Designing for Vulnerable Populations
DESIGN INVESTIGATIONS
when difficulties arise, resilient communities recover quicker
When difficulties arise, resilient communities have the resources to withstand and recover from challenges. With the right infrastructure in place – durable buildings and systems, strong social support networks, and adequate financial resources – both communities and individuals are able to prepare for, endure, and recover from a disaster.
Disasters take many forms, from sudden shocks (a tornado, health emergency, or job loss) to slow-moving stressors (financial strain, neighborhood displacement, or the opioid crisis). In an ideal world, everyone would have the resources to weather a setback and rebuild quickly. Evacuations, damage repairs, medical issues, relocations, and other emergencies all require funding, whether at the household or the community scale. Unfortunately, not everyone has the emergency reserves or the support systems to navigate a crisis. An unexpected expenditure for someone living paycheck to paycheck can be devastating.
Some communities, and some individuals, are more at risk than others. The Center for Disease Control (CDC) and Agency for Toxic Substances and Disease Registry (ATSDR)’s Social Vulnerability
Indicatori identifies several key variables to help focus resources where they’re most needed in the wake of a disaster, with an interactive mapping tool.ii Variables include:
• Socioeconomic Status (150% of the federal poverty level, unemployed, housing cost burdened, no high school diploma, no health insurance)
• Household Characteristics (age 65 and older, age 17 and younger, civilian with a disability, single-parent households, and limited English language proficiency)
• Racial & Ethnic Minority Status
• Housing Type & Transportation (those living in multiunit structures, mobile homes, crowded conditions/group quarters, or with no vehicle)
Others who may be struggling include the working poor, who may earn too much to qualify for assistance but not enough to cover necessities; those living with mental health or substance abuse issues; and people who are displaced due to a natural disaster, the impacts of climate change, or other untenable situations.
Some communities, and some individuals, are more at risk than others.
Designers alone can’t solve the systemic challenges that lead to social vulnerability. We can, however, be a part of a compassionate solution. Design excellence isn’t just for the wealthy, and can be life-altering for those who need it most. Affordable housing with dignity, facilities for the homeless which provide safety and welcome on the way to addressing underlying issues, places where those in a mental health or substance abuse crisis can receive care in an appropriate and therapeutic environment, and accessible environments where all people can thrive can be transformative for people in a difficult chapter of their lives.
Creating thoughtfully designed places for our most vulnerable populations is not only the right thing to do: making sure that all people in our communities have the resources they need also makes our cites healthier and helps us target our financial and social resources where they can be most impactful.
Design excellence isn’t just for the wealthy, and can be life-altering for those who need it most
Why Are Our Neighbors Struggling?
The rate of poverty in the United States has remained relatively stable in recent years at around 11.5%, approximately 37.9 million people.iii Poverty, currently defined as an individual income lower than $14,850 per year or $30,000 per year for a family of four, iv has proven to be a relatively intractable problem nationwide. It’s not just people who meet federal definitions of poverty who are struggling. Low-income households (those making less than 200% of the poverty threshold v) accounted for 29% of the population in 2021.vi Even those in the middle class are vulnerable; in 1971, this category encompassed 61% of the US population, and by 2021 that percentage had fallen to 50%.vii This change represents upward mobility for those at the top, and economic stressors for those nearer to the bottom, but the middle class is definitely shrinking, and the divide between the “haves” and the “have nots” is growing wider.
One reason for this change is that cost of living has risen much faster than wages over the last 50 years. Education, housing, healthcare, and transportation have all become exponentially more expensive relative to income, and people entering the workforce today have 86% less purchasing power than their counterparts a few generations back.viii The affordable housing crisis means that many people are forced to overpay for shelter, and a modest two-bedroom apartment is currently unaffordable for 60% of workers.ix People spending disproportionately on housing may have difficulty budgeting for essentials such as food, transportation, and healthcare, and have difficulty saving for the future - making them more vulnerable in an emergency.
Rising healthcare costs can also be financially debilitating. Annual per capita spending on healthcare has increased 290% since 1980,x and the cost of a medical emergency or chronic diagnoses can lead to financial distress or bankruptcy. Cycles of poverty in under resourced families and communities can be difficult to break, and a growing mental health and substance abuse crisis creates additional challenges in communities that are already strained.
Architects, planners, and designers bring unique perspectives and skills to the task of building more livable communities where all people have the opportunity to prosper. Through innovation and experience, we can work with local governments, healthcare providers, community organizers, and other stakeholders to deliver solutions which can aid our most vulnerable neighbors in building a better life.
The Need for Affordable Housing
Affordable housing is commonly defined as costing 30% or less of the occupant’s gross income, including utilities. The demand for affordable housing far exceeds the current supply, and the need is greatest for those at the very low-income level. The shortage for extremely and very low-income residents is approximately 8 million units.xi The housing crisis eases slightly as income levels rise; however, the lack of affordable housing for middle-income earners creates downward pressure on the market as even higher earners are competing for affordable options. The result is that many households end up cost burdened to find available shelter, creating additional financial vulnerability.
