of life [19]. It can include both health and social care related support services and takes place in various settings (e.g. home, within the community or in facilities). Supported by a cultural change movement, a fundamental shift in thinking about long-term care environments has emerged [34]. Increasingly older people wish to remain in their own home and age-in-place [20]), with research showing living at home to be an essential part of an individual’s identity and social network, relating to positive feelings, memories and well-being [4]. However, as a barrier to aging in place a substantial proportion of older people will become frail, develop chronic and complex diseases and experience intensive long-term needs for care, such as day-care or 24 h care in nursing homes. With the expectation of a continued increase in the size of this population, long-term care facilities (e.g. care homes, nursing homes, assisted living facilities) progressively aim to provide care and service delivery in a home-like environment, thus, supporting normal daily life [28]. Values such as autonomy, retaining one’s own identity and meaningful engagement in activities and social networks are key. Technology, including e-health applications, home electronics and robotics play an important role in enabling these goals, supporting residents’ autonomy, and facilitating staff [31].

Current evidence indicates that traditional long-term care facilities are often not effective in supporting everyday functioning and may even be harmful [15, 28]. Traditional care environments are often associated with poor outcomes for residents, including inactivity, high levels of neuropsychiatric symptoms (e.g. agitation and depression),use of physical restraints and high levels of psychotropic drugs [6, 7, 12, 17, 21, 22]. As a result, alternative care environments are urgently needed, using enabling environmental design to promote health and well-being of older people with complex conditions. Especially for people with dementia, the care environment plays a crucial role to support their daily functioning and well-being, for example when the disease progresses and 24 h care is required. Behaviour and everyday functioning are the result of an interaction between the individual and her/his environment (Lawton et al. 1970 [23]; Lewin 1951 [24]). Depending on the scientific discipline scholars take, long-term care environments have been described (Charras et al. 2016 [8]) as 1) being therapeutic or rehabilitative, focusing on compensating for existing deficits (mainly geriatrics and health sciences origin); (Chaudhury et al. 2014 [9]; Zeisel et al. 1994 [36]) 2) needs-based, focusing on how the environment can meet the needs of people with dementia (rooted in nursing science and psychology (Algas et al. 1996 [2]; Morgan et al. 1999 [26]) or 3) or experience-based, focusing on how people pose meaning to a place through interaction with their environment (i.e. gerontology and social ecology) (Davis et al. 2009 [10], Molony et al. 2011 [27]). Following these descriptions, researchers have aimed to develop evidence-based interventions to improve the well-being and daily life of residents with dementia, especially in traditional nursing homes, with mixed results (Charras et al. 2016 [8]). What often is neglected in practice and research is that congruence is needed between the different environmental components (physical, social and organisational), in order to promote well-being and adapted behaviours for people with dementia and their caregivers (de Boer 2021 [11]). Current long-term care environments may also have highly task-oriented organisational approaches. A mechanism is needed for long-term care environments to adapt, adjust or reconfigure their resource base in response to changing environmental conditions, so-called dynamic capabilities of an organisation (Pablo et al. 2007 [29]). Evidence suggests that shared values and supportive leadership for staff help in setting priorities and improve the delivery of person-centred care (Backman et al. 2020 [3]; Edvardsson 2011 [16]; van Beek et al. 2010 [32]).

More knowledge is highly warranted to disentangle environmental working mechanisms that influence daily functioning in older people in their real-life context, especially for those with dementia. This will increase the effectiveness of quality improvement initiatives and interventions. Furthermore, it will inform practitioners and policy makers in the evidence-based design of care environments for older people. An interdisciplinary approach is needed, synthesizing insights of how the environment is experienced (mainly rooted in gerontology and social ecology), how the environment is used (mainly rooted in geriatrics, nursing, and psychology), how the environment is designed (architecture) and finally how care services are provided in the environment (service science and strategic management). Existing theories of functioning mainly focus on biological and/or (psycho) social aspects of ageing and insufficiently consider the interplay of physical, social, and organisational environmental mechanisms. Furthermore, current studies mainly take a deficit-based approach, which ultimately may have negative consequences for functioning in residents’ daily life. It seems more promising to look beyond the disability of older people and focus on their remaining capacities, determining how gains and positive outcomes can be enabled and preserved [14, 25]. This requires that an organisation can continuously adapt to change, and therefore possesses dynamic capabilities in their strategic approach.

Innovative, alternative care environments are being developed that have radically changed long-term care environments. For example, community-based living concepts, green care farms, shared housing arrangements or dementia care villages (De bruin et al. 2017 [13]; Peoples et al. 2020 [30]; Verbeek et al. 2021 [33]). These projects have in common that they aim to provide a homelike environment for older people, encouraging remaining capacity and increasing engagement, autonomy and participation in normal daily life. The role of staff is also changing, with more focus on encouraging remaining capacities, instead of taking over tasks, forming partnerships with family caregivers (Adams et al. 2018 [1]; Gilster et al. 2018 [18]). Furthermore, most projects explicitly aim for embedding within the local community and social networks.

