Rural Resolve by H D R

RURAL RESOLVE An HDR Fellowship

RURAL RESOLVE IMAGINING THE FUTURE HEALTH AND WELLBEING OF SMALL COMMUNITIES

WINNER OF THE NATIONAL AIA AAH AWARD FOR URBAN DESIGN AND MASTER PLANNING

0087059 1220

IN PARTNERSHIP WITH:

University of Kansas School of Architecture and Design University of Nebraska - Lincoln College of Architecture

A 2020 FAST COMPANY WORLD CHANGING IDEA FINALIST

THOMAS J. TRENOLONE, AIA, EDITOR

“Over time silos rose with ever greater assurance and created the landscape of the New World. In abandoning the problem of form, they rediscovered architecture.” — Aldo Rossi, describing the grain elevators of the Great Plains

Introduction Thomas J. Trenolone, AIA About 41 percent of our nation’s rural hospitals nationally operate at a negative margin, meaning they lose more money than they earn from operations. More than 20 percent of them, or 430 hospitals across 43 states, are near collapse. Since 2010, 113 rural hospitals across the country have closed. This is happening despite the fact that rural hospitals are not only crucial for healthcare but also for the survival of their small rural communities. About 60 million people—nearly one in five Americans—live in rural areas and depend on their local hospitals for care. Many residents of rural communities are familiar with the consequences that a lack of access to hospital and emergency care means if they break a leg, go into early labor, or have progressive chronic diseases. These consequences are compounded by other signals of decline and deterioration. Hospitals are financial and professional anchors as well as a source of pride for their small rural communities. A rural hospital closure often means loss of other employers or inability to recruit new employers due to lack of nearby healthcare. When a rural hospital closes its doors, unemployment often rises and average income drops.

This publication represents the findings from a number of parallel research investigations that explore the following questions: •• Can a new concept in master planning— one informed by unconventional thinking about building typologies, their related programmatic elements, and how their adjacency to one another can be a catalyst to transform rural communities in order to mitigate or reverse the devastating impacts of recent trends. •• By encompassing the multiple issues of health, wellness, economics and design, can we create an environment that offers a unique and positive community identity and helps improve the quality of life in rural towns throughout the country? •• Can a reimagined main street bustling with activity be the economic engine that can potentially save thousands of small rural communities and provide residents with critical access to convenient health services by increasing the financial security of their health provider? •• Can this same concept be replicated in rural communities throughout the country, helping to revive and save Main Street USA?

Introduction 02 Gotta Have Some of Your Attention by Thomas J. Trenolone Unique Pairings by Thomas J. Trenolone

STATE OF THE RURAL

05 11

Timeline 18 Rural Demographics

Culture of Community: A Precision Approach to Small-town Living by Ashley Glesinger

02 EVOLVING HEALTHCARE

Recent Headlines

Rural Healthcare by the Numbers

Case Studies: Rural Towns

03 ESTABLISHING FRAMEWORK

Can the Countryside Change the Fabric of America? by Melissa Smith University of Kansas Case Study: (reFORM): Saving Main Street USA Impacting the Health of a Rural Community by Designing a Hybrid Community Hospital by Kent Spreckelmeyer, FAIA

95 104

121

04 BROAD DIAGNOSIS

135

University of Nebraska-Lincoln – Arch 610 Studio

138

Case Study: Fairbury, NE

144

Case Study: Beatrice, NE

154

Case Study: Alliance, NE

164

05 APPLIED PROTOTYPE

173

Case Study as Catalyst: Haxtun, CO

06 LAST WORD Like Water, We Work over Time by Thomas J. Trenolone

07 SOURCES AND ACKNOWLEDGMENTS

176

219 221

225

Gotta Have Some of Your Attention Thomas J. Trenolone, AIA This publication represents several years of investigation on a subject that is quite personal to me and my fellow contributors. You see, many of us have family members who farm in small communities throughout central Nebraska, and we’ve witnessed through their eyes the devastating impacts that have resulted from the collapse of healthcare facilities and networks in these small towns. And yet, what we discovered during our research is this: The issues they face are similar to those faced by components of large cities like Chicago and Detroit. Admittedly, racial diversity and population might be significantly different in each case, but the pervasive problems of health and wellness are the same regardless of a person’s address. With this in mind, we selected three key issues to explore in this publication: Access, affordability and—especially relevant and timely to this conversation—attention. The first two are issues inherent to healthcare delivery and have been the subject of many investigations. We’ve added attention as a third because, frankly, the time has come to accentuate the rural healthcare crisis. It was for that reason that I was very excited to experience Rem Koolhaas’s “Countryside” exhibit at the Guggenheim in New York. But like so many others, I was ultimately unable to visit it—or participate in a planned symposium

on the subject—because of COVID-19. Our team was especially interested because we found the conversation that Koolhaas championed with this narrative significant. It was a narrative that I first heard him speak about at the World Architecture Festival (WAF) in Amsterdam in 2018. “I definitely contributed to the enthusiasm about cities, but at some point I simply woke up to new logic...if you look at the countryside you see changes that are really drastic, really large scale, really physical, substantial, sociological, anthropological, and political. Therefore, the countryside is a much more unstable world than the urban environment. Particularly if you then also combine that and look at the rhetoric of the smart city and the pressure to continuously welcome a more wired and sensor-based urban life and the incredible pressure to also modify architecture though the same technology— then you begin to see that this neglect of the countryside not very smart or fair.” Rem Koolhaas, World Architecture Festival, November 30, 2018 His words affected me profoundly. For not only do I have family seeking to survive in rural communities, but I am also a graduate of two land grant institutions and a leader in a design practice that came into its own by literally helping light up rural communities during the period of the Rural Electrification Act of 1936 (introduced, interestingly, by U.S. Senator George William Norris, also from Nebraska). I feel the time has come again to focus on the Rural and to resolve to stop neglecting it as designers. Yes, cities are facing important issues—but so are rural communities and together they are equal parts of the greater whole that is our world.

The rural component might be defined by smaller populations, but those numbers alone do not make it insignificant or meaningless. During our research for this book, we began to better understand and see the physical reinforcement of the comments made by Koolhass in Amsterdam. Coincidentally, in a recent design competition, a member of the jury offered this comment about the concepts and proposals we explore in this study: “Too focused on rural transects, and fails to provide a compelling economic argument for the large capitalization required.” We saw this comment as an indictment of the current health and wellness establishment. It identified just how focused our society is on the idea of apps and telemedicine, on the idea of “the smart city” and how “modifying architecture through that technology” is the only way to innovate. But where does that leave the fact that physical space helps us behave and connect to one another? We are not naive to believe that architecture and design can solve all the world’s problems, but we do believe that architecture and design needs to lead the conversation. And though we have not solved the economic argument in this publication, we posit that perhaps the current way of thinking is too concerned with this. After all, if that singular argument had been made when faced with the issue of rural electrification, many small communities would still be reading by candlelight.

We have assembled Rural Resolve in the grand tradition of the fantastic collaboration between architects Steven Holl, Mark Mack and bookseller William Stout when they first published Pamphlet Architecture in 1978. What we hope you will find in these pages are ideas and data that will spark conversations, identify champions and engage collaborators. We hope you will be introduced to ideas that will help communities examine issues from a new point of view. It’s critical to note that this publication was not researched, designed, or assembled by a single person. It was created through an energized collaboration of different generations, institutions and professionals. Each person represented a unique background and experience, and through this united effort, these many voices came together to focus attention and resolve to the future of rural communities. We did so inspired by the lyrics of the Pretenders’ song; “Brass in Pocket:”

“Gonna use my, my, my imagination… Gonna make you, make you, make you notice.”

Unique Pairings Mom, Dad, Baymax, and the Critical Access Hospital Thomas J. Trenolone, AIA MOM AND DAD My mother is an art teacher and my father was a United States Marine, who later became a hospital administrator. At the end of his tour in Vietnam, he served as part of the Marine detachment on the United States Navy hospital ship Sanctuary. This experience would go on to define his career managing medical centers and later, after receiving his Master’s degree, becoming a hospital executive overseeing strategic master planning and construction of several systems. My father was not an architect, but he loved building big complex things that required working with teams of people. My mother—not to be outdone—was an art teacher and early adopter of innovation and new media. In the’70s, every Wednesday during the school year children in classrooms all across Nebraska would tune into Nebraska Educational Television (NET) to see my mom teach art: illustration, drawing, painting and ceramic sculpture. She also inspired my love of art and design books. I surround myself with more books than my dyslexic brain could ever read in my lifetime (an addiction that could be the subject matter of its own essay). My parents’ unique life experiences taught me discipline and a love for being part of a group, while also fostering a need for dissent and a dash of revolutionary thinking.

Additionally, a middle-class American upbringing built on the struggles and risk of immigrant relatives instilled the need to look out for my fellow man. My family was a melting pot of European cultures and values (German, Irish, and Italian) wrapped in a very ‘70s and ‘80s American blanket. You can see how an architect could evolve from such an environment. My first exposure to real-life architects came from meeting members of the firm working at my father’s hospital, Good Shepard Medical Center in Longview, TX, as they renovated the delivery department. I have always seen healthcare as a noble building type and, to honor my Dad, I continue to make it part of my architecture practice. Two recent engagements have inspired me to more in-depth study about the intersection of architecture and health and well-being.

BAYMAX I’ve been an avid comic book fan even before Hollywood began its epic binge on the matter. I’ve also been a Marvel loyalist for as long as I can remember. I was saddened when Marvel Studios was acquired by Disney, but then subsequently surprised when the obscure Marvel title “Big Hero Six” was its first collaboration with Disney Animation Studios—and that the imagination of the team and one of its central characters was outstanding.

Baymax, the robot at the center of the “Big Hero Six” narrative, was built by a young designer/inventor named Hiro and his “wicked, like MIT smart” friends. Originally designed as a healthcare companion, Baymax sits in his compact charger and when you call for him or say “ouch,” he inflates and comes to your aid. This version of Baymax is a soft white marshmallow fellow with a soothing First, I have been fortunate to work with the voice. But then tragedy ensues when Tadashi, CEO of Saint Anthony Hospital, Guy Medaglia, Hiro’s big brother and fellow inventor, is killed as he seeks to realize a development called in a suspicious fire. In his grief and need to the Focal Point Community Campus, a avenge his brother’s death, Hiro sets out to new vision of health and wellness for the create a suit of armor for Baymax. One of the Chicago communities of Little Village and most memorable quotes from the film comes North Lawndale. Working on this project has as Baymax is fitted with his new shiny red and prompted me to wonder what pairings we purple armor that gives him, among other would need for health and wellness to flourish things, the power of flight. Baymax turns to in the future city. Additinally, the support Hiro and says “I do not see how flying makes of community/economic leaders like Trisha me a better healthcare companion?” Herman, executive director of Phillips County Economic Development in Colorado, and As health and wellness designers and her involvement with our effort to reimagine leaders, how often do we ask this same type the Haxtun Hospital District motivate me to of question? search for ways we can reconsider health and wellness through unique pairings in the rural/ At the climax of the film, a young woman needs rescuing and the only way Baymax can small town setting in a time where access to reach her is by flying to her. At this moment, healthcare in small communities continues to Baymax realizes that flying does indeed simply disappear. 12

make him a better healthcare companion. He understands that as good and dependable as he is as a caregiver, the most important thing he can do is be preventative and proactive toward injury and illness. Most healthcare professionals know this is not a new revelation. But what if we could pair their understanding and insight with the outreach of our day-to-day environment, like Hiro did with Baymax and his armor?

MAIN STREET AND THE CRITICAL ACCESS HOSPITAL In the United States, rural hospitals are facing a crisis of their own, one many consider a mass extinction event. They are being forced to close in increasing numbers, creating gaps in important emergency transit times and leaving community residents without access to medical care in their community. The idea that a resident of a town of a thousand people can’t receive emergency, orthopedic physical therapy or OBGYN services without making a two-hour trek seems wrong. Concepts of Micro-Hospitals or freestanding Emergency Departments are worthwhile stop gaps, but they are finite at best. In many ways we’re repeating the same mistakes that mall owners made when they believed that a theme refresh and new retail tenants would resuscitate a dying bricks and mortar retail model. “The same but different” can extend the model, but it is not a sustainable solution . However, when retail was combined with diverse programs that anchor people to areas where they work, live and socialize, and when people can navigate in a safe pedestrian environment, the success rate has been exceptional. So much of what we value in vibrant communities comes from the roots of

the agora that subsequently evolved into the main street that is and/or was the bedrock of America’s rural towns. As cities and towns have evolved, civic anchors paired with the main street (agora) and public square (piazza) also changed. In ancient times, it was the Forum. During the Renaissance and Medieval times, cathedrals became the focus. In another time, the courthouse became an anchor for the towns of the American west. I offer this history lesson as part of the evolution of the critical access hospital, which is frequently a community’s largest employer (often 10 to 25 percent of the community’s population). Could it be the next civic anchor to be paired with the main street? Particularly now when the greatest threats to civilization is not lawlessness, but climate, equity, health and wellness? Is the main street paired with the critical access hospital the answer to the crisis facing our rural hospitals? Mixed with other program elements like a retail pharmacy, a retirement center/long term care facility, can we offer the ability to remove the critical access hospital from its isolation and self-dependence? I believe that the long-term solution of the rural medical center is not breaking it up and leaving the Emergency Department behind, but instead pairing it with community/ national retailers and civic institutions and returning them to main street. These unique pairings and partnerships will become the critical access hospital’s suit of armor, providing the power of flight. By combining them with some “wicked smart” partners, they will realize that flying makes them a better healthcare companion! 13

STATE OF THE RURAL We began our investigation by exploring the current state of small communities, including a look at the historical events and happenings that have contributed to their present-day status. Information presented on the following pages provide a solid foundation for how we might address the future.