High quality affordable housing is key to solving this crisis, and it’s about more than cost. High quality housing is:
• Conveniently located. While land in more remote areas might be less expensive, proximity to resources is critical to residents who need to be able to reach jobs, schools, services, and amenities to help them engage fully with their communities.
• Accessible by multimodal transit options. Proximity to public transit, greenways, bike paths, or well-designed pedestrian routes will help connect residents with employment, educational opportunities, cultural resources, and the broader community while reducing the need for car ownership, maintenance, and fuel.
• Contextual and beautiful. Designs that are seamlessly integrated into established neighborhoods provide dignity for residents and add value to the community.
• Sustainable and energy efficient. Homes that require less energy to operate translate directly into lower utility bills for residents and significant savings over time. Variable energy costs affect lower income households disproportionately.
• Conducive to health and wellness. Access to green space and pedestrianoriented development will encourage physical activity. An investment in healthy environments (including careful siting away from environmental hazards, and materials selected for healthy indoor air quality) will be beneficial to occupants’ long-term health and wellness.
The demand for affordable housing far exceeds the current supply, and the need is greatest for those at the very low-income level.
Case Study
Chicora Crest Affordable Housing
Greenville, SC
The Chicora Crest Development, orchestrated by Homes of Hope and designed by LS3P, includes eleven initial affordable-rental structures as part of a managed approach to improving the affordable housing stock of this historic neighborhood. Future construction of eighteen additional single-family structures will introduce new affordable owner-occupied for-sale properties to the neighborhood.
Homes of Hope’s goal is not simply to build homes, but also to improves lives by reinforcing the architectural character of the culturally vibrant neighborhood. A home’s physical character is inextricably linked to self-esteem and to community pride; thus, high-quality affordable housing must prioritize good architecture and craftsmanship.
The designs are authentically compatible with the neighborhood context, with five key design components including 1) designing to enhance the pedestrian orientation of the urban street grid; 2) maintaining the neighborhood’s traditional building setbacks for porches and façade elements; 3) complementing the geometry of the existing homes in the neighborhood and its surroundings; 4) detailingthehomesinkeepingwiththesurroundingpredominant architectural styles and 4) maintaining a density equal to or slightly greater than the balance of the neighborhood.
Challenges to providing additional affordable housing include high land costs, zoning constraints, and NIMBYism, among others. Many case studies, however, demonstrate that high quality affordable housing is possible, and the industry is ripe for innovation. Housing can be made affordable by subsidy, or by design, or both; ideally, stakeholders (cities, nonprofits, architects, planners, developers, neighborhood representatives, and residents) can partner on strategies to achieve affordability without requiring subsidies. Proven and emerging strategies include:
• Accessory Dwelling Units (ADUs): These small units –often referred to as granny flats or backyard cottages –are located on the property of a primary residence. The concept has been popular for generations, but cities often prohibit or restrict ADUs through exclusionary zoning. In recent years, however, many cities have changed their policies to allow and encourage ADUs as an attractive, contextual, integrated solution to providing more affordable housing options.
• Form-based codes: Unlike traditional codes which focus primarily on land use, form-based codes focus first on the form of the building and how it interacts with its context. Form-based codes allow for greater flexibility within certain parameters, which creates the opportunity to innovate and re-imagine assumptions about how affordable housing must be designed and constructed.
• Prefabricated modular units: Prefabricated modular construction offers exciting opportunities to reduce costs through economies of scale. Individual units are meticulously designed, then constructed in a controlled factory setting for assembly onsite within a superstructure. This construction method minimizes waste and elevates quality while increasing speed to market; if implemented on a large scale, the potential impacts of this method are substantial.
• 3-D printed housing: While still an emerging technology, some companies are delivering houses which are 3-D printed using stacked layers of concrete. This technology can construct up to 40% of a home with minimal supervision, and can save 15% on materials costs over traditional wood construction.xii
• Incentives for developers: Many municipalities offer targeted incentives for developers to encourage the construction of new affordable housing units. These incentives may include density bonuses, fee waivers, expedited processing, parking reduction, and tax abatement in exchange for a certain percentage of affordable housing development.xiii
• Public/Private Partnerships: Affordable housing can be a huge issue for any one entity to address. When multiple partners are involved – civic, commercial, or nonprofits – diverse perspectives, skill sets, and resources can often lead to collaborative successes. In this contractual relationship, all partners share the risk, and all partners share in the benefits.
• Advocacy and Innovation: When the status quo is not working, architects and designers have the responsibility to advocate for a better way. The path forward might involve new technologies, inventive use of materials, or advocacy for better and more flexible codes; innovation will be necessary to closing the gap between affordable housing demand and supply.
