A Careful Response
During the past 10 years, there’s been a dramatic and accelerating change in both the number and the nature of behavioral healthcare construction projects. Where once the majority of projects consisted of either the renovation of inpatient units at general hospitals, the occasional outpatient clinic, and the even more occasional replacement of a large and outdated state hospital, today we’re seeing small and large freestanding specialty hospitals, new mental health units, and integrated outpatient treatment centers being built in cities across the country. There are 10 major drivers causing this evolution that design and construction professionals should consider.
1. Growing capital investment
In 2015, mental illness and substance abuse disorders were leading contributors to disease burden in the U.S., or the total societal costs associated with disease, according to an article in the Journal of the American Medical Association. Research correlates this trend with a lack of treatment or delayed treatment of mental illness. Clinical and epidemiological studies conducted over the past decade have concluded that early diagnosis and treatment of mental illness can change the course of care and dramatically improve outcomes, influencing investments now being made in new facilities to support those efforts.
2. Responding to children’s mental health
Mental illness frequently manifests itself before adulthood. Considering this and the above regarding the importance of early diagnosis and treatment, providers are making significant investments in child and adolescent psychiatry facilities. For example, the Marcus Autism Center in Atlanta is pioneering a treatment approach for the most challenging patients that offers intensive day hospital programming in lieu of the more traditional extended inpatient stay, finding that lessons learned and applied with children in both the home and treatment setting are more effective, and affordable, in the long term. There’s also a current emphasis placed on offering a wider range of on-site services than traditionally provided. For example, Big Lots Behavioral Health Pavilion, which is under construction at Nationwide Children’s Hospital in Columbus, Ohio, will provide a day hospital for intensive outpatient treatment, outpatient clinics focused on specific illnesses, inpatient beds, and an observation space. This approach allows patients to be placed in the setting that’s most appropriate for their needs while providing clinicians and researchers with access to a diversity of treatment tools.
3. Reducing stigma
Much of the untreated mental illness in this country can be traced to patients and families who don’t want to present evidence of a problem by seeking treatment. The mental health community has long understood that reducing stigma is a key part of decreasing the time between the onset of symptoms and the initiation of treatment. While design alone can’t eliminate these negative associations, designers are increasingly providing an experience that combats traditional preconceptions by creating environments as similar to their equivalents outside facility walls as possible, such as in-hospital schools, living areas, and amenity spaces. Designers can further diminish stigma by avoiding institutional finishes, materials, and layouts.
4. Increasing active treatment models
Long-term inpatient care has moved from medical and custodial models to one involving active treatment that’s focused on assisting patients in gaining the skills they need to achieve their individual life goals. This new care model is fundamentally based on providing environmental supports such as smaller and more customizable spaces in lieu of purpose-built activity workshops and arts-and-crafts rooms that marked an older generation of psychiatric hospitals. This care model also requires the involvement of peer counselors and care teams that include multiple disciplines, resulting in an increased need for office, counseling, and meeting spaces to accommodate those teams as well as individual and group therapy sessions.
5. Creating ED alternatives
Hospital emergency departments (EDs) have been overburdened in recent years by a growing volume of hard-to-place mentally ill patients, leading to increased investment in mental health crisis care as an adjunct to emergency care or as a substitute via freestanding psychiatric EDs. It’s also not unusual to see alternatives like transitional living units or 72-hour assessment beds provided in conjunction with these EDs, allowing clinicians to avoid admitting patients to inpatient care. Medical clearance (physical exams that establish that there’s no prioritized comorbid medical issues present) and triaging comorbid physical ailments are a critical driver of the location, organization, and staffing of psychiatric EDs, with some hospitals collocating mental health and general medicine triage capabilities at the ED entrance, while others push psychiatric services downstream after medical clearance has been established.
6. Improving patient safety
The Joint Commission issued a formal Sentinel Event Notice in 1998 that called attention to the range of environmental features patients were using to harm themselves. This increased risk awareness led the National Association of Psychiatric Hospital Systems and the State of New York’s Office of Mental Health to develop patient safety guidelines that many organization have since followed. Today, however, the Centers for Medicare & Medicaid Services (CMS) and The Joint Commission are revisiting the issue, prioritizing a suicide reduction goal in environments providing care for the mentally ill. In the wake of this, many hospitals and health systems are seeing an increase in requested environmental corrections during inspections by state health agencies operating as agents for CMS and by Joint Commission surveyors. This shift in policy is resulting in an increase in spending to retrofit existing spaces to accommodate these changes.
7. Introducing new diagnostic and treatment interventions
Clinical practices in mental healthcare have broadened to include greater utilization of specialized diagnostic and treatment (D&T) approaches, such as acupuncture, functional magnetic resonance imaging, electroconvulsive therapies, and transcranial magnetic resonance. These resources will likely see traffic from both inpatient and outpatient departments, and collocation of services will eliminate the need to duplicate staffing and space. This trend is expected to accelerate, too, as research improves the field’s understanding of the biological basis for various kinds of mental illness. Planners and designers should leave ample soft space or appropriately located expansion space in D&T areas in anticipation of future needs.
8. Integrating research
New construction projects including integrated research space as a part of outpatient treatment settings have proliferated dramatically in recent years. Much of the research being conducted is focused on longitudinal studies and requires support areas including shared waiting rooms and consultation rooms that surround staff support and office space. Additional space allocations for testing, records storage, clinical pharmacies, and office and workstations for larger research teams should also be considered.
9. Reducing patient violence and aggression
Healthcare design researcher Roger Ulrich and a team of investigators recently conducted a study at new psychiatric hospitals in Sweden on the role of the environment in reducing violence and aggression in inpatient units. The team concluded that several environmental features can contribute individually and collectively to creating a safer setting. Those features include private bedrooms and bathrooms, smaller units or subdivided units, ample day rooms and lounges, views of nature, access to gardens and courtyards, nature art, and natural light.
10. Reducing the use of seclusion and restraints
Many organizations, especially those with average lengths of stay exceeding two weeks, have committed to reducing, and even eliminating, the use of seclusion and restraints to achieve a clinical setting that’s less coercive and not as likely to trigger further escalations of adverse behavior. These settings are thought to be more conducive to a recovery-based treatment philosophy. Seclusion and restraint reduction policies also have planning and design implications, as facilities look for alternative future uses of seclusion rooms, such as additional office space or consultation areas. Comfort rooms, quiet rooms, and sensory rooms have also become popular additions to mental healthcare facilities as alternatives to seclusion to manage or de-escalate a crisis.
Although presenting plenty of opportunity for the design and construction industry, the acceleration in mental healthcare and related capital investments poses some significant process challenges, as well. Many (if not most) behavioral health clinicians and administrators have had little experience with building projects and few opportunities to redesign patient and clinician experiences and care delivery models. Similarly, A/E/C professionals may have limited experience with mental health projects. The planning process is benefitted by visiting new peer facilities and gathering advice from clinicians as well as members of the design community who have a broad base of experience in this sector. This will help organizations better address emerging trends as well as tailor a space to the specific drivers for each unique project at hand.
Francis Murdock Pitts, FAIA, FACHA, OAA, is a planner and designer of psychiatric facilities (Troy, N.Y.) and former president of the AIA Academy of Architecture for Health. He can be reached at firstname.lastname@example.org.