This year’s Design Connections conference was full of dialogue around the continuum of care. It addressed care population needs and extended into the material selections required for successful healthcare settings for all ages. I encourage design professionals and manufacturers to include this venue on their 2016 calendar. The sessions, relationships, and overall knowledge shared is guaranteed to be worth your time!
As part of the three-day programming, Teri Bennett, RN, CHID, IIDA and Andrea Hyde, CHID, MDCID of Johns Hopkins in Baltimore and I were tasked with leading two breakout sessions exploring the continuum of care. Teri and Andrea took half of the attendees for a discussion focused on hospital and outpatient care, and I led the other half through a discussion of long-term care. Later in the day we presented our findings across the board, to highlight commonalities between different sectors and identify opportunities for improvement.
surveys set the stage
Prior to the event, we sent a survey to attendees, and the results provided some interesting points about the evolution of healthcare environments. Approximately 10 years ago, the most important measure to designers was aesthetics, according to a survey sent to the Healthcare Forum Membership. Now the top two criteria have become durability and cleanability, according to the Design Connections results. Both findings indicate an increased focus on adverse events—such as healthcare-acquired infections (HAIs), higher acuity of patients and residents in healthcare settings, longer time periods between cycle renovations, and higher traffic from mobility devices, carts, and equipment.
Unsurprisingly, surface materials were of the most interest to designers surveyed. They seek options that better support the many demands of healthcare settings. One survey question about acoustics revealed that wall treatment and flooring are the biggest concerns in this area, while a question about which product categories required more innovation shows a virtually equal balance among upholstery, furniture, surface materials, and modular casework.
Survey responses from the acute/outpatient care designers also indicated that there has been an uptick in design work in outpatient care, which was anticipated with the ACA and Accountable Care Organizations. As a true complement to the care continuum, the designers working predominantly in the long-term care area are seeing a strong repositioning with independent living settings and community-based services.
side sessions probe problems
Once everyone was gathered into the two breakout groups at the event, we facilitated discussion around the following scenario:
You have a care setting built in the 1980s or 1990s. What challenges do you have with older infrastructure? What are current best practices and how can they accommodate these older settings? What changes have occurred that have significantly impacted design solutions supporting person-centered environments?
That seemingly simple prompt unleashed a whirlwind of ideas and sparked far more conversations than we had time to complete or even fully digest. But it was thrilling to see so many eager participants, and a clear sign that we should find more opportunities to keep the dialogue open in the future. For now, we can recap a few of the main takeaways.
Renovating concrete block walls—bearing as well as non-bearing—presents infinite obstacles, specifically with utilization of advanced technologies. Even with wireless technology, signals are blocked by the thickness of walls combined with rebar configurations. Therefore, design professionals are looking for products that work better in older infrastructure. Discussions included abatement versus replacement or encapsulation—as asbestos in flooring, ceilings, and insulation still exists and causes cost concerns in complete renovations.
PageBreakAnother challenge is completing renovations in occupied buildings, particularly settings where residents or patients have cognitive issues. The lack of compliance with ADA and building codes was an important point in the discussion. Furthermore, minor improvements for accessibility are often not completed because bathrooms and other key areas are not completely compliant with requirements. Unfortunately, most jurisdictions treat this as an all-or-nothing scenario, so incremental updates are not allowed. This may be a good topic for the Facility Guidelines Institute and ICC to consider, working closer with the Federal Access Board to create mutually acceptable resolutions.
There was a good amount of discussion regarding not only the need for better storage, but also its location at the point of service for equipment and supplies. Creating a separation between public or community circulation and service circulation can better accommodate materials management. Plus, keeping resident, patient, and family spaces separate from the service component encourages person-centered solutions.
We also discussed care populations being served—including the need for a shift in culture and mindset to accommodate change not only in the physical environment, but also from a systematic perspective, starting with operational culture change and a focus on desired outcomes. Another concern is identifying
bariatric population needs as part of the renovation process: How does a provider design areas with increased size accommodations that include doorways, circulation paths, and FF&E?
As a commonality, all healthcare environments are being used predominantly by people aged 65 or older. The number of older adults utilizing long-term care or alternative residential care settings is projected to increase from 15 million in 2000 to 27 million in 2015, based simply on the aging population. These numbers not only represent a larger need for management of chronic diseases, but also provision of acute care services and outpatient clinics that provide wrap-around services. Unfortunately, few facilities are designed through “aging lenses,” and the lack of universal design solutions creates a stigma by not addressing the needs of older adults. But further, universal design addresses the needs of people of all ages, like an active teenager using an assistive device to walk, a young mother with a stroller, or a veteran with TBI.
Across the healthcare spectrum, too, there is often the false economy of value engineering—the infamous bean counter—focusing on the initial cost versus the lifecycle cost evaluation to demonstrate long-term value, cost savings, and improved outcomes that support increased revenue. The working groups at Design Connections felt this was a potential barrier in the development of quality healthcare design.
solutions for the future
Looking forward, our discussion centered on opportunities to connect millennials with the elderly population. Not only should we engage younger designers in the healthcare marketplace, we also want to foster relationships between the two generations. They have a lot in common. These two groups seek a balanced lifestyle, connection to nature, and meaningful activities. Both support each other through technology. No longer can we design in a vacuum without including multiple generations. Community design needs to foster the inclusion of multiple generations as we focus care services on a community-based level.
We also asked ourselves: If the future of the continuum of care is focusing on the home, what does this mean to older adults? Could a typology ever truly emulate common aspects of home? Truthfully, the one consistency is that it has to be based in regionalism and culture. Part of the solution is in the focus group process during the initial planning and programming of a healthcare setting. Two great resources are the Facility Guidelines Institute and the Senior Living Sustainability Guide.
And finally, evidence-based design for the use of surface materials and other components is reinforced through mock-ups and collaboration between designers and the maintenance and environmental services departments. For the “bean counters,” utilize research to establish the return on investment—and make decisions based on cost-benefit analysis. (This was the goal of the “Fable Hospital” developed through the Center for Health Design.)
Jane Rohde, AIA, FIIDA, ASID, ACHA, AAHID, LEED AP, is the founding principal of JSR Associates, Inc., located in Ellicott City, Md. She champions a global cultural shift toward de-institutionalizing senior living and healthcare facilities through person-centered principles, research and advocacy, and design of the built environment. Clientele includes non-profit and for-profit developers, government agencies, senior living and health care providers, and design firms. Rohde speaks internationally on senior living, aging, healthcare, evidence-based design, and sustainability. For more information or comments, please contact her at [email protected].