Homelessness
The homeless population in America is estimated by an annual “point in time” count conducted each January to gauge the number of people experiencing homelessness on a given night. In 2022 that estimate was 582,462 people, a number that has risen 6% since 2017.xiv Lack of affordable housing options is a significant cause: even those who are successful at securing housing for a time are at risk of losing that housing after a setback such as a medical expense, car repair, or job loss if they are struggling financially. Limited work opportunities and a fragile social safety net exacerbate these issues. Other factors which increase the risk of homelessness include poverty, mental illness, substance abuse, or domestic violence.xv People of color and those who identify as LGBTQ are disproportionately impacted. Many of the homeless are veterans living with PTSD.
Understanding the underlying issues is an important first step to designing compassionate, effective solutions. Chronically homeless people (around 30 % of the homeless population) are those who have been homeless more than a year, or who are experiencing frequent episodes of homelessness. These individuals are frequently dealing with compounding factors such as medical, behavioral, or substance abuse issues. Connecting these people with resources and assistance over the long term requires getting them into stable housing. The Permanent Supportive Housing (PSH) model (also known as “Housing First”) makes treatment a benefit of, and not a condition for, attaining housing. Lowering the barriers to access acknowledges that complex and co-occurring issues can best be addressed once housing is secured. Housing can be provided at a single location, integrated into other housing developments, or sprinkled across individual sites,xvii but in every case, stability and access to supportive services is key.
“Homelessness results from a complex set of circumstances that require people to choose between food, shelter, and other basic needs. Only a concerted effort to ensure jobs that pay a living wage, adequate support for those who cannot work, affordable housing, and access to health care will bring an end to homelessness.”
- National Coalition for the Homeless
Case Study
Eden Village
Wilmington, NC
Eden Village, a new tiny home community in Wilmington, NC, has reduced the number of Wilmington’s chronically homeless population by 31 individuals. In addition to fully furnishing housing in tiny homes fully furnished by donors, the pedestrianonly neighborhood includes a community garden and supportive services provided onsite.
LS3P designed the Eden Village community center as part of the firm’s pro bono “Design In-Kind” program. The net zero building houses offices, laundry facilities, a full kitchen with a dining area for up to 50 people, and a welcoming front porch gathering space. Eden Village was founded by philanthropists Tom and Kim Dalton; other key contributors include a team of contractors and subcontractors who provided in-kind and deeply discounted services: Thomas Construction Group, Cheatham and Associates, Woods Engineering, and Coastal Land Design.
The link between stable housing and improved health outcomes for the chronically homeless is bolstered by evidence from hospitals working in partnership with local housing authorities and community organizations supporting the homeless. Hospital systems such as the University of Illinois Hospital and Health Sciences System in Chicago, Denver Health, Boston Medical Center, and Bon Secours Mercy Health in Baltimore were all aware that many homeless individuals were using their emergency departments as a first line of defense in a crisis. In addition to being an expensive solution, these emergency room visits were not fully meeting the needs of their patients who were treated and released without stable environments in which to recover. By investing in housing as a critical part of the healthcare plan, these providers connected their patients with ongoing assistance, dramatically reduced emergency room visits, reduced costs, and supported better long-term outcomes for all.xviii
Unlike the chronically homeless, most people who experience homelessness over the course of a given year are situationally homeless. These people, often including families with children, are dealing with a sudden catastrophe such as a job loss, medical crisis, or natural disaster. People who are experiencing a temporary housing crisis may require a very different set of services. Rapid re-housing in the form of rental assistance, public housing, and vouchers such as those administered by the U.S. Department of Housing and Urban Development (HUD) can provide stability to individuals and families in financial distress before long-term homelessness occurs. Section 8 vouchers subsidize privatemarket housing, a critical factor in housing affordability for many families. For those who qualify, federally funded public housing also provides a safety net for vulnerable populations such as the elderly and the disabled.
Designing with dignity should be an integral goal in creating facilities for this population. Understanding that people experiencing homelessness may feel vulnerable, stigmatized, or unwelcome in unfamiliar environments, those who design facilities for this population must be particularly sensitive to the physical and emotional needs of the building’s end users. Whether providing housing or offering related services, successful designs will not only meet the needs of the client’s program, budget, and schedule, but will also prioritize dignity and an intentional sense of welcome.
Setting the tone begins with the first approach to the facility. The site should be landscaped and well maintained, with good visibility from the outside in, and from the inside out for wayfinding and comfort. Transitional space outside the building will allow guests to decompress as they come off the street and into an indoor environment which may be unfamiliar. Sheltered outdoor seating offers shade and protection from rain and provides a relaxed area for resting or socializing. The entry should be visible and easily accessible to people of differing physical abilities, and the form and detailing of the building should be attractive and uncluttered.
