Best Practices in Behavioral Health Design Elevated expectations We believe architecture and the built environment can and should support best practice medicine and improve clinical outcomes. Behavioral health facilities are among the top service lines where the effects of a healing environment can be felt. Patients, family members and staff all benefit greatly from a well-conceived, well-built unit, building or campus.
Table of Contents
Why the C-Suite is Taking a Second Look at Behavioral Health Service Lines 7 Trends Impacting Behavioral Health Design
14
Best Practice Design Supports Best Practice Medicine
17
Designing to Reduce Risk
18
Nurse Stations: Communication Hubs for Milieu Therapy Approach
20
Design Considerations
22
Impact of Color in Behavioral Health Environments
27
Renovation Design Considerations
30
PAGE 4 | Best Practices in Behavioral Health Design
“Array designed patient care areas that are warm, welcoming, therapeutic and healing for our patients, as well as productive workspaces for our staff. They were attentive and responsive to clinical input and demonstrated exceptional compassion and respect for all of the stakeholders: patients, family members, clinicians, administrators, and donors. It was a collaborative effort with truly spectacular results.� - Marybeth McManus, MPA, BSN, RNC Assoc. Executive Director, Patient Care Services, The Zucker Hillside Hospital
Best Practices in Behavioral Health Design | PAGE 5
Zucker Hillside Hospital / Glen Oaks, NY Photographer: Jeffrey Totaro
“My goal is to see that mental illness is treated like cancer� - Jane Pauley, Newscaster Author of Skywriting: A Life Out of the Blue documenting her life-long struggle with bipolar disorder. PAGE 6 | Best Practices in Behavioral Health Design
01 THE FACTS
One in five adults has experienced a mentalhealth issue.
Why the C-Suite is Taking a Second Look at Behavioral Health Service Lines Just like cancer or diabetes, mental illness is a medical condition that affects the lives of individuals and their family and friends. The facts are staggering.
Suicide is the 10th leading cause of death in the United States. It accounts for the loss of more than 38,000 American lives each year, more than double the number of lives lost to homicide.
- According to MentalHealth.gov
Greater acceptance marks a significant and welcome shift. According to the U.S. Centers for Disease Control and Prevention, half of all Americans will experience some type of mental health problem in their life. One out of four adult Americans will experiHalf of all mental-health disorders first show up before a person turns 14.
ence some form of diagnosable behavioral or mental illness in a given year. These conditions run the gamut from substance abuse and eating disorders to post-traumatic stress and mild to severe depression.
The National Institute for Mental Health concurs that about one quarter of U.S. adults are diagnosable for one or more disorders in a given year, but it also notes that the main burden of illness is concentrated among a much smaller proportion. About six Three-quarters of mentalhealth disorders begin before 24. But less than 20% of children and adolescents with mental health problems receive the treatment they need.
One in 20 Americans live with a serious mental illness, such as schizophrenia, bipolar disorder or major depression.
percent, or one in 17, suffer from a seriously debilitating mental illness.
Best Practices in Behavioral Health Design | PAGE 7
Why the C-Suite is Taking a Second Look at Behavioral Health Service Lines
Zucker Hillside Hospital / Glen Oaks, NY Photographer: Jeffrey Totaro
According to a report published in 2013 by the Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration and the U.S. Department of Health and Human Services: among adults aged 18 or older in 2012, 9.6 million (4.1%) had serious mental illness (SMI) in the past year defined as bipolar, panic, obsessive-compulsive, personality, depression disorders and schizophrenia.
PAGE 8 | Best Practices in Behavioral Health Design
MENTAL HEALTH IS AN “ESSENTIAL HEALTH BENEFIT” While a law to change the way insurance companies reimbursed for mental health treatment was passed years ago (the Mental Health Parity and Addiction Equity Act of 2008), the rules to carry it out were not passed until November 2013 under the Affordable Care Act. The passage of the Affordable Care Act identified 10 “Essential Health Benefits” requiring coverage by insurance plans sold on public exchanges. Mental healthcare and substance abuse treatment are included in the list.
ten
ESSENTIAL HEALTH BENEFITS
1
2
3
4
Ambulatory Patient Services
Emergency Services
Hospitalization
Maternity & Newborn Care
10
9
8
Pediatric Services; Dental & Vision
Preventive & Wellness Services; Chronic Disease Management
Mental Health & Substance Use Disorder Services
5
Laboratory Services
7
6
Prescription Drugs
Rehabilitative & Habilitative Services & Devices
Sources: http://www.healthcare.gov/news/factsheets/2011/12/essential-health-benefits12162011a.html http://ccilio.cms.gov/resources/files/Files2/12162011/essential_health_benefits_bullentin.pdf
Best Practices in Behavioral Health Design | PAGE 9
INCREASED REIMBURSEMENT FOR MENTAL HEALTH+ MORE COVERED PATIENTS= PROFITABLE SERVICE LINE As insurance payers have started to cover more behavioral health treatments, the Behavioral Health Service Line is getting increased scrutiny by the hospital C-Suite who see a fast-growing, high-performing market with a guaranteed revenue stream. This, combined with incentives contained within the ACA to migrate to an Accountable Care Organization, are causing hospitals to look at their facilities and how they can support this service line. Once considered high risk and prone to low margins, there was a significant reduction in the number of psychiatric units within the US:
Total Number of Psychiatric Units in U.S. Hospitals and Total Number of Freestanding Psychiatric Hospitals in US. Note: Includes all registered and non-registered hospitals in the U.S. (1) Hospitals with a psychiatric unit are registered community hospitals that reported having a hospital-based inpatient psychiatric care unit for that year. (2) Freestanding psychiatric hospitals also include children’s psychiatric hospitals and alcoholism/chemical dependency hospitals.
