Normalizing the patient environment Current trends in facility design aim to make inpatient psychiatric care less institutional
by KENT MUIRHEAD, AIA and DAVID TREECE, AIA
As society's awareness and understanding of mental health have evolved, so too have behavioral health treatments and the inpatient environments in which they are delivered. The old model of inpatient behavioral management, in which patients often were viewed as incurable and thus often confined for life, has given way to a new model. Now, structured programs are designed to rehabilitate patients within a reasonable period and return them to productive lives in the community.
This evolution has been supported by state legislation mandating shorter patient stays and greater accountability from behavioral health professionals. In turn, today's inpatient facilities are designed to create a normalizing environment that supports the new behavioral healthcare model.
The normalizing environment is a concept parallel to the healing environment supporting physical healthcare delivery. The normalizing environment is created through a holistic planning and design approach that integrates private and public spaces to support a continuum of socialization within a safe, secure campus. Among the issues driving the planning and design of today's behavioral healthcare inpatient facilities are security, patient room type, dining and recreational facilities, flexibility, and financing.
Transparent Security
The safety and security of patients, staff, and the surrounding community remain critical to the facility's mission, yet today they must be accomplished in a way that is transparent to users. This means creating an environment that feels open and visually connected to its surrounding landscape by using alternatives to traditional fortresslike security walls and fences.
Figure 1. This psychiatric facility for the state of North Carolina is designed to have only a few entrances, increasing security. Image courtesy of Cannon Design.
Figure 2. Courtyards in a facility for the state of North Carolina allow for secure patient recreational activities and outdoor dining. Image courtesy of Cannon Design.
Security often is now achieved using limited, controlled access to a walled or fenced campus monitored with closed-circuit television (CCTV). There are generally just two or three entrances: one for staff and visitors, one for patient admissions, and perhaps a third for materials management. Similarly, individual buildings have limited, controlled access and CCTV monitoring. Inside, however, the environment is predominantly open, with a few high-security exceptions, such as areas serving forensics, pretrial patients, and adolescent patients.
Reflecting these concepts, three prototype campuses of various sizes were developed for the state of North Carolina (figure 1). The largest, a 432-bed facility under construction in Butner (scheduled to open in the summer of 2007), will have just two entrances to the campus, with three building access points: public/visitor, patient admissions, and materials management. In contrast, the former Raleigh campus was half the size and had 26 entrances.
Private Versus Semiprivate Bedrooms
The ongoing debate between experts favoring private patient bedrooms versus those favoring semiprivate rooms is based on differing philosophies of which facility model better supports rehabilitation—one that offers opportunities for solitude as well as interaction, or one that discourages isolation.
Each treatment philosophy can be supported effectively with sensitive facility design. For example, the North Carolina prototypes will have in each unit 22 private bedrooms of approximately 130 square feet, with private in-room full baths, and 2 semiprivate rooms of 220 square feet, also with in-room full baths. In contrast, a new 156-bed facility under construction for Essex County, New Jersey (in the Newark suburb of Cedar Grove), will have a mix of four 130-square-foot private rooms and ten 185-square-foot semiprivate rooms in a unit, each with an in-room full bath. All the facilities will have secure, fixed furniture and large, vented, yet secure windows.
The Dining Experience
Two major trends in patient dining facilities reflect treatment approaches, as well as facility size and staffing concerns. In the Essex County facility, a dining room will be included within each of the six patient living units to maintain the small community environment and associated relationships, as well as continuity of staff supervision. Patients will eat within their units, leaving after breakfast for their morning treatment and activity programs, returning for lunch, and so on until they return again for dinner. Meals will be prepared in the central kitchen, distributed to each unit via elevator, and served on trays. Patients will be engaged in setting tables and cleaning up.
The large North Carolina facility, however, will function more efficiently in providing all patient meals from three centralized dining facilities. Each is designed around a different theme and type of food service, including a small cafeteria with tray service and a grill/café that will offer meal choices at several serving stations. The dining experience will support individual treatment programs, as patients will be assigned to the dining facility deemed most appropriate to their capabilities at each phase of treatment.