The interior materials palette also sends a powerful and immediate message to guests. A thoughtful and cheerful design with new, clean and coordinated furniture and finishes indicates that someone cares and wants the best for this group of people.
Serene wall art and plants help the space to feel welcoming; including local artists in the interior design can help to build connections with the community. Spaces that look and feel clean contribute to dignity, so materials should be easy to clean and maintain over the life of the building. These materials don’t have to look institutional: color, pattern, and biophilic elements all add appeal and make a space feel more welcoming. Donor walls can provide recognition but also add interest and a positive distraction.
The lobby offers an opportunity for a friendly face-to-face welcome, so the layout should draw from hospitality designs. Phone charging stations and self-serve stations for water, ice, and warm drinks give guests some autonomy within the space and something to do while they wait. For intake areas, offices with glass fronts allow users to speak privately while preserving visibility – an important consideration for those who might feel uncomfortable in a small, enclosed space.
Where possible, multi-purpose spaces help to maximize the owner’s budget while also providing spaces for community. For example, a dining room with flexible furniture and A/V equipment can double as a training room, or meeting rooms can be used by the wider community to bring people together and reduce stigmas. Flexible spaces can easily convert to additional emergency shelters as needed.
Sleeping areas should be semi-private for both dignity and safety. For example, a room with a cased opening instead of a door provides a sense of privacy and security, but allows visual connection and access in case of a medical emergency which can be common with at risk population. Clever built-in beds and storage can maximize space use to allow more beds in limited square footage. To discourage pests, anything porous (wood, mattresses, etc.) should be sealed. Sleeping areas should be tailored for men, women, and families; ideally, a parent should have a semi-private space to be near children but in their own bed. Guests should be encouraged to personalize their space if desired, for example with a magnet board for posting photos and notes.
A variety of storage spaces will be necessary throughout the facility. For guests, lockable storage will allow them to secure their belongings and feel safe while sleeping or accessing services. Donated items will also require substantial storage space adjacent to a designated place to receive and sort these materials. Many guests will also require secure bike storage (and, ideally, access to an onsite bike repair shop).
Providing areas for personal care is also critical to dignity. The plumbing should be designed to prioritize always-available hot showers, and heavy-duty laundry machines should be simple to use for both guests and staff. Ironing board stations will be helpful for those preparing for work.
Kitchen and dining areas should be designed for volume production and storage. These spaces may be used by community volunteers and may need to accommodate variable amounts and types of donated food, so both food preparation and storage areas should be generous and accessible. Both indoor and outdoor seating options will help to accommodate overflow as well as individual preferences.
Other amenities include spaces for children that support play, art, or studying; kennels to make sure that caring for a beloved pet doesn’t prevent someone from seeking shelter; lounges with a mix of comfortable seating and TV; and a computer lab with printer station.
Case Study
Oak City Cares
Raleigh, NC
Oak City Cares is a multiservices center providing critical support to those experiencing homelessness in Raleigh, NC. Formed as part of a unique partnership between Wake County, the City of Raleigh, and Catholic Charities, the center provides a welcoming, supportive environment for those experiencing homelessness. Guestscantakeahotshower,dolaundry,chargetheirphones,and find coordinated intake services under one roof for everything from mental health support to housing referrals.
Dignity is central to the design and the experience: it its first year of operation, Oak City Cares provided 9,096 showers, 6,129 loads of laundry, and 78,286 weekend meals for its guests.
The design creates transparency through a series of vertical openings in the envelope. These openings provide abundant natural light in the lobby and encourage guests approaching the building to feel safe and comfortable entering the space. The building includes an entry designed to feel more like a hotel lobby than an institutional space, laundry and shower facilities, multipurpose educational space, private offices for client interviews, and an outdoor gathering area with seating and shelter.
Case Study
One 80 Place
Charleston, SC
With a mission to end and prevent homelessness “one person at a time, one family at a time,” One80 Place provides comprehensive services including housing, temporary shelter, healthcare, legal services, veterans’ assistance, job training, work experience, and meals.
One80 Place’s newest facility will greatly expand its capacity and services with a design that appears rooted in Charleston’s neighborhood fabric. The large structure is broken into smaller volumes to maintain a residential scale, meeting the street with a three-storyspacewhichincludespedestrian-friendlystorefronts, a café staffed by graduates of One80 Place’s culinary training program, and an inviting colonnade leading guests into the site.
The building rises to eight stories at the rear of the site to accommodate 73 apartment units, a family center, office space, andavarietyofamenitiesandgatheringspaces.Themodern,open interior borrows from a contemporary hospitality palette to feel as welcoming as a high-end hotel. Bright colors, family-friendly spaces, natural light, and conveniences such as mailboxes and a computer center create a sense of security and inclusion.
