What’s Your Equation for Successful Healthcare Solutions?

We need to look at aging differently, as something concurrent with life, not something to be cured, which is how much of the medical profession currently views it. By looking at the whole you can build a relationship based on trust and working toward a common, understood goal. This is especially important in long-term care where people often have multiple practitioners. If everyone isn’t on the same page,  the patient may be getting contraindicating medications based upon not being evaluated as an individual, unique, whole being. 

Functional Programming

Design also needs to be intuitive, understanding and supportive of the staff. A functional programming process is essential to understanding the needs of everyone within the space. Functional programming is the evaluation of the care model, the staff and flow of every function within the space, and is a way to fully understand how things happen within and between spaces.

One recommendation is to spend time with each department within the space to understand the needed work flow and identify their needs. This could be done by conducting focus groups and job shadowing to better understand operations.

Consider including:

• Care staff
• Facilities, transportation, security, food services
• Environmental services and volunteers
• C-suite

Mapping out the circulation and workflow of all services and care, as well for incoming and outgoing movements of people, deliveries and removals is necessary for the development of a successful design.

This diagraming also supports efficiency and opportunities to include places that provide a moment of respite, access to daylight and potential landmark locations for wayfinding built into the design at critical decision points throughout the built environment.

The term “functional programming” is utilized in the licensing codes, and refers to understanding  the facility’s operational intent: the care model, how the staff are interacting, all the different activities that go on in a hospital, an outpatient care facility or long-term care setting, to better understand everything that’s going on and how design can improve the experience and efficiency for everyone.

Too often the staff is not considered in the design process. A lack of operational input into a design can make the staff’s tasks much more difficult, to the point that it impedes caregiving. In one case the layout forced staff to move soiled materials/waste through the clean materials section for disposal because the two areas weren’t properly divided in the design.

Input from Staff: “A Day in the Life”

Research shows that a facility’s staff is a healthcare facility’s most valuable asset. To keep staff working and happy, we need to provide for moments of respite, particularly when they’re taking care of terminally ill patients. How can we make things better for someone who’s been on 12-hour shifts working with hospice residents? It may be as simple as making sure they have a place for their personal belongings or moving the breakroom from the basement to an area that gets daylight and access to nature. These changes can impact the quality of outcomes.

Seeking the input of staff at all different levels is the best way to create a smoothly functioning healthcare setting. Focus groups, or even shadowing a patient, CNA, nurse or environmental worker to create a “day in the life” profile, are effective ways to spot possible design problems. It’s important to really understand who you’re designing for; not just the patient and family, but all of the staff as well. This includes understanding that there may be significant diversity in the ages of the staff, just as there is within patient and resident care populations.

Focus groups may be conducted in various ways. Specifically, in the senior living sector, residents and their adult children often have completely different perspectives. The family members may want bigger spaces, shiny floors and big chandeliers, where the resident’s main concerns include the corridors are too long and they don’t have enough time to enjoy dinner.

The goal of the first equation – Dignity + Respect = Humanity – is to better understand true needs of the care population, their families and facility staff. Research, study, identify, and document the full extent of all interactions taking place to create a design that works best for all.

Convenience + Interaction = Relationship

There are many factors that have changed where care is being delivered. These factors can be influenced by:

• Cost reduction goals
• Focus on increased quality outcomes

Money spent in the U.S. compared to other developed countries is disproportionate; our outcomes do not match the monies spent on healthcare and services. According to a December 2018 report from National Health Expenditure Accounts & OECD¹⁵:

• Relative to the size of its wealth, the U.S. spends a disproportionate amount on healthcare
• In 2017, health spending per person in the U.S. was $10,224, which was 28% higher than Switzerland, the next highest per capita spender
• On average, other wealthy countries spend about half as much per person on healthcare than the U.S.

