New Model Of Care: Designing For Medical Homes
A century ago, a doctor’s visit meant the doctor came to you and managed everything from lumps and bumps to minimal surgical procedures. Going to the hospital happened only when all other options were exhausted.
In today’s healthcare environment, with its spiraling costs and downward pressures from the Affordable Care Act, it’s no wonder the question’s been raised whether that old-fashioned approach might be updated for today’s needs. Some industry leaders are saying yes—and they point to the medical home delivery model as a possible solution.
A medical home is any place where an integrated team of providers can meet the gamut of a patient’s primary healthcare needs without sending the patient to a more expensive, specialty hospital. Taking a leaf from the pediatric world where parents must often coordinate immediate, ongoing, and follow-up visits for young children, the medical home setting offers both the staff and the patient a variety of healthcare and social services, either on-site or in another immediately accessible department. “It’s coordinated care for a patient within that 60- to 90-minute visit,” says Brenda Bush-Moline, associate principal at VOA Associates Inc. (Chicago).
This means medical homes can be located wherever there’s an urgent need for primary care, says Suzy Cobin, senior vice president of HSA Primecare (Chicago). She sees medical homes in rural areas ranging from Alaska, North Dakota, or the Adirondacks in upstate New York to regional health systems in Chicago and California, where hospital officials are thinking through outpatient centers in retail strips, standalone buildings, or in conjunction with an existing specialty practice.
Such facilities are also a creative boon to architects, presenting them with a golden opportunity to radically rethink healthcare delivery through sites capable of both general wellness maintenance and specific illness treatment. “The doctors are the ones who say, ‘Here is our concept, design something around it,’” says Martin Valins, principal at Stantec (Philadelphia). “It’s a blank design slate influenced primarily by the operational policies of the healthcare practitioners.”
A closer look
Chase-Brexton Health Services in Baltimore is one example of a patient-centered medical home design. Offering services for HIV-positive patients and the local lesbian, gay, bisexual, and transgender population, the facility was designed by NBBJ (New York) to re-interpret how care is brought to the patient, not vice versa. As a result, a care suite approach, where everyone works in one location—the doctor, case manager, behavioral health expert, nutritionist, nurse, and financial adviser—was created.
“All care providers work in what we call teaming spaces,” says Kris Krail, senior associate/healthcare planner at NBBJ. Medical staff examines patients in the bays surrounding the teaming space. If a private discussion is needed, connected rooms are available, but otherwise there’s no need for the patient to leave the suite.
The medical home concept is also scalable for entire communities. “It’s a holistic approach to healthcare,” says Sarah Bader, principal at Gensler (Chicago). “Instead of focusing on one disease, medical homes focus on the whole body—live healthy, eat healthy, educate healthy—for communities that suffer from health problems but can’t always access help.”
She points to the Martin Luther King Jr. Medical Center Campus in Los Angeles, which is incorporating walking and biking paths within its healthcare campus in addition to providing community parks and local school-based health clinics. “Small changes like accessible bike lanes, providing public transportation, or community gardens—you have to look at a hospital not as an island in the city but how it touches the entire space around it,” says Bader.
But it’s not just the patients who can benefit from a medical home. Providing an attractive, complementary space that responds to both patient needs and medical diagnostic requirements is another way to create the all-in-one facility. A recent project with the Rehabilitation Institute of Chicago, which treats complex traumas such as amputation rehabilitation via thought-controlled bionic limbs, challenged Bader to create the next generation of medical homes that meshed high-tech research laboratories, clinicians’ offices, and patient rehabilitation equipment into one location. The result is a site where feedback from a patient’s rehabilitation session is immediately transmitted to the research laboratory for review. If treatment requires adjusting, the changes can be made and quickly transmitted back to the doctor for immediate application within that therapy session.
While such cutting-edge technological incorporation isn’t typical of every all-in-one facility, thorough patient information and technology integration is and remains the key to an effective primary care medical home facility. Ranging from simple analysis of the smoking or diabetic problems of the local patient pool via electronic medical records to allowing nurses to diagnose and treat pinkeye via Skype (while doctors are freed for the more complex cases), this kind of fingertip-available, integrated access means patients are more likely to receive the necessary general or chronic healthcare treatment in-house and less likely to be sent to a specialty hospital.
Secrets to design success
With technology getting smaller, cheaper, and more transferable, how does the architect design a medical home space that successfully manages today’s needs and maintains enough flexibility for tomorrow? “We want it to be high-tech but also high-touch,” Bader says. “Make it all accessible, don’t make anything built-in.”
VOA Associates’ Bush-Moline is seeing more work surfaces and counters designed at standing height to better accommodate use of mobile devices. “We’re doing much less built-in and depending more on wireless connections,” she says. Another innovation she sees is the mini alcove, where staff can step aside to receive and answer texts. “People can get out of the way and text instead of stopping abruptly in the hall and causing someone else to run into them,” she says.
Radical all-in-one design around the demands of an operational practice also means engaging the users from the very beginning. In order to do this successfully, Bader recommends having multiple conversations to ensure the architect has heard the staff correctly and can help them understand the where and why of the design. After all, an architect can provide the most efficient, practice-oriented building out there, but if the staff doesn&rsqu
o;t want to adapt, then it’s just a very well-integrated building.
“Everybody always likes the design on paper,” Krail says. “But then it becomes apparent that they’ll have to deliver care in a different way.” For Krail, staff engagement with the design team from day one is integral, not only for ensuring that the ongoing process matches the initial plans but also for smoothing any post-implementation cultural change adjustments. She recalls one medical home design that had a functional teaming space in the core of an exam pod. Once the changes became real, the staff realized individual offices were no longer available for them to have lunch or to make private calls.
Krail eliminated this transition bump by highlighting the design efficiency of the teaming space along with the positives of not having an office, such as being able to take breaks in a brightly lit, community lunch room or using touchdown spaces for private phone calls. She compared that to previous negatives of the space, like bumping into patients or feeling left out behind closed doors.
The potential market for these all-in-one, integrated design facilities is impressive. Cobin estimates the market for 10,000- and 20,000-square-foot functionally integrated offices will increase over the next several years. However, she tempers this assessment by noting many facility executives are waiting to see what colleagues are doing first before dipping their own toes into the medical home pool.
One reason for doing so is simple: capital. Over the past few years, the push to invest in technology upgrades along with the costs associated with buying and integrating primary care doctor practices have left many facilities short on cash. As a result, “A lot of organizations are waiting to feel the effects and the surge in patients before making these changes,” Cobin says.
A lack of clear profit benchmark measurements is another reason many hospitals hesitate to implement this delivery method. “Doctors get paid now on every click [and test ordered], but with medical homes, they will have to move from this individual approach to a long-term, preventive maintenance panel approach. How do you bill on this?” asks James Fox, director and senior CFO consultant, Warbird Consulting Partners LLC (St. Paul, Minn.).
While a shortage of capital and the hesitancy to depart from easily measured, definable short-term profitability goals may keep the medical home delivery concept on the back burner for a few more years, the current emphasis on increased primary care dictates an eventual change. “It’s where the future of health and wellness is going. It’s uniquely designed to support people and their quest to stay healthy,” Bader says.
Gwynneth Anderson is a freelance business writer. She can be reached at firstname.lastname@example.org.