Large segments of the population throughout the Great Plains and agricultural Midwest are facing a crisis in maintaining, upgrading, and replacing aging healthcare facilities. Most rural hospitals, which were built during the post-World War II period under the Hill-Burton Act, have reached the end of their useful lives. Meanwhile, the increasing elderly population keeps adding pressure to the existing healthcare system. Rural healthcare facilities also face challenges in relation to energy access and efficiency, especially because buildings in this sector are the second most energy-intensive building type. More importantly, rural hospitals play a major role in the economic vitality of small cities and towns, serving as critical sources of employment and acting as economic engines within their communities. In addition to its regional and national impact, research on rural healthcare design has strong global relevance. Many developing countries such as China, India, Southeast Asia, and Latin America share similar challenges in their rural healthcare systems and facilities.

This is the context that formed the central focus of a one-day think tank titled “Innovations in Rural Healthcare Environments” at the University of Kansas in Lawrence this past March. The symposium brought together more than 100 healthcare providers, policy makers, and designers to outline specific research issues about how innovative design solutions can improve the efficiency and effectiveness of rural healthcare systems. The organizers will use the information collected during the day to form research collaborations and funding partnerships over the next two years to study the issues in detail and provide information to the design, healthcare, and policy communities.

The panel discussions during the day were focused on three topic areas: healthcare system challenges and opportunities; policy implications for rural healthcare; and the role of innovation and technology in rural healthcare. The first panel session discussed the ways that healthcare providers will need to adapt to changing practice models and constricted economic conditions in rural settings in the future. Decreases in service lines of care and in the number of solo practices will continue to put pressure on rural providers in isolated and remote healthcare environments. The concept of “stealth-health facilities” was presented by Michael Pulido, chief administrative officer of Mosaic Life Care, as a possible way to blend traditional medical environments into the fabric of the surrounding communities they serve.  In this model, the local gas station--not the critical access hospital--may be the appropriate rural setting to initiate primary care healthcare discussions.

A major theme that emerged from the second panel on policy was the likelihood that the traditional critical-access hospital model would be replaced in the near future by a facility type that concentrated on primary and outpatient services, community-based health maintenance programs, and information technology rather than bricks and mortar.  This new rural healthcare environment has been variously called the “community outpatient hospital,” “primary health center,” and “integrated rural clinic.”  Rural healthcare environments will likely be viewed as “community organizers” rather than freestanding and independent institutions in this new model, and medical services will be delivered outside the confines of traditional settings. Brock Slabach, senior vice president for member services at the National Rural Healthcare Association, reminded designers to be much more attuned to the realities of “form follows finance” in an era that includes Medicaid expansion, results-based reimbursements, and financial rewards for improving population health.

The final panel discussed the roles of technology and design innovation in rural healthcare environments. Building on the previous panels, the narrative of this session focused on finding ways to use environmental quality to improve the rural community’s well-being.  A common theme shared by the panel was the concept of the healthy village, where the hospital was only part of the equation for community health. “Eat well, stay well, get well” was proposed as an approach for the continuum of healthy living. The panelists also highlighted the importance of population health and partnerships with the local community. Future rural healthcare designs should recognize the root causes of community health issues and also address individual uniqueness. Big data could support the understanding of the holistic patient profile, but Erik Gallimore, director of rural health at Cerner Corp., also stressed the importance of designers listening to the individual stories within rural communities.

The keynote address was delivered by Marci Nielsen, chief executive officer of the Patient-Centered Primary Care Collaborative. She focused on the shifting emphases in American medicine from illness to health, from the provider to the patient and family, and from inpatient to outpatient services.  She challenged the audience to conceive of a rural healthcare system that sustains itself through local community values and strength, and to recognize that there was not a uniform definition of “rural healthcare,” but rather a continuum of healthcare needs in rural settings.  

Many of the issues that were discussed throughout the day were illustrated by design proposals presented by students in Professor Hui Cai’s Health & Wellness graduate studio. Prototypes of healthcare facilities for Phillips and Harper counties in Kansas were reviewed by the audience and provided a range of design options that addressed the ways that traditional inpatient hospitals could be repurposed and refocused. For instance, Erin Hoffman, Erica Hernly, and Connor Crist’s design explored an alternative model of “community outpatient hospital” (COH) that eliminated the inpatient unit of a critical-access hospital. The COH focuses on the role of rural hospital as community hub and education center for healthy living and preventive care.  

In another project, Rachael Wotawa and Briana Sorensen’s group developed a master plan for Cerner Harper County Healthy Village with a full range of health and wellness services, including hospital, nursing home, assisted living, independent living, retail, apartments, educational building, intergenerational activity space, and community center. They also proposed a universal care room to replace the traditional med/surg inpatient room, which could serve as an observation bed for the emergency department and a transitional care bed. Their design considered the implementation of health IT and telehealth throughout the health village, which would support holistic care and the family involvement and bring state-of-the-art care close to home.

“Innovations in Rural Healthcare Environments” was organized by Professors Hui Cai, Kent Spreckelmeyer, and Frank Zilm from the School of Architecture, Design and Planning’s Health & Wellness Graduate Program and Professor Mario Medina from the School of Engineering. It was supported by the University of Kansas, Office of the Provost, Level II Strategic Initiative Grant. The organizers would like to thank David Engle from Philips County Hospital; Jessica Hunter and Jim Chromik from Cerner Work Group; and Jody Gragg from Via Christi Health for their support to student projects. A podcast and more information are available for download at https://ruralhealthenv.wordpress.com/photo-galley/.