Although it has been shown that the U.S. health system is performing better, outcomes are still lagging behind other countries, considering how much money is spent on healthcare in the U.S. We know:

• When there is a strong relationship between patient and provider the outcome is much better
• Quality of service is being measured now more than ever
• Quality surveys are impacting reimbursements, creating a direct tie from care to return on investment

FGI Guidelines

The Facility Guidelines Institute (FGI) is an independent, not-for-profit organization dedicated to developing guidance for the planning, design and construction of hospitals, outpatient facilities and long-term care and support facilities.

The FGI was developed to provide the framework for physical environments that support positive resident and staff outcomes and respond to the national movement to integrate person-centered practice and the built environment. The evolution of communities focused on the person-centered values of choice, dignity, respect, self-determination and purposeful living has begun to transform services for seniors and others who need long-term care in the United States. 

The FGI guidelines are utilized as licensing code throughout the U.S. Healthcare settings have to comply with both licensing as well as building code. Designers have the difficult task of trying to align both of these. Certain details have conflicted over the years, but the FGI strives for complimentary and supportive language to building code. The current revision cycle of the three FGI Guidelines books is underway with publication in 2022.

The guidelines are published in three books focused on each facility type and revised every four years. These guidelines are adopted by various states and departments within those states as licensing code for healthcare settings. They are used by designers, providers/healthcare systems and the regulatory departments that license various types of healthcare settings.

They are developed by the Health Guidelines Revision Committee, which is made up of:

• Physicians
• Caregivers
• Specialists (i.e. gerontologists, infection control preventionists, industrial hygienists, lighting designers, acousticians, etc.)
• Nurses
• Researchers
• Architects, interior designers and engineers
• Addition subject matter experts in related fields as needed

Care is Shifting to Outpatient Facilities

The majority of care is shifting to outpatient settings for various reasons, including the Affordable Care Act and Accountable Care Organizations which partner with outpatient, hospital and long-term care providers. The largest driver is technology that allows more care to occur at home as well as in outpatient settings, at lower costs than in acute-care settings.

Intensive care and complex acute conditions are being treated within hospital settings, while medical procedures, such as minimally invasive surgical procedures, are moving into outpatient facilities mainly due to technological advances.

There is a push for prevention that supports proactive health and wellness, versus leaving chronic diseases unmanaged that lead to unnecessary trips to the emergency department. Emergency department visits are very expensive:

• Often the most expensive cases are from about 5% of the population, called “Super Users”
• This five percent of patients account for about half of the country’s health care spending¹⁵

This article is advertiser sponsored

We also know that:

• Consistency of the practitioner and interaction leads to stronger relationships that foster positive outcomes. 
• High-touch [frequent visit] care models are assisting with improved outcomes and reduced healthcare costs

• Each model of high-touch care is different but the basics are the same:
  • Focusing on prevention
  • Ensuring basic needs are met
  • Reducing unnecessary treatments
  • Building meaningful, consistent and high-touch relationships with patients

A completed research project in Camden New Jersey found that these Super Users didn’t always have acute health issues. One person had a severe recurring respiratory issue that brought him to the emergency department on a regular basis, only to find out it was caused by a mold issue in his home. Another had developmental disabilities and would call 911 every day, solved with social integration services. These are cases where people didn’t have access to outside resources to help them address issues that weren’t related to the perceived need for acute care.¹⁴
 

Better Life Coordination

The idea of connective,  coordination of services for independent living residents is a care model that works for anyone managing chronic disease. Positive outcomes have been demonstrated at the Southcentral Foundation run by Dr. Douglas Eby in Alaska for native American peoples. The same is true with projects like Smart Living 360, created by Ryan Frederick, and Live Together, a multi-generational care model under development by JSR Associates Inc. These approaches focus on care, service and amenity needs coordination for improved outcomes for all ages.

So often the solution is matching the right resources with the right people and evaluating from the whole-person perspective including the home situation, access to quality food and transportation, and access to needed care and services.

