The AIRP-HEAP tool is an adapted version of the Hospice Environmental Assessment Protocol (HEAP) tool developed by Kader [20] as part of her doctoral dissertation. The HEAP tool was developed following the conceptual framework of the Professional Environmental Assessment Protocol (PEAP), a widely recognized, evidence-based tool for evaluating the quality and therapeutic potential of long-term care and dementia care environments [21,22]. The HEAP tool was developed as a standardized method for evaluating whether the spatial and placemaking characteristics of hospice buildings support the following 11 therapeutic goals: (1) continuity of self, (2) access to nature, (3) privacy, (4) social interaction, (5) safety and security, (6) autonomy, (7) stimulation and sensory therapies, (8) spiritual care, (9) family accommodation, (10) support after death, and (11) support for staff [20] (see Textbox 1 for definitions of each goal). Each goal includes several design objectives and subobjectives that operationalize the respective goal, and each objective includes specific environmental items that are observable within the hospice environment, totaling 295 items. For example, the therapeutic goal of “continuity of self” has the following two design objectives: (1) creating a noninstitutional environment or home-like environment and (2) scope for personalization, which each have specific environmental items. The “scope for personalization” objective includes wall shelves present to display personal belongings, and adequate space in individual rooms is provided to bring personal belongings. We adapted these 11 therapeutic goals for the AIRP-HEAP tool to be conceptually linked to domains within the AIRP project’s framework [3]. The AIRP project’s framework was developed to provide a practical conceptualization of 6 indicators that contribute to aging in the right place for OPEH, and the AIRP-HEAP tool domain was based on this framework [3]. Based on this framework, the AIRP-HEAP tool domains are (1) built and natural environment; (2) housing access and home modification; (3) emotional place attachment; (4) social support, participation, and inclusion; and (5) safety and security. The synergy between the AIRP framework’s concepts and the therapeutic goals of the AIRP-HEAP tool helps to ground the environmental characteristics of hospice sites within the conceptual discussion of aging and end-of-life care in the right place. Each audit domain is intentionally structured to theoretically align with the AIRP framework, as illustrated in Textbox 2. This bridging of theory and measurement allows the audit to focus on the environmental elements that support the distinct needs and vulnerabilities of older adults in the hospice setting.

The AIRP-HEAP audit tool is designed to collect data on the presence or absence of environmental features with the options: “Yes,” “No,” or “N/A.” According to Kader [20], when a majority of these items are present in a hospice setting, it suggests that the therapeutic goals are being achieved. For this study, Kader’s original HEAP tool [20] was revised to better align with the needs of AIRP study participants, as the original tool was initially designed to evaluate hospice sites for the general population. With input from relevant partners, the team, consisting of the principal investigators and master’s students, made several adaptations to Kader’s [20] tool to include considerations for the unique needs of OPEH in hospice. For example, the goal “spiritual care” was reconceptualized as “culturally appropriate, relevant, and supportive spiritual care” to align with the needs of the Indigenous population, who are overrepresented in homeless counts in Metro Vancouver [1] and elsewhere in Canada [23]. In addition, the definition of “family accommodation” was expanded from “family members” to “loved ones” to represent the diverse support networks of OPEH who receive care and support from friends and close nonkin loved ones [24]. To adopt a less biomedical approach, we replaced “patient” and “nurse” with “staff,” “individuals,” and “people.” Furthermore, we added an open-ended comment section for each goal to allow auditors to provide detailed notes for additional context as needed.

While the AIRP-HEAP tool captures data about the indoor space of hospice sites, a separate, complementary tool, the AIRP-HEAP secondary observation tool, is used to capture contextual data on the neighborhood surrounding the hospice site. The AIRP-HEAP secondary observation tool was adapted from the qualitative observation section of the Stakeholders Walkability/Wheelability Audit in Neighborhoods (SWAN) tool [25], which is a user-led audit tool that evaluates the environmental barriers to walkability and wheelability of neighborhoods for diverse older adults and persons with disabilities. The AIRP-HEAP secondary observation tool consists of 6 open-ended questions about land use, area characteristics, quality of public space and amenities, feelings of safety, travelling on foot or wheeling, and overall traffic volume, speed, and noise.

