“Whether it be [sic] the sweeping eagle in his flight, or the open apple-blossom, the toiling work-horse [sic], the blithe swan, the branching oak, the winding stream at its base, the drifting clouds, over all the coursing sun, form ever follows function, and this is the law. Where function does not change, form does not change. The granite rocks, the ever-brooding hills remain for ages; the lightning lives, comes into shape, and dies in a twinkling.
It is the pervading law of all things organic and inorganic, of all things physical and metaphysical, of all things human and all things superhuman, of all true manifestations of the head, of the heart, of the soul, that the life is recognizable in its expression, that form ever follows function. This is the law.“
“Pink Sunrise” Photo by Mandy Kottas from office, March, 2014
A brief history of hospitals
The ancient Greek civilization believed that the Gods taught the art of healing to Aesculapius, a son of Apollo. Temples built to worship Aesculapius contained areas for the afflicted to sleep. Snakes were set free in these rooms during the night. In the morning, the patients were asked to relate their dreams to the priest who recommended treatments to rebalance their systems. This is the origin of the “staff of Aesculapius” the symbol of modern medicine. The Romans carried on the traditions of the Greeks but added “valetudinarian”, military hospitals for the legions. The floor plans of these hospitals showed patient rooms arranged around central treatment areas. Each patient room had sanitation facilities located on the corridor side connected to flowing sewers. Over time the healing arts became associated with the Christian faith. Following the fall of the Eastern Roman Empire (Byzantine Empire), Persian and Arabic health evolved from the knowledge of the Roman physicians. The word “Maristan” sometimes used to describe the modern hospital stems from the Persian word “bimaristan” meaning “a place for the sick”. Simultaneously, in Egypt the Arabic word “mustashfa” was substituted, meaning “a place where health is sought”. We are still pondering that distinction today.
During the Victorian era when it was discovered that germs caused infections, hospital were built in an early version of the pavilion style. Separate structures for each aliment were connected by enclosed walkways. The concept was that air could circulate between the structures and blow away the germs. If a nasty germ threatened future patients in a particular building, that structure was burned to the ground and a new one built in its place.
Following World War II, the United States had outgrown its existing healthcare facilities and little money was available for new facilities. The solution offered by the government (referred to as the Hill-Burton Act) was that the federal government would put up one-third of the cost of a new hospital if the state and local authorities would each put up one third. The Act proposed a system of hospitals based on a selection of standard hospital plans that were often adapted to a particular site. (Historical information is condensed from “The Fourth Factor, A Historical Perspective on Architecture and Medicine, by John Michael Currie, AIA, FRSH)  As a general rule, each was designed and built as a smaller version of a larger urban hospital and contained the same contingent of departments arranged in silos of care that required the patients to move from department to department where staff would provide diagnostic or treatment services. Many of those hospitals have been renovated or replaced, but have retained the same basic functions and operational patterns. Hospitals were designed and built to reflect the reimbursement formulas of the Centers for Medicare and Medicaid Services (CMS). Hospitals built whatever CMS paid for and the more CMS paid, the more the medical system provided. The advent of the Critical Access Hospitals (CAH) created a formula that, in many ways, discouraged efficiency since reimbursement was based on cost of service. Form has followed function.
The case for functional change
The evolutions of fee-for-service payment systems and the subsequent warping of the basic relationship between the physician and the patient have led us to a healthcare system that overcharges and underperforms. Healthcare is changing the way that it functions. Healthcare in the United States is moving away from a high cost/low quality fee-for-service model to a value-based system where payment is based on improved patient outcomes. Just as the form of hospitals changed in profound ways following the discovery of germs and microbes, healthcare facilities planned, designed and repurposed today must conform to the new reality of a changed healthcare delivery model.
As a society, we must design and build “mustashfas,” places where health is sought, rather than a place for the sick. Healthcare must seek out the patient as opposed to requiring that the patient come to the provider. Providers will no longer be paid on the basis of the number of office visits or services administered. Physicians may need only half as many exam rooms and hospitals may refer patients to the former competitors if they can provide care of higher quality at a lower cost. This is a different philosophy encompassing the meaning and purpose of healthcare going forward.
“The future of the hospital can’t be the building on the corner or down the street. It’s got to be immersed in the daily culture of the community that it serves.” John Bluford, CEO of Truman Medical Center.
It follows then that if we are to change the function of our healthcare system, we must also examine how healthcare facilities are planned and designed. To continue to renovate and build healthcare facilities in a manner that mimics an unsustainable system will put unnecessary cost and inefficiency into a system that thrives on value and positive health outcomes.