Advances in In-Home Care

In-home care is another area that’s changing fast because of technology. Everything from virtual reality to artificial intelligence to video calls plays a role. Younger adults are adapting quickly to this approach, because of their familiarity with technology. Some older adults don’t adapt as quickly, but the latest technologies incorporate user interfaces that are more friendly to mature users.

In addition to outpatient settings, services are being conducted within the home thanks to technological advances:

• Reduces the need for patients to have to go out when not feeling well
  • Video call with a clinician could assist them with diagnosis and prescription needs
  • Followed up with delivery of prescriptions or non-prescription medications
• Overall, this could be better for the patient and the community at-large
  • Contagious diseases are less likely to spread
  • Patient does not have to endure inclement weather or transportation challenges

Types of services available for in-home outpatient care include:

• Primary care visits (“house calls”)
• Care management services for management of chronic illness
• Follow-up from hospital discharge
• Transitional care for those coming from facility to home
• Coordination with primary care
• Coordination through recovery after a procedure
• Portable imaging and lab services that can be brought into the home

Comprehensive transitional care is key in terms of avoiding readmission into the hospital, which not only impacts the quality of life of the patient and puts them at further risk, but also puts the financial reimbursement at risk for the healthcare setting.

Long-Term Care and Financial Issues

Long-term care is economically dependent. There are options available for those with money, and few quality options available for those who don’t have money. Right now, long-term care is designed for the 10% who can afford it.

Therefore, there’s a demand for alternative models of long-term care. Some multifamily developers are doing a better job with designing for long-term care and multifamily generational living than some senior living providers, because the multifamily developers see both millennials’ and boomers’ desires and their relationship between the creation of supportive, inclusive mixed use developments.

What’s interesting is that baby boomers are moving into the same settings that millennials are moving into, for the same reasons:

• Renting instead of purchasing, for the flexibility
• Flexibility and access to amenities
• Access to certain services that they may need
• Access to transportation options
• Potential safety and security
• Simplicity – not having to worry as much about the ongoing maintenance of a home, or the cost of a mortgage and the related costs associated with owning a home

Multifamily developers may not have realized why certain people were moving in, but it boils down to younger and older generations having the same expectations and desires. There are certainly parallels in terms of what people are looking for in the future.

Both groups are experiencing some level of difficulty with finances in terms of fixed incomes. In certain urban areas it’s so expensive that younger people starting their careers are looking into housing alternatives like cooperative or community living models to make ends meet.

Garden Spot Village, a life plan retirement community in New Holland, PA, built a cooperative living home for five unrelated seniors living independently within the same house. They share chores, the kitchen and the community space, and have their own private bedrooms and bathrooms. It’s an interesting and affordable option for folks who can’t afford a continuing care retirement community or wish to have more socialization on a daily basis.¹⁷

“It’s a co-living experience for older adults, regardless of their level of income,” says Steve Lindsey, CEO of Garden Spot Communities. “They pay a month-to-month, sliding scale rent. They get to have an incredible life together, and an opportunity to avoid the isolation that oftentimes comes with aging and with aging and poverty.

“We have people who have lived long lives, who have gained life experience and, hopefully, some wisdom. Now, there’s that opportunity not just to sit on the front porch in a rocking chair, but to become engaged with the world around you and to share that wisdom, to share that life experience out into the world, and to make a difference.

“So, I think that as senior living organizations, that’s our calling. Not just to provide trendy housing, not just to provide great dining. Those things are all important. But we need to actually create an organization that helps people to live their best selves. Frankly, I think if we do that, the future is extremely bright for life plan communities.”

As boomers age and millennials’ lifelong values take shape, people are experimenting with new ways of living together, including multigenerational settings that allow natural neighboring and mentoring to take place, and having roommates to assist with costs.  

“I think the intergenerational approach is on target,” says Jane Rohde, a senior care, healthcare and sustainability expert. “Looking at opportunities, people don’t want to be isolated anymore. So the question is, ‘How do we bring that about, so people can actually live in communities, and create smart-growth cities, towns and villages that support amenities that are needed?’

