Urban Healthcare_NEW by Northeastern School of Architecture

FALL 2013

INNOVATION IN URBAN HEALTHCARE

Northeastern University School of Architecture ARCH 7130 Graduate Research Studio

Fall 2013

INNOVATIONS IN URBAN HEALTHCARE Northeastern University School of Architecture ARCH 7130 Graduate Research Studio

Acknowledgements We would like to thank the following people and companies for their generous contribution of time, knowledge and resources. Without them this book would not be possible.

FACULTY ADVISER

RESEARCH TEAM

George THRUSH Matthew LITTELL Elizabeth CHRISTOFORETTI

Blake COREN Steve DUBOIS Phillip GIORDANO John HO Yanmei LIN Abigail LUPIEN Esraa NAHHAS Sharon PENG Mikala STONE Cory WILDE

The work contained within this publication was created by the Fall 2013 Northeastern University School of Architecture Graduate Research Studio. ÂŠ2013 Northeastern University School of Architecture

SCHOOL OF ARCHITECTURE

Table of Contents

Introduction

Health Care Delivery

COREN, GIORDANO, LUPIEN, STONE

GIORDANO

COREN, LUPIEN, STONE

COREN, GIORDANO, LUPIEN, STONE

162

STONE

178

HO, LIN, NAHHAS

180

NAHHAS

196

NAHHAS

210

226

236

246

LIN

278

LIN

288

DUBOIS ,PENG, WILDE

291

WILDE

313

PENG

349

WILDE

362

DUBOIS

373

DUBOIS

The Basics Organization of Services/Facilities Interior Environments/Types Future Technologies

History and Culture

The Doctorâ&#x20AC;&#x2122;s Office The Hospital The Pharmacy The Retail Clinic Doctor Patient Relationship Psychology of Interior Space Branding/Marketing

Urban Environment Mapping Demographics Zoning Typologies Street Presence

Introduction Urban healthcare is facing a period of transition and opportunity. The Affordable Care Act and other factors such as Accountable Care Organizations present a number of opportunities for architects to add value to the changing landscape of healthcare and urban environments. There is a large contingent of the previously uninsured that lives in cities but has not traditionally had access to primary and preventative care. Many large urban neighborhoods lack the physical infrastructure to supply these services outside of hospital settings. This book catalogues the research of the intersection of urban building typology, new modes of healthcare delivery, such as the CVS Minute Clinic, and new opportunities for integrating healthcare services with other urban uses to create a new kind of urban environment. This includes interior diagnostic spaces, existing urban pharmacies, historical

mixed-use approaches to healthcare delivery, mixed-use urban building types, and the role of new transportation networks in cities as an opportunity for new integration of services. Additionally, new and emerging medical technologies are analyzed to better understand both the spatial needs and the broader organizational issues that might impact these alternative healthcare delivery networks. Much of the research focuses on conditions in Boston, but will address the larger healthcare delivery challenges that face all dense urban centers, both in the United States, and beyond. The Massachusetts Building Code and the Massachusetts Department of Public Health were referenced to determine the standard requirements for healthcare delivery environments. This publication is structured into three sections: (1) an analysis of the typical interior environments of various healthcare

facilities, (2) an in depth look at the less quantifiable aspects of health care such as branding and patient experience, and (3) the urban environments that these facilities typically exist in, including zoning, demographics and street presence examinations. This is not an exhaustive survey of urban healthcare data. Rather, the research represents a 10-week study of topics anticipated to be relevant for architects in the conception of new design ideas around healthcare. This book will be the guide for designers seeking out novel approaches to old problems by using the research to re-frame the discussion about health care delivery models. The topic will afford a wide variety of approaches and scales of intervention, from highly specific architectural proposals to broader scaled urban design ideas.