The 2 trained master‘s-level research assistants will independently audit the hospice sites using the AIRP-HEAP and AIRP-HEAP secondary observation tool. The data collection will take around 2 hours to complete. The audit data will be subsequently exported and organized into a Microsoft Excel file, separated by hospice site for analysis. The raw data will be checked to identify blank entries. If blank entries are identified, they will be discussed with the research assistant who conducted the audit to identify the reason and will be subsequently addressed. Given that 2 research assistants will independently audit each site, raters’ answers will be compared to determine if each response is the same (“=TRUE”) or different (“=FALSE”). The discrepancies will be identified and discussed to understand the reason behind the differences, which will then be resolved by consensus. The final data used for analysis will be a consensus of answers between both research assistants. The “N/A” responses will be omitted from scoring due to their lack of applicability. For instance, if the primary question (eg, room present to accommodate family and loved ones) is answered “No,” then the subquestions (eg, about the size of that room) would be considered not applicable (“N/A”). Qualitative data collected with the AIRP-HEAP secondary observation tool will be imported into NVivo (version 14; Lumivero) [26] for analysis.

After a consensus is reached on the presence and absence ratings for each item (“Yes” and “No”), the data will be converted into quantitative scores (Yes=1; No=0). Quantitative data will be summed, and a total score (%) for each subobjective will be calculated. A 5-level Likert scale will be created to rate each design objective and follow a scoring system where 0%-20%=“Unusually poor,” 21%-40%=“Poor,” 41%-60%=“Moderate,” 61%-80%=“Strong,” and 81%-100%=“Exceptional.” An overall goal score will not be calculated, as each goal has differing design objectives and subobjectives, thus having inequivalent denominators, which would result in an unbalanced interpretation of the data. Therefore, scoring and interpretation will be performed based on the design objectives within each therapeutic goal. Using NVivo (version 14), the qualitative AIRP-HEAP secondary observation data will be coded line-by-line and subsequently collated to form conceptual categories. Two or more trained research assistants will code the qualitative data to ensure rigor and reach consensus. This will initiate the development of a codebook for the AIRP-HEAP secondary observation data that will be derived from the AIRP theoretical framework, which consists of the 6 indicators of aging in the right place. Coders will meet regularly with the principal investigator to discuss any discrepancies or challenges that arise during the coding process to come to a consensus. Coders will conclude coding when no new themes arise and thematic saturation has been reached.

This protocol is reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist to improve transparency, ensure full alignment with qualitative reporting standards, and facilitate the peer-review process. A completed COREQ checklist is provided in Multimedia Appendix 1, where each criterion has been addressed in the manuscript.

Within the AIRP-HEAP tool, certain items were noted as “significant” design objectives based on Kader’s [20] original HEAP tool. The significance of items was determined through literature review, expert consultation, and case evidence [20]. For example, some criteria, such as private rooms, are significant and must achieve an optimal level of environmental quality. These are typically well-established, appearing across all 3 phases of data collection or consistently in case studies. Other criteria serve as optional best practices, noted by a few experts or present in select case studies, and can improve overall scores. Some considerations address building layout (eg, distribution of social spaces), while others concern design quality (eg, use of natural materials like wood and stone). Because each criterion is unique, evaluation patterns vary and depend on the nature of the design feature. To further confirm the significance of these items for aging and end-of-life care in the right place for OPEH, we performed an in-depth review of relevant literature.

In Multimedia Appendix 2, the values under “Significant score” will factor in the weight of these significant scores (as a percentage), while the values under “Total score” will consider all items without accounting for significance (as a percentage). “Significant score” will be calculated by dividing the number of significant objectives that are marked present at the hospice site by the total number of significant objectives as labeled in the HEAP tool. This score will allow us to focus only on those characteristics of the hospice that have broader implications (eg, are mandatory) for aging and end-of-life care in the right place for OPEH. “Total score” will be calculated by dividing the number of objectives that are marked present at the hospice site by the total number of objectives, including the significant objectives. This score will allow us to calculate the overall rating of the hospice site based on the Likert scale, and comparisons between hospice sites will mainly be based on this score. Comparing the “Significant score” and “Total score” provides a comprehensive assessment of the quality of the built environment at the hospice sites.

The HEAP was developed following the conceptual framework of PEAP, which is one of the most widely used environmental evaluation tools. Early conceptual work by Weisman [21] and later scholarship on person-centered environmental assessment [22] positioned the PEAP as a framework for understanding how the built environment influences residents’ well-being and daily function. Its reliability has been demonstrated through strong interrater agreement and consistent scoring across trained evaluators [27,28]. The tool’s validity is well supported. Its content aligns with key therapeutic domains, such as safety, comfort, accessibility, social engagement, and cognitive support, while construct validity has been confirmed by associations between PEAP scores and resident outcomes, including functional performance, agitation reduction, and overall satisfaction [29]. More recently, related research has expanded the field of environmental evaluation, with tools such as the Environmental Audit Screening Evaluation further validating evidence-based design approaches [30] and contemporary reviews emphasizing the enduring value of person-centered frameworks for dementia care [31]. Collectively, these studies confirm that HEAP remains a reliable and valid method for guiding design evaluation and improvement in long-term care and dementia-supportive environments.

