As the demand for behavioral healthcare services continues to increase and reimbursement models begin to favor integrated care, experts say that health systems of all types are turning toward comprehensive care settings. The goal is to safely assess and treat the whole patient with dignity, which speaks to the need for evolving facility designs in the future.
It’s not just the volume of care that’s delivered, but the physical location and the types of services that also must be considered.
Elisabeth Perreault, senior vice president, Cannon Design, says that along with the development of primary care clinics that incorporate behavioral healthcare models, there has also been a move toward establishing crisis stabilization units and psychiatric emergency departments in hospitals.
Some state facilities, however, have started reducing their number of beds, says Jeff Mural, AIA, EDAC, Healthcare Project Architect, LS3P Architects, and patients are starting to seek behavioral healthcare more in private hospitals.
“There are regions currently undergoing shortages that are causing back-ups in emergency departments that traditionally are not equipped to handle these types of patients,” Mural says. “Hospitals, therefore, are trying to accommodate.”
Comprehensive settings of care
Experts agree that the behavioral healthcare is increasingly being integrated into medically acute facilities and vice versa, creating more comprehensive settings of care.
“For a long time, behavioral healthcare has sort of lived in stand-alone, separate facilities, but most patients have co-occurring disorders. So the integration with medical and physical healthcare is helping staff be much more effective,” says Tim Rommel, AIA, MRAIC, principal, Cannon Design.
Comprehensiveness is also being considered in terms of care services provided. Perreault says organizations have also turned their focus to expanding behavioral healthcare programs and inpatient capacity for children and adolescents in response to growing needs within communities.
Health systems can benefit financially from payers willing to reward better care as a result of integrating and becoming more comprehensive, Rommel says. Also, from a social perspective, such integration will only continue to break down the stigma associated with behavioral health at it becomes woven into primary care.
Durability, flexibility and expandability
Another trend in the design space is the increase in projects to overhaul outdated, institutionalized facilities. In some cases, the existing structures are being remodeled or replaced over time, while in others, providers are buying up de novo properties and repurposing them for behavioral health services.
“We’re designing new buildings and facilities that are going to be around for 30 and 50 years, and in some cases longer,” Rommel says.
He says owners and operators want to create functional spaces for today without having to reinvest a lot of capital to incorporate changes in the future.
Jon Sell, principal and technical coordinator, Array Architects, says that a big driver in facility design has been creating spaces that can be multipurpose. Organizations need to be cognizant of functional flexibility. He points to the incorporation of behavioral healthcare consult spaces that have cropped up in outpatient primary care environments as well as the merger of outpatient services into inpatient settings. For example, he says, more providers are holding group sessions during non-patient hours and vice versa.
When it comes to designing acute care spaces, Rommel also emphasizes flexibility as well as expandability. He specifically advises dividing up floor plans into different zones or areas by purpose. For example, create a daytime zone dedicated to patient interaction areas such as a kitchen and lounge; a nighttime zone for residential spaces that might include shared and private bedrooms; and a separate clinical zone.
Rommel adds that by linking two different bedroom units together in one zone—as opposed to separating them throughout a facility—can increase the flexibility of the rooms themselves.
Open care stations
Another trend experts have identified is the continued shift away from old-school, glass-enclosed nurses’ stations. More interior designs include open stations or non-existent designs in light of growing evidence that the openness of such areas can reduce distress for patients and help instill trust in the patient-provider relationship.
Sell says this also provides a way for staff to be more engaged with patients, which can help eliminate outbursts and allow more efficient patient management. Perreault adds that with most healthcare systems fully transitioned to EHRs and paperless processes, the need for a nurses’ station for charting has been greatly diminished.
“Most healthcare providers are moving to mobile tablet charting and encouraging an environment that allows the care providers to be on the unit interacting with their patients rather than sitting behind a care desk monitoring their patients,” Perreault says. “Care desks and nurses stations do not need to be as large as they used to be and really only need to support one or possibly two staff members passively monitoring the unit in the evening while patients are sleeping.”
Mural says one of the ongoing considerations when it comes to facility design has always been safety: striking a balance between making settings safe without making them feel institutionalized or “prison-like.” Healthcare organizations run the risk of designing spaces that are too sterile-looking, so there has been a push to create therapeutic but also beautiful settings of care.
One behavioral healthcare challenge for residential facilities in particular, Mural adds, is that there is no industrywide standard for ligature-resistant products. While there are guidelines and catalogs of products that could easily be implemented, he says those involved in the decision-making process must understand the associated risks of the population that will use the facilities.
Ultimately it boils down to organizations evaluating whether risks would be addressed by design or clinical solutions, he says. For example, installing weight sensors at the top of every bedroom door can provide alerts but so can having staff manage patients that have been deemed potentially suicidal.
Working with different facilities and clinical teams across the country, another trend Perreault has observed is a move toward trauma-informed care and the reduction or elimination of seclusion and restraint practices. Experts believe trauma affects a significant number of people who seek care for behavioral health needs, and it’s becoming a business imperative to recognize it in patient populations.
“Most hospitals that we’re working with have their own initiatives to not re-traumatize patients,” Perreault says. “This relates directly back to the design environment with the introduction of spaces such as quiet and comfort rooms to allow patients to emotionally self-manage, de-escalate and to passively separate patients when needed.”
Mural adds that patient dignity has become a recognized driver in inpatient design, where more organizations are moving toward establishing private rooms for patients with the intent to reduce stress. Likewise, art therapy rooms might help to deescalate patients before they feel a need to lash out.
Acoustics, aesthetics, and natural light
Evidence-based design shows that certain material selections for acoustics, window views, outdoor access and natural daylight all help to reduce stress, anxiety and depression in treatment settings. In particular, the acoustics need to be carefully considered, Perreault says.
“While these environments need to be durable and safe, they also need to be calming,” she says. “Noise is a pervasive stressor in healthcare environments, and we are seeing new products coming on the market to address safety, durability and acoustics.”
Sell says there has definitely been a move toward natural lighting to allow facility space to appear more familiar and home-like, which is inviting yet safe for both patients and staff.
Facilities are asking for as much light as they possibly can get, he says. One solution might be floor-to-ceiling polycarbonate panel windows that can provide light but are also sturdy enough to withstand someone throwing their weight against them.
Sell adds that while security is paramount, treatment settings should be warm and have an open, residential feel. New interior finishes and products for lighting and furniture, for example, have continued to improve and are not nearly as institutional as they used to be.