1,550
700 650 600
1,450
550
1,400
Psychiatric Hospitals
500 450
1,300
400 Psychiatric Units
1,250
350
Psychiatric Hospitals
Psychiatric Units
1,500
300
1,200 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
250
Source: Health Forum, AHA Annual Survey of Hospitals, 1995-2010.
With the ACA covering children to the age of 26 on their parents’ policies, the number of covered lives is growing more rapidly than the availability of services to treat them—creating a high-margin growth business. To get health plan reimbursement, hospitals need to expand their services to include substance abuse and eating disorders.
PAGE 10 | Best Practices in Behavioral Health Design
People with mental illness are our neighbors. They are members of our congregations, members of our families, they are everywhere. If we ignore their cries for help, we participate in the anguish from which those came. A problem of this magnitude will not “go away.� And because it will not go away, we are compelled to take action. Rosalyn Carter Former First Lady Host, Annual Rosalynn Carter Symposium on Mental Health Policy Honorary Fellow, American Psychiatric Association Board Member Emeritus, National Mental Health Association
Best Practices in Behavioral Health Design | PAGE 11
Understanding Mental Hea
under the Affordable Care A ESSENTIAL HEALTH BENEFITS are now required by new insurance plans
WHO IS AFFECTED
62 Million The Affordable Care Act will expand mental health and substance disorder benefits for 62 million Americans.
Mental Health & Substance Abu
coverage are now required to be
accessible as medical surgical
POPULATION An estimated 26.2% of Americans ages 18 and older suffer from a diagnosable mental
26.2%
disorder in a given year.
sources: http://www.whitehouse.gov/blog/2013/08/21/affordable-care-act-and-expanding-mental-health-coverage mentalhealth.gov, nj.com, obamacarefacts.com PAGE 12 | Best Practices in Behavioral Health Design
One in every 3 families canno afford adequat treatment.
alth Coverage
Act
COVERAGE
use
e
l coverage
Most health plans MUST now cover
Young adults will be able to
preventative services like depression
remain on their parents health
screening for adults and behavioral
insurance until the age of 26.
assessment for children.
Prescription Drug Coverage
Pre-screening & Pre-existing Conditions
are now required by insurance plans
plans will no longer be able to deny you coverage or charge you more due to pre-existing health conditions, including mental illness
One in every 4 families is affected by mental illness
6.6 Million people will SAVE
3
ot te
Over 7 Billion dollars on prescription drugs
Best Practices in Behavioral Health Design | PAGE 13
02
Trends Impacting Behavioral Health Design
A number of recent factors have contributed to reducing the stigma associated with a mental health diagnosis:
•
The passage of the Mental Health and Addiction Parity Act in 2008.
•
The number of veterans diagnosed with PTSD.
•
The increased incidence of school/university shootings and the need to prevent them.
•
High profile spokespeople who have openly discussed their mental illness.
As a result, a paradigm shift in how mentally ill patients are care for and treated has occurred. Some of the shifts include:
PAGE 14 | Best Practices in Behavioral Health Design
These shifts are influencing the planning and design of behavioral health projects. Design drivers now include:
•
Providing operational flexibility to account for changing patient populations.
•
Ensuring safe, secure and dignified environments for family members and staff.
•
Remaining open to community review, while providing appropriate levels of privacy for patients.
•
Offering clarity of unit and building organization to facilitate patient orientation and movement.
•
Designing humanely scaled home-like environments to support treatment and support programs.
The design of behavioral health facilities have changed to reflect this as well. With the service line becoming more visible due to societal acceptance and understanding, as well as increased reimbursement through passage of the ACA, there will be more integration of behavioral health into the hospital campus. Many hospitals are embedding social workers in their primary care teams to better identify potential at-risk patients for depression. As behavioral health treatment increases as an outpatient offering, location and visibility of the service becomes very important. Models of care have evolved as well. The introduction of modern psychotropic drugs have reduced Length of Stay (LOS) for patients. As a result patients are now treated with the goal of returning to their family and careers. According to the National Association of Psychiatric Heath Systems, depending on the severity of illness, the average length of stay in a Behavioral Healthcare facility is only 9.6 days.