The new model
There are currently approximately 1,328 CAHs spread across the United States, although that number is shrinking every day. It is impractical to assume that either the will or resources are available to repurpose, renovate or replace that volume of capital investment in the near future. It is, however, reasonable to view planning activities and future investments through the lens of a value-based delivery model. In keeping with previous articles, I believe that strategic planning for rural and community hospitals should focus on the implementation of a sustainable value-based healthcare service model.
A life enhancement center (LEC) is a new, renovated or repurposed healthcare facility that is designed and constructed to address the needs of the citizens within the service area of the facility. In a value-based compensation model, medical services provided must meet the test of being the highest quality (based on positive patient outcomes) at the lowest cost to the system. In keeping with a value-based model, the facility must meet both the short term needs of the customers through collaboration with integrated practice units (IPU)s, outpatient care and urgent care needs; but also the long term need to improve the lives of the population served through patient-centered medical homes and wellness programs. The physical attributes of an LEC will vary greatly, but should closely track community needs as opposed to the fee-for-service reimbursement models of the past. A life enhancement center may or may not be classified as a hospital for regulatory purposes depending on specific regulatory definitions. A life enhancement center may include the following elements:
- Wellness/rehabilitation A wellness center can become a social magnet for the people within the general area. It also identifies the life enhancement center as a place that supports a healthy lifestyle. Other public organizations, educational systems and private employers should become partners in supporting a program that promotes healthy activities. Recognize that in a value-based environment, physicians are rewarded for keeping their patients healthy. Health coaches and wearable electronic devices will play an active role in monitoring physical health.
- Nutritional services. Nutritional services create an opportunity to refocus the dietary department to become a community-wide nutrition resource. The dietary department should become part of an outreach program to provide nutritional education and coaching for those who would benefit from high quality, easily prepared meals or specialty meals for those struggling with chronic illnesses. Quality foods and proper preparation play an integral role in the services of patient care coordinators and other related community support organizations.
A farmers market, featuring locally grown meats, fruits and vegetables could be held on the facility campus. This farmers market could become a source for nutritious food stock for the life enhancement center and could reinforce the commitment to good health by the organization.
- Patient-centered medical homes (PCMH). Patient-centered medical home concepts have struggled in fee-for-service reimbursement systems. They will flourish in value-based direct-care models. At the nerve center of a quality PCMH are qualified physicians or non-physician providers who act as the patient care coordinators for the practice. This person, or persons depending on the number of providers, is generally located at the heart of the practice. The patient care coordinator must act as the patient advocate receiving information from the field and determining the correct response. The mobile care provider in the field will report directly to the patient care coordinator. The mobile care provider or “Angel” will act as the eyes and ears of the care coordinator and also of the physician. The patient care coordinators will become the field marshals of the organization, bringing the proper resources to bear to elevate the health of the people in the wellness district. Since care will be provided as close to the patient as is practical, the PCMH will need fewer exam rooms. The physicians will focus their time and attention on those individuals that will most benefit from their involvement and to coordinate the involvement of the integrated practice units (IPUs). The clinic would have flexible group classrooms to efficiently provide information to the public on such topics as diabetes, birthing or other subjects of common interest. The rooms would be flexible enough to adjust to anything from nutritional training to group exercise. Conference rooms would be available for care planning teams and individual work spaces available for team members to focus on patient support services such as mobile care coordination. Some of the exam rooms will be designated as quick turnaround rooms for phlebotomy, vaccinations or observation and one or more rooms may be designed to accommodate bariatric patients.
- Emergency, urgent care and nursing services. Life enhancement centers should have, with rare exceptions, a strong, well-equipped emergency services function capable of handling all but the most intense trauma conditions. Low volume and limited access to specialists in remote locations demand creative technical solutions to address the needs of high quality emergency care. A high speed connection to a teletrauma services provider associated with a regional trauma center will prove essential. Nursing services and patient observation are a part of the areas of responsibility of the staff of this combined department. The number of observation beds is dependent upon the program requirements. Inpatient beds may or may not be included as part of an LEC.
- Clinical services. Traditional siloes of clinical services are integrated into a single customer-focused diagnostic and treatment center. The range and variation of clinical services will depend on a number of factors, including geographical location, demographics of the served population, patient volume and sharing arrangements with other area wellness districts. A customer-focused outpatient center arranged so that services are easily accessible from a single reception point will improve the patient experience. Personal data systems can assist the staff in meeting the individual needs and expectations of each visitor. The goal should be to make the visit smooth and seamless without wait time in the care delivery process. Depending on the functional program, clinical services may include:
- Outpatient service center
- Universal exam rooms/urgent care/recovery
- Surgery center
- Imaging center
- Sleep study
- Integrated Practice Unit (IPU) tele-video support
- Respiratory therapy
- Treadmill – EKG
- Pulmonary function testing (PFT)
- Outpatient service center
- Administrative services and Retail operations Administrative and business functions can be condensed and consolidated. In a direct care system there will be fewer business office functions.
