In February 2014, St. Joseph’s Healthcare Hamilton opened the Margaret and Charles Juravinski Centre for Integrated Healthcare in Hamilton, Ontario. The project was impressive for its size alone, with 850,000 square feet and more than 300 psychiatric beds, as the provider brought all of its mental health and addiction services together under one roof in a modern and comfortable setting.

But it stood out for another reason, as well: During the renovation, the operator decided to add an ambulatory care center with diagnostic, imaging, and outpatient medical services.

The project captures a trend beginning to emerge across North America. Behavioral healthcare clinics, emergency room crisis centers, and new freestanding facilities are being built, while older, existing wings are getting the green light for renovation and expansion. Together, these projects illustrate how far mental healthcare has come from its days tucked into faraway hospital units or in institutionalized facilities, as well as its growing role in a more integrated care approach.

Tim Rommel, a principal with Cannon Design and leader of the firm’s national behavioral design group (Buffalo, N.Y.), says his firm has about a dozen new freestanding behavioral health hospitals on the design boards right now. “If you asked me 10 years ago would we ever get to that point, I would have laughed at you,” he says. “Two years ago, we opened 1,500 psychiatric beds in one year. That’s a huge number of beds being added to the system.”

So what’s driving this growth? For one, there’s more awareness of mental health and more open discussions about the need for treatment. People also have greater access to insurance coverage, which has fueled greater demand.

Heather Treib, director of operations, hospital-based services, at Pine Rest Christian Mental Health Services in Grand Rapids, Mich., says her freestanding facility houses seven inpatient units and has expanded significantly in the past five years. The reason, she says, isn’t because there are more mentally ill patients but because of several new or expanded healthcare programs, including Medicaid expansion, healthcare reform, and the Mental Health Parity and Addiction Equity Act of 2008, which mandates that medical insurance providers cover behavioral healthcare at the same level as physical healthcare.

“A lot of people can get benefits now to cover behavioral healthcare services,” she says.

While demand has risen, industry professionals say reimbursement rates have not, meaning the incentive to build cost-effective facilities is ever-present. Providers have also seen lengths of stay decrease, while the availability of outpatient behavioral healthcare services has grown. That means providers are designing more short-term care facilities that are serving the most acute mental health patients.

Jim Hunt, president of Behavioral Health Facility Consulting in Topeka, Kan., says penalties for readmissions is another reason why more care providers are addressing their behavioral healthcare services. “It’s been a revolving-door process for a number of years, where insurance companies would only allow seven-, five-, or three-day stays. They’d discharge them after that time and [the patients] would turn around and come back the next day or week. They’re in and out, in and out, but they’re not in long enough to really get a handle on what’s going on,” he says. “Providers are incentivized now to try to solve the problem.”

The challenge for designers, architects, and operators is to find cost-effective solutions that meet facilities’ high safety and security needs while still providing an environment where a patient can stabilize and receive treatment. “If we can make that a more efficient process, then we’ve helped that provider either treat more individuals or made it more economical for them to provide care,” Rommel says.

Evolution of care environments

In this new chapter of behavioral healthcare design, Don Thomas, principal at BWBR in Saint Paul, Minn., says he’s seeing the emergence of freestanding or hospital-based assessment centers, or crisis stabilization units, where clinicians can have more time to observe and understand a patient’s needs before admitting them into a specific mental care program. “What they’re finding is that sometimes they would put people in the wrong place,” he says, such as placing someone with an addiction issue in a high-acuity treatment center.

Dedicated psychiatric EDs that are designed to address the safety needs of someone in mental crisis have also become more popular in the last 10 years, says Cannon Design’s Rommel. “In an emergency room in an acute care environment, you have lots of equipment and tools that can be very dangerous,” he says. A psychiatric exam room, on the other hand, has such features as soothing lighting, tamper-resistant light fixtures, and sliding doors that conceal medical gases and equipment when they’re not in use.

In addition to these alternative care settings, Thomas says he’s also seeing an increase in intensive outpatient programs where patients can go to attend group activities, engage with staff members who are monitoring their medications, and get counseling. “It’s kind of a misconception that if you have a mental illness, then you have to be in a locked-down unit,” he says. “There will always be the need for inpatient [units] for people in extreme crisis, but not everybody needs that.”