The spatial organization supports each patient’s clinical, emotional and physical needs and provides a safe and efficient facility allowing caregivers to deliver healthcare in a compassionate environment. Photographer: Jeffrey Totaro
Click Here
to view a collaborative case study for Mercy Health
Best Practices in Behavioral Health Design | PAGE 15
Trends Impacting Behavioral Health Design
Holy Redeemer Health System Behavioral Health Unit Huntingdon Valley, PA Photographer: Jeffrey Totaro
Caregivers now practice patient-centered care, not control-focused care. This has had a significant impact on the design of behavioral health facilities. Facilities are being designed for multiple space configurations to support a variety of activities and encourage patients to be an active participant in their treatment. Today’s behavioral health facilities are being designed with open space and fewer corridors. First, caregivers need to observe patients regularly. Secondly, the open space encourages communication and interaction and allows family members to become an active member of the care team. Patient and staff safety remain very high priorities in design. Access to natural light and the outdoors are considered critical design elements in behavioral health facilities. Offering patients a sense of control is an important factor contributing to the healing of a variety of mental illnesses. Designs providing patient control of elements within their environment (acoustics, lighting and furniture options) has contributed to shorter lengths of stay and a reduced need for medication. Alternate therapies, including chromotheraphy and audiotheraphy have also been introduced as ways to reduce the use of seclusion (including emergency response strategies by staff) and pharmacological interventions. This is changing the face of treatment and outcomes by giving the practitioner more time to treat because they require less time and resources to “manage� disruptive patient populations. While passage of the ACA established Mental Health and Substance Use/Abuse as an Essential Benefit, outcomes and results will increasingly drive decisions within behavioral health. Insurance payers and Medicare/Medicaid will demand empirically-proven treatment and performance measures. This is an important element to consider when designing a behavioral health setting.
PAGE 16 | Best Practices in Behavioral Health Design
03
Best Practice Design Supports Best Practice Medicine
Holy Redeemer Health System Behavioral Health Unit Huntingdon Valley, PA Photographer: Jeffrey Totaro
The design of mental health facilities affects how services
•
Decentralized nurse stations with minimal or no phys-
are provided and the efficacy and efficiency with which care
ical barriers between staff and patients are becoming
is delivered. Just as important is how the design impacts
more desirable.
and influences the people occupying the space. Facility design impacts the beliefs, expectations and perceptions
•
day rooms.
patients have about themselves, the staff who care for them and the care they receive.
•
during the day for a bit of solitude or for socialization in
temporary best practices in design emphasize a more open
a smaller, less overwhelming group.
layout and architecture, which can include: A universal room or pod design. This has become desirable because it can accommodate distinct patient populations and be adapted for changing demographics.
•
Quiet spaces or “living rooms,” separate from patient bedrooms, enable patients to step away from the group
While risk management is of paramount importance, con-
•
Larger, open activity areas are replacing small enclosed
•
Elimination of “dead ends” and recesses improves observation, security and safety while expanding the reach of natural light, opening outdoor views and orienting staff and patients to the time of day and the season.
“Main Street” circulation spines-even separate corridors for patients, visitors and staff are replacing conventional double-loaded corridor designs.
Best Practices in Behavioral Health Design | PAGE 17
04
Designing to Reduce Risk
A best practice approach to design of a behavioral health unit considers three zones of risk: public, supervised patient treatment/activity, and patient solitude zones.
Zucker Hillside Hospital / Glen Oaks, NY Photographer: Jeffrey Totaro
PAGE 18 | Best Practices in Behavioral Health Design
JON SELL
Behavioral health disorders are among the most prevalent forms of disease in the nation. Evidence-based design has demonstrated that clustered housing units, access to natural light, and re-
THREE ZONES OF RISK
taining staff are all positive influences against these disorders. At Array, we
Because the public zone is rarely accessible to patients, the need for pa-
have taken great strides in pushing the
tient-related security and anti-ligature measures is usually minimal. Finishes
envelope of designing for behavioral
and furnishings selected for the public zone can be similar to those of a hospitality lobby. One exception to this guideline is toilet rooms that are accessible to patients before or during the admissions process. Special attention should be given to the design of these toilet rooms to ensure patient safety. Supervised patient treatment/activity zones comprise all areas in which patients receive treatment and participate in staff-supervised daily activities. While the finishes and furnishings in this zone must be safe and durable, they can be selected with the knowledge that staff supervision and visibility generally help to reduce patients’ risk of self-harm. Patient solitude zones refer to those areas where patients may be alone and unsupervised-typically each patient’s bedroom and bathroom. Because of the higher risk of self-harm, room finishes and furnishings need to be carefully selected for durability, damage resistance and safety. Consideration
health facilities. We understand that there can be provisions for increased security, long-term acute care, structured activity, isolation, and group therapy while still infusing residential elements, warm colors, and an overall less “institutionalized” design. Jon Sell’s career includes 20 years of experience in healthcare design with 15 of those years on two separate tours at Array Architects. Now a Principal with Array, Jon has completed projects throughout the country with a focus on planning and planning implementation. He has focused extensively on Behavioral Health design
starts with the ceiling, which must be monolithic, seamlessly incorporating
completing projects for private, public
security lighting, heating/cooling and sprinkler fixtures. The furniture must
and government clients. His work has
be durable, free of sharp edges & corners and should be securely fastened
been featured in Behavioral Healthcare
to the walls.