178 | Health Care Delivery Models

Health Care Delivery Models

2 Basics of Code Organization of Services/Facilities Interior Environments/Types Emerging Technologies

Sources | 179

012 | Health Care Delivery Models

Basics of Code Exam Room Unit

Basics of Code | 013

Exam Room Unit Accessible Exam Room

A clear floor space, 30” X 48” minimum, adjacent to the exam table and adjoining accessible route make it possible to do a side transfer. Adjustable height accessible exam table lowers for transfers. Providing space between table and wall allows staff to assist with patient transfers and positioning. When additional space is provided, transfers may be made from both sides. Amount of floor space needed beside and at end of exam table will vary depending on method of patient transfer and lift equipment size.** Accessible entry door has 32” minimum clear opening width with door open 90 degrees.

Note: Additional clear floor space can be provided by moving or relocating chairs, trash cans, carts, and other items.

014 | Health Care Delivery Models

Maneuvering clearances are needed at the door to the room. Accessible route connects to other accessible public and common use spaces.

**The room should also have enough turning space for an individual using a wheelchair to make a 180-degree turn, using a clear space of 60 inches in diameter or a 60 inch by 60 inch T-shaped space. Movable chairs and other objects, such as waste baskets, should be moved aside if necessary to provide sufficient clear floor space for maneuvering and turning.

The clear floor space can also make it possible for use of a portable patient lift.

Basics of Code | 015

016 | Health Care Delivery Models

Organization of Services/Facilities Services Provided by License Typical Nursing Services Healthcare Facilities Facility Flow Chart

Organization of Services/Facilities | 017

Services Provided by License

The diagram opposite this page shows four different healthcare licenses and their ascribed responsibilities. The grey zones represent “grey areas” where services are shared by two different licenses. It is less common for a service to be exclusive to one license. Most services can be performed by multiple licenses. Included is each license’s average salary per year, from the Bureau of Labor Statistics. Interestingly, a physician (MD) and a nurse practitioner (NP) can legally perform most of the same services, yet the MD’s salary almost doubles the NP’s. This may account for the rising demand for nurse practitioners.

018 | Health Care Delivery Models

common for a service “ Ittoisbelessexclusive to one license. Most services can be performed by multiple licenses.

“

Healthcare services cannot be broken down into clear categorical levels. Rather, they overlap in terms of the facilities they are performed at and who is allowed to perform them by license. A “Venn diagram” approach is appropriate when attempting to classify healthcare services because of this overlap.

Also included are the average years of training (education and residencies) each license requires. This shows why an MD’s salary is so much higher than an NP’s: they require almost double the years of training. However, these variables might influence an employer’s decision of which healthcare professional to hire. It also affects the decision a student might take when deciding which license to pursue.

Physician (MD)

Average salary: $180,850 Average training: 11-15 years Treats diseases using drugs, procedures, or surgery Run their own office Prescribe medication Analyze diagnostic tests Order diagnostic tests Perform physical exams Patient diagnosis Discharge approval Cast bones Draw arterial blood

Simple procedures like sutures Foreign body removal from ears/nose/etc. Asses minor injuries Assess minor illnesses Treat eye injuries

Nurse Practitioner (NP) Average salary: $91,450 Average training: 6-8 years

Treats and manages common and chronic illnesses

Administer medicine Suture removal Collect data (blood pressure, urine samples) Emergency CPR Medication renewal

Registered Nurse (RN) Average salary: $67,390 Average schooling: 2-4 years

Patient education Administer diagnostic tests Treat minor injuries (dress wounds) Treat minor illnesses Recording medical histories Administer vaccinations Consultation on common ailments Promotes wellness

Pharmacist (RPh) Average salary: $114,950 Average schooling: 6 years Average salaries from Bureau of Labor Statistics, May 2012.

Compound and dispense prescriptions

Interior Environments/Types | 019

Typical Nursing Services Vaccinations Flu Shot Flu Shot High Dose Pneumonia (Pneumococcol) Hepatitis A/Hepatitis B Hepatitis A Hepatitis B Chickenpox (Varicella) HPV (Human Papillomavirus) Meningitis (Meningococcal) MMR Shingles (Herpes Zoster) Td (Tetanus booster) Tdap (Whooping Cough) Polio Typhoid