Timeline

This timeline highlights key milestones of growth and evolution for urban and rural communities. Notable is that upward spikes for rural communities coincided with capital infusions by state and federal government programs that attempted to make development more equitable. Indicators show that without these occasional moments of assistance, rural communities would quickly fall behind, which is especially evident with the Rural Electrification Act of 1936 and Hill Burton Act of 1946. 1833 Chicago’s First Post Office Begins Service

1848 Galena & Chicago Union Station Begins Service

1856 America’s First Integrated Sewer System was Built in Chicago

1850 1 Post Office for Every 1,250 People, 3/4 of Rural Towns not Serviced

25.7%

1800

7.3%

7.2%

8.8%

1810

1820

1830

10.8

1850

39.6% 35.1 28.2

1908 Kansas City Begins Using 1892 Electric Chicago’s ‘L’ Streetcars Train System Begins Operation

19.8%

1860

1870

1862 Pacific Railroad Act of 1862 Homestead Act of 1862 80.2%

RURAL 93.9%

92.7%

80.2% 92.8%

91.2%

89.2%

84.6%

Taft 1909-1913

45.6%

1840

Roosevelt 1901-1909

1893 Chicago World’s Fair Midway designed by Frederick Law Olmsted

15.4% 6.1%

McKinley 1897-1901

1888 Edison’s First Central generating station o pens in Chicago

1882 Kansas City’s Main street is Electrified 1973 KC Library is Founded

Cleveland 1893-1897

B. Harrison 1889-1893

Garfield 1881 Arthur 1881-1885 Cleveland 1885-1889

Hayes 1877-1881

Grant 1869-1877

Johnson 1865-1869

Lincoln 1861-1865

Buchanan 1857-1861

Taylor 1849-1850 Filmore 1850-1853 Pierce 1853-1857

Van Buren 1837-1841 Harrison 1841 Tyler 1841-1845 Polk 1845-1849

Jackson 1829-1837

J.Q. Adams 1825-1829

Monroe 1817-1825

Madison 1809-1817

Jefferson 1801-1809

J. Adams 1797-1801

ADMINISTRATION

1880

1890

1890 Carnegie Grants for Library Buildings

1900

1902 Rural Free Delivery Becomes Law 60.4%

64.9% 71.8%

1910

54.4%

Biden 2021-2024

Trump 2017-2020

Obama 2009-2017

G.W. Bush 2001-2009

Clinton 1993-2001

G.H.W. Bush 1989-1993

Reagan 1981-1989

Carter 1977-1981

Ford 1974-1977

Nixon 1969-1974

Kennedy 1961-1963 L.B. Johnson 1963-1969

Eisenhower 1953-1961

Truman 1945-1953

F.D.Roosevelt 1933-1945

Hoover 1929-1933

Wilson 1913-1921

Harding 1921-1923 Coolidge 1923-1929

80.7%

73.6

56.1%

59.6%

56.5%

73.7

79.0%

75.2%

URBAN

63.1%

51.2%

CONDITION OF THE BUILT ENVIRONMENT

2007 The iPhone is Released with Service Provided by AT&T

2012 89% of Americans Have Broadband Access (11% of Not Access Primariy in Rural and Tribal Areas)

1920

1930

1940

1950

1960

1946 Hill Burton Act

1934 Communications Act

1970

1980

26.4%

26.3

1990

24.8%

36.9% 48.8%

1914 Smith Lever Act Establishes University Extensions

43.9%

21.0%

19.3%

2020

1997 Critical Care Hospital Legislation

1956 Federal Aid Highway Act of 1956

1936 Rural Electrification Act

2010

2000 Ethynol Boom

40.4%

43.5%

2000

1980 1980’s Farm Crisis

2018 Consolidated Appropriations Act

Rural Demographics Agriculture Then and Now 1860–2010

1860*

2010**

% Change

Number of farms

2,044,000

2,201,000

7.68

Total acreage

407,213,000

921,000,000

126.17

Average acreage per farm

199

418

110.05

Total U.S population

31,443,321**

308,745,538

881.91

Labor force in agriculture

15,141,000***

2,113,000

-86.05

% of population in agriculture

48%

0.68%

N/A

% Change -100 -80 -60 -40 -20 0 20 40 60 80 100

200

300

Total U.S population Total acreage (2010) Average acreage per farm (2010) Labor force in agriculture (2010) Number of farms (2010)

% Change

400

500

600

700

800

County Economic Typology 2015 Edition

OGY

Nonmetro Counties Farming - Dependent (391 Counties) Mining - Dependent (184) Manufacturing - Dependent (348)

NTIES NONMETRO COU

S) ENT (391 COUNTIE FARMING - DEPEND ENT (184) MINING - DEPEND ) - DEPENDENT (348 MANUFACTURING

AS URBANIZED ARE S METRO COUNTIE ) DEPENDENT (239 GOVERNMENT FEDERAL - STATE ) RECREATION (229 D (585) NONSPECIALIZE

Urbanized Areas Metro Counties Federal - State Government - Dependent (239) Recreation (229) Nonspecialized (585)

Median Household Income $54,300 $56,100

Median Net Worth $154,000 $93,300 $50k

$100k

$150k

$200k

US Median

Income and Net Worth Net worth measures total household assets (homes, vehicles, investments, etc.) less any debts, both secured (e.g. mortgages) or unsecured (credit cards). Household income and net worth are estimated by Esri.

$250k

$300k

HOUSING

FOOD

APPAREL & SERVICES

TRANSPORTATION

HEALTH CARE

ENTERTAINMENT & RECREATION

135

EDUCATION

PENSIONS & SOCIAL SECURITY

266

OTHER

66 0

100

150

200

250

300

Average

Average Household Budget Index This index averages the amount spent in rural household budgets for housing, food, apparel, etc. 100 is average.

Where Income Goes Per Year Fishing $200 Gaming $864

Mower $2,000

UTV $11,000

Guns $500

Gardening $300

Alcohol $500

Media $1200

Truck $34,000

MEDIAN HOUSEHOLD INCOME: $52,386

Tractor $4,000

Dog $3,000

Tiller $400

SCOTLAND NECK, NC Halifax County

SWEET SPRINGS, MO Saline County

TILDEN, NE

Antelope County

BOONEVILLE, MO Cooper County

HORTON, KS Brown County

ELLINGTON, MO ReynoldsCounty

DONIPHAN, MO Ripley County

OSWEGO, KS Labette County

ELLIJAY, GA Gilmer County

STIGLER, OK Haskell County

MARKS, MS Quitman County

HAMLIN, TX Jones County

WINNSBORO, SC Fairfield County

FLORALA, AL Covington County

LOW ACCESS TO FOOD*

HIGH DISTANCE TO SUPERCENTER*

*COMPARED TO NATIONAL AVERAGE 26

LOW ACCESS TO FITNESS CENTER*

HIGH DIABETES RATE*

Population, low access to stores (2015) 0–2,500

2,501–5,000

5,001–50,000

>50,000

of Midwest farmland is corn and soybeans

(2017). Agriculture in the Midwest. USDA Climate Hubs. www.climatehubs.usda.gov/hubs/ midwest/topic/agriculture-midwest

49% animal feed 30% biofuel

CORN

4% corn syrup 2% sweeteners 2% cereals

70% animal feed

SOY

15% human consumption 5% biofuels

Food Deserts

FOOD DESERTS AND INEQUALITY Population, LowNUTRITIONAL Access to Stores (2015) Drug convenience Drug andand Convenience

Supercenter, Supercenter, club, Club,and andlarge Largegrocery Grocery 1.0 Zip code store count per 1,000 residents

Zip code store count per 1,000 residents

.08

.07

.06

.05

.80

.60

.40

.04 20

Zip median income ($000s)

100

Zip median income ($000s)

Store Counts by ZIP Code Median Income Store Counts by ZIP Code Median Income

Rural Housing

Poverty rates by metro/nonmetro residence, 1959-2018 Percent poor (persons) 35

Poverty Rates by Metro/Nonmetro Residence, 1959–2018 Poverty rates by metro/nonmetro residence, 1959-2018 30 Percent poor (persons) 25 35 20 30

Nonmetro

16.1%

15 25 10 20

Metro

12.6%

Metro

16.1% 3.5% 12.6% points

Nonmetro Nonmetro-metro gap

5 15 0 10 1959

1969

1979

5 0 1959

1989 1999gap Nonmetro-metro

2009

2018 3.5% points

1969

1979

1989

1999

2009

2018

Population Change Metro and Nonmetro Population change by metroby and nonmetro status, 1979-2019Status, 1979–2019 Percent change from previous year 1.6 Population change by metro and nonmetro status, 1979-2019 1.2 Percent change from previous year 1.6

Metro

0.8 1.2

Metro

0.4 0.8

Nonmetro U.S.

0.0 0.4

Nonmetro

-0.4 0.0 1979 34 -0.4

U.S.

1979

1983

1987

1991

1995

1999

2003

2007

2011

2015

2019

1983

1987

1991

1995

1999

2003

2007

2011

2015

2019

Rural Home Ownership

RENT

20.7%

79.3%

OWN

Farm Worker Housing 55 50 45 40 35 30 25 20 15 10 5 0 Single Family Home

Manufactured Apartment Home

Dormitory

Duplex

Other

Motel

Campsite/ Tent

This OSHA diagram illustrates the dangers of grain engulfment. We found it ironic that it also served to illustrate the state of rural healthcare. Things might look OK on the surface, but dangerous instability of wellbeing, health and community is just beneath the surface

Culture of Community: A Precision Approach To Small Town Living Ashley Glesinger M.Arch Graduate Student, University of NebraskaLincoln College of Architecture In 1862, the Homestead Act brought settlers to the Midwest. With the agreement to stay a minimum of five years, these pioneers, my ancestors included, were given 160 acres of public land to settle as they saw fit. People did their best to create a sense of community and provide resources for the influx of people arriving in the rural Midwest. Shops, schools, and public amenities were established in hopes of creating a higher quality of life for the growing population. Now, though, urbanization is depleting the populace of these small Midwest towns. Its effects are also seen in the diminished quality of life of those who remain. Growing up in rural Nebraska, I have witnessed the consequences as well as creative attempts to combat them first hand. At the time of the Homestead Act, the rural Midwest was a land of opportunity for those looking for employment, particularly in agriculture. However, the business and technology of farming has evolved over the years to allow fewer growers to achieve higher levels of production than ever before. According to the U.S. Department of Agriculture, since 1860 the amount of farm ground has stayed relatively constant, but the population who work those farms has decreased from 48% to 0.68% of the nation’s total population.

Courtesy of Matt Glesinger

New markets like Precision Agriculture allow farmers to attain higher yields with less input. Experts in this field focus resources more strategically to increase production with the same or lesser amounts of time, energy, man power, and resources. With the need for fewer laborers to work the same number of acres and lower profit margins, agricultural employment opportunities have become scarce. Fewer farmers also means a reduced demand for supporting service industries. Without a consistent job market, pursuing a farming career (which often means returning to the family farm) after college can be challenging.

options for renters are scarce, usually limited to older single-family rentals or pre-manufactured trailer houses. Multifamily homes and apartments are hard to come by. In addition to housing, shopping and entertainment look different in small towns. Rather than shopping at well-known national brands, locally owned businesses provide amenities for residents. These businesses try to offer some assortment of merchandises, but struggle to compete with big box stores and online merchants when it comes to variety. This forces small town residents to drive further for commodities, which can have health impacts.

Lack of employment isn’t the only setback for small towns. Many young people move away for education and then get used to the conveniences urban life has to offer. One of the most fundamental of those amenities is housing. Young adults or couples looking for their first place aren’t provided many choices in rural towns. Although purchasing prices for homes there are significantly lower than those in more urban areas,

Health and wellness are seasonal in small town life. Summer gardens provide fresh fruits and vegetables, but the cooler weather shifts diets to more nonperishable items. Long distances to grocery stores make keeping fresh produce on hand impractical. The same cycle applies to physical activity. In the summer, nights and weekends are spent outdoors. Children are sent outside to ride bikes, go swimming, or spend the day at

Courtesy of Matt Glesinger

the neighborhood park with the stipulation they return before supper. Adults’ evenings are filled with sand volleyball, golf league, and slow pitch softball. When the weather grows colder, the once active community goes idle. Facilities for exercise are scarce. Beyond the high school gym, many rural residents are stuck without even a mall to take a walk in. These communities also have a large aging population in need of care. The lack of economic gain for corporation-owned skilled nursing facilities has caused many to shut their doors. To combat this, some facilities have switched to village-owned systems. This keeps the doors open, but it’s difficult to retain staff because pay is lower compared to wages paid in facilities in larger towns. These types of issues are perceivable in facilities like the Greeley Care Home in Greeley, NE, and other smaller skilled nursing facilities that struggle to deliver specialized care. In the case of Greeley, the closest emergency care is over 20 miles away, and specialists

over an hour away. Despite these issues, management works to provide care because they feel a responsibility to their town and the families that make up their local community. The obstacles facing rural America in 2020 differ greatly from those in 1860, and it might seem impossible or futile to overcome these issues to renew the desire for small town living. But the fact remains that rural residents deserve the same opportunities for a great quality of life as their urban counterparts. In order to do this, we have to understand what is working well, and use a precise and strategic implementation of program and built interventions. A preconceived notion exists that one must travel to the city to experience culture, and that rural areas are simply the “back of house for urban civilization.” I argue, however, that the countryside has a unique culture of its own. Rather than push urban ideals onto these areas, celebrating what makes rural America unique will be key in

Courtesy of Nebraska State Historical society

the comeback of the countryside. Rural Midwesterners are scrappy and resilient, and will creatively combat issues to improve life for their communities. It is important that we lean into this culture of community that keeps small towns alive.

nurses, CNAs and administrators moved into the facility for three months. By sacrificing their own personal lives for the safety of others, these workers are an example of the dedication to each other on which small communities rely.