“If you’re going to locate a housing development where it’s isolated from amenities like transportation or grocery stores, or lacks the physical access to get to various care services like home healthcare or physical therapy, then you’re missing the point. It’s time to evaluate senior living and healthcare in a different way. And I think the generational elements will play a large role in creating all-inclusive communities.”

Universal Design + Services = All-Inclusive Community

Universal design, by definition, is design that's usable by all people, to the greatest extent possible, without the need for adaptation or specialized design.

Think of it as creating accessible design that’s not stigmatizing. Dr. Jordana Maisel and Dr. Edward Steinfeld from the University of Buffalo’s IDeA propose a new definition:

“Universal Design is a process that enables and empowers a diverse population by improving human performance, health and wellness, and social participation.”

This interpretation includes the physical environment, as well as improving human performance, health, wellness and social participation, which depend on access to services and amenities.

“When we talk about senior living we don’t talk about ‘designing senior living’ anymore, it’s ‘living,’ and it’s ‘community,’” says Rohde. “That’s what we mean by an inclusive approach, taking into consideration culture and human interaction, as well as access to services and amenities in the physical environment. It’s a more comprehensive, inclusive view than we’ve ever seen in the past, toward truly living life as fully as possible for all ages.”

Based upon the research of Drs. Maisel and Steinfeld, the following are elements for consideration during the programming and design of a healthcare environment: 

1. Social Integration – all abilities coming together versus isolating by ability
2. Social Identity – no labeling or stigmatizing design
3. Design for Social Participation – providing opportunities to socialize
   • Interacting with neighbors naturally
4. Health and Wellness – design and operations working together for positive outcomes
   • Consideration of tools such as the WELL Building Standard and Fitwel for guidance
   • Design promotes exercise, healthy food options
5. Response to Context – understand surroundings and not designing in a vacuum
   • Looking at the community at-large
   • Includes places to be outside, playgrounds, connecting to existing walking trails and pathways
   • Understanding services and amenities that are available and those that are needed near a new building or space
6. Service Design – anticipate community and personal needs in the built environment
   • Appropriate coverings at a bus or train stop to protect people from inclement weather
   • Supporting everyday tasks in the community by understanding the project’s place within the community and the needs that are unmet

Wisdom + Youth = Collaboration

How does design benefit from generational collaboration?

“Bringing together the experience of older adults and the understanding of technology and generational design of emerging professionals creates successful solutions,” says Rohde. “We know that, we’ve seen the results. We also see it with the integrated design process, with sustainable design and green building initiatives. We know that the building comes out better and the building users have improved outcomes when there’s an integrated process.”

“The process can sometimes begin to ‘silo’ in the design development phase, or there’s a disconnect between people doing the programming versus people who are actually completing the design. We think it’s important to integrate those up front. When we look at generational collaboration, we’re really looking at that emerging professional, and we’re taking them very seriously in terms of not just design input, but also in developing ideas to support the care process. Collaboration breaks down silos within healthcare systems as well as within design practices.”

“Successful design thrives on diversity,” says Rohde. “Beyond different generations, bringing together people of different ethnicities, backgrounds, cultural differences and experiences into a collaborative community, creates better projects.”

It’s important that designers don’t feel they are just there to be a draftsperson. Integrating team processes and not letting them go vertical during the construction document process, or worse, in the value engineering process, helps create a framework for decision making that doesn’t lose sight of the goals set out in the upfront programming. Without this the thread is lost and the process breaks down.

“In our project work what we have found is it’s really a three-legged stool,” says Rohde. “You really need three people, both from the owner’s side and the design team, coming together to make a three-legged support to the project framework. It provides an opportunity to build buy-in from both the design side and the care side. Decisions are made by consensus by people who are all on the same page, versus making decisions that aren’t necessarily in context, which we find happens all too often contributing to poor outcomes.”