Magazine, (Zucker Hillside Hospital) and he has spoken at national con-
Understanding the unique requirements of behavioral health facilities,
ferences on Behavioral Healthcare
particularly inpatient environments, is critical to their design. Safety is the
Design Best Practices. Recently he
first concern and always top of mind in making design choices. But safety is no longer considered in isolation. “Developing mental health facilities that are safe and healing are not incompatible processes or goals,” states the VA Mental Health Facilities Design Guide.
Click here to watch a 4-part series from Jon Sell on the design drivers behind
has helped create a new brand for the entire behavioral healthcare service line for Mercy Health and is currently engaged in 8 Behavioral Health projects for that client.
Click here to visit Jon’s Thoughts page.
Zucker Hillside Hospital, a behavioral health facility in Glen Oaks, NY.
Best Practices in Behavioral Health Design | PAGE 19
05
Nurse Stations: Communication Hub for Milieu Therapy Approach Overall, architectural and interior design must contribute to creating a safe, secure environment for patients, visitors and staff. Decentralized nurse stations or satellite nurse stations are one way to enable staff to be more involved in day-to-day activity on a unit and better able to observe potentially hazardous behavior. “Opening up” nurse stations, perhaps by removing the glass or by utilizing frame-free glazing panels, can help increase interaction between the staff and their patients. This is especially critical when supporting behavioral health providers who are focused on patient-centered care and practicing Milieu Therapy. Milieu is a French word that refers to the social environment of the individual. Milieu Therapy is a type of treatment that involves changing this environment in the hope that it will encourage a client to develop new coping strategies. This approach has been used for over a century in the treatment of psychiatric disorders and other behavioral problems.
Milieu Therapy usually involves an inpatient stay within a hospital but it can also be conducted in an outpatient environment. The goal of the architect is to create the right environment where change can take place – and this is where architecture and interior design can contribute significantly to patient outcomes.
In Milieu Therapy the nurse station becomes a Communication Hub to support dialogue between caregiver and patient and set an example for open communication for patient-to-patient interface. The Hub should be an open desk with no glass barrier, breaking down the “us vs. them mentality.”
PAGE 20 | Best Practices in Behavioral Health Design
KEY DESIGN CONSIDERATIONS
•
Provide large open milieu space anchored by a Communication Hub with flexibility to subdivide into different configuration to support multiple programs, patient populations and social interactions.
•
Place key therapy areas close to the Communication Hub to encourage interaction between staff and patients.
•
Organize rooms to maximize sight lines to patient rooms, confirming the patients feel supported but not controlled as well as encourage patient interaction and discourage remote observation.
•
Consider an “on-stage/off-stage” design that locates support spaces adjacent to provide support zones away from the public or patient areas to concentrate on paperwork/ charting and for staff decompression. This room should have a door and windows onto the unit that offer the same direct views to key therapy spaces. The windows must be glazed with shatterproof material. Furnished with a conference room, charting and electronic equipment, staff lockers should be accessed from this room.
•
The “On Stage” Communication Hub should be sized to limit the number of staff who can work behind it as patient/staff interaction is a critical element of Milieu Therapy and staff should be circulating in therapy areas.
•
While maintaining the openness of the Communication Hub, be aware that some patients may want to gather or congregate nearby. Make sure you can move the furniture to avoid HIPAA violations.
•
Layout space to minimize recesses in corridors around support spaces which can become safety hazards by providing patients places to hide.
•
Incorporate training space for staff, making sure it is flexible to accommodate different classes and education events. Continuing education is important along with non-patient staff collaboration opportunities.
•
Similar to desks in the patient rooms, the “On Stage” Communication Hub desk should be constructed of solid
Communication Hubs Photographer: Jeffrey Totaro (Zucker Hillside Hospital & Holy Redeemer Health System)
surface materials with rounded edges to limit any damage to or by patients.
Best Practices in Behavioral Health Design | PAGE 21
06
Key Design Considerations
By merging best practices in behavioral health treatment with best practices in design, Array Architects is utilizing innovative space planning and architectural & interior design strategies to meet these changing needs of behavior health providers and support evolving models of care.
Mercy Clermont Behavioral / Batavia, OH Photographer: Jamie Franz
PAGE 22 | Best Practices in Behavioral Health Design
PATIENT ACTIVITY AREAS Care models for behavior health patients have change significantly in recent years based on societal demands, reimbursement changes and the introduction of modern psychotropic drugs which have dramatically reduced Length of Stay for patients. Caregivers now practice patient-centered care, not control-focused care and this has had a significant impact on the design of patient activity areas. By merging best practices in behavioral health treatment with best practices in design, Array Architects is utilizing innovative space planning and architectural & interior design strategies to meet these changing needs of behavior health providers and support evolving models of care. Key design considerations include:
•
Create an inviting non-institutional environment without features that may facilitate assaults or self-harm. Patient activity areas are typically supervised by staff and consequently present less of a safety/security threat than patient bedrooms, bathrooms and other areas where a patient may be left unsupervised for a period of time.