Displacement
The homeless are not the only people who may find themselves in need of temporary housing, though many principles of designing for the homeless will apply to other displaced populations. People move for many different reasons: to access better employment or educational opportunities, to be closer to loved ones, or to experience a new city or landscape. Increasingly, people are moving in response to both slow-and fast-moving climate emergencies. In the coming decades, an estimated 143 million people worldwide are likely to be displaced by the impacts of climate change (rising seas, heat waves, and drought). Another 21.5 million people annually are displaced by natural disasters.xix Secondary factors, such as hunger or rising gang violence in povertystricken areas increasingly plagued by drought, are difficulty to quantify. Often, those who are displaced relocate within their own cities if possible. Others cross state or international borders. Many of those displaced are already struggling financially and have limited housing options.
Viewed through a different lens, climate migration may also include more affluent people relocating to milder climates and popular destinations. This influx can create downward pressure in places with a higher cost of living where housing is already scarce, creating stressors for established residents who are suddenly at risk of displacement themselves.
Displaced people need safe, accessible, affordable housing options that can be deployed quickly after a large-scale event. For short term needs such as temporary cooling centers or evacuation centers, community facilities such as the gymnasium at a local school may be adequate for meeting urgent needs. For those displaced for longer periods, a more sustainable solution will be needed until permanent housing can be secured. Sometimes temporary housing accidentally becomes permanent – think FEMA trailers in the wake of Hurricane Katrina – leading to longer term issues. Thoughtful housing solutions may need to include models for easily dispatchable, flexible designs that are intended to become permanent, and that allow for alteration and reconfiguration over time.
Many of those displaced are already struggling financially and have limited housing options.
It’s not just individuals who will be affected by displacement. Critical infrastructure such as hospitals and emergency operations centers may also need to relocate to higher ground, preferably long before a disaster renders them inaccessible or unusable. Organizations seeking to build resilience into their long-term planning should be building for strategic redundancy for critical operations. For example, what happens if a coastal hospital is temporarily disabled in a natural disaster? Does the hospital system have a “hub and spoke” model that would relocate or redirect patients to a nearby facility? Does a pharmaceutical company who manufactures lifesaving medications have a contingency plan to shift operations quickly if a plant is damaged so that the whole supply chain is not impacted? Long-range planning for critical facilities should acknowledge long-term risk scenarios and build in opportunities for redundancy.
People who are displaced are likely experiencing trauma, so designing every step of the disaster relief and recovery process will help to minimize disruption and get communities back up and running. This process should include regional coordination, design, and planning for safe evacuation routes, emergency shelters, temporary housing as needed, and resilient infrastructure which can withstand a natural disaster with as little damage as possible. The more resilient our built environment becomes, the faster people can safely return to their homes, schools, and businesses.
Mental Health + Substance Abuse Recovery
According to the National Alliance on Mental Health (NAMI), one in five adults and one in six youth in the US experience mental illness every year. One in fifteen people experience both a mental illness and a substance abuse disorder.xx The number of people seeking treatment has increased in recent years.xxi This trend may be due to an increase in mental health issues in the wake of the COVID pandemic and other large-scale societal issues; it may also be due to reduced stigmas around seeking behavioral health issues. A recent report by the Substance Abuse and Mental Health Services Administration (SAMHSA) found that 46.3 million people in the US meet the criteria for a substance use disorder.xxii
Too often, the first line of defense for people experiencing a mental health crisis is the emergency room. While an ER is well equipped to handle triage and medical treatment, it’s a less than ideal solution for treating someone in mental or emotional distress who needs a calming therapeutic environment which allows for observation, stabilization, and safety. Spaces designed specifically for behavioral health are better suited to healing.
Making it Easy to Seek Treatment: Normalizing behavioral healthcare is an important part of improving access. Designing facilities which feel more like wellness facilities than institutional spaces can reduce stigmas around seeking treatment. Behavioral health spaces can weave in elements of other typologies such as hospitality or spa design to create a serene, welcoming environment that lowers barriers and builds a better patient and family experience. Smaller facilities located closer to a patient’s neighborhood can also provide familiarity and care at a more personal scale than a large hospital setting.
Finding the Right Number of Beds: Communities often struggle to balance the right number of inpatient beds and the desire to treat patients in the least restrictive environment appropriate for their care. Inpatient care used to be the default treatment method in a behavioral health crisis; however, a combination of budget cuts and advances in psychotropic medication have led to many more patients being treated at home. In a crisis, however, the lack of available beds has too often resulted in “hoteling” patients in emergency departments until a bed becomes available. Providing behavioral health urgent care facilities with welldesigned, therapeutic spaces for observation and treatment is a more effective solution for all. These facilities offer 24/7 access, and patients can be triaged and recommended for a 23-hour observation period, discharged, or referred to an onsite inpatient care center (with separate facilities for pediatric and adult patients). This model relieves the burden on emergency room physicians while providing a more compassionate treatment experience for the patient and their families.