I have often witnessed firsthand the culture of community encouraging towns to survive—most recently at the onset of the COVID-19 pandemic. The aforementioned skilled nursing facility in Greeley decided that a single loss of life to the virus would be too many. The workers grew up with many of the residents, and see them as extended family. Knowing even a minor outbreak would cause a shutdown in their small facility, they decided to put their community first, and took extreme action. Six workers,

If the goal is economic gain, the revival of rural lifestyle will be a losing battle. Getting the community to personally invest themselves in the future of their community is key. To overcome the lack of funding, a precision approach is necessary. In the case of the rural Midwest, passion and dedication are not lacking. If we are strategic in planning, precise in application of funds and energy, we can one-finger farmer-wave hello to a healthier and happier countryside.

EVOLVING HEALTHCARE On the following pages, we explore the current state of rural healthcare and the services that the critical access hospital is being asked to provide. We also offer insight into several case study communities with an expanded data set for the communities of Horton, KS, and Tilden, NE, which have both recently suffered the closure of their critical access hospitals.

Recent Headlines

Rural Healthcare by the Numbers Medicaid Expansion  States that have not adopted Medicaid expansion  Nebraska has adopted but not yet implemented Medicaid expansion

NC SC

KS OK MO MS

Rural Hospital Closures  States with 5 or more rural hospital closures since 2010

TN 14

NC 7

TX 21

Although the majority of states in the U.S. have expanded Medicaid (first offered at the beginning of 2014), a few have opted out. The goals of Medicaid expansion were to provide health insurance to more low-income adults, support states’ uninsured populations with federal dollars, reduce uncompensated care for uninsured individuals, and promote economic growth. The majority of states that have opted out of expansion are in the south, and known for their agricultural economies (5 are among the top 10

KS 6

OK MO MS 8 7 5

AL 6

GA 6

agricultural producing states in the nation, according to the USDA). The states with the most rural hospital closures since 2010 have all opted out of Medicaid expansion. Many states that have opted out of expansion also have some of the highest poverty rates, such as Mississippi, North Carolina, Alabama, Florida, South Carolina, Oklahoma, Tennessee, and Missouri.

Closures Before Expansion  States that experienced rural hospital closures from 2010–2013, before Medicaid expansion was an option

SD 1

MN 1

WI 1

MI OH 1 1

ME 1

PA 1 CA 2

VA 1 NC 1 SC 1

AZ 2

TX KS OK 3 1 1

MS AL TN GA 1 5 2 4

Closures After Expansion  States that experienced rural hospital closures after January 1, 2014, when most states adopted and implemented Medicaid Expansion  States in blue opted out of Medicaid Expansion MO n/a 6 NE 2018 MN 2014 1 3

CA 2014 2 NV 2014 1 KS n/a 5 OK n/a 7 AZ 2014 1 LA 2016 1 TX n/a 18 AK 2015 1

Although the states that opted out of Medicaid expansion have experienced far more rural hospital closures than those that adopted and implemented Medicaid expansion, it is clear that expanding Medicaid is not the only factor impacting the rural healthcare issue. States that have expanded Medicaid are still experiencing closures and have experienced an average of 1.6 closures per state since 2014. Conversely, states that have not expanded Medicaid have experienced an average of

TN n/a OH 2014 12 1

IL 2014 1

IN 2015 1

NY 2014 2

PA 2015 3

MA 2014 1

KY 2014 4 NC n/a 6 SC n/a 3 GA n/a 2

MS n/a AR 2014 4 AL n/a 1 1

FL n/a 2

six rural hospital closures per state since 2014. The expansion of Medicaid can make a difference, however states that expanded Medicaid are still experiencing high rural hospital closure rates; some have seen up to 3 rural hospitals close since 2014. This led us to believe that there are potential architectural or design solutions that could be implemented to help save rural hospitals and foster a greater sense of rural community.

2020 9

as of April 16, 2020

Rural Hospital Closures 2010–2020 I-70 Community Hospital, MO Horton Community Hospital, KS Haskell County Community Hospital, OK

Hamlin Memorial Hospital, TX Fairfield Memorial Hospital, SC

Our Community Hospital, NC

S. GA Medical Center & Gilmer Nursing Home, GA Quitman County Hospital, MS

2019 19

2018 14

2017 10

2016 12

2015 17

Tilden Community Hospital, NE

2014 16

Florala Memorial Hospital, AL

2013 14

2012 9

2011 5

2010 3 52

Medicaid Expansion

Findings

Case Study Selection

Before 2014, when Medicaid Expansion was first an option, the rate of rural hospital closures was steadily increasing. After the adoption of Medicaid expansion by most states in 2014, the rate of rural hospital closures began to decline. However, closures are once again rising, mostly in states that have not adopted Medicaid expansion, but some in states that have. Our research aims to find solutions to help.

We selected 10 case study rural towns to research standards of living in order to gain a better understanding of general rural life, rural access to healthcare, and rural access to food. Because of our proximity to the Midwest and neighboring regions, we narrowed our search to towns within these areas. Each town selected has experienced a rural hospital closure in the last 10 years and is located in a state which has not implemented Medicaid expansion.

The Rural Health Dilemma High Cost and Chronic Illness

Roughly of the land in the United States is considered urban; most of the remaining land is considered rural.

20%

Roughly of the U.S. population lives in rural areas. 54

Only

of U.S. physicians live in rural areas.

U.S. Cost of Living Index Average Population Average Density Average Cost of Health

RURAL 10 STATES

DENSITY/ SQ MI

POPULATION

100 (U.S. Average) 2,011 938.1 people per sq mi 108.4 COST OF LIVING

COST OF HEALTH

AL NE GA MS NC TX SC MO KS

Florala

1,549

147.1

74.0

99.5

Tilden

932

1,539.3

80.7

141.2

Ellijay

2,918

823.3

92.6

107.2

Marks

1,741

1,356.3

71.2

96.1

Scotland Neck

1,899

1,161.7

70.8

112.8

Hamlin

1,740

329.1

70.8

101.3

Winnsboro

3,280

1,016.1

74.0

101.8

Sweet Springs

1,572

945.3

72.5

105.6

Horton

1,758

1,053.1

70.6

101.5

Stigler

2,725

1,009.3

73.5

117.1

Average Population Average Density Average Cost of Health

URBAN 10 STATES AL NE GA MS NC TX SC MO KS OK

623,890 2,249 people per sq mi 103.1

POPULATION

DENSITY/ SQ MI

COST OF LIVING

COST OF HEALTH

209,403

1,452

74.1

101.1

Omaha

478,192

3,356

89.8

130.3

Atlanta

506,811

3,539

107.5

91.8

Jackson

160,628

1,524

82.3

103.7

Birmingham

Charlotte

885,708

2,757

98.8

100

2,320,268

3,613

96.5

92.4

Charleston

137,566

1,233

111.5

98.1

Kansas City

495,327

1,528

86.2

94.5

Houston

Wichita

389,938

2,431

82.1

102.1

Oklahoma City

655,057

1,053

85.4

117.2

Increased competition for patients drives down the cost of healthcare in densely populated urban areas. Conversely, in sparsely populated rural areas with few physicians,

the cost of healthcare is higher due to lack of competition. In 2017, for example, ruralarea benchmark premiums were roughly $39 more per month than in urban areas. 55

The Rural Health Dilemma High Cost and Chronic Illness

Urban v. Rural Healthcare Spending Urban Rural $1,061.40

Prescription Drugs

$1,278.30

and the opioid epidemic Patients in rural counties have an 87% higher chance of receiving an opioid prescription than those in large central metropolitan counties

of urban patients have an opioid prescription

The opioid epidemic has impacted as many as 74% of farmers, according to the National Farmers Union and the American Farm Bureau Federation

The Risks: Prescription drug use and misuse at an earlier age; larger populations of older adults; limited access to alternative therapies; higher rates of poverty and unemployment; isolation.

5.2%

9.6%

of rural patients have an opioid prescription

The Benefits of a Hybrid Community Hospital

concentration and increase of healthcare resources on mainstreet

Outpatient Care

Hospital Inpatient Care

Hospital Emergency Care excluding zero users

Total Expenditures

bolster the town’s sense of community to decrease feelings of isolation

introduce resident health as an enjoyable part of their everday life

decrease stigma behind seeking treatment by making healthcare central to the community

$1,252.70 $1,306.20

$1,602.80 $1,574.70

$1,636.40 $1,167.40

$4,929.50 $5,172.30

Health Inequity Urban

Rural

13.9%

Perceived Physical Health Very Good / Excellent Good Poor / Fair

17.7%

27.0%

29.1% 59.1%

53.2% 8.3%

7.1%

Perceived Mental Health Very Good / Excellent Good Poor / Fair

26.6%

22.9%

Number of Chronic Diseases None 1 2+

70.0%

65.0%

35.7%

30.3%

50.4%

42.4%

19.3%

21.9%

Perceived Limitation on Physical Functioning

33.3%

25.3%

Yes No 74.7%

66.7%

There are only 22 generalist dentists per 100,000 rural residents, compared with 33 for urban.

Rural residents are less likely to be insured for mental health services. Rural youth are 2X more likely to commit suicide than urban youth.

11% of rural adolescents smoke compared to 5% of urban adolescents.

53% of rural Americans lack access to highspeed internet, hindering their access to information.

Over 50% of vehicular crash-related fatalities occur in rural areas. Less than 1/3 of miles traveled occur in rural areas.

Rural residents are more likely to be uninsured. They are also more likely to be unemployed.

There is an additional 22% risk of injuryrelated death in rural areas.

Rural residents tend to be poorer and are more likely to live below the poverty level. Roughly 25% of rural children live in poverty. 57

The Rural Health Dilemma High Cost and Chronic Illness

Spending on Rural Financial Assistance Programs by Department Total

Agriculture

$30,743,538,121

38 programs 94.5% $29,060,803,252

$2500

other spending

public welfare spending $0 2017

1977

4 programs, 2.4%

$751,633,279

Transportation

1 program, 2.0%

$619,956,000

Education

1 program, 0.6%

$175,840,000

7 programs, 0.3%

$102,655,675

1 program, 0.1%

$24,231,823

1 program, 0.0%

$5,000,000

2 programs, 0.0%

$3,418,092

Interior

Health + Human Services Justice Housing + Urban Development Veterans’ Affairs

Health Similarities Similar issues affect the health of both the most rural populations and inner-city populations.

Poverty

People with lower incomes living in rural areas or inner-city areas are more likely to report unmet health needs, less likely to have health insurance, and less likely to receive preventative healthcare.

Violence

Rural residents are less likely to claim that violent crime is a major issue in their communities versus urban residents. However, rural areas have, in the past four years, seen notable increases in incarceration rates.

Mental Illness

Both rural and urban residents tend to feel slightly more lonely and isolated from those around them than suburban community members. Both groups are also less likely to feel they have someone they can turn to for support and are slightly less optimistic about their lives.

Substance Abuse

Roughly half of both rural (46%) and inner-city (50%) residents claim drug addiction is a major issue in their local communities. Lack of access to specialized healthcare in both areas worsens the problem.

Shortage of Primary Care Physicians

Significant shares of both rural and inner-city residents claim that access to good doctors and hospitals, high-speed internet, and grocery stores are all at least minor problems in their communities.

Racial/Ethnic Health Disparities

Although the majority of urbanites claim white people benefit from societal advantages, both white urban and rural residents are more likely to claim they do not benefit from societal advantages based on race. Concern over racism is comparable in urban and rural communities.

Environmental Issues

Although cities consume more resources that rural areas and pose various environmental risks, rural areas are guilty of low-density occupation of large areas of land and agricultural practices that pose environmental concerns. 59

Case Studies: Rural Towns Demographics Florala, AL

Covington

1,984 Median Age Household Income Poverty Rate

10.5 mi2

38.3

$25,031

$51,571

29.4% 86%

Gilmer

2,918

Transit to Work

3.5 mi2

23.8% 13%

48%

41%

with Broadband

69%

73.7%

Own a Computer

77%

82.5%

12.2%

24.7%

Florala Memorial Hospital

North Georgia Medical Center

N/A

Walk Score

Uninsured Hospital Closed Beds Lost

Hamlin, TX

Jones

1,740 Median Age Household Income Poverty Rate Walk Score with Broadband Own a Computer Uninsured Hospital Closed Beds Lost

Winnsboro, SC

5.3 mi2 44

$52,639

$30,730

21.6%

30.9%

76%

18%

77%

Fairfield

3,280

35.3

Transit to Work

Ellijay, GA

3.2 mi2

17%

70%

52.4%

85.5%

74%

19.1%

12.2%

Hamlin Memorial Hospital

Fairfield Memorial Hospital

Marks, MS

Quitman

1,741

1.3 mi2

Scotland Neck, NC

1,899

41.5

50.4

$31,172

$22,750

31.8% 91%

1.2 mi2

35.5% 5%

83%

10%

52.7%

56.9%

70%

75.6%

16.6%

13.3%

Quitman County Hospital

Our Community Hospital

33 (8 psychiatric)

Sweet Springs, MO

1,572

Saline

Stigler, OK

1.7 mi2

36.6

$39,318

$26,975

14.3%

31.7% 16%

81%

Haskell

2,725

43.5

77%

Halifax

2.7 mi2

11%

73.5%

63.1%

82.4%

77%

12.8%

21.3%

I-70 Community Hospital

Haskell County Community Hospital

25 61

Program

Museums

Fitness Centers

Higher Education Movie Theaters

Florala, AL Covington

Libraries

Food Sellers

Parks

20 4 17

Nursing Homes

Museums

Libraries

Fitness Centers

Hamlin, TX Jones 21 miles

Winnsboro, SC Fairfield

2 1

22 miles

Higher Education

1 16

Churches

2 4

Grocery Stores

Parks

1 Local

7 2

Care Homes

5 1

Pharmacies

27 miles

Churches

Movie Theaters

Ellijay, GA Gilmer

3 1

0 1 2

Marks, MS Quitman

24 miles

Scotland Neck, NC Halifax

22 miles

0 14

1 6

1 1

Sweet Springs, MO Saline

0 1

27 miles

0 0

Stigler, OK Haskell

1 1

1 Local

5 1

1 8

3 3

5 2

2 63

Average Population: 2,011 Average Area: 3.18 sq mi Average Density: 938.1 people per sq mi

14.3%

0.3%

78.4%

0.2%

3.9%

2.5%

Transport to Work

Town Programs

0.4

1.6

0.9

Rural populations are aging. Young people and families are seeking education, work, and activity in urban or suburban environments. These things cannot often be found in rural towns. The average case study town had one movie theater (some had more, many had none at all), almost no museums, and roughly one library. Most lacked institutions of higher learning. Most had at least one or two fitness centers. Activities are lacking in rural towns. These 64

activities are also sources of employment and economic growth that are missing from the towns. The one source of community engagement and activity remaining in high numbers in rural towns is the church. We must examine how design can help solve these problems of lacking activity and employment in an effective and efficient way to draw life back into the rural town, while caring for the health needs of the aging community members.