•
The design goal is to support milieu-oriented therapy, where specific activities and social interactions are prescribed according to a patient’s needs and condition. The physical environment is an important element in that therapy.
•
Patient activity areas can include dayrooms, dining areas, private therapy offices, group and family meeting room spaces, a quiet room for retreating and secure outdoor spaces.
Optimistic healing environments promote positive outlooks. •
Remember to include areas for exercise, especially important if the unit is on an upper floor and does not have access to a secure outdoor area. Some insurance regulations may require that patients stay within a locked environment, consider including a pacing loop designed into the floor which offers a place to walk, either for relaxation or exercise.
•
Providing a more residential and less institutional environment is the goal while balancing healing environments with safe environments.
•
Look for opportunities to support social interaction. Large open day rooms break down the barrier between patients and staff and encourage communication with each other. Circular group therapy rooms create a sense of equality among all members and contributes to increased communication.
•
Remember families are important too, especially for adolescent patients. In addition to large patient activity areas, make sure smaller, private and more intimate environments are available. Consider locating these near the unit entrances to protect the privacy of other patients.
•
Remember people in recovery need to stay connected to their support network. Include a “communication hub” within the public area so patients can charge their phones, get online, use their tablets, etc. Best Practices in Behavioral Health Design | PAGE 23
6 5 1 1 4
7
2 3
PATIENT ROOM DESIGN While most hospital inpatients spend the majority of their time in their room recovering, patients in behavioral health facilities are not encouraged to spend large amounts of time in their rooms. Typical med/surg rooms are designed to ac-
8
2. Maintainability and durability must also be addressed in design. Behavioral health environments are often subjected to significant wear and tear. Furniture and surfaces need to be impact resistant. This is especially important in bathroom design.
commodate family members, while behavioral health units
3. Special attention needs to be paid to acoustics within the
need to have space set aside for family visits. New models
patient room environment. Patient rooms often feature hard
of care encourage interaction and participation with others
surfaces to meet durability and safety requirements and
and staff. Patient rooms in behavioral health facilities are
this can lead to an “echo� effect that results in an institu-
used for relaxation, time alone and treatment and the room
tional feel.
design has a significant impact on the recovery and behavior of patients.
4. Patients need to be able to personalize their rooms. Furniture that provides shelves for patients to store their
The trend is moving toward single occupancy rooms. This
belongings is both safe and attractive. Marker boards and
allows more patient assignment flexibility, enhances patient
wall surfaces that can accommodate pictures/posters helps
privacy and reduces disruptions and incidents related to
patients feel at home.
a shared patient bedroom. However, double occupancy rooms may be desirable for some patients for social or clinical reasons.
5. Room color can be another important factor in creating a calm environment. Chromotheraphy studies show that rooms in blue, green and violet result in less agitated and
Design considerations include:
aggressive behavior.
1. Safety is of paramount importance. Selecting tamper
6. Lighting is very important in behavioral health design.
proof furniture, fixtures and other elements such as win-
Lights timed to match circadian rhythms helps to establish
dows with integral blinds and laminated glass on the interior
routines for patients. Lighting can also help create visual
surface, anti-ligature doors and hardware is critical to en-
texture in rooms.
suring the safety of patients and staff. PAGE 24 | Best Practices in Behavioral Health Design
7. Access to nature, whether through direct views to the outside or nature-themed art has been effective in reducing medication needs and contributes to a calming environment.
dignity, while incorporating patient safety features. Whether you are renovating a space or designing a new facility, the subject of patient bathroom doors will be a ‘hot topic’ of discussion. Many factors must be considered, in-
Click here to view our design book on
cluding the acuity of the patient, single or double occupancy,
“The Healing Power of Art.”
sight lines of staff and patient privacy.
8. Wood grain pattern sheet vinyl flooring and molding pro-
To prevent barricading and enhance patient safety, all pa-
file rubber base provide a residential feel, while offering easy
tient bathroom doors should:
to clean and sound-absorbing materials. Seemingly small details must also be carefully considered, in particular, the type of floor base and how securely it is attached to the walls; doors; and, door hardware. In addition,
•
Swing out into the patient room.
•
Feature a continuous door hinge.
•
Include lever-type door hardware with no return for use
there are a multitude of products available which can reduce the risk of sentinel events, such as sensors that alert staff if pressure is exerted on
as an anchor point.