There are many questions that must be asked in creating successful healthcare design solutions. Like any theorem, one equation is simply never enough to solve the problem. Involving the community at-large during the design process, designing for human interaction, identifying  the care population and their needs, identifying staff and  their needs, and getting everyone’s input consistently is a process that can deliver results.

Only with input from everyone who will be utilizing spaces will a design be successful. That alone does volumes for strengthening the design process and strengthening the outcomes. Don’t forget the human aspect, the human use, the human interactions that take place in the spaces. Designers must take the lead in this, asking the right questions, doing the evaluations and keeping the original framework intact.

Final Thoughts

Healthcare environments are an extension of the care provided. How do we create a space that’s nurturing and supportive of all human conditions and interactions?

By looking at it through the lens of all the users we can provide spaces that support human interaction including the provision of varying levels of privacy, dignity and amenities.

“Every time you are stuck in the design process,” says Rohde, “take that moment, take that breather, take that thought and evaluate the human interaction.”

CASE STUDIES

The following case studies illustrate elements of inclusive and integrated design. This is a different way of looking at design and the built environment related to outcomes.

The Shirley Ryan AbilityLab, Chicago

The Shirley Ryan AbilityLab has redefined the ways in which science and care coexist. It looks like transitional care, but you have science and care concurrently happening in real time, and that’s shared with the care provider as well as the patient. It’s a top destination for adults and children living with the most severe conditions.

This 1.2-million-square-foot facility reshapes the future of rehabilitation in its role as a translational research hospital, clinicians, scientists and technologists work together in shared spaces to discover and apply new approaches to care in real time.

Integral concepts in the field of translational care drove every facet of the planning and design process. Within the facility, research does not merely intermingle with patient care; it is fully integrated into the clinical environment and engages patients in the process. It supports social integration, social identity, health and wellness, response to context and service design – all elements of universal design as a process.

All five of the facility’s ability labs, as well as its applied research and therapeutic spaces, include highly visible areas for working with patients and private space for analysis and planning. The client’s vision was to reshape the future of rehabilitation and transform how discoveries are applied to advance human ability, and the design reflects that vision inside and out.

Motivational environmental graphics and wayfinding support the patient experience. The wayfinding in the project uses color and different aspects of ceiling design and other elements, to help people identify where they are within various spaces. The east and west corridors are punctuated by views to give patients and visitors a break from the rigorous therapy, providing a respite opportunity to take advantage of the extraordinary views of Chicago and Lake Michigan.

The floors are free of glare and shiny surfaces, which are disorienting for people with vision issues or impairment. Environmental services of all types of healthcare settings, often associate shiny with clean, therefore it’s an educational opportunity and significant adjustment for them as well. The contrast of the gray floor and orange furniture makes boundaries very easy to see for those with low vision. The entire space is visually supportive to users.  

The spaces are integrated for patients to work with clinicians and researchers. Five of the ability labs represented within the space are:

• Think + Speak
• Legs + Walking
• Arms + Hands
• Strength + Endurance
• Pediatric

Technology is embedded throughout each lab to support analysis and planning behind the scenes. Clinicians and researchers measure every aspect of patients’ activities to mine data that improves outcomes and enables researchers to learn and share new insights in real-time.

Small alcoves provide the opportunity to meet and reflect. City views provide the respite, and private spaces allow staff and patients and families to have conversations. This experience is manifested through the design in many ways, from the extra wide corridors, which are curved at every corner for better sight lines and mobility, to optimized spaces that communicate wellness. The opportunity to choose and have choice and dignity is very important.

Every inch of the building is designed for care; every inch is designed for research. The patient experience has multiple touch points and extends along the entire journey, from the entrance to the care areas and in between.  

Turntable Health, Las Vegas

This design provides an outpatient care model that changes from patients attending nonrelated appointments to a wrap-around model that evaluates each person as a whole, instead of treating each component separately and out of context.