Case Study
Guilford Behavioral Health
Greensboro, NC
The Guilford County Behavioral Health Center(BHUC),whichopenedtopatientsin 2021, provides integrated, compassionate care for patients experiencing behavioral health issues. The Center, which features a 24/7 behavioral health urgent care and a facility-based crisis center, was created in a unique partnership between Guilford County and Cone Health (and with input from NCDHHS). An adjacent facilitybased crisis center for children and teens is run by Sandhills Center; together, these programs are transforming the way behavioral healthcare services are delivered in the region.
In the BHUC’s first year of operation, Cone Healthsawa20%reductioninEmergency Department visits due to behavioral health issues. The center averages about 425 visits per month, and 79% of patients are stabilized and discharged onsite without the need for hospitalization. Readmission rates for behavioral health patients dramatically improved as well,
with only 9-14% of patients readmitted within the six months after treatment (as opposed to an average readmission rate of 43% for patients treated in emergency departments).
The Center creates a “one-stop shop” for mental health needs, and the integrated care model helps to eliminate visits to multiple agencies or specialists. The design conveys a sense of welcome, underscoring the message that each patient is valued and important. Doubleheight lobbies filled with natural light, clerestories at the nursing stations, and a palette of therapeutic, enlivening, and vibrant colors all help to create a healing environment communicating that each patient matters, that these facilities deliver the same top-level patient care as any other medical facility, and that behavioral health is an important and valued part of holistic healing.
Prioritizing Patient-Centered Design: Researchers Mardelle
Shepley and Samira Pasha have identified key characteristics of therapeutic behavioral health environments.xxiii These include the balance between personal space and density, control and choice, sensory conditions, spatial clarity, access to nature, connection to the outside, stress reduction, comfort, and hominess. An emphasis on biophilic design supports healing; natural light, framed views to nature, nature-inspired art and textures, plants and water feature, wooden elements, and organic shapes and forms are all conducive to a sense of calm.
Case Study
MUSC Modern Minds
Charleston, SC
This innovative mental health and wellness center provides treatment for adults who are struggling with mental wellness, as well as those who are seeking growth in their personal and professional lives. The 3,400 SF renovation includes check-in and waiting areas, private waiting area, consult rooms, group therapy room, observation room, and both private and open offices.
The design was crafted to create a soothing environment to reduce stress and remove the stigma of receiving mental health services. LS3P provided schematic planning, construction documents, and interior design, including structural finishes, furniture, and artwork.
Designing for Safety:
Patients in a behavioral health crisis may be vulnerable to self-harm, and designing for safety is paramount. The Joint Commission recently updated its patient safety guidelines in the “2023 National Patient Safety Goals (NPSGs) for the Behavioral Health Care and Human Services” document.xxiv Implementing best practices for minimizing ligature and other safety risks is important even in lower acuity settings.
Meeting the Needs of Multigenerational Populations:
People of all ages seek behavioral health services, but their physical and emotional needs may be very different. Pediatric patients should be treated in kid-friendly facilities designed and scaled for their developmental stage, and will need additional spaces for family support. College and university students need easy-to-access campus facilities that balance privacy needs while destigmatizing seeking assistance, such as those located near popular campus amenities. Older patients may be dealing with layers of issues including dementia, and the demand is growing for both providers and facilities to meet the needs of an aging population.
Caring for the Carers: Recruitment and retention of healthcare providers is a growing concern in a high-burnout field. Designing working environments that support these critical workers means providing safe, attractive, and efficient spaces to help them manage their workloads and also dedicated respite spaces for wellness and recharging.
Creating
a Supportive Community: Adults living with mental illness or substance abuse may struggle to live independently, but may thrive in a supportive setting. Whether through day programs or residential options, places that provide job and life skills training, social and educational opportunities, and a nurturing community can be transformative in helping people manage their issues and find a path forward.
Recruitment
and retention of healthcare providers is a growing concern in a high-burnout
Case Study
Gateway House
Greenville,
SC
Greenville’s Gateway House provides multilevel support for adults with severe mental illnesses, serving over 225 members each year. The unique “Clubhouse” model helps people transition to full independence by helping them build social, interpersonal, educational, and employment skills. Gateway House reduces the need for hospitalization in a caring environment with in-house jobtraining,supportedoutsideemployment,assistanceaccessing and succeeding in educational programs, and a network of social support. Gateway includes 72 independent living apartments, and 13 units of housing for those needing assistance navigating daily life with medication reminders, grocery shopping, cleaning, or other tasks.
LS3P is designing a new 20,000 SF Clubhouse for Gateway’s vital programs. The Clubhouse will anchor Gateway’s campus and serve as a central gathering space, with a design focused on openness, natural light, safety, durability, and flexibility. The buildingwillhouseasnackbar,kitchen,cafédiningroom,clerical workspace, members’ bank, newsletter and video production space, administrative spaces, executive offices, and meeting rooms. The new Clubhouse is carefully detailed to reflect the scale and design character of surrounding built environment so that it feels integrated into its surrounding neighborhood.