•
The door latch should release when attempted to be used as an anchor point.
the tops of doors should a patient attempt to
There are numerous options to select from:
harm themselves. Option 1 – Door-Top Pressure Sensitive Alarm: This option
Recognizing patients
allows a standard door to be installed in inpatient rooms. A
may need to transition
sensor either mounted on the door top or within the door
from their private room
frame, signals the nurse station if weight is applied to the
into a more public so-
door.
cialization zone, consider providing a built-in
Option 2 – Out-Swinging Door with Sloped Top utilizes a
bench and a soffit to
standard swinging door with the top of the door cut at a 30°
create a “front porch.”
angle or greater to prevent the top of the door being used as
Including artwork will create a unique identifier
Toilet room at Children’s National Medical Center Photographer: Halkin Mason
to assist in finding their room.
an anchor point. This modified door is not as visually appealing and home-like as a straight edge door and provides less privacy. Option 3 – Soft Suicide Prevention Door: This product eliminates many of the self-harm hazards associated with a typ-
INPATIENT BATHROOM
ical door. The door is attached by magnets that break away with the application of only 20 pounds of vertical pressure.
Inpatient bathroom design is one of the biggest design
This door cannot be locked or latched in any manner.
challenges within a behavioral health unit. According to the Joint Commission, 75% of inpatient suicides take place in
Option 4 – No Door: With more and more facilities migrating
the bathroom, bedroom or closet, so designing for patient
to a private patient room model for inpatient mental health
safety is an important design driver. However, it is import-
facilities, many are eliminating bathroom doors entirely and
ant to achieve the correct balance between patient safety
opting for privacy curtains at the bathroom entrance. Similar
and creating an environment that supports recovery. The
to cubicle curtains, privacy curtains can also be designed
bathroom should be designed to respect patient privacy and
ligature-safe. Best Practices in Behavioral Health Design | PAGE 25
SAFE DESIGN CAN BE BEAUTIFUL You can achieve a residential feel within an inpatient behavioral health bathroom. For the Zucker Hillside Behavioral
2
Health Pavilion at North Shore Long Island Jewish Hospital in Long Island, NY, Array Architects balanced safety and aesthetics:
4
1. Use of large tile on the walls and color coordination of the large tile with smaller 2” x 2” floor tiles, utilized for slip
5
resistance. 2. Inclusion of accent tile around a safety mirror to add color and create a non-institutional environment.
6
3. A built-in niche for the sink with solid surface material provides a vanity-like amenity and reduces looping hazards.
3
The built-in panel protects the pipes below the sink and is
1
attached with tamper proof screws. 4. Incorporate built-in shelving to hold personal items and toiletries. 5. The inclusion of a “Brainwave” shower and faucet system
is especially important to specify behavioral unit-specific bathroom accessories.
allows the patient to control the temperature of the water up
Grab bars are recommended for both ADA-accessible and
or down by a set amount of degrees. This offers the patient
regular rooms, as many inpatient behavioral health patients
control over their environment, a critical element in recovery.
may be on medications that could increase their fall risk.
6. By including a built-in seat covered in wall tile, the shower is both ADA accessible and provides a spa-like feel. TOILETS, FIXTURES AND ACCESSORIES
The grab bars should be fixed to the wall with a solid blocking material on the bottom of the bar to prevent using these bars as anchor points or becoming a looping hazard. While most state behavioral health codes allow a six inch
Patient toilets in behavioral health facilities need be de-
cord on nurse call systems, Array recommends the use
signed with both durability and patient safety in mind. They
of push button nurse call systems and locate them within
should have a shape that discourages ligature attachment,
reach of the floor in all rooms, again in case the patient does
as patients have been known to loop sheets around the
fall.
toilet and create a “twist ligature.” For this reason, there should be no exposed piping. Controls should be installed to prevent excessive flushing that could result in flooding. Push button or motion-activated flushometers should be considered and mounted either recessed or flush to the wall to avoid looping hazards.
Toilet tissue dispensers need to be completely recessed into the wall so as not to present a ligature hazard and coat hooks need to feature pressure sensing mechanisms so that when looped and pressure is exerted, it will automatically tip down so as not to present a looping hazard. These items often need to be approved by the respective state
Array recommends floor-mounted toilets with an integral or
mental health authorities, so consider that before specifying
built-in seat. Wall mounted toilets can be ripped from the
any accessories.
wall by stepping/jumping/standing on them. In addition, detachable toilet seats can be used as a weapon. It PAGE 26 | Best Practices in Behavioral Health Design
All fixtures and accessories need to be installed with tamper-resistant screws.
07
Impact of Color in Behavioral Health Outcomes
“An individual’s response to color is too complex to allow a simple model of interpretation. But, I believe there is a relationship between color and personality.” - Carl Jung Best Practices in Behavioral Health Design | PAGE 27
MEDITATION IMPACT OF COLOR Colors can have a psychological and physiological effect on all of us. Color comes from daylight which contains all eight colors of the spectrum: red, orange, yellow, green, turquoise, blue, violet and magenta. Color therapy is the use of color in a variety of ways to promote health and healing and is based on the premise that different colors evoke different responses in people. Based on numerous studies by Drs. Morton Walker, Robert Gerard and Faber Birren, the link between color and physiological response has been well documented. Their research demonstrated that an individual’s pituitary gland sends signals to the adrenal gland and adrenaline is released when exposed to red. Conversely, when exposed to blue, an individual’s brain secretes hormonal neurotransmitters that have a tranquilizing effect. 1, 2 Color has played a role in healing for centuries.