This wrap-around care model is person-centered; there’s no glass window that you approach upon entering, with someone loudly asking what your name is, your date of birth, and have you eaten or drank anything today. Instead, a health coach comes out and greets you upon arrival.

This example supports social integration, social identity, health and wellness, and service design – all elements of universal design as a process.

When you enter you either go to your examination/consult room or relax in the waiting room where:

• Various seating configurations are offered
• There’s a stocked kitchen with nutritious options available
• Health and wellness options, including classes, are posted

The exam/consultation room is designed to support the patient and a family member or friend with a small curved table intentionally designed to address this opportunity for collaboration. A mounted screen allows everyone to share information and see X-rays, notes, prescription information or other unique requirements of the patient. Daylight filters through the transom window, and vibrant colors provide appropriate contrast for older adults to clearly see the edges of the room, the floor-to-seat boundaries of the furnishings and the examination table constraints.

Easter Seals Adult Day Care, Windsor Mill, MD

This care model takes the institutional aspects out of daily care and access to service, and is supportive of all ages of adults needing some supervision, socialization and activities during the day.

An adult daycare model takes cues from a “household” care model used in innovative nursing homes and assisted living communities, making “home” the basis of care, with the kitchen and living room provide the “hearth” or center of the home. The design isn’t stigmatizing but rather welcoming as residents arrive in the morning to have a cup of coffee and assemble for the days’ activities.

This example supports social integration, social identity, design for social participation, health and wellness, response to context and service design – all elements of universal design as a process.

Community spaces are conducive to staff needs and provide oversight from the core of the building. Warm, well-lit spaces encourage participants to engage in multiple types of activities throughout the day. Details like tonal carpet and zero thresholds between flooring materials supports independence versus reliance or dependence.

Providing even lighting that has various adjustments and acoustical layering treatments supports reduction of noise within the space. Exterior spaces that are adjacent to the community and activity spaces maximize the limited area to provide access to a garden. A quiet room or “Snoezelen” (pronounced Snooze – lan) includes views of the garden as part of the therapeutic attributes designed into the space.

A quiet room is used to reduce agitation and includes various types of positive distractions for the participant; quiet rooms are also helpful for care staff to take a moment of respite from their day

Choctaw Nation Regional Health Clinic Durant, OK

The Choctaw Nation Regional Health Clinic embraces heritage by creating a cultural awakening in a place of health, or Ahlakofi, for the Choctaw Nation and its employees, represented in the entry by the 12-foot wide mosaic made by a Choctaw artist.

The building was designed to be LEED certified, supporting its sustainability aspects. This special state-of-the-art project was completed through a joint venture agreement between the Indian Health Service and the Choctaw Nation.

The outpatient clinic is equipped to care for 7,000 outpatients per year, and the inclusion of an MRI machine will allow patients from far southeastern Oklahoma to be tested in Durant instead of driving to other locations outside the tribal health system.

This example supports social integration, social identity, design for social participation, health and wellness, response to context, and service design – all elements of universal design as a process.

Outside the building are life-sized bronze sculpture by artist Mathew Placzek that are representative of the Choctaw heritage and respectful recognition of the culture of the patients being served. Overall the integration of the Choctaw tribal culture is fulfilled by incorporating artwork completed by many Choctaw artists, while providing a wide range of services that contribute to positive patient outcomes, and providing access to amenities and services within a geographic area that was lacking access within a sustainable and accessible building.

References

SHIRLEY RYAN ABILITYLAB 
HDR / Gensler / Collaboration with Clive Wilkinson Architects and Egg Office
Photos: Dan Schwalm / Translational Care

IORA TURN TABLE HEALTH 
LGA Inc. 
Community-based health care

EASTER SEALS ADULT DAY HEALTH CARE 
JSR Associates Inc. 
Person-centered care

CHOCTAW NATION REGIONAL HEALTH CLINIC
Childers Architects / Skyline Art
Community-based Supportive Care

Take the Test