50 years

Average Age

42.23

Case Study Towns

38.2

U.S.

0 years

Average Household Income Case Study Towns

$65,000

$61,937

U.S.

$36,852

Average Below Poverty Line Case Study Towns: 24.64%

$25,750

U.S.: 12.3%

U.S. poverty line for a family of 4

$0 65

Tilden, NE Tilden, voted a “Best Place to Raise Kids in Nebraska” in 2011 by Bloomberg, is located on the county line between Antelope and Madison counties, roughly 22 miles west of the town of Norfolk. It is known for its annual Tilden Prairie Days event held the last weekend of July, which attracts a few tourists and brings the town together for activities, vendors, competitions, and performances.

Tilden is a pleasant town with several parks and trails available for outdoor activities: Sunrise Park (a local campground), the Tilden City Playground, Horseshoe Bend Park, the Duck Pond, the Cowboy Trail, and the Tilden Spur Trail. The town also has a baseball diamond and football field called Richie Ashburn Field where it hosts school or town games. Its outdoor swimming pool offers lessons, water aerobics, and pool parties.

Tilden has many local businesses which supply health services, insurance, salon services, food, and other products. These business also help to employ town residents. In 2017, Tilden opened its first community-run thrift store called New 2 U Community Thrift. The store is run by volunteer labor and donates money back to local causes and individuals in need. The local library, opened in 2001, provides Tilden residents with print and audio books, movies, magazines, and other material. The library also provides the town’s residents with 10 internet access computers and one ADA computer, as well as three noninternet access children’s computers. There is free public wifi in the building as well. The library also features several displays of Tilden artifacts.

Text from City of Tilden website: http://tmgcommunityfoundation.org/city-of-tilden/ Image from Nebraska State Historical Society, “Looking down Center Street in Tilden, Nebraska,” 1910: https://nebraskahistory.pastperfectonline.com/ photo/63BB975B-7DC3-43CB-B2D9-234784759013

Population Area Density

23%

Age

932 0.7 sq mi 1,539.3 people per sq mi

28%

65 and over

Tilden: 39.3 Nebraska: 36.4 U.S.A.: 38.2

18 to 64 Under 18 Household Income

49% 9%

Median Income

under $50k $50-100k $100-200k

Tilden: $51,000 Nebraska: $59,116 U.S.A.: $61,937

39% 47%

over $200k Below the Poverty Line

Median Age

Poverty Rate

Seniors (65+)

Tilden: 5.2% Nebraska: 11.6% U.S.A.: 12.3%

poverty non-poverty

99%

Transport to Work

9% 0% 0%

Mean Travel Time Tilden: 22.6 min Nebraska: 18.6 U.S.A.: 27.1 min

5% Other

0% 5%

Walk Score: 31 Bike Score: 46

Tilden Community Hospital Location Closure Date Type Beds Employed Reason for Closure

Services Lost

Neighboring Cities with Hospitals

Tilden’s population size has remained relatively stable since 2010, shrinking only a small amount. Tilden does have an aging population, with almost one-quarter of its residents aged at least 65 years or older. The poverty rate in Tilden, despite almost half of Tilden households making less than $50k annually, is quite low at only 1%. (The cost of living in small towns tends to be lower than in medium to large cities.) The hospital was a major employer; its closure accounted for the loss of at least 70 jobs.

308 W 2nd St 1 July 2014 Critical Access Hospital 21 70 Declining inpatient numbers New government requirements Changing demographics, drop in population Cost of adding services was too high Clinical Lab Inpatient Rehab Occupational Therapy Outpatient Surgical Unit and Post-Op Pharmacy Speech Pathology Emergency Care Long-Term Care (Swing Beds) CT Scanners, MRI, and Radiology Pediatric Neligh (13 mi) Norfolk (20 mi)

This left many Tilden residents out of work, potentially seeking employment in nearby towns. In 2018, Tilden had double the percentage of people working from home than the average rural case study town. This is an interesting statistic, especially in the time of COVID-19, as we learn that many jobs can be completed from outside the office. This could open opportunities for people to live in rural towns, working remotely from employers who are based in cities. 69

Tilden Program

Antelope Memorial Hospital

Health + Wellness Tilden Pool Tilden Pharmacy Prairie View Assisted Living Horseshoe Memorial Baseball Field Tilden East Park Campground AMH Tilden Clinic Dr. James R. Crabb, DDS Faith Regional Physician Services Tilden Family Medicine

Many of the remaining health services in Tilden, such as the AMH Tilden Clinic, a dentist, and another physician clinic, are already located on or near 2nd Street, which is its main street. This would make the Main Street Initiative proposal of moving health services to a central campus located on 2nd Street very feasible. Tilden is a small town, providing ideal proximity between the neighborhoods and 2nd Street, 70

13 mi.

allowing people easy access to a potential community hub. Tilden has two parks in town, providing space for kids to play and people to enjoy a bit of the outdoors. If we connect the senior home, called Prairie View Assisted Living, the main street area, and the parks via a bus route, the seniors could move more freely between areas, getting exercise, fresh air, and a chance to interact with their friends in town.

Faith Regional

20 mi.

Tilden Program

Pierson Wildlife Museum, Antelope County Museum, Neligh Mill State Historic Site Food + Entertainment Thriftway Market Mountain Man Nut & Fruit Co. Old Buzzard Antiques New 2U Community Thrift Store Tilden Public Library Churches (4) Mid-to-Low End Dining (2)

Tilden has a few small grocery stores, shops, and eateries on its main street. The town could benefit from the addition of some attention-grabbing shops or dining options to help pull in travelers from the intersecting highways. Even a small uptick in tourism could help revitalize the town and its economy. As of now, TIlden residents need to travel to neighboring towns for community engagement, cultural centers 72

13 mi.

(i.e., movie theaters and museums), and healthcare. Like many small towns, it seems much of Tilden’s community and culture is centered around its many churches. Church communities could be a real asset in organizing the town around a design solution where its main street could be reimagined and redeveloped into a community hub for health, recreation, and culture.

Elkhorn Valley Museum

20 mi.

Nearest Wal-Mart: Norfolk, 20 mi. Nearest Hotels/Motels: Neligh, 13 mi.; Norfolk, 20 mi.

Tilden Program

Education + Work Elkhorn Valley Schools (Elementary + High Schools) Healthcare Government Utility Services (electric, gas, internet, T.V., water/sewage/trash) Education Construction

A college in a town like Tilden contributes greatly to its success as it draws in people and money. Although Tilden may not have the resources or population necessary to warrant a school of higher education, alternatives do exist that could help bring education and even tourism to the town. One option is to bring in guest lecturers from nearby state universities or other colleges to speak to Tilden residents. These lecturers 74

could visit the town’s elementary and high schools and give interesting presentations about their fields or research, much like a TED lecture. They could also visit the senior living facility and speak there or lead workshops. The goals of our research are to both create a stronger sense of community in small towns via the provision of health services and to create stronger ties between towns and their neighboring cities.

Northeast Community College 25 mi.

Horton, KS Located in Brown County, Horton is roughly 13 miles from the town of Hiawatha and 18 miles from the town of Holton. Founded in 1886, Horton was named for Chief Justice Albert H. Horton of the Kansas Supreme Court. Most residents (82.5% ) of Horton are white, according to the 2010 Census. The second largest population demographic are Native Americans, at 10.7% of the population, followed by 3.7% who identify as Hispanic or Latino.

Other buildings are also being repurposed as apartments, shops, and restaurants. The Horton community is dedicated to reinventing itself and promoting its history and culture, making it an ideal location for a Hybrid Community Hospital that would support local businesses, resident health, and community culture.

The climate is often quite humid, with hot summers and cold winters. As part of the 2013 season of the CNBC show called “The Profit,” Horton began the “Reinvent Horton” campaign to update its community’s resources, including its curbs, sidewalks, lights, and buildings. The goal, according to the Reinvent Horton Mission Statement, was to combat community deterioration by encouraging community development and rehabilitation, while preserving Horton’s cultural and historic roots. As of 2018, Horton is working toward opening a town museum in a Baptist church that was built in 1919 for and by black families who were moving to Horton to work on the railroad.

Horton also hosts the Brown County Fair, filled with food and activities, that draws tourists and brings the town together. Although the town has lost its hospital, it appears the town has not lost its determination to thrive.

Text from City of Horton website: www.cityofhorton.com Image of the 2nd Baptist Church from the Kansas Historic Resources Inventory: https://khri.kansasgis.org

Population Area Density

Age

1,758 1.7 sq mi 1,053.07 people per sq mi

Median Age

17% 65 and over

Horton: 40.4 Kansas: 36.5 U.S.A.: 38.2

18 to 64 Under 18

24%

59% 8% 1%

Household Income

Median Income

under $50k $50-100k $100-200k

Horton: $37,333 Kansas: $57,422 U.S.A.: $61,937

29%

62%

over $200k Below the Poverty Line

12%

Poverty Rate

Seniors (65+)

Horton: 22.2% Kansas: 12.4% U.S.A.: 12.3%

poverty non-poverty

88%

84%

Transport to Work

8% 0% 0%

Mean Travel Time Horton: 22.1 min Kansas: 19.3 min U.S.A.: 27.1 min

3% Other

1% 4%

Walk Score: 34 Bike Score: 38

Horton Community Hospital Location Closure Date Type Beds Employed Reason for Closure

Services Lost

Neighboring Cities with Hospitals

Horton’s population is shrinking; since 2010, its population has decreased by 5.63%. The average age in Horton is greater than both Kansas and U.S. averages. Poverty levels in Horton are almost double those of both Kansas and the U.S. This mix of a declining population, a larger senior population, and a larger in-poverty population strains the town’s existing healthcare systems. The elderly tend to need more care and have trouble affording it without sources like

240 W 18th St 12 March 2019 Critical Access Hospital 25 40-50 Months overdue utilities payments EmpowerHMS bankruptcy, potential billing scheme Takeover by iHealthcare occurred too late Unpaid staff since 15 February 2019 Emergency department Surgery Cardiac rehabilitation Radiology Lab Inpatient beds Physical rehabilitation & treadmills Swing bed EKGs Specialty clinic Hiawatha (13 mi) Holton (17 mi)

Medicaid. After the town’s hospital closed, finding primary and preventive care in Horton became more challenging than in neighboring towns with hospitals. Primary care is critical to keeping populations healthy and decreasing the need for more serious and costly interventions. Additionally, with a lack of public transit, it is harder for the elderly to move around the town and find activities to keep the mind and body healthy.

Horton Program Hiawatha Community Hospital

13 mi.

Health + Wellness Horton Rural Health Clinic Chiropractic Clinic (2) Dental Clinic Kex RX Pharmacy Tri-County Manor Parks & Pools Lakeview Fitness Center

Horton’s current options for healthcare are spread around town. Some clinics are located on Horton’s main street, called E. 8th Street; other clinics and the senior care facility are located near where Horton’s hospital used to be, at the north edge of town. By clustering health and entertainment around E. 8th Street, as some of our design solutions suggest, Horton could gain a central activity hub. Fitness and wellness 80

could become part of everyday life, not simply an occasional activity. By adjusting the town program to cluster wellness with other town services, a more successful and sustainable community could be designed. A bus route could also connect neighborhood areas, main street and the town’s parks to further promote movement in and around the town.

Holton Community Hospital

Horton Program Brown County Museum

14 mi.

Food + Entertainment Motel Country Club Boutiques, Shops, Thirftstore Churches (8) Horton Public Library Dollar General Horton Thriftway North End Liquor Mid-to-Low End Dining

Golden Eagle Casino

Horton’s entertainment and food services lack any sort of community hub. The absence of this central location decreases chances for impromptu community gatherings while also promoting excess sprawl in a town that already lacks density. The existing public library on E. 8th Street could provide a nice community center, which could incorporate health services, eateries, shopping, and entertainment. A handful of potential tourist destinations 82

6.7 mi.

do exist that could be stops along the highway to draw in additional customers to an improved main street area. Horton, like Tilden, also has many churches that could provide further assistance in developing a town center and fostering a greater sense of community. Encouraging partnerships between already-existing shops, health services, and entertainment options could help boost the local economy and save local shops.

Nearest Wal-Mart: Hiawatha, 15 mi.

Horton Program

Education + Work Horton Elementary School Horton High School Healthcare (less after hospital closure) Government Electricity Agriculture Infrastructure Water Education

Horton, like Tilden, also lacks a source of higher education and could benefit from the same TED-style guest lectures from neighboring colleges and state universities recommended for Tilden. Although Horton lost many jobs when the hospital closed, the town has a fair amount of work in electricity, government, and infrastructure. Additional sources of employment could come from the lecture partnership with nearby colleges and 84

universities. These jobs could be remote, and higher education facilities could help provide the necessary technology and IT services needed to upgrade the town to meet modern standards. Both Horton youth and senior citizens could benefit from the guest lectures and educational activities. Similarly, the guest lecturers could benefit from learning more about the towns from which some of their students originate.