•
At the temple of Heliopolis in ancient Egypt, patients were treated in rooms specifically designed to break up the sun’s rays into the colors of the spectrum.3
•
In ancient Greece the physical nature of color was dominant. Color was intrinsic to healing, which involved restoring balance and colored miner-
STRESS REDUCER
als, stones, crystals, salves and dyes as remedies. 4
•
In India, practitioners of Ayurveda teach that specific colors corresponded with each of the seven chakras, the energy centers that represent organs, emotions and aspects of the spirit. Today Ayurvedic medicine continues to use color to treat a wide range of mental and physical symptoms.5
As healthcare designers and providers, it is important to understand the impact of color on the built environment. Beginning in 1979, Alexander G. Schauss (Director, The Institute for Biosocial Research, Graduate School,
PASSION AND ENERGY
City College, Tacoma, Washington) published multiple papers on the tranquilizing effect of colors and found that color reduces aggressive behavior and violence. 6 In 1990, scientists reported to the annual conference of the American Association for the Advancement of Science on the successful use of blue light in the treatment of a wide variety of psychological problems, including addictions, eating disorders and depression. As a result, color is becoming widely accepted as a therapeutic tool in behavioral health settings. Array has recently completed work with Catholic Health Partners on several behavioral health projects which were designed by incorporating chromotherapy into color selections.
SOURCES: 1. The Power of Color by Dr. Morton Walker (1990) 2. Color Psychology and Color Therapy by Faber Birren, McGraw-Hill Book Company (1950) 3. Chromopathy by Hassan, M, Peshawar: Institute of Chromopathy (2000) 4. Colour Therapy by Graham H. Discover, California, USA: Ulysses Press (1998) 5. http://nccam.nih.gov/health/ayurveda/introduction.htm 6.Schauss AG. Tranquilizing effect of color reduces aggressive behavior and potential violence. J Orthomol Psych 1979;4:218 7. The Power of Color: Creating Healthy Interior Spaces by Marberry, S. O., & Zagon, L, New York, USA: Wiley (1995)
PAGE 28 | Best Practices in Behavioral Health Design
EMOTION AND WARMTH
OPTIMISTIC AND CLARITY
CALM
HEALING AND NURTURING
RELAX Best Practices in Behavioral Health Design | PAGE 29
08
Renovation Design Considerations
St. Joseph’s Behavioral Health Recovery Center / Tampa, FL Photographer: Scott B. Smith
When renovating a patient floor into a behavioral health unit, especially one focused on integrated or Milieu Therapy, there are many factors to take into consideration. There are significant differences:
Medical/ Surgical Unit Treatment takes place primarily in patient room
Behavioral Health Unit Treatment takes place outside of room in activity spaces or interview rooms
Nurse Station location dictated by travel distances and primary
Nurse Station location dictated by sight lines to patient rooms
traffic flow
and unit observation
Family space in patient room is important
Family space is discouraged in patient room
Multiple product and material hazards in room (medical gases,
Minimal product and material hazards in room. Focus is on
furniture, etc.)
keeping patient safe from self harm.
Additional space on unit is not required (i.e. group therapy,
Unit needs to include different types and sizes of spaces for
dining)
large and small meetings, reception.
Direction of door swinging not important
Direction of door swing is important to resist barricading.
Requires safety and fall prevention equipment
PAGE 30 | Best Practices in Behavioral Health Design
Requires specialty hardware and fixtures that are tamper resistant.
Behavioral Health Safe Hardware
DIFFERENCES IMPACT COST The most significant differences between a medical/surgical unit and a behavioral health unit are often the items you DON’T see. Due to safety requirements, behavioral health units require specialized, tamper proof fixtures and equipment that are more expensive than traditional hospital construction costs. Many are obvious: door hardware, toilets, faucets. However, there are many others that are not as obvious such as specialized lights and windows. Below find a comparison of costs between basic items in each type of unit:
Medical/ Surgical Unit
Behavioral Health Unit
R8 2x4 Volumetric Light
$124.00
R8 2x4 Volumetric Light Sealed
$515.70
Night Light
$10.17
Vandal Resistant Night Light
$146.00
Toilet Room Door
$245.00
Sloped Safety Door
$794.00
Toilet Paper Holder
$12.50
Recessed Toilet Paper Holder
$150.00
Best Practices in Behavioral Health Design | PAGE 31
DESIGN CONSIDERATIONS:
2
REUSE OF EXISTING PATIENT ROOM 1. Rooms have headwalls that are not needed
1
2. Rooms have lighting that is not Psych safe and devices in ceiling such as HVAC, sprinkler heads and curtain tracks need to be
3
modified or replaced
8
3. Rooms do not have impact resistant walls 4. Windows are not impact resistant, Replace/Retrofit? 5. Mechanical devices typically need to be replaced; thermostats
4
7
should be located in the return ductwork. Providing individual con-
6
trollability to the rooms is desirable as well as keeping any serviceable item located outside patient room for safety.