We anticipate that older people requiring long-term care reside in a variety of living arrangements and care concepts in the future. This requires a changing role for all actors involved in the ecosystem of long-term care, including older people, their family care givers, professional caregivers, long-term care providers, social care providers, municipalities, funding agencies, housing organizations and local and national governments.

Long-term care environments can include the home, the community, assisted living facilities, care homes or any facility where people receive long-term care. As such, optimizing the long-term care environment requires the input of multiple disciplines to solve the complex problems highlighted in this article. In this series, we will present original empirical research, evidence synthesis, quality improvement studies and discursive commentaries that move society’s understanding of long-term environments forward. Contributions that consider the relationship between the physical, social, and organizational aspects on the long-term care environment are particularly encouraged. The aim of this collection is to provide high-quality science that can be freely accessed by people who receive or provide care, deliver healthcare education or undertake research in long-term care environments. We hope that this collection will facilitate and empower these individuals to find new ways to optimize care provided within their own long-term care environment.


  1. Adams J, Verbeek H, Zwakhalen SMG. The Impact of Organizational Innovations in Nursing Homes on Staff Perceptions: A Secondary Data Analysis. J Nurs Scholarsh. 2017;49(1):54-62.

  2. Algas D, Beck C, Kolanowsk A, Berent S, Richards K, & Beattie E. Need-driven dementia-compromised behavior: An alternative view of disruptive behavior. Am J Alz Dis. 1996;11(6):10–19.

  3. Backman A, Ahnlund P, Sjögren K, Lövheim H, McGilton KS, Edvardsson D. Embodying person‐centred being and doing: Leading towards person‐centred care in nursing homes as narrated by managers. J Clin Nurs. 2020;29:172–183.

  4. Beard JR, Officer A, De Carvalho IA, Sadana R, Pot AM, Michel JP, et al. The world report on ageing and health: a policy framework for healthy ageing. Lancet. 2016;387(10033):2145–54.

    Article  Google Scholar 

  5. Beard JR, Bloom DE. Towards a comprehensive public health response to population ageing. Lancet. 2015;385(9968):658–61, ISSN 0140–6736.

    Article  PubMed  Google Scholar 

  6. Björk S, Juthberg C, Lindkvist M, et al. Exploring the prevalence and variance of cognitive impairment, pain, neuropsychiatric symptoms and ADL dependency among persons living in nursing homes; a cross-sectional study. BMC Geriatr. 2016;16:154.

    Article  Google Scholar 

  7. Blasco J, Igual-Camacho C, Pérez-Moltó F, García-Molina P, Gómez-Salgado J, Wazen-Hervás M. Use of physical restraint in nursing homes in Spain and relation with resident characteristics: a retrospective multi-Centre cohort study with a self-organised maps approach. Ageing Soc. 2019:1–19.

  8. Charras K, Eynard C, Viatour G. Use of space and human rights: Planning dementia friendly settings, J Gerontol Soc Work. 2016;59(3):181-204.

  9. Chaudhury H, Cooke H. Design matters in dementia care: The role of the physical environment in dementia care settings. In M Downs and B Bowers (Eds.), Excellence in dementia care (2nd Edition). UK: Open University Press; 2014. p. 144–58.

  10. Davis S, Byers S, Nay R, Koch S. Guiding design of dementia friendly environments in residential care settings. Dementia. 2009;8(2):185–203.

  11. de Boer B, Bozdemir B, Jansen J, Hermans M, Hamers JPH, Verbeek H. The Homestead: Developing a Conceptual Framework through Co-Creation for Innovating Long-Term Dementia Care Environments. Int J Environ Res Public Health. 2021;18(1):57.

  12. de Ouden BMC, Meijers JMM, et al. Daily (in) activities of nursing home residents in their wards: an observation study. J Am Med Dir Assoc. 2015;16(11):963–8.

    Article  Google Scholar 

  13. de Bruin S, de Boer B, Beerens H, Buist Y, Verbeek H. Rethinking dementia care: the value of green care farming. J Am Med Dir Assoc. 2017;18(3):200-3.

  14. Dröes RM, Chattat R, Diaz A, et al. Social health and dementia: a European consensus on the operationalization of the concept and directions for research and practice. Aging Ment Health. 2017;21(1):4–17.

    Article  Google Scholar 

  15. Eckermann S, Phillipson L, Fleming R. Re-design of aged care environments is key to improved care quality and cost-effective reform of aged and health system care. Appl Health Econ Health Policy. 2019;17:127–30.

    Article  Google Scholar 

  16. Edvardsson D, Fetherstonhaugh D, McAuliffe L, Nay R, Chenco C. Job satisfaction amongst aged care staff: Exploring the influence of person‐centered care provision. Int Psychogeriatr. 2011;23(8):1205–12.