Highland Comm. College 19 mi.

Everest Middle School

5 mi.

Health Clinics Health Clinic options could be another opportunity for partnership, but at this time none have been truly tested in rural communities.

Clinics

CVS RiteAid The Little Clinic Target Walmart Walgreens

Clinics CVS

RiteAid

The Little Clinic Target

Walmart Walgreens

ESTABLISHING FRAMEWORK In this section, we review the great work that our team completed with the University of Kansas, School of Architecture and Design. In collaboration with the KU Institute of Health + Wellness Design, we investigated possible design solutions for small communities looking to transform themselves with the critical access hospital at the center of it all. We continued this work with students of KU’s 808 Studio. With the help of great educators Frank Zilm, Kent Spreckelmeyer and Hui Cai, we were able to begin research and start applying design ideas to address the major issues the research uncovered. This is also where the community of Haxtun, CO, became our partner and muse.

Can the Countryside Change the Fabric of America? AN URBAN PERSPECTIVE ON THE FUTURE OF THE RURAL PROGRAM Melissa Smith M.Arch Graduate Student, University of Kansas Having grown up in Denver, I haven’t experienced much of the countryside aside from the occasional trip to a small Rocky Mountain town. This changed when I attended the University of Kansas. While Lawrence isn’t the “countryside” going to school there allowed me to meet people who had grown up in rural areas. Those connections afforded me a deeper appreciation for the rural way of life. I realized how different urban and rural lifestyles were, but I also learned how similar people can be. Through my work on this research project with HDR and the University of Kansas, I delved deeper into the American countryside, learning more about its challenges, interests, and cultures. My research introduced me to “Countryside, The Future,” Rem Koolhaas’s Guggenheim exhibit in New York City. Although I wasn’t able to see the exhibit due to COVID-19, our research team did read Koolhaas’s book on the subject, Countryside, A Report. What follows are some of my thoughts about the book and my own experiences in the countryside—and ties both to this research project.

My major impression about Countryside, A Report was that most of the essays look at rural life through an urban lens, as that is where Koolhaas has focused the majority of his career. Some may argue that this urban viewpoint is good because it may spawn more interest and investment in rural areas than if it had been informed by a solely rural perspective. My issue, however, is that rural residents are unlikely to be exposed to the very concept of the countryside becoming a futuristic utopian hub of humankind and technology. Because poverty is high among American rural populations, few rural residents could afford an expensive trip to New York City to visit the exhibit. Additionally, according to the National Rural Health Association, over half of rural Americans

lack access to high-speed internet, so unless the book is made widely available at rural libraries and promoted in rural towns, it’s unlikely that residents there will read or even hear about it. But I do think the book brings some important points to light. I found the chapter about the advancement of the Kenyan countryside to be particularly interesting and relevant to our research (Gichuyia and Madete, “Ocha: African Avant Garde,” p. 88-103). Dr. Gichuyia and Etta Madete discuss possible futures for the Kenyan countryside as it redevelops as an important place of work, life, and recreation, and investments in the Kenyan countryside grow to create a more connected Kenya.

I found several methods used in Kenya to be potentially applicable in the U.S. Some of the successful initiatives discussed and attempted in rural Kenya include: easier and more accessible digital banking and money transfer; improved access to internet and Wi-Fi; the creation of an Airbnb-equivalent for countryside tourists; bringing in guest lecturers from urban universities to rural schools; the creation of a high-speed rail system; and the provision of technology. These initiatives helped connect the countryside to the urban, but more importantly they made it easier and more enjoyable to live and work in the countryside. Many Americans feel they need to move to a city for work even though they’d rather remain in the countryside. As architects

and designers, we could advocate for some of these solutions in order to create a more connected and viable countryside, and a more connected and viable United States. Two of my roommates live in rural areas. I’ve visited both of their homes and discussed with them about their countryside experiences on many occasions. What I’ve learned is that many rural and urban people would choose to live in the countryside over the city. I’ve learned that rural life is quite different from city life and requires different attention, care, and policies. Certain things that work well in cities may not make sense in the countryside - and vice versa. Our approach to healthcare is just one example. Because rural towns lack the density and competition necessary to drive down

healthcare costs and attract specialists, we need to explore the viability of other healthcare delivery models. For example, while rural towns could have regular physical doctors and dentists in the town, and provide emergency services, residents could receive specialized care through telemedicine. The rural issue isn’t a lack of interest in countryside life, but rather lacking resources. Rural areas offer fewer employment opportunities, fewer recreational activities, and less access to healthcare, making the city seem like a more attractive option, especially for young families and recent graduates. By providing essential services and more amenities in the countryside, more people who want to live there might be able to do so, which could also potentially ease city overcrowding.

This brings us to our research: The Main Street Initiative. The intent of the Main Street Initiative is to explore the potential of this critical community hub to return promise to rural towns by entwining health with day-to-day rural life. What if rural residents visited main street for their annual physical, to work out at the fitness center, to visit the community center, go to a movie or shop, or go out to eat? What if all of this was available within a few city blocks that were a short walk or bus ride from their homes or workplaces? What if main street became a mixed-use destination with health and wellness as the foundation? By redefining main street, the idea of healthcare is shifted from an occasional requirement to a way of life, promoting prevention over treatment, a

healthy lifestyle over a long hospital stay. This could help return life and employment to the countryside and could potentially afford people the chance to choose countryside over city if they wanted to. In the post-COVID world, people may even work remotely for companies based in the city while living in the countryside. The addition of high-speed rail lines, like those in Kenya, could encourage more countryside tourism and allow those working remotely to visit the city if need be. We can look to other methods implemented in the Kenyan countryside, and all over the world, to connect the rural and the urban, and to allow people more freedom of employment and movement. Although “Countryside, The Future” looks at the countryside from an urban lens, it allowed us to glimpse what our countryside could be and how the countryside could change America as we know it.

100

University of Kansas School of Architecture and Design Marvin Hall

101

102

University of Kansas School of Architecture and Design Marvin Hall The Forum

103

University of Kansas School of Architecture and Design Case Study (reFORM): Saving Main Street USA Studio 808 Haxtun, CO

MAIN STREET AMERICA

PARIS ILLINOIS

CUSTER SOUTH DAKOTA

LUSK WYOMING

SCOTLAND NECK NORTH CAROLINA

SIGOURNEY IOWA

BRITTON SOUTH DAKOTA

OBERLIN KANSAS

NEOSHO MISSOURI

ROUND UP MONTANA

NOR

PRINCETON ILLINOIS

RAWLINS WYOMING

PROJECT NAME (reFORM): Saving Main Street USA STUDIO NAME

Great Plains Studio + Studio 808 (KU)

OFFICE LOCATION Omaha, Nebraska TEAM MEMBERS Kent Spreckelmeyer, Tom Trenolone, Ian Christopher Thomas, Matthew

Goldsberry, Matt Stoffel, Studio 808 (Nicole Mater, Rachel Keeven, Liz Nikoomanesh, Phillip Perkins, Hannah Kramer, Lauren Amos, John Barnthouse, Chelsea Campbell, Cole Giesler, Chinoso Ike, Kathy Kim, Ashley Lawrence, Chang Liu, Sarah Moser, Eman Siddiqui, Mahzad Talaei, William Weiner, Dana Wellman) CLIENT Haxtun Hospital District, CO

104

ELECTRA TEXAS

SPARTA SPARTA RTH CAROLINA NORTH CAROLINA

WINNER WINNER SOUTH DAKOTA SOUTH DAKOTA

HAXTUN HAXTUN COLORADO COLORADO

MAIN STREET MAIN STREET AMERICAAMERICA

ORD ORD NEBRASKA NEBRASKA HOXIE HOXIE KANSAS KANSAS

SHELBINASHELBINA MISSOURIMISSOURI

RED LODGE RED LODGE MONTANA MONTANA

O’NEILL O’NEILL NEBRASKA NEBRASKA JULESBERG JULESBERG COLORADO COLORADO

ANAMOSA ANAMOSA IOWA IOWA

OSHKOSHOSHKOSH NEBRASKA NEBRASKA

BIG LAKE BIG LAKE TEXAS TEXAS

105

106

107

B U R NS

CORNING

ELECT R A

GANADO

2,806

1,635

3,122

2,769

1,227

Sales & Office

Services

Production &Transportation

Sales & Office

-5.46%

-0.25%

3.6%

-1.79%

0.9%

120 Miles

45 Miles

19 Miles

132 Miles

6.5 / 10

3 / 10

4.5 / 10

3 / 10

O SHKO SH

QUINTER

RED LO D G E

SH ELBIN A

SP A R T A

884

918

2,125

1,704

1,770

Service, Sales & Office

Professional Occupations

Sales & Office

Production &Tran

-0.9%

-0.39%

0.77%

-3.0%

129 Miles

51 Miles

55 Miles

29 Miles

37 Miles

2 / 10

4.5 / 10

3 / 10

Data derived from the US Census (citydata.com and bestplaces.com)

108

COR YD O N

ffice

INA

ffice

G A NA D O

HIAWASSE

J ULES BURG

LUSK

M UN ISIN G

1,227

880

1,227

1,568

2,355

Sales & Office

Sales & Offce, Service

Service

0.9%

5.63%

0.9%

6.74%

-4.07%

132 Miles

32 Miles

132 Miles

96 Miles

38 Miles

3 / 10

3.5 / 10

1 / 10

S PA RT A

SUSQUEHANNA TOWNSHEND

W IN N ER

H A XT UN

1,770

1,643

1,232

2,897

946

Production &Transportation

Sales & Office

-3.0%

3.87%

-0.29%

-3.13%

-7.76%

37 Miles

19 Miles

23 Miles

154 Miles

111 Miles

3 / 10

2 / 10

3 / 10

2 / 10

109

MAIN STREET

VACANT AND OCCUPIED BUILDINGS VACANT OCCUPIED

110

RELOCATION + PUNCTUATION OF PROGRAM

DISTRIBUTION OF SERVICES

111

112

COMMUTER CHARACTER

GENE

A Haxtun, CO residents daily access to goods not available within Haxtun through commuting.

How a reside vary from yo

Julesburg

39%

49min

of Haxtun has a commuter in the household

Sedgwick

is the average commuting time to Sterling

Sterling

0.7%

Fleming Haxtun Holyoke

53%

20%

37%

have daily access to fast food

36%

have daily access to large grocery stores

21%

have daily access to department stores

21%

have daily access to ‘big box’ retail stores

20%

Healthcare, Agriculture, and Retail are consistently the highest fields of employed workers throughout the 5 northeastern counties.

Yuma

113

114

The towns with greatest risk of disappearance are, unsurprisingly, largely rural and/or were built around industries now in decline (if not entirely gone). This is particularly noticeable in the American West, where towns built around the rail network have suffered under the primacy of the interstate highway system. Crucial resources are often far away. When it comes to healthcare, this can be a matter of life and death. Mobile and modular architecture can be transported along rail networks to serve as temporary and affordable solutions as these towns teeter on the precipice. If the town’s fortune is good, these structures can be replaced by more permanent options; if it turns, the architecture can serve the town until it is no longer needed—at which point it is packed up and passed along. Traditional architectural responses are inappropriate in these environments, but that’s not to say that architecture can’t help at all.

115

116

117

120

Impacting the Health of a Rural Community by Designing a Hybrid Community Hospital THE UNIVERSITY OF KANSAS SCHOOL OF ARCHITECTURE, DESIGN, AND PLANNING AND HDR GREAT PLAINS STUDIO(S) Reprinted with the permission of Kent Spreckelmeyer, University of Kansas

Introduction Access to clinical preventive services and healthy environments can improve overall health outcomes and promote human well-being, although Americans report receiving only half of the recommended preventive care they need. This lack of adequate healthcare services is made more acute in rural areas because of geographic and economic challenges and an aging population base.1 This study will create a model that suggests alternative healthcare facility designs to improve health outcomes in rural communities. The study recognizes that a range of environmental, cultural, and socioeconomic factors are involved in making progress in helping people improve diet, increase physical activity, and other lifestyle changes. Hence, the study plans to concentrate on strategies that support environments where people can engage in outdoor social activities that resonate with the identity of that smalltown community; encourage and support mobility for all people regardless of functional ability; increase the delivery of clinical preventive services; and increase economic and cultural activities. 121

There are approximately 2,000 rural community hospitals in the United States serving one-fifth of the total US population. 2 Approximately two-thirds of the subcounty municipalities in the US have populations of less than 2,500, although these communities account for less than two percent of the overall population. 3 Since 1997 more than 1,300 of the smallest of those 2,000 rural communities have been served by critical access hospitals (CAHs). CAHs are healthcare facilities that provide inpatient and primary-care services to communities that would otherwise be underserved and remote from essential medical resources. They are established by regulation to receive reimbursements from Medicare sources to serve communities more than 35 miles from adjacent medical facilities. CAHs must have less than 25 inpatient beds and maintain a 24/7 emergency room. There are concentrated heavily in the “Grain Belt” from the western Gulf coast to the upper Midwest.4

122

Small rural communities served by CAHs face two major healthcare and environmental challenges. The first is providing healthcare services to an aging population, and the second is reviving the economic vitality of small towns with populations of less than 2,500. The hospitals in these communities are important economic assets, and the basic assumption of the project is that the healthcare system can play a major role in revitalizing the commercial core of the town. 5 The focus of this project is to create social connectedness, economic prosperity, and community-clinical integration for the delivery of preventive services along with critical care access by designing a Hybrid Community Hospital (HCH).