Outdoor Recreation
Today's outdoor recreational spaces are designed to complement indoor recreational, physical, and occupational therapy programs by providing a continuum of individual and group activities. Activity spaces, such as walking and jogging paths, basketball courts, soccer fields, and outdoor teaching areas, are organized around a series of courtyards. Additional, smaller courtyards adjacent to dining facilities offer the option of outdoor dining in mild weather (figure 2). Some facilities provide separate recreational facilities for staff, such as an outdoor fitness path planned for the Essex County facility.
Recreational facilities can be designed as innovative responses to the unique needs of the patient population. For example, Arizona State Hospital's new 16-bed (expandable to 32 beds) inpatient facility for seriously mentally ill adolescents on its existing campus in Phoenix features an outdoor 4-foot-deep swimming pool to meet its young patients’ needs for active recreation and improved fitness.
Designing for Flexibility
Today's new behavioral health facilities also provide optimal flexibility to support changes in patient census and in therapeutic programs. For example, private bedrooms can be sized slightly larger to allow conversion to semiprivate bedrooms if census increases, or a certain number of private bedrooms located between units can be sized larger to act as swing rooms.
At the same time, the main activity and therapy rooms can be designed as column-free spaces to accommodate changes in treatment programs. The result is a hybrid structural system comprising traditional, low-cost, load-bearing masonry-block construction in patient units and cast-in-place concrete or steel in activity spaces. Building construction becomes more complicated, but in the end the facility provides tremendous operational flexibility. Moreover, money not spent on the traditional load-bearing construction allows the owner to allocate additional funds to the treatment spaces—where they really count. Both the Essex County facility and North Carolina prototypes are designed this way.
Figure 3. Arizona State Hospital features an exterior covered social rehabilitation “street” adjacent to courtyards. Photographer: Bill Timmerman.
Figure 4. The new Essex County campus will occupy only 20 acres; 280 acres of the original campus were sold. Image courtesy of Cannon Design.
Activity spaces can be designed for diversity as well as flexibility. For example, Arizona State Hospital's 200-bed facility for adults with behavioral health problems consists of patient living units lining an outdoor social rehabilitation treatment “street”—a series of courtyard spaces that includes dining areas, patient finance, library, training and education, rehabilitation activities, clothing store, on-site courtroom, barbershop, patient-run café, human-rights office, volunteer services, gardening areas, and a medical clinic (figure 3). A Teflon-coated fabric provides shade from the hot Arizona sun.
Leveraging Land Value
Planning and building a behavioral health treatment facility that meets today's needs, with flexibility for future changes, poses economic challenges. Nevertheless, at many older mental health facilities, operational costs have risen to the point that they have surpassed the buildings’ capital value: To state it simply, some decades-old buildings have become money pits. Yet these buildings often are sitting on large parcels of increasingly valuable land. Many owners have discovered that they can leverage their existing campus's land value to finance all or part of a new facility's costs.
For example, the original Essex County campus occupied approximately 300 acres. The owner retained 20 acres, sold the other 280 acres and original buildings to a developer, and used the proceeds to finance new construction (figure 4). The state of North Carolina sold its 300-acre Raleigh campus, which is adjacent to North Carolina State University's main campus, allocating the proceeds toward the purchase of three new parcels of land for its prototype facilities and the construction of the first and largest facility in Butner. The state will merge the populations of the existing campus in Raleigh and another facility in Butner into the new campus.
Similarly, several years ago the owner of a mental health facility on 350 prime waterfront acres on Chesapeake Bay in Cambridge, Maryland, sold the property to a resort developer. With the proceeds, the owner purchased a new parcel of land and constructed a new inpatient treatment facility. The campus also has been planned to accommodate a medical facility.
Conclusion
The new model of behavioral health treatment requires individualized, structured programs designed to rehabilitate patients in the shortest time and return them to productive lives in the community. The revenues associated with shorter patient stays and higher throughput, combined with the land value of existing campuses, are enabling owners to fulfill the mission of providing the optimal normalizing environment—often for the same amount of money, or less, than what was spent on operating and maintaining obsolete buildings. Created using a holistic planning and design approach, and evidence-based medical models, these new facilities integrate private and public spaces to support a continuum of socialization. They provide a safe, secure campus; are cost-effective to operate and maintain; and have the flexibility to respond as patient census fluctuates and behavioral health treatment programs evolve.
Kent Muirhead, AIA, is Associate Principal at Cannon Design. David Treece, AIA, is a Vice-President with the firm.
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