In theory, nursing homes in the United States are expected to provide elderly people with health care and with room, hoard and opportunities for social growth. However, too often they offer neither a real home nor good nursing care. The purpose of this study is to explain why certain physical design parameters and concepts lead participants in the design process to build nursing homes the way they do.

In terms of a research mode, the qualitative approach was used to explore the range of behaviors linking the design process and a designed place. Four design processes of nursing homes built in recent years in the Midwest were followed. Data were gathered through observations, collection of documents, and in-depth interviews with participants in the design processes. The analysis was carried out in the framework of grounded theory that stresses discovery and theory development.

The results lend weight to the supposition that the architecture of long-term care facilities in the U.S. is embedded in the cultural history of aging, and is a reflection of the political and social policies toward the elderly in this country. The physical environment of the nursing home is the result of (1) thinking of aging as a medical problem; (2) regulations and reimbursement systems which discourage innovative design; and (3) conflicting interests of the participants in the design process that lead them to limited medical model solutions.

Nursing homes, as we design them now based on the medical model, promote cost effective care, but contradict individual autonomy and conflict with private lives in public places. The findings support the growing recognition that continued reliance on nursing home care as the primary service option for frail elderly is neither economically wise nor socially desirable. Future policy will have to enable development of consumer-driven models of long-term care that respond to the needs of frail persons and emphasize individual's values and lifestyle choices.