A Case Study Eighteen students in the Health & Wellness Master of Architecture graduate program in the School of Architecture, Design & Planning at the University of Kansas, in collaboration with HDR’s Great Plains Studio(s), created a model for an HCH using a small town in the western Great Plains as a case study. The 25-bed CAH has served the community since the 1940s, and its current facility was constructed in 1965. The project explores the relocation of the hospital to the heart of the downtown, and the goal of the project is to design a facility that provides not just healthcare, but attracts people living in the surrounding communities to other commercial and educational services. The hospital is the largest single employer in this community of 950 people, accounting for 16% of total employment, and represents a significant generator of economic activity in the core of the town. When combined with the consolidated school district in town, these two employment sectors represents a quarter of the daily working population and have the potential to bring an influx of people

to the downtown every day, which could in turn help grow other businesses and community services. In addition to this one case-study town, approximately a dozen towns with CAHs and populations of less than 2,500 throughout the plains states were analyzed to find commonalities in the economic, demographic, environmental, and cultural lives of these communities. What the students were attempting to create throughout the project were not only multiple design solutions for a single small town but prototype proposals that could be applied to a multitude of rural communities. The students’ analyses of these communities confirmed a general pattern of healthcare facilities found throughout rural America. In comparison to residents served by urban healthcare systems, the rural population is older and less likely to be insured, more prone to chronic medical conditions, more dependent on CAHs for long-term and skilled nursing services, and more reliant on primary and outpatient diagnostic and treatment services because of remote locations from teaching or tertiary-care facilities. CAHs operate in older and technically less sophisticated facilities than their urban counterparts, and

123

the economics of reimbursement practices often disadvantage rural healthcare systems.1 What emerged from this analysis was a general set of principles that the students used to inform three distinct design solutions for a hybrid community hospital. These principles were: 1. Consider the new CAH as a community focus for the social, economic, environmental, and medical health of the community. Define “health” in the broadest terms possible. 2. Bring life to the heath of the town, and integrate the CAH into the fabric of the existing physical context of the community. Create an intensity of use that will build on the strength of the existing main street activities. 3. Use the most current construction and medical technologies to integrate economies of scale, flexibilty, and quality of outcomes in the design process.

124

1. “Master Hub” Designers: Chelsea Campbell, Cole Giesler, Chinonso Ike, Kathy Kim, Ashley Lawrence, and Sarah Moser Networks come in many forms—biological, mechanical, electronic—but but they all exhibit similar properties in their ability to transmit information, materials, or people through efficient and elegant patterns. The key element of any network is a central node that collects the strands of the disparate components of the system and directs their movement to the appropriate adjoining areas. These “synapses,” “switches,” or “routers” are the organic nerve center of any successful network, and they provided the inspiration for this team’s design concept. They took this organizing principle as a way to add density to the community’s resources and provide a strong physical identity to the town. Their research of the social and healthcare systems in the community indicated they were being diluted by the necessity of travelling significant distances to larger towns for medical specialties, consumer goods, education, and entertainment. They also discovered that

the primary vehicular route connecting the town to the major highways bypassed the town center, which provided little incentive to focus critical activities in the heart of the community. They proposed that the center of the town become the primary node of a new network—what they called the “master hub”—that would concentrate all the essential components of a new healthcare facility in a revitalized town square.

In a symbolic way, this design decision was meant to knit together what had previously been a disjointed and dispersed set of critical community assets. At the same time, the activities the team envisioned for the entry would consolidate services and amenities— the community center, school art program, restaurants, outpatient clinics—that gave purpose to reoccupying and revitalizing the town core.

In their analysis of the existing community resources, the design team found that the CAH to the west, the school and community center to the north, and the commercial area to the south of the historic town center were all within walking distance of each other. The state highway meant to link these activities, however, was located a block east of what should have been the major north-south axis of the town. The team rerouted the highway to provide a continuous path from the school to the commercial center and placed the primary entrance to the new CAH equidistant on this route. This master hub became visually and functionally the new center of the town, located in such a way that would cause traffic to slow and bend around the CAH entry. The new hospital lobby, situated next to the historic city hall, would become an unavoidable feature of a new community network that celebrated rather than hid the hospital’s front porch.

Most communities that are served by a critical access hospital struggle to create a density of social and physical assets to maintain a vibrant and commercially stable main street. In their analyses of the case study CAH communities, the studio found that even in those that had a viable downtown, most lacked a strong focal point or an essential function that would anchor the environment or prevent the eventual hollowing-out of the town center. The question posed by the studio was “Why can’t the community hospital be the social, economic, and physical nerve center of the town it serves rather than an asset remote from the historic heart of the main street?” Can the CAH foster the health of a community center by creating a hub of activities that extend beyond the medical services provided by the traditional rural hospital?

125

Existing community resources

Consolidation in the “Master Hub” 126

2 Phase 3

Phase 2

Phase 1

Current

Evolution of Community Synergies 127

2. “Small-Town Synergy” Designers: Lauren Amos, John Barnthouse, Chang Liu, Eman Siddiqui, Mahzad Talaei, and Dana Wellman The most consistent finding of the students’ research was the fact that the economic and social anchors of CAH communities are the healthcare and consolidated school systems. Often times accounting for more than a third of the employment opportunities, the hospital and school provide the bedrock on which the town’s survival depends. These two institutions also provide critical ancillary services to small towns in the form of housing for aging residents, social services for young families, and community identities. The school and hospital are always open, regardless of the vagrancies of the economic cycles that sustain rural communities. These towns are alive on football and basketball nights, daily meals are made and served in both cafeterias, and the life cycles of the residents are literally and symbolically centered on the hospital. This design team began with the idea that the synergy created by the activities of the hospital, the school, and the town center should focus the way the community changed and evolved over time. The primary architectural device that organized this idea

128

was the creation of an open campus that linked the existing CAH with the main street of the town. The concept was evolutionary because it recognized the healthcare system was no longer a monolithic “hospital” as much as a series of social supports. In the initial phase, for example, the long-term care and rehab functions of the hospital were linked to the main street buildings and clustered around what was envisioned as a common lawn and recreation landscape. In subsequent phases of the design, incremental additions of medical, educational, commercial, and residential activities began to create a campus that tied together all aspects of the town’s life. In the final phase, the old hospital site is cleared and occupied by the school’s athletic fields. At the same time, the main street that connects the school and the town center was reconceived as a pedestrian concourse that created a ceremonial and visual link between the healthcare, residential, and educational functions of the town. The ultimate goal of this scheme was to leverage the innate and deeply-felt qualities of the two most important institutions of the community into a comprehensive vision of how the town as a whole could be seen as a “campus for a healthy community.”

3. “Modular Duality” Designers: Rachel Keeven, Hannah Kramer, Nicole Mater, Lizzy Nikoonamesh, Phillip Perkins, and William Weiner The third design team recognized that even though the CAH towns shared many economic, social, and healthcare commonalities, each was a unique and independent entity. Some towns may thrive and grow in the future, while others will contract and decline. The team labelled this the “duality” of the natural life cycle of a community’s development. What all the communities possessed, however, were a historic dependence on agricultural technologies, highly developed rail and highway networks, and a culture of self-reliance. This team began with the assumption that the design of the healthcare system should be as much about process as final product. They conceived an approach that utilized automated and decentralized modular fabrication technologies to provide a facility system that could expand or contract. They coupled this idea with the fact that much of what now occurs within the confines of a healthcare facility is being replaced by digital diagnostic and treatment technologies. Their design thinking,

therefore, began not at the town or site level, but at the scale of discrete human activities—the medical exam, a surgical procedure, an inpatient bed. They then proceeded to expand this basic activity module to include those spaces that exist within the town outside the CAH— residential bedrooms, cafés, offices. The most provocative question they posed in this design was “Can a community that has always relied on its own mechanical ingenuity and was connected to the outside world by an integrated rail and truck network use digital technologies to design, build, and transport components of a sophisticated healthcare facility?” In a part of the country where agriculture is being transformed by GIS-driven tractors, where wind turbines are now as ubiquitous as oil derricks, and communication is virtual, it seemed natural to assume that these communities are well-positioned to construct—or deconstruct—their physical environments as conditions demand. The modular system they devised utilized off-the-shelf technologies and materials that could be incorporated in the local implement dealership, the metal shop, or the grain elevator.

129

3. Community Modular System

PATIENT ROOM (192 Square Feet)

1 Structural Unit 4 Roof/Ceiling Panels 4 Floor Panels 12 Exterior Panels 57 Interior Panels

EXAMINATION ROOM X2 (192 Square Feet)

1 Structural Unit 4 Roof/Ceiling Panels 4 Floor Panels 16 Exterior Panels 52 Interior Panels

130

COFFEE HOUSE (576 Square Feet))

3 Structural Unit 12 Roof/Ceiling Panels 12 Floor Panels 16 Exterior Panels 116 Interior Panels

TWO BEDROOM APARTMENT (768 Square Feet)

4 Structural Unit 16 Roof/Ceiling Panels 16 Floor Panels 56 Exterior Panels 134 Interior Panels

131

4. A Prototype Vision for a Hybrid Community Hospital

Conclusion The final products of this studio exercise were three visions of how the design of a new rural critical access hospital can contribute to the health and human wellbeing of the small community it serves. The designers from HDR’s Great Plains Studio(s) had explored this concept in a dense, urban context, and their charge to the studio at the University of Kansas was to explore if this concept and way of seeing the healthcare system had relevance in a different environmental context. Medical centers in the under-served areas of American cities face challenges as severe as those described above in rural communities. The prevalence of “food deserts,” lack of opportunities for recreation and community assembly, and access to basic primary-care health

132

services characterize many urban sectors of this country. These problems primarily affect the young in urban settings, whereas healthcare systems in rural areas affect to a greater degree the elderly. Although many of the most disadvantaged in the cities live adjacent to the most sophisticated medical centers in the world, they often remain just as remote to those they should serve as the most isolated rural communities. What the studio discovered was that, although the contexts and cultures of rural and urban environments are distinct, the opportunities for improving community health and wellness through healthcare design share many commonalities.

Essay sources 1.

American Hospital Association (AHA). 2011. “The Opportunities and Challenges for Rural Hospitals in an Era of Health Reform.” Trendwatch, April.

2. Frieden, T.R. 2014. “Six Components Necessary for Effective Public Health Program Implementation,” American Journal of Public Health, 104(1), pp. 17-22. 3. Krist, A.K. et al. 2012. “A Framework for Integration of Community and Clinical Care to Improve the Delivery of Clinical Preventive Services among Older Adults.” National Association of Chronic Disease Directors, July. 4. National League of Cities. 2013. “Sub-county Municipal Governments by Population-Size Group and State: 2007.” http://www.nlc.org/build-skills-and-networks/resources/cities-101/city-structures/number-ofmunicipal-governments-and-population-distribution. 5. Rural Access Center (RAC). 2014. http://www.raconline.org/topics/critical-access-hospitals. 6. U.S Department of Commerce, Bureau of the Census. 2013. “2010 Census Urban Area Facts.”

Kent Spreckelmeyer, D.Arch., FAIA, Paola Sanguinetti, Ph.D., and Faria Islam (University of Kansas Faculty) Tom Trenolone, AIA, Matthew Goldsberry, Matthew Stoffel, and Ian Thomas (HDR Great Plains Studio(s)) Lauren Amos, John Barnthouse, Chelsea Campbell, Cole Giesler, Chinonso Ike, Rachel Keeven, Kathy Kim, Hannah Kramer, Ashley Lawrence, Chang Liu, Nicole Mater, Sarah Moser, Lizzy Nikoonamesh, Phillip Perkins, Eman Siddiqui, Mahzad Talaei, William Weiner, and Dana Wellman (University of Kansas Graduate Students)

133

134

BROAD DIAGNOSIS We believe that the best way to solve a problem is to bring a diverse set of minds to focus on the issues. In this section, we highlight some of the work completed in partnership with Dean Katherine Ankerson, Past Architecture Chair Jeff Day, and the University of Nebraska-Lincoln College of Architecture. As part of the school’s Graduate Studio 610 course work, led by our designers, we asked students from small communities served by critical access hospitals to consider how we could transform them using the new program elements that were identified in the previous collaboration with KU.

135

University of Nebraska-Lincoln – College of Architecture Arch 610 Studio

Phung Hong Alliance, NE

Kurt Lawler Ogalala, NE

Danielle Banzhae Indianola, NE

Maren Elnes Leadville,CO

138

Scott Kenny Atkinson, NE Mariah Tobin Tekamah, NE

William Pokojski Neligh, NE

Ezra Young Schuyler, NE Neely Sutter Benjamin Macke Beatrice, NE Holdrege, NE Brooke Sayler Fairbury, NE

Emelia Thompson Missouri Valley, IA

Allen Phengmarath Brownville, NE

139

140

University of Nebraska ARCHITECTURE HALL

141

142

University of Nebraska College of Architecture “The Link”

143

Case Study: Fairbury, NE Arch 610, AND fairbury, NE Brooke Sayler Creating a connection between new and old by opposing the existing block boundaries and creating a new type of public space with less articulated boundaries. Connecting elements cut through the blocks to literally connect new and old and the public to the new community program.

144

145

146

147

148

149

150

151

152

153

Case Study: Beatrice, NE Arch 610, AND BEATRICE, NE Neely Sutter With no current community center, Beatrice is in need of a space that can bring the city together. This development will become a place for the community to gather, celebrate, and grow.

154

155

156

157

158

159

160

161

162

163

Case Study: Alliance, NE Arch 610, AND ALLIANCE, NE Phung Hong

Alliance 8,491

Population in 2010

8,476 Population in 2016

8,451 Population in 2021

4,117

Number of Housing Units

23.2% -

Housing 1939 or

39.1% -

Housing 1959 or

25 Units 2010 - Present

ESTIMATED YEAR UNITS BUILT

Housing Rehabilitation Areas

7 2

New Housing Development Areas

Alliance 8,491

20%

Population in 2010

15%

8,476

10%

Population in 2016

8,451 Population in 2021

164

4,117

Number of Housing Units

89%

64%

36%

et e r St

• Provide career guidance/ classroom for people who are seeking future education/business opportunities.

Street View Perspective Critical Access Hospital Public

• Hospital programs that are open to the public.

