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Jefferson, North Carolina: Adaptive Reuse of a Historic Hospital Preserves a Community Asset

Photograph of the front façade of a stone building with a portico marking the entrance and, in the foreground, a freestanding sign reading “Historic Ashe Hospital.”
Low-angle aerial photograph of a stone building in front of a parallel brick building, connected by a central hyphen.
Photograph of a walkway leading to a courtyard containing five raised planters and a new, two-story building in the middle-ground.
Photograph of an apartment, with a sofa, chair, and potted plants in the living area in the foreground, and  a kitchen area in the background.
Photograph of a landscaped courtyard framed by the two sections of the historic building, with a paved walkway and railings in the foreground.
Photograph of a large room with several mission-style chairs and tables and potted plants.
Photograph of several people in a large room preparing food around a table holding bowls and other food containers.
Photograph of a woman seated in a wheel chair giving candy to two costumed children who are accompanied by a woman.


Home >Case Studies >Jefferson, North Carolina: Adaptive Reuse of a Historic Hospital Preserves a Community Asset


Jefferson, North Carolina: Adaptive Reuse of a Historic Hospital Preserves a Community Asset


In 2013, the need for affordable housing in Ashe County, North Carolina, came to the attention of Northwestern Regional Housing Authority (NRHA), a nonprofit organization developing affordable housing projects in the Blue Ridge Mountains. No affordable housing had been constructed in the county in the previous 10 years. At the time, Ashe County had 3,000 low-income senior households, 6 times the amount in surrounding counties. To fill this affordable housing gap, NRHA decided to reuse a New Deal-era hospital in the town of Jefferson as a senior independent living facility. The 46-unit complex, named Historic Ashe Hospital, received the 2020 Advisory Council on Historic Preservation/HUD Secretary’s Award for Excellence in Historic Preservation for saving a community landmark and enhancing its residents’ lives.

Historic Ashe Hospital

Opened in 2019, Historic Ashe Hospital houses seniors who are at least 62 years of age and persons with disabilities who are at least 45 years of age. Eligible residents, who earn less than 50 percent of the area median income, can choose a one- or two-bedroom unit, both of which include a kitchen, living room, and full bath. The apartments are distributed throughout the old hospital building and a new wing that was added when the senior housing was created. The old hospital consists of two sections; the original portion, which was constructed as a New Deal project in 1941, and an expansion that was added in 1952. Because the old hospital is listed in the National Register of Historic Places, NRHA partnered with Tise-Kiester Architects to preserve historically significant elements of the old hospital. This effort included preserving major aspects of the hospital layout, such as the hallways leading to the original wards, which were suites that were occupied by several patients receiving the same care. In the adaptive reuse, 2 to 3 wards were combined to make each of the 19 apartments located in the old building. All the old ward doorways were kept, even though some are no longer used, to preserve the character of the hallways. The original wood window frames from the 1941 construction were repaired or, if beyond repair, replaced with matching windows. Each apartment has six to eight windows and high ceilings that provide abundant natural light. Several common areas — a memory room, a library, office space, meeting rooms, and a computer room — are also located in the old hospital.

The development team also took care to preserve significant exterior features, including the rough-faced, random-coursed granite walls of the 1941 section of the building. The two sections of the historic building are H-shaped and frame two courtyards that NRHA upgraded with sidewalks, landscaping, lighting, benches, and handrails. The new wing, whose design complements the hospital’s historic features, provides 27 apartments and a group study room.

Second Life for a Community Asset

The hospital building has been a shared community asset since its beginning, when local officials raised funds at the end of the Great Depression to ensure its construction. The local money supplemented Works Progress Administration funds to complete a project that provided not only jobs but also health care as the county’s first hospital. The community, which supported NRHA’s decision to reuse the building, has participated in the design phase and continuing operations of the development. Although the hospital had been vacant for 19 years, many county residents have loved ones who were born and cared for in the hospital. Historic Ashe Hospital has a memory room located at the entrance of the historic building that displays apothecary cabinets, doctor’s bags, medical instruments, an examination chair, and photographs.

The new wing also features interior and exterior spaces that facilitate community participation. A large meeting room, which can host up to 50 people, is used for city council meetings and informal gatherings. Historic Ashe Hospital residents also use the room to discuss issues to be addressed by management. The new wing and the old hospital building frame a third courtyard containing a gazebo and a community garden, which has five raised garden beds. Seniors plant flowers and vegetables in the garden beds that they enjoy once harvested. As places where residents of Historic Ashe Hospital and the county can gather, these opportunities also reduce the seniors’ feelings of isolation and bring life to an old building.

Services for Historic Ashe Hospital residents are provided onsite and near the property. The county health department and a community paramedic program provide in-home services such as physical therapy, medical assessments, and chronic disease care. Vaya Health Services, a regional public managed care organization, arranges mental health classes at Historic Ashe Hospital. Located approximately 3 miles from the residence, Ashe Senior Services for the Aging provides residents with door-to-door transportation to access services such as fine arts, computer, and fitness classes.

Financing for Historic Ashe Hospital

The development’s largest source of funding came from Red Stone Equity Partners, which purchased low-income housing tax credits as well as state and federal historic tax credits (table 1). As a housing tax credit development, Historic Ashe Hospital was automatically eligible for the North Carolina Housing Finance Agency’s Rental Production Program, which provided an $800,000 loan. Two deferred loans covered more than $2 million in development costs and required no payments from operations and cash flow. One of these was from the Federal Home Loan Bank of Cincinnati’s Affordable Housing Program. In addition to lower fees and interest rates, a $700,000 conventional first mortgage included a nonrecourse characteristic.

Table 1: Historic Ashe Hospital Financing

State historic tax credits$597,913
Federal historic tax credits749,309
Low-income housing tax credits3,839,277
Rental Production Program loan800,000
Affordable Housing Program Advantaged Loan (Deferred)880,170
Advantaged Loan (Deferred)1,269,207
Deferred developer fee289,890
Conventional first mortgage700,000

Future Adaptive Reuse

NRHA, which has produced $100 million of affordable housing projects across seven counties in the Appalachian Mountains, completed its first conversion of a historic building to affordable housing 16 years ago. Based on that experience, NRHA was inclined to renovate the abandoned hospital in Jefferson, which was not immune to development challenges. NRHA had trouble finding experienced labor and qualified subcontractors, who gravitate toward the more numerous job opportunities in urban areas. In addition, NRHA had to tear down a childcare facility to build the new wing of Historic Ashe Hospital; as part of the agreement with the owners of the facility, the developer found a suitable replacement site and raised the funds to purchase the site and build a new facility.



The contents of this article are the views of the author(s) and do not necessarily reflect the views or policies of the U.S. Department of Housing and Urban Development or the U.S. Government.