Equitable Neighborhood Design
Our neighborhoods can have a powerful impact on our health and prosperity, even more so than genetics. According to the National Community Reinvestment Coalition, up to 60% of health is determined by zip code.xxv Access (or lack of access) to healthy food through proximity to affordable, full-service grocery stores is a key driver of community health.
In areas where car ownership is low, robust public transit systems and attractive, walkable neighborhoods can provide a valuable lifeline connecting residents not only to grocery options, but also better opportunities for work, education, and community building. Green space is also vital to mental and physical health.
Environmental and climate justice are additional factors. Lower income neighborhoods have often been relegated to less desirable land such as tracts near highways, industrial uses, or low-lying areas. The resulting pollution, noise, and flooding risk contribute to myriad health issues in populations which may already be struggling. Designing cities for equity, wellness, and equal access to opportunities paves the way for better health for all residents.
Case Study
Legacy Place
Raleigh, NC
This neighborhood development plan protects and showcases the site’s natural amenities by wrapping the Main Street around the existing creek and riparian buffer. The landscape becomes a central “green spine” that anchors the district, and natural amenities are woven into the plan throughout the site in the form of programmed play areas, natural landscapes, and multimodal pathways.
The vision for this reimagined district is to bring new uses, new opportunities, and new investment to a historic neighborhood that has traditionally been marginalized and under resourced. As it is implemented in phases, the district will become a mixed use anchor and destination for the entire city. The flood plain and creek offer unique challenges that are to be showcased rather than overlooked; pairing key program elements with unique nodes allows the design to harness the best aspects of the natural landscape.
Inclusion for Every Body, in Every Building
Sometimes designing for vulnerable populations means admitting that we, as designers, don’t always know who is struggling. At any given time, someone using our buildings may be navigating a hidden or a temporary disability. They may be neurodivergent, have impaired hearing or vision, or may be dealing with physical or mental issues we can’t see. Universal Design offers strategies to make our buildings more welcoming and accessible for all people – an important aspect of Justice, Equity, Diversity, and Inclusion in the built environment. According to the Center for Excellence in Universal Designxxvi, the seven principles include:
Equitable Use: Encourages use by people of diverse abilities. (example: barrier free corridor design)
Flexible Use: Encourages a wide range of preferences and needs.
(example: adjustable furnishings)
Simple and Intuitive: Requires no background knowledge to understand.
(example: color-coded wayfinding)
Perceptible Information: Conveys information quickly (example: pictographs on public signage)
Tolerance for Error: Minimizes the risk of accidents (example: guardrails at train platforms)
Low Physical Effort: Can be used easily and without fatigue. (example: automatic doors)
Size and Space for Approach and Use: Sized for ease of use regardless of physical constraints. (example: generous open floor spaces in public transit to accommodate strollers and wheelchairs)
Code minimums dictate requirements for accessibility and egress, but exceeding these requirements by even a few inches can provide ease and better accessibility in the built environment. We often “don’t know what we don’t know,” so engaging diverse stakeholders in the planning and design of any project will help us build environments that work better for all.
The “wicked problems” our communities are experiencing today are complex and systemic. We can’t design our way out of these issues; we can, however, bring our unique problemsolving and design-thinking abilities to bear in addressing them. We can advocate for change at the local, regional, national, and global levels, and we can work with stakeholders to design compassionate, scalable solutions which prioritize the people who most need our help.
Works Cited
i ATSDR. N.d. “CDC/ATSDR Social Vulnerability Index.” Accessed Augst 21, 2032. https://www.atsdr.cdc.gov/placeandhealth/svi/index. html .
ii ATSDR. N.d. “Overall SVI Nationwide Comparison.” Accessed Augst 21, 2032. https://www.atsdr.cdc.gov/placeandhealth/svi/interactive_ map.html .
iii US Census Bureau. January, 2023. “National Poverty in America Awareness Month: January 2023.” https://www.ers.usda.gov/dataproducts/chart-gallery/gallery/chart-detail/?chartId=98028 .
iv HealthCare.gov. n.d. “Federal Poverty Level.” Accessed August 15, 2023. https://www.healthcare.gov/glossary/federal-poverty-level-fpl/
v Kilduff, Lillian. January 31, 2022. “How Poverty in the United States Is Measured and Why It Matters.” https://www.prb.org/resources/ how-poverty-in-the-united-states-is-measured-and-why-it-matters/#:~:text=Families%20with%20incomes%20below%20200,for%20 a%20family%20of%20four).
vi Kochhar, Rakesh and Sechopoulos, Stella. April 20, 2022. “How the American Middle Class Has Changed in the Last Five Decades.” https://www.pewresearch.org/short-reads/2022/04/20/how-the-american-middle-class-has-changed-in-the-past-five-decades/.