There’s also growing interest in integrating primary and mental healthcare. Last February, behavioral health not-for-profit Centerstone of Tennessee opened a new 18,090-square-foot outpatient facility on the six-acre Dede Wallace Campus in Nashville, Tenn., combining primary and behavioral healthcare services for children, adolescents, and adults all under one roof.

“Clinicians are realizing that a substantial percentage of their regular acute care patients also have some behavioral healthcare issues, either caused by the acute issue or vice versa,” Rommel says. “So they’re starting to treat it as a co-occurring disorder.”

Meeting expectations

As more behavioral healthcare projects come online, designers and architects are taking cues from acute care facilities and employing hospitality-inspired aesthetics, artwork, and daylighting—efforts that are resulting in some new approaches to layout. For example, the mental health unit at St. Joseph’s Medical Center in Tacoma, Wash., had located all the activity spaces in the interior of the unit while all of the bedrooms were spread out into four quads with windows in each room.

“But behavioral patients spend very little time in their bedrooms,” says Tammy Felker, an associate partner at ZGF (Seattle). To increase access to outside views and daylight, as well as improve the overall ambience of the space, the unit was renovated with all the activity spaces moved to one quad, and the other three designated for patient rooms.

The move toward single patient rooms in acute care hospitals is also changing expectations for private rooms in behavioral healthcare. The set-up helps eliminate some of the issues with compatibility among patients and has a
lso reduced the use of seclusion rooms at some facilities, since care teams can invite patients to go into their own rooms to de-escalate a situation, Thomas says.

Others, however, say that facilities shouldn’t rush to all-private bedrooms without considering some of the benefits of double rooms, including those for patients who have separation anxiety and can’t be alone. Some cite studies that found having a roommate led to fewer suicide attempts. “My current suggestion is to go with mostly single patient rooms, but put in a few two-patient rooms to help keep your census up and give you some flexibility,” Hunt says.

The move to open-concept nurses’ stations is another trend affecting facility design, Treib says. During a redesign at Pine Rest, glass-enclosed workstations were replaced with a half-wall with counter space. Treib says the staff was concerned that patients would reach in and grab the computer screen or jump over the counter. Instead, they’ve found improved comingling between the staff and patients as well as decreased agitation and anxiety among patients, she says.

A matter of choice

While these best practices are helping behavioral health environments catch up to the rest of the healthcare industry, other design interventions must be specific to the sector and the treatment being provided. For example, while exercise has been widely accepted as beneficial to one’s health, it hasn’t always been an option for mental health patients because treatment approaches were more based on talk therapy and a limited repertoire of medications, therefore providers didn’t feel the need to allocate space for it.

However, as more research has linked physical activity to combatting depression, providers have begun allocating space for exercise equipment, such as placing stationary bikes in activity rooms, and, today, some are adding dedicated exercise rooms. Facilities are also increasing access to outdoor areas and walking paths as another therapeutic option. “[Exercise] is really important to mood stabilization,” says ZGF’s Felker.

And while finding safe and accessible outdoor areas can be challenging, especially when renovating an existing space to integrate behavioral health into an acute care facility, Felker says it’s a huge amenity, especially for adolescent and pediatric populations. For a project at Seattle Children’s Hospital’s Psychiatry and Behavioral Medicine Unit, ZGF incorporated an outdoor playground and, in a second phase, will add a second-floor outdoor terrace.

Comfort or sensory rooms are another important feature in modern behavioral healthcare environments, a place where patients can go when they start to feel out of control or need to calm down. These quiet rooms may offer aromatherapy, music, mood lighting, blankets, and soft furniture, and patients have a degree of control within the space, whether it’s the lights, sound, temperature, or music.

“The idea is that we want patients to learn how to manage their emotions and behavior in appropriate ways,” Felker says.

Treib says one area that she thinks still needs addressed is the incorporation of technology. “Everyone walks around with their own personal device, and then when you come into a behavioral hospital, that’s all taken away from you,” she says.

She recognizes that not having the ability to check emails or reach out to friends can be a major source of stress for patients, but says facilities still need to figure out how to pay for the technology, lock down devices, and maintain privacy and safety for users. For Pine Rest, she says she’s considering a “technology room” that would be open at specific times for patients to check email, use apps, or listen to music on devices, while being observed by the staff.

“So many people think of behavioral healthcare patients as different from you and me, but they’re not,” she says. “We need to think of the things we wouldn’t be able to go without and find a way to incorporate that.”

Anne DiNardo is senior editor of Healthcare Design. She can be reached at