5
6. Door hardware needs to be replaced as well as features such as top of door alarm sensors considered. 7. Patient casework / wardrobes are not Psych safe, solid Phenolic
Existing medical surgical patient room at Mercy Lourdes Behavioral Health in Paducah, KY. Photographer: Lee O’Kelley
material vs. laminated materials are better suited to this environment 8. Flooring is often not monolithic, base is typically easily removed DESIGN CONSIDERATIONS: REUSE OF EXISTING PATIENT TOILETS
•
Door and hardware not psych safe. Consider eliminating doors in private rooms.
•
Plumbing fixtures and toilet accessories are not anti-ligature
•
Lighting, electrical and plumbing have the ability to be con-
Existing medical surgical toilet room at Mercy Lourdes Behavioral Health. Photographer: Lee O’Kelley
trolled and disabled, if required, from the staff station.
•
Outboard toilets are better than inboard. A nested toilet design is optimal. TYPICAL IN-BOARD TOILET CONFIGURATION
TYPICAL OUT-BOARD TOILET CONFIGURATION
NESTED TOILET CONFIGURATION IS OPTIMAL
VARIES 24'-30' TYPICAL
VARIES 24'-30' TYPICAL REQUIRES THREE ROOM MODULES
DOOR SWINGS IN SINGLE DRAIN
NO UNIQUE IDENTIFIERS FOR THE ROOM IN THE CORRIDOR
OUTSWINGING DOORS
BENCH WITH ARTWORK
ADDITIONAL DRAIN TO CATCH FLOODS FLOOR MOUNTED WC SINK BUILTINTO ALCOVE BLIND SPOT
8'-0" CLEAR
PRIVATE GRAB BARS EXTEND TO CORNER
ALL HEADWALL SERVICES NOT REQ'D WINDOW REQUIRES PROTECTION
SEMI-PRIVATE
DESK WINDOW AND LIGHT IS FAR FROM BED
WARDROBE
OTHER ITEMS TO CONSIDER: 100 SF PRIVATE 160 SF SEMI CLEAR FLOOR AREA REQUIRED
OTHER ITEMS TO CONSIDER:
IF BATHROOM IS RENOVATED TO BE ADA ACCESSIBLE FITTING TWO BEDS IS OFTEN PROBLEMATIC
PAGE 32 | Best Practices in Behavioral Health Design NO MIN. BED CLEARANCES ARE REQUIRED
- LIGHTING - SPRINKLER HEADS - HVAC DIFFUSER TYPE -PLUMBING FIXTURES - DOOR HARDWARE - CUBICLE CURTAINS - CEILING HEIGHT AND TYPE - WARDROBE AND DESK
TYPICAL IN-BOARD TOILET
- IN GERIATRIC MAY WANT BED ON SAME WALL AS TOILET WITH HANDRAIL TO PREVENT FALLS - LARGE EXTERIOR WALL PROMOTES MORE NATURAL LIGHT - ACCENT COLOR/ARTWORK TO HELP WITH WAYFINDING
TYPICAL OUT-BOARD TOILET
NESTED TOILET CONFIGURATION IS OPTIMAL
Who We Are ARRAY-ARCHITECTS.COM SAMPLE RENOVATION FLOOR PLAN STRATEGIES
•
For preferred design of the patient toilet the option of utilizing the space taken by 3 patient rooms the design can allow for back to back nested toilets between 2 patient rooms. This requires relocating plumbing risers and is typically budget driven
•
The core needs to accommodate very different programs such as large open day spaces, minimizing blind corners and promoting good staff supervision.
•
Designing spaces flexibly, using multi-purpose space and dual function group rooms that can serve Inpatient and outpatient population through scheduling.
MERCY LOURDES BEHAVIORAL HEALTH FLOOR PLAN- BEFORE
We Are Healthcare Architects We are a team of architects and designers with unique backgrounds, but we all have one thing in common - we share a strong desire to use our expertise and knowledge to design solutions that will help people in moments that matter most. This focus makes us leaders in our field. Array Architects offers a full complement of knowledge-based services including planning, architecture, interior design and advisory services. Array is ranked by Modem Healthcare in the top 35 largest firms in the US, by design fees earned in 2013. When comparing fee volume of design firms focused exclusively on healthcare, Array has a #1 ranking across the U.S. In Architectural Record’s Top 300 List, Array is ranked 83 worldwide. Array Architects is recognized by Architect Magazine in their Top 50 for Business ranking. Together, we discover optimal solutions with our clients. It is our four decades of specialization that allows for effective communication, collaboration and precision in the complex, changing world of healthcare.
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Click here to visit our blog. MERCY LOURDES BEHAVIORAL HEALTH FLOOR PLAN- AFTER
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