Many remote and rural areas in the United States lack adequate access to basic healthcare services found in more urban locations, such as primary, urgent, and emergency care. In addition, many of these communities are composed of an increasing aging population, a growing number of residents with chronic illnesses, and, in some communities, tourists who may require urgent care. The need is apparent, but patient volumes overall remain low.

Evolving patterns of care delivery, advances in technology, and physician shortages are affecting how access to medical care can be delivered in geographically isolated locations. Additionally, critical access hospitals (CAHs), which have historically served as the facilities for primary healthcare needs of rural communities, are struggling with reimbursement challenges. Before 2015, CAHs received Medicare reimbursements for health services at

101 percent. New policy changes from the Affordable Care Act gradually decrease reimbursements to 100 percent by 2020.

As a result of all these pressures, an even greater need exists for rural healthcare providers to deliver care in an appropriately designed environment that supports effective—and cost-effective—care delivery.


Establishing design guidelines
Architects and designers working on rural projects must create spaces that support high-quality and sustainable care. Research digs deeper into what best practices can be used to create facilities that answer rural hospitals’ main objectives through a graduate thesis concluded in May 2015 at Clemson University as part of the AIA Arthur N. Tuttle Jr. Graduate Fellowship in Health Facility Planning and Design.

The effort studied the implications of rural healthcare delivery and the impact they have on best practices in the design of remote health facilities. Research included a literature review that focused on accessibility, high-quality care, sustainability, and cultural relevance. These objectives set the basis for facility observations and site visits to Ely Bloomenson Community Hospital in Ely, Minn., renovated by DSGW Architects in 2009; Cook Hospital in Cook, Minn., designed by DSGW Architects in 2012; Fort Providence Health Centre in Fort Providence in the Northwest Territories of Canada, completed by PSAV Architects in Spring 2015; PeaceHealth Peace Island Medical Center in Friday Harbor, Wash., designed by Mahlum Architects in 2012; and Cross Road Medical Center in Glenallen, Alaska, a demonstration site of a frontier extended-stay clinic from 2010-2013.

Here are a few examples of the major principles of rural healthcare design that emerged.


Optimize accessibility
Facilities should be highly accessible to all patients, which can be achieved by locating health centers centrally to dispersed populations and near other essential services in a community. Frontier areas typically have great distances between towns that are often only connected by a two-lane primary road. Clinic locations along these critical transportation arteries optimize navigation to the facilities for patients as well as providers and suppliers. Remote regions that attract high volumes of visitors should locate health centers on main axis roads.

For example, the frontier town of Glennallen, Alaska, was selected as a site for a clinic on local Highway 1, which is the only vital connection between the regional city of Palmer and the western Alaskan frontier. Palmer is home to the closest hospital, which is 136 miles away from Glennallen, making the Cross Road Medical Center location a convenient destination for those seeking care in the area who use Highway 1 for routine travel.


Operate self-sufficiently
Remote locations often come with unpredictable weather conditions and limited connections to the outside world, requiring buildings to be as self-sufficient as possible. This includes being conservative in energy usage and having reliable, independent back-up sources of energy.

For instance, Kiowa County Memorial Hospital in Greensburg, Kan., was the first CAH to receive LEED Platinum certification in 2010, serving as an example of how rural facilities can operate effectively while employing a variety of environmental features, such as a wind turbine, water conservation measures, and a heat recovery system.

New-build CAH Peace Island Medical Center also uses many sustainable features, including generating energy from a geothermal system and collecting water for designated rain gardens to minimize demands on the small available staff. The hospital’s use of a variety of environmentally sustainable features provided additional operational savings in maintenance of the facility.


Standardized and adaptable clinical spaces
The limited number of working healthcare providers in medically underserved areas influences the need for standard design and universal room modules in clinical layouts—exam rooms that are assigned for primary care and can support urgent care overflow, as needed, for example.

Design standards also help providers jumping between locations. Fort Providence Medical Centre uses this concept for clinicians rotating through its health system. Each facility organizes the patient and provider areas with similar dimensions, casework and furnishings, and equipment.

Clinic design must also be flexible for changing regulations, services, and patient volumes. Universal rooms can fluctuate between purposes as service demands change. To that end, Fort Providence uses a single multipurpose screening room for all imaging and small procedures. The room contains a mobile X-ray unit and radiolucent stretcher and can accommodate telemedicine, observation, patient holding, general exam, and dialysis. A 12-by-12-foot room dimension (as opposed to a more standard 10-by-12-foot universal exam room size) accommodates the extra equipment in the space.


Maximize staff connectivity
Rural facilities are often run with minimal staff who may need to move easily between greeting people as they arrive, providing patient care, and coordinating with one another. To ease this process, plan departments around centralized work spaces and open clinical pods.

Clinical circulation that connects staff work areas with adjacent clinical space is also useful. The planning should include a central core support area with connection to the clinician zone without interruption from public circulation.

Ely-Bloomenson Community Hospital, for example, was renovated in 2009 with a central staff area that supports emergency and inpatient care and is connected as one work zone. Core support spaces are designed to keep visual and physical connection between staff and minimize redundancy.


A look ahead
These are just a few guidelines to help launch design work on rural projects and support the unique operational goals of CAHs. Rural healthcare is moving away from acute care and increasing appropriate primary care components, such as mental health services and specialty telehealth appointments. Additional information gleaned from the case studies includes the need to adapt primary care areas for these additional services through mobile equipment as well as additional storage or partitions to separate areas to accommodate temporary needs.

Rural hospitals and their delivery of care are expected to continue to develop with the recent introduction of the Save Rural Hospitals Act to support s
tabilizing operations and provide innovative care models.

Kirsten Staloch received her MS in architecture and health from Clemson University in May 2015. She works at HGA Architects & Engineers (Minneapolis). She can be reached at