- Retail operations
- Durable medical equipment
- Health and fitness
- Administrative services
- Administrative and business staff
- Information technology
- Human resources
- Retail operations
Clinical services in a Life Enhancement Center must be provided in the most cost-effective manner possible. A highly capable cross-trained staff is already a feature of many rural and community health centers. It is time to take this attribute to the next level.
Life Enhancement Centers must take advantage of those services that can be provided better than others, improve the services that are marginal and be willing to forego those services that cannot be provided in a high quality, cost effective manner.
A life enhancement center should be an open, airy and sunlit space where wayfinding is natural and intuitive. The frame should consist of large structural bays, without bearing walls, with the superstructure high overhead. A high superstructure allows an intervening space to be built above the ceilings of the occupied spaces. This space will contain mechanical, electrical and communications systems, so that the occupied spaces below can be modified or reconfigured at will and at a reduced cost.
Whenever possible, LECs should be designed with features promoting a healthy and safe environment, not only for visitors and guests, but also for the staff and caregivers. Evidence-based Design is a relatively new field of study that is working to document scientific evidence of design concepts that have been shown to reduce stress, enhance safety and promote healing environments. Rigorous documentation of evidence-based design studies can form the basis of anticipated performance in a new facility.
Anything, anytime, anywhere.
The LEC will become the coordinator of health-related data and communications for the wellness district. With a broadening definition of what information is health related, issues of privacy and data security will also expand exponentially. Electronic data will play a major role in monitoring the health-related activities and lifestyles of the general population.
Privacy and security in a system that values widely spread and diverse data sources will require different levels of security and protections. Cloud-based systems can provide the ability to share data across multiple platforms from any location with internet access or with smartphone coverage.
Access to mobile physicians or non-physician providers for consultation in a dynamic dance of collaborative care reduces the need for costly infrastructure investments and allows for greater flexibility to adjust to new technologies.
As wondrous as technology has become, it is of little value without human interaction. A patient who has diminished capacity or who may have fallen behind the technology curve will derive little value from a monitoring device or communication tool that he or she does not understand. Having a mobile care provider come to the home and interact with him or her will pay dividends. With the mobile care provider maintaining routine personal monitoring, the primary care physician will be able to devote more of his or her time to a reduced number of clinic visits. This will result in doubling or even tripling the amount of time that a physician can use in quality interactions with those patients needing his or her attention.
Margin to sustain the mission
Moving from a fee-for-service model to a value-based model will move the providers, represented by a wellness district, to a merit-based business model. Providers will be able to weigh and mitigate risk and formulate strategies to increase margins by optimizing performance. A capital investment that will improve operational and clinical efficiency can have a demonstrated positive impact on patient outcomes and on the system’s bottom line.
A healthcare system based on value seeks speed and efficiency to provide positive outcomes and thus improve the provider’s margin. It has been shown that the total cost of a healthcare facility including the building, equipment and design fees accounts for approximately nine percent of the total cost of a healthcare facility over its twenty-five year life expectancy.
Public/private partnerships (P3s) may become an attractive alternative to traditional sources of capital such as USDA loans, public bond offerings or loans from financial institutions. In a fast-moving ever-changing healthcare environment, asset liquidity is important. Partnering with an investor who has experience in recognizing and leveraging risk versus potential reward may be an intelligent decision. P3s can be structured to provide a design, build and leaseback arrangement with the operating costs of the facility built into the contract.
A hospital that has become an edifice to a system that is no longer viable can be transformed into or replaced by a life enhancement center (LEC), which is an investment in a brighter future.
Form ever follows function, but function is determined by a culmination of societal, cultural, financial, political and technical issues. We are a large diverse culture that strives for a healthcare system that is responsive to our needs and accountable for our care. An LEC’s form may be as diverse and unique as the community it serves. It may also change, morph, expand or contract as the needs of the community evolve and as the methods for fulfilling that need come onto the scene and then fade away. It is an investment in a dynamic, fluid form that forever chases the most challenging, yet rewarding callings in history.
A building is the embodiment of its purpose for being. By defining its purpose, you define its function. By defining a building’s function, you define its form.
The LEC can become the center of community social activity and the focal point of healthy lifestyles. A system that is self-supporting and achieves a symbiotic relationship with the community it serves will be sustainable well into the future.
Edited: Oct 2015