OSH's evolution

The Salem campus's first hospital building opened in 1883 and was designed in accordance with Dr. Thomas Kirkbride's writings, the era's widely accepted standards on the planning of mental health facilities. The “Kirkbride Plan,” described in Dr. Kirkbride's On the Construction, Organization and General Arrangements of Hospitals for the Insane, envisioned a central administration building with symmetrical wings consisting of staggered wards on either side. Male patients were housed in one wing and females in the other. A hierarchy was established within each wing by grouping patients according to their illness' severity: The most ill patients were placed in wards on the lower floors and farthest from the central administrative wing, while those with better behavior and more rational thought were placed on higher floors and closer to the center.

Dr. Kirkbride's recommendations are reflected not only in the 1883 hospital building, but also in the related support facilities, farm, and landscaped park. Dr. Kirkbride believed that the natural environment was crucial to patients' recovery. He advocated removing them from the ills associated with typical urban environments and exposing them to the natural beauty of landscaped parks to stimulate and calm the patients. Participating in grounds maintenance provided a sense of purpose while work on the farm made the institution more self-sufficient.

Over the years, several other building and site improvements were constructed to support the increasing demand for mental healthcare. The hospital experienced a great deal of growth until the late 1950s, when admission requirements changed to admit only those patients deemed to be a danger to themselves or others.

OSH's current care model is unit based: Patients live and receive care in the same location. While this care model may provide for easier logistics and a feeling of enhanced security, it has numerous challenges. In the unit-based care model, expanding treatment modalities and tailoring treatment to the individual are difficult because of the restricted space and available staffing. The boredom, dreariness, and lack of expectations characteristic of “ward life” destroy hope, which is indispensable in patients' recovery. Furthermore, a patient's isolation from society is worsened by the ward's isolation from the rest of the hospital community.

“The current Salem campus facilities are not appropriate for long-term continued use for the care and treatment of those with mental illness.

• Patient rooms are overcrowded and undersized relative to Oregon Administrative Rules (OAR).
• Patient and staff spaces are not well designed for treatment, safety, or security.
• Patient wards are overcrowded.
• Structural conditions of many buildings housing patients do not comply with current seismic requirements.
• Buildings do not comply with current building or energy codes for secure psychiatric facilities.”

The new campus will include ample windows to let in natural light as well as have secure outdoor courtyards.

The report also found that environmental hazards are present in a large number of the buildings.

Creating a treatment mall

The state is responding to these issues by pursuing the treatment mall recovery care model, which embraces the values of increasing self-determination, empowering relationships, developing meaningful roles, and eliminating stigma and discrimination. Although these values primarily drive organizational concepts and services, they also affect the built environment.

In the treatment mall care model, the primary elements are the “house,” “neighborhood,” and “downtown,” combined with centralized medical services. Immediately adjacent to the residential areas are treatment areas, where patients will receive a minimum of 20 hours of active treatment per week. Studies indicate that more patients are motivated to participate in treatment when it takes place apart from the living units.

The “house” is where the patient lives. It includes his/her sleeping unit along with a multipurpose area (essentially the living room), a kitchenette, a laundry room, and clinical support spaces. The “neighborhood” is the area immediately adjacent to the “house,” where patients from several living units receive treatment and meals and participate in recreational activities. Finally, the “downtown” is comprised of unique treatment spaces such as the gymnasium, hair salon, and art therapy room. Access to the downtown is a privilege and provides patients with a goal as part of their treatment plan.

In the treatment mall care model, staff and patients leave the house at the same time each day and proceed to the neighborhood. Because patients are separated from their house and all of the inherent distractions (such as TV) that it brings during the daytime hours, they are motivated to engage in treatment. This “patient as mall participant” approach increases responsibility, provides choices, and promotes independence.

The treatment mall's centerpiece is a series of rehabilitative skill-building activities. Development of leisure and recreational skills also is part of the program. This care model's intent is to normalize patients' daily lives, with the hope of returning them to their community.

While this care model has many benefits, it is not without its challenges. The movement of large patient groups presents logistical problems that require scheduling software to manage. Electronic record documentation for communication and care continuity also is desirable. Finally, security becomes an issue because of the increased number of patients and staff in one area.


Steven V. Riley, AIA, LEED AP

The treatment areas are designed to give easy access to the residential component. A central corridor is provided for easy visualization of patients by the staff. The group activity rooms are centrally located, with administration spaces located at either end-enabling easy staff access. Patient dining facilities and visitor areas also are provided. Access to several outdoor spaces facilitates a variety of activities. A medical service component is centrally located for easy access by all patients. The vocational component is adjacent to the warehouse building for easy access of materials delivery.

The new buildings are being integrated with the Kirkbride building with an interior circulation spine connecting the downtown treatment areas (in the first floor of the Kirkbride building and adjacent new structure) with the new neighborhood malls. Architecturally, the new buildings are positioned as a backdrop to the Kirkbride building, leaving it as the “front door” to the new facility.

Conclusion

The treatment mall care model will enable OSH to meet patients' needs through the provision of individualized treatment plans, greatly improving the chances for successful long-term recovery. For example, the new treatment model will double the number of staff and provide a multitude of new treatment spaces, providing the ability to focus more on the individual than the group.