Commercial Container Business Incubators • Provide business incubators to support local business. • Create attraction to bring people back to the downtown area

Alliance 8,491

20%

Population in 2010

15%

8,476

10%

Population in 2016

8,451

4,117

d 3r

e re t S

Number of Housing Units

23.2% 39.1% -

Housing Units Perspective

Population in 2021

Housing Built in 1939 or Before

89%

64%

36%

Occupied Housing

Owner Occupied

Renter Occupied

Housing Built in 1959 or Before

25 Units

91 Units

301 Units

532 Units

1,198 Units

2010 - Present

2000 - 2009

1990 - 1999

1980 - 1989

1970 - 1979

ESTIMATED YEAR UNITS BUILT

356 Units 1960 - 1969

N 70% i22% ob 8%ra

North 414 Units

North Elevation Elevation 243 Units

1950 - 1959

Single Unit Multi - Unit Mobile Home

1940 - 1949

55% -

Under $100K

24% -

$100K - $200K

8% -

$200K - $300K

2% -

$400K - $500K

956 Units 1939 - Before

$93,700 Median value of owner occupied housing units

165

Residential

Container Housing Unit • Housing unit for CAH employees. • Create attraction for young professional employees. • Provide collaborative green space with great view. • Add natural light into programs below with the skylight system

Critical Access Hospital Private

• Hospital programs that require privacy. • Great view of highway • Great view of business incubator area

Civic Building Renovation • Provide career guidance/ classroom for people who are seeking future education/business opportunities.

Critical Access Hospital Public • Hospital programs that are open to the public.

Commercial Container Business Incubators • Provide business incubators to support local business. • Create attraction to bring people back to the downtown area

166

356 Units

ESTIMATED YEAR UNITS BUILT

414 Units

243 Units

1950 - 1959

1940 - 1949

1887

1960 - 1969

Commercial

Housing Rehabilitation Areas

Container Business Incubators New Housing Development Areas

• Provide business incubators to support local 1886 business. • Create attraction to bring people back to the

70% 22% 8%

downtown area

Single Unit Multi - Unit

1887

Under $100K

24% -

$100K - $200K

8% -

$200K - $300K 1900 $400K - $500K

World War II

1887

1910

The Changes

1887

886

1900

1980

1886 1886

1980

1887

1910

The Immigrant Wave

Street View Perspective

1886

960

Free land and1900 individual 1980 freedoms were too much for the average European to ignore.

es. fessional

1976

1960

1887

ace with

1910

1980

Within 1900 eight weeks of the founding, 250 buildings were built, mostly of wood and tar paper, all of which was shipped in by rail.

1980

privacy.

The 1970’s - 1980’s will be known for the growth of the Burlington Northern Railroad in Alliance.

1976

6,862

1940

1950

1940 1950

The Rapid Grow

1886

1940

1920

1976

1960

The Great Depression

This allowed1920 the arid Sandhills area to 1930 be settled and brought a large number of people into Alliance to file for Kincaid grants on June 24, 1904.

1976

below with 1960

Alliance was not devastated 1940 by the Great Depression of the 1930’s. Added a new public 1930 buildings through various federal work programs.

The Lindcaid Aid

1900

1960

V 1920

1980

1950

1930

2,535

1980

1886

1976

1940

4,591

re St

Army equipment was called in to move snow, carry people and goods to and from Alliance and rescue motorists caught in the storms. Losses to farmers and ranchers in the area were extremely large.

1940 1920

1910

1976

1950

6,253

1920

8,959 Burlington Northern Railroad.

1950

1940

1976

7,845

1960

8,491

The Blizzard of ‘49 and effects

1930

3,105

829

1960

6,669

1960

7,891 1950

1930

1900

1887

1976

1960

1980

1940

9,765

1980

1920

Alliance’s famous brick streets became a 1910rebuilt. Alliance had reality. Sewers were become a center for business, medicine, finance, and freight and passenger 1900 service. 1900

1887

1930

1950

1930

Alliance Air Base was built on former farm and ranch land southeast of Alliance. Alliance doubled in size as construction workers and later troops “invaded” Alliance. It equipped with a theater, chapels, bowling alley, hospital, laundry, and bank. 1930 1910

1920

1900 as the growth in industry and manufacturing 1920 1950s-1960s will be known plants in Alliance. Box Butte General Hospital was built in 1976.

9,920 1910

$93,700

Median value of owner occupied housing units

1910

The Industrial Revolution 1886

1887

1910 1939 - Before

55% -

2% -

Mobile Home

956 Units

1976

Housing Units Perspective

Alternative Pedestrian Circulation

or area

sroom for people /business

en to the public.

Bo x North Elevation

East Elevation

Alternative Circulation

Hospital and Residential

Alternative Pedestrian Circulation

Proposal Storefront Elevation

native Pedestrian Circulation

tors

o support local

ple back to the

levation evation

e re St

Alte Cir

ont Historical Building Renovatie

d 3r

re St

Alternative Pedestria 167

Wellness Program _ Section Perspective

168

169

170

171

172

APPLIED PROTOTYPE We put our university studio investigations to the test and asked some of the best urban designers along with health and wellness designers to consider what a mixed-use, main street concept focused on retail, long-term care and the critical access hospital would look like. Partnering once again with the Haxtun Hospital District and Phillips County Economic Development, the concept featured here represents a solution that puts the hospital at the center of the town’s resurgence.

173

Case Study as Catalyst: Haxtun, CO HDR Great Plains Studio(s)

176

177

178

Haxtun, CO, is located in northeast Colorado, in what is considered the Great Plains Region of the United States. The landscape and context is very similar to other rural areas found in Kansas, Nebraska, and South Dakota. The 2010 Census reported Haxtun’s community population at 946 people. One hundred of those are employed by the Haxtun Hospital District, making it the community’s largest single employer. However, towns like Haxtun are up against tremendous odds: Currently, more than 25 percent of rural critical access hospitals (hospitals with less than 25 beds, like the one in Haxtun) are on the brink of collapse. Rural communities are also increasingly becoming food deserts as the result of rising closures of local grocery markets. The town of Haxtun (while significantly different in population, demographic, and size) has a great deal in common with inner-city communities that face issues of poor walkability, limited access to fresh fruits and vegetables, and good public spaces for all seasons.

179

180

181

182

183

184

185

SITE RESEARCH

186

187

188

189

190

191

Program

Clearing shed and cleaning scrap yard site to the back of main street will allow for future expansion

Using the dimensions from exisiting buildings allow for addiions to work with currurent configuration

The programming of the space focuses on how each program can work flexibly with the site

192

Shared spaces and corridors are created to enhance the space

A series of metal buildings create density on the site

Exisiting buildings renovated to fit new programs

193

194

195

196

197

STROHM ST 1 16 15 13

14 12

MAIN ST

LOGAN AVE

11 10 3

9 8

4 6

FLETCHER ST

Ground Floor

198

1 2 3 4 5 6 7 8 9

Visiting Doctor Housing Outpatient Clinics Physical Therapy Studio Pool Gym Basketball Court Assisted Living Haxtun Market Pharmacy

10 11 12 13 14 15 16 17

Community Hall Gathering Space Cafe Kitchen Auditorium Lobby / Prefunction Emergency Department Surgery

STROHM ST

MAIN ST

LOGAN AVE

19 21 20

FLETCHER ST

Upper Floor

18 19 20 21 22 23

Inpatient Ward Skilled Nursing Rooftop Garden Greenhouse Community Education Administration

199

200

201

202

203

204

205

206

207

208

209

210

211

212

213

Government Agencies

The Centers for Medicare & Medicaid Services

The United States Department of Agriculture

The Health Resources and Services Administration US Department of Housing & Urban Development

The Agency for Healthcare Research and Quality

The Indian Health Service

The Substance Abuse and Mental Health Services Administration

Federal Communications Commission The Mine Safety and Health Administration

The Environmental Protection Agency

214

The Centers for Disease Control and Prevention

National Organizations

The American Hospital Association

The National Low Income Housing Coalition

The Association of American Medical Colleges

The Association for Community Health Improvement

State Organizations

The Kansas Rural Health Association

The Office of Rural Health

The Nebraska Rural Health Association

215

218

LAST WORD

219

220

Like Water, We Work over Time Design in the Great Plains Thomas J. Trenolone, AIA When I was a kid, my family—like many others—took a summer vacation together. Most often it involved a road trip; we would drive across the country and experience how life was different in other states. On one such trip in the early ‘80s, we loaded up our Ford Econoline conversion van and headed north to the great state of South Dakota (before it became famous for the Kevin Costner film “Dances with Wolves”). Our loop through the state began at the falls of the great Sioux River in the appropriately named town of Sioux Falls, SD. From there we turned west to Pierre in order to fulfill my mother’s quest that we visit every state capitol. (This might have something to do with my passion for architecture.) We continued westward through Badlands National Park, the infamous Wall Drug Store and eventually made our way to Rapid City. There we experienced the epic Mount Rushmore and viewed the emergence of the Crazy Horse Memorial. Next we headed south to Wind Cave National Park. I remember the arrival sequence to Wind Cave vividly: a winding road navigating through rolling plains, with small buffalo herds in the distance and signs reminding you not to feed the prairie dogs. I was quickly becoming irritated; this, I thought, was not what a great cave experience is about. When we arrived at the visitor center, I was crushed. Instead of a grand lodge built in a cliff side, all I saw was a simple single-story structure sporting tan stucco and a brown roof. 221

All I could think was this: “cool cave—NOT!” My father bought us tickets and we followed a path and joined the waiting tour group. Our fellow visitors hailed from all over: Denver, CO; North Platte, NE; Spearfish, SD; Toronto, Canada; Sydney, Australia; Knoxville, TN; Cleveland, OH and, of course, my father and I representing Omaha, NE. A little background on the Wind Cave: It was discovered by brothers Tom and Jesse Bingham in 1801 after hearing wind rushing out of a 10-inch by 14-inch hole. It is a place steeped in Native American history, believed to hold a portal to the spirit lodge and the spirit world. Today, as when my Dad and I toured the cave, you enter via an engineered staircase with more than 200 steps that cascade down into one of the longest caves in the world. Wind Cave is wholly unique in that it is very lateral, absent of any kind of mega soaring spaces filled with stalactites and stalagmites. Visitors wind through numerous tight crevasses, arriving in a space where a group can expand from a single file line. Here, several lights point up to the cave’s ceiling. These lights reveal the speleothem (aka cave formations) that make Wind Cave so unique. One speleothem that is more exceptional and abundant than others is called Boxwork, which is made of thin blades of calcite that project from cave walls and ceilings, forming an intricate honeycomb pattern. The fins intersect one another at various angles, forming “boxes” on cave surfaces. I recently made a return trip to Wind Cave, this time with my son. As we descended into the cave and entered that room, I was overcome by the same sense of awe

222

as before by the beautiful network of intersecting blades. As I considered these stunning formations, it struck me that this cave is a perfect example of how change is inevitable over time, even in the presence of one of the most rigid and solid of all environments. In the building profession, we consider bedrock to be an element of foundation; it helps things stand up and makes them stable. But in the case of Boxwork, the formation is created by the fractures that result from stresses when gypsum dried and then rehydrated. The resulting formation is lighter than the original and, in many ways, stronger. The strength comes from the triangulation of all these unique intersections. It all started, though, with a single crack, which led to another and another. Over time this network evolved and created a new matrix, one that is both complex and fluid, and above all interconnected. Other speleothems, such as stalactite and stalagmites, establish individual entities that are found in groups. Boxwork, by its very nature, requires the support of other formations. I believe it’s appropriate that the best examples of these formations are tied to the Great Plains, a part of the world where limited population has required groups to work together in order to overcome the environment. I have also wondered about the Boxwork structure and its applicability to the traditional corporate world. As a company or institution’s culture evolves, a need exists to focus on the organization’s collaborative entity, not on the singular cult of one

personality. I think the Boxwork is a beautiful metaphor for the collaborative creation that results when traditional understandings are eroded. The wonderful thing about erosion is that the formation it acts on maintains its original foundation, but outside forces—the world, the market, the culture—shape it. Ironically, from the outside, the Wind Cave appears as a nondescript hole in the ground. Like the settlers who uncovered it, we must also explore or insert ourselves into situations of seemingly average appearance in order to focus lights on the transformation of our entities. If we liken the simple singlestory stucco structure with its brown roof to that of a corporation—or a healthcare archetype like the one we explore here—we can envision what might result if we engage and transform them from the inside as the water and wind shaped the Wind Cave. Every effort to do so, every stress we encourage for it to expand or contract, ultimately adds to the beautiful and unique formation that is part of the Boxwork of our rural resolve.

