One in four Americans experience a mental illness or substance abuse disorder each year. Nearly half will develop a mental illness during their lifetimes.
Since 1995 the capacity for treating behavioral care issues has been shrinking. The number of psychiatric units reduced from over 1,500 to fewer than 300.1
The need for improved access and outcomes has never been greater. The Patient Protection and Affordable Care Act (ACA) expands coverage of mental health and substance use disorder benefits and federal parity protections to over 60 million Americans. The Act promotes the development of new care delivery models, creating imperatives for providers to provide more integrated care. 2
Psychiatric care needs to be integrated into the broader care continuum, and the time is right to apply the lessons from the design of acute care facilities to behavioral health care environments.
Balancing dignity with privacy
As hospitality trends make their way into the design of acute care facilities, key elements found in the hospitality industry are appropriate in the behavioral care setting. Behavioral care patients need an environment that is not only non-threatening, but will help overcome their natural skepticism and ambivalence about treatment. Allowing first-time patients and visitors to register at the main desk, while directing others to an internal location to check in, can help alleviate patients’ apprehension.
- The renovation of the Prime Health St. John Behavioral Care Unit, Leavenworth, KS, features a Concierge/Greeter/Intake desk that provides a designated location for new patient intake and visitor orientation while protecting the privacy of the inpatients. Additionally, the facility features a mix of private and semi-private patient rooms that allow for a blend of patient conditions and therapy protocols.Single rooms eliminate compatibility issues and can help enhance patients’ privacy and sense of dignity. Care teams can invite patients to go to their own rooms to help defuse a situation, and single rooms can reduce the need for seclusion rooms.
Double rooms offer benefits for patients who have separation anxiety and can’t be alone. A mix of private and semi-private rooms can provide the flexibility to address the needs of a varied patient case load.
The success of single patient rooms in acute care hospitals is changing expectations amongst behavioral patients and caregivers alike. While semi-private inpatient rooms are valued for some patients at risk for depression or suicide, single patient rooms are becoming the preferred setup for many patient populations.
The focus on improved outcomes that is driving changes in care strategies including enhanced staff/patient interaction and integrated care
Architects are beginning to apply Evidence Based Design in the psychiatric care setting as well as incorporating aesthetics inspired by the hospitality industry. These initiatives are resulting in more focused approaches to layout and details that address issues unique to behavioral care.
The focus on improving outcomes is driving changes in care strategies including enhanced staff/patient interaction. Some providers have found improved comingling between the staff and patients as well as decreased agitation and anxiety among patients when barriers between patients and staff are eliminated.
- At Two Rivers Psychiatric Hospital the dining, activity and group therapy spaces were designed to provide a patient-focused environment with the goal of improving patient satisfaction and adapt to the growing numbers of patients diagnosed with co-morbidity. The nurse stations were reconfigured, removing the former sealed glass barriers to provide enhanced patient and staff interaction.
As Roger Ulrich outlined in his 1984 study, View Through a Window. May Influence Recovery From Surgery, natural views have a restorative effect on patients. Providing access to access to nature and daylight is even more important for behavioral patients. Architects need to design activity spaces with ambiance, as well as provide patient access to the outdoors whenever possible. Solar orientation and the quality of views are no less important. The value of these spaces is enormous for patient well-being, especially in pediatric and adolescent populations.
- The Generations Unit at Mercy McCune-Brooks replacement hospital in Carthage, MO was designed using Evidence-based design, paying attention to solar orientation to minimize the effects of seasonal affective disorder and “sundowning.” Large windows capture views of the central healing garden. All spaces were designed to provide for staff assistance, and the flooring pattern minimizes visual ambiguity for older adults. The effectiveness of the design strategies is tangible. The numbers of slips and falls has dropped by 35%, and the use of PRN medications has been reduced by 50%.
Incorporating holistic approaches that treat the mind and body through traditional as well as alternative therapies
Traditional therapies had focused almost exclusively on psychotherapy and a limited panel of effective medicines, many with debilitating side effects. Physical activity has long been linked to combating depression.
Some providers are adding dedicated exercise rooms, or have placed stationary bikes in activity rooms. Walking paths are being added as a therapeutic option.
- In the design of Signature Psychiatric Hospital, the core strategy focuses on an holistic approach that treats the mind through traditional treatment as well as alternative behavioral therapies. The facility features indoor and outdoor activity areas for yoga, music therapy, art and recreational therapy.
Comfort or sensory rooms are important feature in some behavioral care environments. The idea is that patients need to learn how to manage their emotions and behavior in appropriate ways. These spaces are places where patients can go when they feel out of control or need to calm down. Many offer aromatherapy, music, mood lighting, and comfortable furniture, as well as a degree of control within their space.
- Truman Medical Center in Kansas City’s geriatric care unit features a Namaste Room, that provides a comfortable environment where patients may participate in sensory-focused activities including music, light therapy, massage and aromatherapy.
Data-driven, recovery-focused patient care
Data will increasingly drive decisions within behavioral health. Twenty years ago, providers were paid on a fee-for-service basis. No one ever asked if the patient got better. Care is shifting from simply reducing symptoms to promoting long-term recovery.
The definition of success is also changing. Psychologists are beginning to embrace changes as profound as deinstitutionalization. The new definition of success is re-integration into a productive life in the community, not merely being discharged.3
- In addition to its inpatient and outpatient programs, Signature Psychiatric Hospital in North Kansas City, MO has created programs for patients to better transition back into the community. The facility serves as a clearing house for behavioral care in the region, accessing the resources of over 130 therapists and psychologists that coordinate patient care.
The rising human as well as economic costs of fragmented psychiatric care, especially for those with the most complex needs, have fueled demand for more patient-centered approaches to the design of behavioral health environments.
Facilities that improve the integration of physical and behavioral health care are attracting attention and taking hold. As design approaches emerge and evolve, it will be important to evaluate their performance from the perspective of outcomes and the patient experience.
Article Written By: Earl Wilson, NCARB, EDAC, LEED AP
Earl Wilson is the Senior Medical Planner for HMN Architects, Inc.
He can be reached at: ewilson@HMNarchitects.com
- Health Forum, AHA Annual Survey of Hospitals, 1995-2010.
- American Hospital Association, TrendWatch – January 2012
- The future of behavioral health care, American Psychological Association, Rebecca A. Clay , May 2011, Vol 42, No. 5
Earl will be providing a Master Planning presentation at the KCAHE meeting on June 14th at the Courtyard Kansas City at Briarcliff.