  17. Ferreira AR, Simões MR, Moreira E, Guedes J, Fernandes L. Modifiable factors associated with neuropsychiatric symptoms in nursing homes: the impact of unmet needs and psychotropic drugs. Arch Gerontol Geriatr. 2020:103919.

  18. Susan D Gilster, PhD, RN, LNHA, Marie Boltz, PhD, GNP-BC, FGSA, FAAN, Jennifer L Dalessandro, BSHSA. Long-Term Care Workforce Issues: Practice Principles for Quality Dementia Care. Gerontologist. 2018;58(suppl_1):103–S113.

  19. Harris-Kojetin Lauren D, Sengupta Manisha, Lendon Jessica Penn, Rome Vincent, Valverde Roberto, Caffrey Christine. Long-term care providers and services users in the United States, 2015–2016. Vital and health statistics. Series 3, Analytical and epidemiological studies; no 43;DHHS publication; no. 2019–1427. 2019. URL:

  20. Hatcher D, Chang E, Schmied V, Garrido S. Exploring the perspectives of older people on the concept of home. J Aging Res. 2019;2019:2679680. Published 2019 Jun 18.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Helvik AS, Selbæk G, Šaltytė Benth J, Røen I, Bergh S. The course of neuropsychiatric symptoms in nursing home residents from admission to 30-month follow-up. PLoS One. 2018;13(10):e0206147.

    Article  Google Scholar 

  22. Hofmann H, Schorro E, Haastert B, et al. Use of physical restraints in nursing homes: a multicentre cross-sectional study. BMC Geriatr. 2015;15:129.

    Article  Google Scholar 

  23. Lawton MP, Nahemow L. Ecology and the Aging Process. Washington: American Psychological Association; 1970.

  24. Lewin K. Field Theory in Social Science. New York: Selected Threo Cartwright; 1951.

    Google Scholar 

  25. Mitchell G, McTurk V, Carter G, et al. Emphasise capability, not disability: exploring public perceptions, facilitators and barriers to living well with dementia in Northern Ireland. BMC Geriatr. 2020;20:525.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Morgan DG, Stewart NJ. The physical environment of special care units: Needs of residents with dementia from the perspective of staff and family caregivers. Qual Health Res. 1999;9(1):105–18.

  27. Molony SL, Evans LK, Jeon S, Rabig J, Straka LA. Trajectories of at-homeness and health in usual care and small house nursing homes. Gerontologist. 2011;51:504–15.

    Article  Google Scholar 

  28. OECD/European Commission. A good life in old age? Monitoring and improving quality in long-term care, OECD Health Policy Studies, OECD Publishing; 2013.

  29. Pablo AL, Reay T, Dewald JR, Casebeer AL, Identifying, enabling and managing dynamic capabilities in the public sector. J Management Stud. 2007;44:687-708.

  30. Peoples H, Pedersen LF, Moestrup L. Creating a meaningful everyday life: perceptions of relatives of people with dementia and healthcare professionals in the context of a Danish dementia village. Dementia. 2020;19(7):2314–31.

  31. Royston C, Sheeran C, Strain J, et al. Optimising dementia care in care homes: the TRaCAd. Dementia. 2020;19(4):1316–24.

    Article  Google Scholar 

  32. van Beek AP, Gerritsen DL. The relationship between organizational culture of nursing staff and quality of care for residents with dementia: questionnaire surveys and systematic observations in nursing homes. Int J Nurs Stud. 2010;47(10):1274–82.

  33. Verbeek H, Peisah C, de Mendonça Lima CA, Rabheru K, Ayalon L. Human rights to inclusive living and care for older people with mental health conditions. Am J Ger Psych. 2021;29(10):1015–21.

  34. White-Chu EF, Graves WJ, Godfrey SM, Bonner A, Sloane P. Beyond the medical model: the culture change revolution in long-term care. J Am Med Dir Assoc. 2009;10(6):370–8.

    Article  PubMed  Google Scholar 

  35. Wittenberg Y, Kwekkeboom R, Staaks J, Verhoeff A, de Boer A. Informal caregivers’ views on the division of responsibilities between themselves and professionals: a scoping review. Health Soc Care Community. 2018;26:e460–73.

  36. Zeisel J, Hyde J, Levkoff S. Best practices: An environment–behavior (E-B) model for Alzheimer special care units. Am J Alz Care Related Disorders Res. 1994;9:4–21.

Download references

Author information

Authors and Affiliations



HV drafted the manuscript, with critical revisions of GM. The authors read and approved the final manuscript.

Corresponding author

Correspondence to Hilde Verbeek.

Ethics declarations

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Verbeek, H., Mitchell, G. Changing the long-term care spectrum. BMC Geriatr 22, 303 (2022).

Download citation

  • Published:

  • DOI: