an urban healthcare model for outpatient care and wellness and wellness amy d. kircher 2012 AIA Arthur N. Tuttle Fellowship
Background Best Practices A li ti Application table of contents
Study Concept and Background
PART ONE
WELLNESS • • • • • • •
OUTPATIENT
?
Location/Access to care Program components Functional adjacencies Functional adjacencies Create link wellness to outpatient care architecturally Urban context L d Landscape design & elements d i & l t Welcoming and interactive environment
project goals
defining typology
Impacts of Healthcare Reform Shift Towards Outpatient Care Outpatient Care Need for a New Healthcare Typology Challenges to Ch ll t Address
the concept
• Policy changes. Accountable Care Act • Reimbursement models and soft costs (ACO, PCMH) • Health management Health management • Increase in % of population with chronic diseases • Patient‐centric era • Changes in medical procedures and technology • Need for preventive care and wellness • Education about health d b h lh • Changing image of primary care • Organizational changes Organizational changes • New architectural spaces • Aesthetics
major issues
Wellness
Health Ed ti Education
Chronic Disease
Health Literacy
Demographics
Types of Programs
Outpatient U.S Healthcare System Policy Changes
Diagnosis ACO, PCMH Management
Community Involvement
literature review
Types of Facilities
Urban Models
Location
Day Surgery
Location
Insurance
Diagnostics
Access
Primary Care
Active Living & Built Environment major topics explored
D Decentralized t li d Part of Campus
Incorporate initiatives and published guidelines as a foundation for ideas, information, resources, and project goals
project goals
recent guidelines
Case Studies and Best Practices Best Practices
PART TWO
Urban Context
Physical Context
Services Outpatient Services Offered P Preventive Care i C Wellness
Arch. Design Site Cli i D i Clinic Design Branding Facility Planning/Approach
Message to the Community
Functional Context Program Components Operations Functional Organization
Best practices
Connection to City Urban P bli S Public Spaces Location
Community Outreach/Programs Healthy Communities Education
case study selection
Best practices
cities visited
Message to Community
Urban Context
Case Study
Connection to City Urban
Bellevue Children's Rehab
CAMH
Kasier Center for Total Health & Capitol Hill Medical Center Mayo Dan Abraham Center for Healthy Living Methodist Outpatient Center Wellness Facility MGH Ambulatory Practice of the Future Mills City Clinic Polyclinic Randall Children's Hospital UMCG Outpatient Clinic Wellspring Medical Center Woodburn Whittier Clinic YMCA Houston
Physical Context
Functional Context
Preventive Functional Arch Site Clinic Facility Public Community Healthy Outpatient Services & Wellness Programatic Services Components Operations Organization Design Design Design Branding Planning Spaces Location Outreach Communities Education Care Offered
Services
Best practices
case study analysis
Whittier Clinic Minnesota
HGA Architects, 2010
Mayo’s Healthy Living Center
Amy Kircher, 2011
• Design process • Atmosphere different involved community than other Mayo • Features design for dual facilities use by facility and for • Abundance of natural community after hours light and courtyard • Concept of pocket spaces gardens • Strategic use of high quality materials
case studies
Mill City Clinic Minnesota
Woodburn Health Center, Oregon
Perkins & Will, 2008
Clark/Kjos Architects
• Lobby open for community use • Shell space used for clinic events about health • Natural light in a retrofitted space
• Community wellness center with multiple program components • Adaptive re‐use of old box store • Integration of daylight and courtyards
lessons learned
Message to Community
Urban Context Connection to City Urban
Definition
Goals
Services
Functional Context
Physical Context
Preventive Public Community y Healthy y Outpatient p Services & Wellness Programmatic g Functional Arch Site Clinic Spaces Location Outreach Communities Education Care Offered Services Components Operations Organization Design Design Design Branding
Location of facility in city and Programs, services, and the relation to adjacent approach to involving buildings. community in facility.
Position the facility as a destination point within the context of the city
• Allocate portion of site to public usage • Locate the facility to provide y p access from public transportation, pedestrians, Applications bicycles, and vehicular traffic • Relate facility to nearby facilities architectural and site design
Types of services in the Adjacencies and locations of facility offered to patients, different functions and the public, and staff. departments.
Connect to the community to Provide a range of services Connect to the community to Provide a range of services Design the facility to optimize increase health awareness of for a variety of users, while the functional and operational the public and users of the balancing soft and hard aspects. facility. costs. • Relate facility to nearby buildings through programs offered offered • Include nearby businesses and community in the design process. • Provide areas of the building that can be used “after hours” by the public
• YMCA Houston • CAMH • Whittier Clinic Case Study • Whittier Clinic • City Mills Clinic • Kaiser Center for Total Exemplars • UMCG • City Mills Clinic • Polyclinic ‐ Seattle • Philips Powderhorn
Best practices
• Include diagnostic and treatment services that keep some patient groups out of the main hospital • Provide wellness services that add value to the building and attract a range of demographics.
Facility y Planning
Architectural design and aesthetics of the facility. How the clinics were design and planned. Create a facility that speaks of Create a facility that speaks of health rather than illness. Change the face of what a healthcare providing facility can be.
• Create adjacencies between • Create an open and welcoming treatment and wellness services environment at the public level and p where spaces and services can spaces be shared • Design the site to allow wellness • Evaluate the operations of the programs to utilize the space facility in terms of hours open vs • Give the facility a brand that services provided represents the values of the facility • Design the soft costs spaces to in regards to community health be flexible for future changes in and wellness. services offered services offered
• Wellspring Medical • Mayo DACHL • Methodist Wellness • City Mills Clinic • Bellvue Children's Rehab • Whittier Clinic • Wellspring Medical Center • City Mills Clinic
case study analysis
• YMCA Houston • Whittier Clinic • City Mills Clinic • UMCG • Polyclinic ‐ Seattle
Sick Patient
Traditional patient description – suffering from a health problem and in need of diagnosis and a health problem and in need of diagnosis and treatment.
Well Patient
Patient seeking preventive or routine care. Long term follow up for chronic patients. Also includes health education and counseling.
Non Non Patient
All other visitors and users of the facility. Wide range includes healthy visitors staff Wide range, includes healthy visitors, staff and service providers, and even pedestrians on the street.
user groups
definitions
Staff
The overlaps between two or more groups represent the interactions.
Sick Patient Well Well Patient
user groups
Non N Patient
interactions
The interactions can be translated to architectural spaces.
Non Patient Sick Patient
user groups
Well Patient
variations
Sick Patient Well Patient
Non Patient
user groups
Sick Patient Well Patient
Non Patient
variations
Sick Patient Well Patient
Non Patient
Application: City Master Plan and “Flagship” Flagship Facility Facility
PART THREE
Generate a master plan for the city of Portland showing variations of this facility, and demonstrate the concept of a network of urban, decentralized, outpatient facilities.
This project is 40,000 square foot prototype facility located in downtown Portland, Oregon that will incorporate primary care, diagnostic, and wellness services. These facilities will provide outpatient and primary care services, wellness services recreational opportunities education on a variety of healthcare topics, services, recreational opportunities, education on a variety of healthcare topics and create a community identity related to health rather than treatment.
concept
about this project
1 2 3 4
Encourage an active lifestyle and wellness through architectural design and space planning. (Brownson, Baker, et. al., 2001; City of New York, 2010, Frank, Engelke & Schmid, 2003; Lee & Moudon, 2008; Nicoll & Schmid 2003; Lee & Moudon 2008; Nicoll & Zimring, 2009; Zimring, et. al., 2005) & Zimring 2009; Zimring et al 2005)
Incorporate learning environments throughout the building and site d i . (Downey & Zun, 2008; Hoving, et. al., 2009; Kaiser Permanente, 2011; McCusky, 2008; design Nahrsted, 2004; New York City Commission, 2006)
Provide access and views to nature for all user groups. (Cooper Marcus & Barnes, 1999; Gerlach‐Spriggs, et. al., 1998; Ulrich, 1999; Rodiek, 2009)
Design building to incorporate daylighting to all major user groups. (Joseph, 2003; Figueiro, et. al., 2002; Leather, et. al., 1998; Millard, 2011; Ulrich, 1991; Alimoglu & Donmez, 2005)
ebd concepts
key issues
Specialty Services PCP Clinic
Education
Ambulatoryy Services
Treatment
Connection
Wellness Services
Recreation
Diagnostics
Retail
Community
program concept
Nutrition
defining components
The city of Portland developed the Portland Plan in response to the growing challenges p g g g for the city y including growth, education, income, and environmental concerns. The Portland Plan was created through the collaboration of the city and the public. Comments and involvement from the residents of Portland was welcome. (Over 20,000 comments from residents to date.) Advancing equity is the foundation of the Portland Plan.
master plan
based on portland plan
20 Minute Neighborhood Analysis based on an individual’s needs Developed to track where amenities are concentrated Describes in detail the services and amenities available Can be used to determine the missing or lacking amenities in a community
city master plan
portland plan
Healthy Connected Neighborhoods Based on the 20 Minute Neighborhood analysis. Hubs are anchors for the 20 Minute Neighborhood. Hub could be a community center, park, school, housing, or any public gather place.
city master plan
portland plan
Healthy Connected Neighborhoods Priority to create a network of city greenways. Greenways at different scales: • preservation of forests • development of parks • tree canopy growth • neighborhood sidewalks • pedestrian boulevards pedestrian boulevards
city master plan
portland plan
Neighborhood Demographics Can be used to see the missing pieces in each specific area. area There are no community centers in the city center and healthcare services are scarce. Diverse part of the city Diverse part of the city ranging from high rise commercial to high density residential.
city master plan
portland plan
the city
portland, oregon
city master plan
network of facilities
Neighborhood Strip Mall
Neighborhood Freestanding
• Family Practice • Family Practice and and/or d/ Pediatric P di t i Pediatric focused P di t i f d focused • Robust recreational • Family oriented and wellness education programs p g program p g • Smaller facility in size • Medium to large sized facility
example of types
Downtown Leased Floors
• Family Practice and I t Internal Medicine l M di i focused • Wellness, nutrition, & stress management g focused • Smaller to medium sized facility
Downtown Freestanding
• Family Practice and I t Internal Medicine l M di i focused • Recreation and wellness focused • Medium to large sized facility
facilities within network
Neighborhood Strip Mall
Neighborhood Freestanding
• Family Practice • Family Practice and and/or d/ Pediatric P di t i P di t i f d Pediatric focused focused • Robust recreational • Family oriented and wellness p g education programs program p g • Smaller facility in size • Medium to large sized facility
example of types
Downtown Leased Floors
• Family Practice and I t Internal Medicine l M di i focused • Wellness, nutrition, & stress management g focused • Smaller to medium sized facility
Downtown Freestanding
• Family Practice and I t l M di i Internal Medicine focused • Recreation and wellness focused • Medium to large sized facility
facilities within network
city master plan
downtown freestanding
Site Selection • Locate Locate building near park building near park to encourage outdoor activity (Zimring, et. al. 2005; Nicole & Zimring, 2009) • Add to the neighborhood to encourage physical activity (Lee & Moudon activity. (Lee & Moudon, 2008) • Impact of the built environment on physical environment on physical activity in the community. (Frank, Engelke, & Schmid, 2003).
central city
portland, oregon
the city
urban context
HIGH RISE & COMMERCIAL
MID RISE & MIXED USE / RESIDENTIAL LOW RISE & THEATER & MIXED USE / ART DISTRICT RESIDENTIAL
the city
urban context
Challenges •Small Small Site (200 Site (200’ by 200 by 200’)) •Sloped (19’ across diagonal) •Connection Connection to existing to existing building •Limited options for service entries •Multiple approaches to site from public and private transportation
the site
existing conditions
Concepts • Ability to cross site Ability to cross site • Create new public spaces • Limit size of building Limit size of building footprint • 5 Design Variables: Image, Enclos re H man Scale Enclosure, Human Scale, Transparency, Complexity (City of New York, 2010)
the site
existing conditions
Clinics Diagnostics Support/Admin Wellness Public/Retail / Support/Parking k Parking
program
preliminary stacking
Clinics Diagnostics
Entry Gardens Main Lobby Café Education Pharmacy
user groups
Entry Gardens
Sick Patient Well Well Patient
Non Non Patient
interactions
Massage Counseling Fit Fitness Wellness Admin Pharmacyy
Landscape Program • Limit size of building footprint • User exclusive gardens User exclusive gardens • Dense and open gardens • Public plaza Community Spaces • Gardens • Plaza • Active store front on first level Active store front on first level Locate building near park to encourage outdoor activity (Zimring, et. al. 2005; Nicole & Zimring, 2009) Nicole & Zimring, 2009) 5 Design Variables: Image, Enclosure, Human Scale, Transparency, Complexity (City of New York, 2010)
site design
concepts & parti
main entry
SITTING AREA
STAFF TERRACE
• Skylights in staff working area of the Diagnostics Dept and Clinic. (Joseph, 2003; Figueiro, et. al., 2002; Leather, et. al., 1998)
EXISTING BUILDING
• Provide views and access to nature (Ulrich, 2009)
PLAZA
• Create views from clinic interior to roof top garden interior to roof top garden
ROOFTOP TERRACE
CONTROLLED ACCESS GARDEN
PUBLIC ACCESS GARDENS
• Roof top garden access for multiple building users while maintaining clinic while maintaining clinic privacy Sick Patient
site plan
building footprint
Well Patient
Non Patient
SITTING AREA
• Design stairs for everyday use. (City of New York, 2010; Nicole & Zimring, 2009)
EXISTING BUILDING
DOCK CAR RAMP
• Integrate learning zones in lobby and waiting areas. y g (Downey, 2008; Nahrsted, 2004; Kaiser Permanente, 2011)
PLAZA
CONTROLLED ACCESS GARDENS
PUBLIC ACCESS GARDENS
• Add education areas that are open and accessible to all users and the public. (Hoving et al 2010) (Hoving, et. al., 2010) Sick Patient
“POCKET GARDENS”
site plan
site & garden design
Well Patient
Non Patient
• Design stairs for everyday use. (City of New York, 2010; Nicole & Zimring, 2009)
SITTING AREA CAR RAMP
• Integrate learning zones in lobby and waiting areas. y g (Downey, 2008; Nahrsted, 2004; Kaiser Permanente, 2011)
PLAZA
PUBLIC
EDUC.
CAFÉ
CONTROLLED ACCESS GARDEN
PUBLIC ACCESS GARDENS
Sick Patient
“POCKET GARDENS”
level 1
• Add education areas that are open and accessible to all users and the public. (Hoving et al 2010) (Hoving, et. al., 2010)
public & services
Well Patient
Non Patient
interiors
public spaces
LOCKERS
AEROBICS
YOGA
• Design stairs for everyday use. (City of New York, 2010; Nicole & Zimring, 2009) • Overlap departments with similar functions to create interactions (McCusky, 2008) • Provide views to nature (Ulrich, 2009)
LOBBY
PHYS. THERAPY
• Incorporate daylighting for all users ((Joseph, 2003; Figueiro, et. al., 2002; p g Leather, et. al., 1998)
FITNESS Sick Patient
level 2
physical therapy & fitness
Well Patient
Non Patient
interiors
wellness spaces
MASSAGE
• Design stairs for everyday use. (City of New York, 2010; Nicole & Zimring, 2009) • Provide views to nature (Ulrich, 2009)
CONSELING
• Incorporate daylighting for all users (Joseph, 2003; Figueiro, et. al., 2002; Leather, et. al., 1998) STAFF PHARM.
ADMIN & CONF ADMIN & CONF.
Sick Patient
Well Patient
level 3
admin, staff, massage, counseling
Non Patient
STAFF ROOF TERRACE
ULTRA SOUND
CARDIO.
MAMMO. STAFF WAITING
CT R/F
• Design stairs for everyday use between clinic and diagnostic staff areas. (City of New York, 2010; Nicole & Zimring, 2009) • Provide views to nature from select clinic spaces and staff areas (Ulrich, 2009) • Incorporate daylighting in patient waiting areas, for staff and selected clinical spaces. (Joseph, 2003; Figueiro, p ( p g et. al., 2002; Leather, et. al., 1998)
DRESSING X‐RAY
Sick Patient
LAB
Well Patient
level 4
diagnostics
Non Patient
• Design stairs for everyday use between clinic and diagnostic staff areas (City of New York, 2010; Nicole & Zimring, 2009)
CLINICS 3 PODS 3 PODS STAFF CONSULT.
WAITING
• View from clinic pubic and staff spaces to roof top garden. Views to park block and site design from staff work spaces. (Ulrich, 2009) • Incorporate daylighting for all users ((Joseph, 2003; Figueiro, et. al., 2002; p g Leather, et. al., 1998)
ROOFTOP TERRACE
Sick Patient Well Patient
level 5
clinics – family practice
Non Patient
CONTROLLED ACCESS TERRACE CLINICS
EXISTING HISTORIC BUILDING
DIAGNOSTICS ADMIN FITNESS LOBBY
MECH. & SUPPORT PARKING PARKING
section a.
program stacking
STAFF TERRACE CONTROLLED ACCESS TERRACE CLINICS DIAGNOSTICS WELLNESS
ADMIN
LOCKERS SERVICE
THERAPY PASSAGE
LOBBY O PARKING
MECH. & SUPPORT
PARKING PARKING
section b.
program stacking
Sick Patient Well Patient
section b.
user circulation
Non Patient
urban context
scale of facility
urban context
scale of facility
urban context
scale of facility
• Highlight building activities from pedestrian perspective • Create different levels of transparency into the building • Create unique views from the building g from different users
from art museum
Art installation with Portland Museum
from residential
Rheinzink – bright rolled powder coated metal panel powder coated metal panel
view from park
A special thanks to… The AIA Tuttle Fellowship Committee and The AIA Academy of Architecture for Health. The AIA T ttle Fello ship Committee and The AIA Academ of Architect re for Health Steris for their generous sponsorship. My Final Study Chair Prof. Kirk Hamilton and Committee Dr. Mardelle y y Shepley p y and Dr. Jon Rodiek for their guidance and support. and to the many individuals and organizations who assisted me along the way: D b hS Deborah Sweetland, Alejandro Iriarte, Freek tl d Al j d I i t F k de Bos, Heather Voorhaar, Karl Sonnenberg, d B H th V h K lS b Suanne, Barton, Stephen Black, Tom Clark, David Frum, Ron Smith, Randal Brand, Michele Cohen Idoine, Ian Sinclair, Terry Montgomery, Alice Liang, Maggie Duplantis, Gary Oftedahl, Jon Hallberg, Chris Backous, Allison Schwab, Courtney Duke, Massachusetts General, Mayo g, , , y , , y Clinic and Center for Innovation, Methodist Hospital, Philips Powderhorn, City Mills Clinic, ICSI, Kaiser Permanente, Polyclinic, Virginia Mason, Wellspring Medical Center, and University Medical Center Groningen.
thank you!
Amy D. Kircher adkircher@gmail.com or akircher@pspaec.com
thank you!