vii Kochhar, Rakesh and Sechopoulos, Stella. April 20, 2022. “How the American Middle Class Has Changed in the Last Five Decades.” https://www.pewresearch.org/short-reads/2022/04/20/how-the-american-middle-class-has-changed-in-the-past-five-decades/.
viii McCants, Cassidy. Updated June 1, 2023. “Comparing the Cost of Generations.” https://www.consumeraffairs.com/finance/comparingthe-costs-of-generations.html.
ix National Low Income Housing Coalition. June 14, 2023. “NLIHC Releases Out of Reach 2023: The High Cost of Housing.” https://nlihc.org/ news/nlihc-releases-out-reach-2023-high-cost-housing#:~:text=Out%20of%20Reach%202023%20shows,the%20one%2Dbedroom%20 Housing%20Wage.
x Nunn, Ryan; Parsons, Jane; and Shambaugh, Jay. March 10, 2020. “A Dozen Facts about the Economics of the US Health-care System.” https://www.brookings.edu/articles/a-dozen-facts-about-the-economics-of-the-u-s-health-care-system/ .
xi National Low Income Housing Coalition. March 2023. “The Gap: A Shortage of Affordable Homes.” https://nlihc.org/gap .
xii Bellamy, Claretta. January 4, 2022. “How 3D Printing Can Be the Solution to the Nation’s Affordable Housing Crisis.” https://www. nbcnews.com/news/nbcblk/3d-printing-can-solution-nations-affordable-housing-crisis-rcna10725 .
xiii Inclusionary Housing. N.d. “Incentives.” Accessed August 22, 2023. https://inclusionaryhousing.org/designing-a-policy/landdedication-incentives/ .
xiv National Alliance to End Homelessness. N.d. “State of Homelessness: 2023 Edition.” Accessed August 15, 2023. https://endhomelessness. org/homelessness-in-america/homelessness-statistics/state-of-homelessness/#key-facts
xv National Coalition for the Homeless. N.d. “Why Are People Homeless?” Accessed August 15, 2023. http://nationalhomeless.org/ publications/facts/Why.pdf .
xvi National Alliance to End Homelessness. Updated April 2023. “Chronically Homeless.” https://endhomelessness.org/homelessnessin-america/who-experiences-homelessness/chronically-homeless/#:~:text=People%20who%20are%20chronically%20 homeless,Updated%20April%202023 .
xvii Locke, Gretchen. N.d. “Permanent Supportive Housing.” Accessed August 15, 2023. http://www.evidenceonhomelessness.com/topic/ permanent-supportive-housing/.
xviii Redford, Gabrielle. April 20, 2023. “To Improve Health, Hospitals Partner to Provide Housing.” https://www.aamc.org/news/improvehealth-hospitals-partner-provide-housing#:~:text=Because%20many%20health%20systems’%20most,a%20permanent%20place%20 to%20live.
xix Watson, Julie. July 28, 2022. “Climate Change Is Already Fueling Global Migration. The World Isn’t Ready to Meet People’s Changing Needs, Experts Say.” https://www.pbs.org/newshour/world/climate-change-is-already-fueling-global-migration-the-world-isnt-readyto-meet-peoples-needs-experts-say .
xx National Alliance for Mental Illness (NAMI). N. d. “Mental Health by the Numbers.” Accessed September 5, 2003. https://www.nami.org/ mhstats .
xxi Centers for Disease Control and Prevention. September, 2022. “ Mental Health Treatment Among Adults Aged 18–44: United States, 2019–2021.” https://www.cdc.gov/nchs/products/databriefs/db444.htm .
xxii Substance Abuse and Mental Health Services Administration (SAMHSA). January 4, 2023. “ SAMHSA Announces National Survey on Drug Use and Health (NSDUH) Results Detailing Mental Illness and Substance Use Levels in 2021.” https://www.hhs.gov/about/ news/2023/01/04/samhsa-announces-national-survey-drug-use-health-results-detailing-mental-illness-substance-use-levels-2021. html
xxiii Shepley, Mardelle and Pasha, Samira. July 28, 2013. “Design Research and Behavioral Health Facilities.” Blog_Spec_The Center for Health Design_Design Research And Behavioral health Facilities_20130728.pdf (specfurniture.com) .
xxiv The Joint Commission. July 1, 2023. 2023 National Patient Safety Goals (NPSGs) for the Behavioral Health Care and Human Services.” https://www.jointcommission.org/standards/national-patient-safety-goals/behavioral-health-care-national-patient-safety-goals/ .
xxv Orminski, Emily. June 30, 2021. “Your Zip Code Is More Important than Your Genetic Code.” https://ncrc.org/your-zip-code-is-moreimportant-than-your-genetic-code/ .
xxvi Centre for Excellence in Universal Design. N. d. “The 7 Principals.” https://universaldesign.ie/what-is-universal-design/ the-7-principles/.