223

224

SOURCES AND ACKNOWLEDGEMENTS

225

Sources Adams, Anthony Troy, et. al. (2010). Food Deserts. Sage Publications. https://journals.sagepub.com/doi/ abs/10.1177/193672441000400206. Allcott, Hunt et. al. (2019). Food Deserts and the Causes of Nutritional Inequality. The Quarterly Journal of Economics, Vol. 134, Issue 4. https://web.standford.edu/~diamondr/ FoodDeserts. American Hospital Directory. (28 May 2020). American Hospital Directory, Inc. www.ahd.com. (1960) Armour Food Source Map. Cornell University - PJ Mode Collection of Persuasive Cartography. https://digital.library. cornell.edu/catalog/ss:19343421 Best Places. (2020). 2020 Cost of Living Calculator. Sperling’s Best Places. https://www.bestplaces.net/cost-of-living Bower, Kelly M, et. al. (2014). The Intersection of Neighborhood Racial Segregation, Poverty, and Urbanicity and Its Impact on Food Store Availability in the United States. Preventive Medicine. https://doi.org/10.1016/j.ypmed.2013.10.010

Dickson, V. (19 Oct 2016). Rural hospitals often beat urban hospitals on quality. Modern Healthcare. www.modernhealthcare.com/article/20161019/ NEWS/161019891/rural-hospitals-often-beaturban-hospitals-on-quality Dutko, Paula, et. al. (2012). Characteristics and Influential Factors of Food Deserts. www.ers.usda.gov/webdocs/ publications/45014/30940_err140.pdf ESRI. (2020). TAPESTRY SEGMENTATION Life Mode Group: Prairie Living. ESRI. http://downloads.esri.com/esri_content_ doc/dbl/us/tapestry/6d-prairielivingtapestryflier-g826513.pdf Florala Health and Rehabilitation. (2016). Florala Health and Rehabilitation, LLC. https://floralahealthandrehab.com Gallagher, Mari. (2007). Examining the Impact of Food Deserts on Public Health in Detroit. www.marigallagher.com/2007/06/19/ examining-the-impact-of-food-deserts-onpublic-health-in-detroit-june-19-2007

Cassell, Franceska, et. al. (2018). Legislative Audit Office Pre-audit Report Universal Service Fund. USDA. https:// nebraskalegislature.gov/pdf/reports/audit/ usf_preaudit_2018.pdf

Ghosh-Dastidar, Bonnie, et. al. (2014). Distance to Store, Food Prices, and Obesity in Urban Food Deserts. American Journal of Preventive Medicine. https://doi.org/10.1016/j.amepre.2014.07.005

City of Ellijay, GA. (2016). www.ellijay-ga.gov

Greenblatt, A. (Jul 2018). In Rural America, Violent Crime Reaches Highest Level in a Decade. Governing. www.governing.com/ topics/public-justice-safety/gov-crime-ruralurban-cities.html

City of Horton. (n.d.). www.cityofhorton.com City of Stigler. (2020). www.stiglerok.net

226

City of Tilden. (2020). http:// tmgcommunityfoundation.org/city-of-tilden

Holmes, G, et. al. (Apr 2006). The Effect of Rural Hospital Closures on Community Economic Health. Health Services Research, 41(2), 467-485. doi: 10.1111/j.14756773.2005.00497.x URL: www.ncbi.nlm.nih. gov/pmc/articles/PMC1702512 Housing Assistance Council, The. (2010). Taking Stock: Rural People, Poverty and Housing in the 21st Century. The Housing Assistance Council. www.ruraldataportal.org/ docs/HAC_Taking-Stock-Regions.pdf HUD USER. (n.d.) Preserving Affordable Rental Housing in Rural America. www.huduser.gov/portal/pdredge/pdr-edgefeatd-article-071017.html Kaiser Family Foundation. (27 Apr 2020). Status of State Medicaid Expansion Decisions: Interactive Map. Kaiser Family Foundation. www.kff.org/medicaid/issbrief/ status-of-state-medicaid-expansion-decisionsinteractive-map Knueven, L. (19 Aug 2019). The typical American household earns $61,000 a year. Here are 15 states where the typical resident earns even less. Business Insider. www.businessinsider.com/personal-finance/ poorest-states-in-the-us-by-median-householdincome-2019-8 Koolhaas, Rem. (2020). Countryside: A Report. Guggenheim. Lee, Wei-Chen, et. al. (09 Sep 2014). Rural-Urban Differences in Healthcare Expenditures: Empirical Data from US Households. Hindawi. www.hindawi.com/ journals/aph/2014/435780

National Center for Argicultural Literacy. (2018). Growing a Nation timeline. U.S. Department of Agriculture. https://growinganation.org/content/showcontent/the_seeds_of_change National Low Income Housing Initiative. (2013). Affordable Rental Housing in Rural America. National Low Income Housing Initiative. https://nlihc.org/resource/ affordable-rental-housing-rural-america National Park Service. (14 Apr 2020). Rural Electrification Act. U.S. Department of the Interior. www.nps.gov/home/learn/ historyculture/ruralelect.htm National Rural Health Association. (2020). About Rural Health Care. www.ruralhealthweb.org/about-nrha/aboutrural-health-care NCPSMM Foundation. (15 May 2019). Medicaid Expansion Benefits States and Beneficiaries. National Committee to Preserve Social Security & Medicare. www. ncpssm.org/documents/medicaid-legislation/ medicaid-expansion-benefits-states-andbeneficiaries OMA. (24 Apr 2020). Countryside: Rem Koolhaas. OMA Office Work Search. https://oma.eu/lectures/countryside Parker, K., et.al. (22 May 2018). What Unites and Divides Urban, Suburban and Rural Communities. Pew Research Center. www.pewsocialtrends.org/2018/05/22/whatunites-and-divides-urban-suburban-and-ruralcommunities Primary Care Development Corporation. (20 May 2019). Rural Access to Primary Care in New York State. Primary Care Development Corporation. www.pcdc.org 227

Reamer, Andrew. (Dec 2018). Federal Funding for Rural America: The Role of the Decennial Census. GW Institute of Public Policy, The George Washington University. https://gwipp.gwu.edu/sites/g/files/ zaxdzs2181/f/downloads/Counting%20for%20 Dollars%233%20Federal%20Funds%20 for%20Rural%20America%2012-18.pdf Rosenbach, M, et. al. (1995). Access to Care in Rural America: Impact of Hospital Closures. Health Care Finance Review, 17(1), 15-37. www.ncbi.nlm.nih.gov/pmc/articles/ PMC4193569 Rountree, S. (04 Feb 2018). Hospital closing stirs memories and leaves a void in a town that’s already struggling. The News & Observer. www.newsobserver.com/ article198338509.html Stroudwater. (2018-2020). Closed Rural Hospitals Since 2010. Tableau Software, LLC. https://public.tableau. com/profile/stroudwater.associates#!/ vizhome/ClosedRuralHospitalsSince2010/ ClosedRuralHospitals (2020). TAPESTRY SEGMENTATION Life Mode Group: Prairie Living. ESRI. http://downloads.esri.com/esri_content_ doc/dbl/us/tapestry/6d-prairielivingtapestryflier-g826513.pdf Town of Scotland Neck. (2020). www.townofscotlandneck.com Town of Winnsboro. (2013). www.townofwinnsboro.com

228

Urban Institute. (2020). Public Welfare Expenditures. www.urban.org/policy-centers/ cross-center-initiatives/state-and-local-financeinitiative/state-and-local-backgrounders/ public-welfare-expenditures U.S. Census Bureau. (2018). American Community Survey 5-year estimates. https://censusreporter.org U.S. Centers for Medicare and Medicaid. (n.d.). Affordable Care Act (ACA). Healthcare.gov. www.healthcare.gov/glossary/ affordable-care-act U.S. Centers for Medicare and Medicaid. (n.d.). Medicaid expansion & what it means for you. Healthcare.gov. www.healthcare.gov/ medicaid-chip/medicaid-expansion-and-you USDA Climate Hubs. (2017). Agriculture in the Midwest. USDA Climate Hubs. www.climatehubs.usda.gov/hubs/midwest/ topic/agriculture-midwest U.S. Department of Agriculture. (2015). USDA Coexistence Fact Sheets Corn. USDA. www.usda.gov/sites/default/files/documents/ coexistence-corn-factsheet.pdf U.S. Department of Agriculture. (2015). USDA Coexistence Fact Sheets Soybeans. USDA. www.usda.gov/sites/default/files/ documents/coexistence-soybeans-factsheet.pdf U.S. Department of Agriculture. (2020). Population change by metro/nonmetro status, 1976-2017. USDA Economic Research Service. www.ers.usda.gov/topics/ruraleconomy-population/population-migration

U.S. Department of Agriculture. (2018). Poverty rates by metro/nonmetro residence, 1959-2018. USDA Economic Research Service. www.ers.usda.gov/webdocs/ charts/56286/povertyratesbyresidence2018_d. html?v=5979.3 U.S. Department of Agriculture. (31 Mar 2020). FAQs. USDA Economic Research Service. www.ers.usda.gov/faqs/#Q1 U.S. Department of Health & Human Services. (2019). 2019 Poverty Guidelines. Office of the Assistant Secretary for Planning and Evaluation. https://aspe.hhs. gov/2019-poverty-guidelines U.S. Department of Labor and the Occupational Safety and Health Administration - rights free (image page 38) Ver Ploeg, Michele, et. al. (2011). Mapping Food Deserts in the United States. USDA. www.ers.usda.gov/amber-waves/2011/ december/data-feature-mapping-food-desertsin-the-us

Areas? Urban Institute. www.rwjf.org/en/ library/research/2018/11/are-marketplacepremiums-higher-in-rural-than-in-urbanareas.html (n.d.) What is the recommended bandwidth for different types of health care providers. HealthIt.gov. www.healthit.gov/faq/whatrecommended-bandwidth-different-typeshealth-care-providers Wishner, J, et. al. (07 Jul 2016). A Look at Rural Hospital Closures and Implications for Access to Care: Three Case Studies. Kaiser Family Foundation. www.kff.org/reportsection/a-look-at-rural-hospital-closures-andimplications-for-access-to-care-three-casestudies-issue-brief World Population Review. (2020). Horton, Kansas Population. https:// worldpopulationreview.com/us-cities/hortonks-population

Walk Score. (2020). www.walkscore.com Wallsten, Scott. (2018). Rural Broadband Subsidies: The Gift that Keeps on Giving. Technology Policy Institute. https://techpolicyinstitute.org/2018/01/22/ rural-broadband-subsidies-the-gift-that-keepson-giving Weisgrau, S. (1995). Issues in Rural Health: Access, Hospitals,and Reform. Health Care Finance Review, 17(1), 1-14. www.ncbi.nlm.nih. gov/pmc/articles/PMC4193574 Wengle, E. (15 Nov 2018). Are Marketplace Premiums Higher in Rural Than in Urban

229

Contributors Ashley Glesinger

University of Nebraska Lincoln - College of Architecture

Growing up in small-town Spalding, NE cultivated Ashley’s desire to work for the betterment of rural communities. She completed her B.S. in Design and is a current M.Arch student at The University of NebraskaLincoln. During her studies, she has received three UCARE Grants and presented her research at the National Conference of Undergraduate Research in 2018 and 2019.

Adrian Silva Princeton University School of Architecture

Adrian attributes his curiosity to growing up in rural Nebraska, and has special interests in objects, infrastructures, materials and space. He completed his B.S in Design at the University of Nebraska-Lincoln, where he worked at multiple scales and formats. He is pursuing a Masters of Architecture at Princeton University.

Melissa Smith

University of Kansas, School of Architecture and Design

Melissa is in her final year in the 5-year Master of Architecture program at KU, pursuing certificates in Health + Wellness and Historic Preservation. She is an Honors Student and was the Vice President of Architecture Student Council. She spent a semester abroad in Copenhagen, Denmark studying architecture in 2019. She received the Architects Foundation / McAslan + Partners Fellowship in 2020.

Kent Spreckelmeyer, FAIA

University of Kansas, School of Architecture, Design and Planning

Kent Spreckelmeyer is a professor and maintains a consulting practice in architectural research and programming. He has co-authored five books that advance architectural knowledge by integrating analytic tools into the design process. Students working under his direction have won numerous national design and research competitions and have incorporated the principles of his work in their own practices. He holds a Doctorate in Architecture from the University of Michigan.

Thomas J. Trenolone, AIA HDR Great Plains Studio(s)

An architect and design advocate, Tom serves as a design director and principal with the firm, and a leader of its Great Plains Studio(s) based in Omaha, NE. He holds degrees in Architecture and Advertising Journalism. Recent project work includes Parkland 3.0 in Dallas, TX, and the Shirley Ryan AbilityLab in Chicago, IL —serving as creative director for both. A recipient of an HDR Fellowship in 2019, Rural Resolve serves as a capstone of Tom’s eight years of research with colleagues at the University of Kansas and the University of Nebraska regarding the future of rural communities and the place that health and wellness occupy in the built environment. 230

Acknowledgments Hank Adams HDR

Marty Amsler HDR

Katherine Ankerson

University of Nebraska – Lincoln

Kevin Augustyn HDR

John Barnhart Barnhart Press

John Bernt

21st Century Agriculture

Dan Bleyhl HDR

Paula Brammier HDR

Hui Cai

University of Kansas

Annette Carraher Greeley Care Home

Jeffery Day

University of Nebraska – Lincoln

William DeRoin HDR

Ella Feng HDR

Matt Goldsberry HDR

Charlie Hales HDR

Tim Hemsath BVH Architecture

Trisha Herman

Phillips County Economic Development

Annette Himelick HDR

Brian Hoppy HDR

Danette Hunter HDR

Sylver Kaufman HDR

David C. Kramer HDR

Michele Lee HDR

Nicole Mater HOK

Desiree Mervau HDR

Lisa Miller

Noddel Companies

Dewane Pace

Haxtun Hospital District

Phillip Perkins HDR

Mahbub Rashid University of Kansas

Kent Spreckelmeyer University of Kansas

Matt Stoffel HDR

Jennifer Straub

University of Kansas

Gabriella Sudbeck University of Kansas

Wyatt Suddarth HDR

Ian Thomas HDR

Scott Thompson

Haxtun Hospital District Board

Greg Wells HDR

Doug Wignall HDR

Tim Williams HDR

Cole Wycoff HDR

Hao Zhang HDR

Frank Zilm

University of Kansas

Joel Satore

Joel Satore Photography

Jeri Soens

Haxtun Hospital District Board

Katie Sosnowchik HDR

231

RURAL RESOLVE An HDR Fellowship

RURAL RESOLVE IMAGINING THE FUTURE HEALTH AND WELLBEING OF SMALL COMMUNITIES

WINNER OF THE NATIONAL AIA AAH AWARD FOR URBAN DESIGN AND MASTER PLANNING

0087059 1220

IN PARTNERSHIP WITH:

University of Kansas School of Architecture and Design University of Nebraska - Lincoln College of Architecture

A 2020 FAST COMPANY WORLD CHANGING IDEA FINALIST

THOMAS J. TRENOLONE, AIA, EDITOR