The protocol for AIRP under the title “Aging in the Right Place: Building Capacity for Promising Practices that Support Older People Experiencing Homelessness in Montreal, Calgary, and Vancouver” was approved by the University of British Columbia (UBC) Rise system through the UBC and Simon Fraser University Research Ethics Board at Simon Fraser University (H24-01268), McGill University (20-09-008), and the University of Calgary (REB20-1229) ethics boards. All study sites provided informed consent.

This protocol aims to provide a comprehensive methodology for conducting a study focused on assessing hospice settings for OPEH in Metro Vancouver. Through this study, new insights into the environmental aspects that influence OPEH’s ability to age and receive end-of-life care in suitable settings will be gained, ultimately contributing to the well-being of this population. Thus, this study allows us to discover information regarding AIRP concepts related to HEAP goals for end-of-life care and identify the environmental facilitators and barriers to improvements in hospice settings in the neighborhoods.

For capturing data and information on this protocol, the AIRP-HEAP tool (for indoor space) includes 295 items categorized into 11 therapeutic goals pertaining to the built and natural environment of hospice sites, and the AIRP-HEAP secondary observation tool (for surrounding neighborhoods) will be used. The most detailed questions in the AIRP-HEAP tool domains are related to the inside of the building and will be asked through a questionnaire in order to evaluate the quality of end-of-life care space. These tools will be used to assess the indoor built environment and the outdoor environment surrounding Maggie’s Lodge hospice in the Metro Vancouver area. Built environment factors that enhance safety, reduce stress, and have spiritual significance will be audited to evaluate the quality of the built environment. For instance, assessing the amount of natural light in the building, ensuring security and privacy measures, providing spiritual and counseling spaces, and creating areas that facilitate social communication are included in the audit tool. Additionally, elements like accessible and wheelable sidewalks, traffic calming features, sufficient outdoor spaces, support services, and social amenities in the surrounding environment are included in the secondary observation tool, as these factors are known to promote potential for social and outdoor engagement for OPEH and their loved ones.

To ensure that the solutions recognized through this protocol can be extended to other hospice centers, we will develop a set of recommendations based on the findings. These recommendations will outline the best practices and actionable steps for improving the built environment and surrounding neighborhoods of hospice settings catering to OPEH. A recent analysis of Canadian homelessness and palliative policy documents highlighted that there is limited guidance for services to provide end-of-life care for OPEH [32]. Additionally, we will share the results of the study, along with the developed guidelines, with relevant stakeholders, including policy makers, urban planners, architects, and health care providers. By disseminating this information widely and encouraging its implementation in other hospice centers, we can promote the adoption of similar improvements across different locations, thereby extending the benefits to a broader population of OPEH. Findings from this study will be context-specific to the selected hospice site, limiting generalizability. However, the adapted AIRP-HEAP tool and conceptual approach can be transferable and applicable to other hospice contexts. By providing a structured framework for examining spatial and organizational dimensions of hospice environments, the tool may support other sites in identifying ways to create more compassionate and inclusive spaces for OPEH.

This study will be conducted exclusively at Maggie’s Lodge hospice during a specific time frame to evaluate the quality of its built environment and the surroundings of the building. While the findings based on the audit tool are expected to contribute to addressing gaps in the literature, the study will be subject to several limitations. First, as the audit will take place at a single point in time, the data will not capture environmental changes that occur over time. Future studies will be able to examine temporal factors and weather impacts on the outdoor spaces of hospices over time. Additionally, while the AIRP-HEAP tool will offer valuable insights into hospice environments, its adaptation from an existing tool may overlook certain unique needs of OPEH. The study’s focus on Maggie’s Lodge hospice site in Metro Vancouver will limit the generalizability of the findings to a broader geographical and cultural context. Finally, findings may not accurately depict the available resources to the hospice, as it omits staff interviews.

The development of the AIRP-HEAP and AIRP-HEAP secondary observation audit tools adds diversity and detail to existing hospice environment assessment methods by incorporating the unique needs of OPEH. Defining therapeutic goals and creating a design checklist for each goal establishes a milestone for theory and practice. The findings from these tools will help identify spatial design and placemaking features within hospice environments that either promote or deter end-of-life care for this population. By aligning the AIRP-HEAP goals to AIRP-related concepts, this research is expected to strengthen the connection between design-related therapeutic goals and research-based conceptualizations of aging and end-of-life care in the appropriate setting. The anticipated findings of the audit are expected to provide guidance for identifying environmental improvements in hospice settings, as well as inform future planning and design guidelines for hospice settings that support OPEH.