020 | Health Care Delivery Models

Minor Illnesses Allergy symptoms (2 years+) Bladder Infection Cold Bronchitis / cough Earache / ear infection Flu-like symptoms Headaches & migraines Joint pain Laryngitis Lyme disease Mononucleosis (mono) Motion sickness prevention Sinus infection / congestion Pink eye & styes Sore throat / strep throat Upper respiratory infection Swimmerâ&#x20AC;&#x2122;s Ear Urinary tract infection Minor back pain

Minor Injuries Blisters Bug bites & stings Deer tick bites Jellyfish stings Minor burns Minor cuts & lacerations Minor wounds & abrasions Splinter removal Sprains / strains (ankle, knee) Suture & staple removal corneal (eye) abrasions foreign body removal from eye and ear

Skin Conditions Acne Athleteâ&#x20AC;&#x2122;s foot Chicken pox Cold sores & canker sores Eczema Impetigo Lice Hives Minor infections Minor rashes Oral / mouth sores Poison ivy / oak Ringworm Scabies Shingles Skin tag removal Styes Sunburn Swimmerâ&#x20AC;&#x2122;s itch Wart Removal

Wellness & Monitoring Health screening Cholesterol screening/monitoring Diabetes screening/monitoring Administrative, camp, school Physicals Birth control injection Ear wax removal EpiPen refill Medication renewal Smoking cessation Tuberculosis Testing Vitamin B12 Injection Weight loss program High Blood Pressure Asthma Acid Influx and Indigestion Cardiovascular Conditions Chronic Bronchitis Emphysema Minor depression Osteoarthritis Osteoporosis Thyroid Disorders A1c check

Lab Testing Blood sugar test $19 Flu test influenza A & B HbA1c Mononucleosis (mono) test Cholesterol screen (Lipid panel) Negative quick strep Pregnancy test Quick strep Urine dip stick PPD Tuberculosis Testing

Interior Environments/Types | 021

Healthcare Facilities By Required Personnel

Another way to analyze healthcare facilities is by required personnel. In order for a facility such as a pharmacy or an emergency department to receive a license from the State of Massachusetts, certain licensed healthcare professionals are required to be present during all hours of operation. Facilities that deal with high acuity cases (emergency departments, urgent care facilities) require more licenses present versus a facility that handles low acuity cases such as a school nurse or a pharmacy. These facilities require only one or two licenses. This diagram also makes apparent which healthcare licenses are more versatile then others, meaning a higher number of facilities require them. Although a registered nurse may not have as high of a salary as a physician, their license is more applicable to a variety of facility types. This might translate to a higher demand for jobs.

022 | Health Care Delivery Models

License Versatility

LICENSE

More Versatile

Less Versatile

Medical Director (CMD) Physician (MD, DO)

Radiologist

Nurse Practitioner (NP) Physicianâ&#x20AC;&#x2122;s Assistant (PA) Registered Nurse (RN)

y ac ar m

FACILITIES

Sc N hoo ur l se

M Re ed ta Cl ica il in l ic

ar y O Car ffi e ce

Pr im

m m H uni e Ce al ty nt th er

en t Fa Ca ci re lit y

rg U

E D me ep r ar ge tm nc en y t

Pharmacist (RPh)

Organization of Services/Facilities | 023

By Level of Service The diagram to the right shows twelve different healthcare facilities organized based on their level of acuity and specificity of services. The top linear chart shows the facilities from low acuity on the left to high acuity on the right. The bottom graph has the acuity scale on the y-axis and adds in the variable of service specificity on the x-axis. The boomerang shape occurs because while operating rooms treat very acute symptoms and wellness facilities treat mild symptoms, they both provide very specialized services. On the other hand, facilities like community health centers and retail medical centers provide general services and fall in the middle of the acuity scale.

024 | Health Care Delivery Models

High Acuity

Operating Room

Emergency Room Urgent Care Primary Care Physician Community Health Center Retail Medical Center Mobile Clinic School Nurse Pharmacy

Low Acuity

Physical Therapy Non-traditional medicine (Acupuncture, etc.) Wellness (Spa, etc.)

Specialized Services

General Services Organization of Services/Facilities | 025

Range of Services vs. Hours of Operation SPA

6PM

COMMUNITY HEALTH CENTER NON-TRADITIONAL MEDICINE

PRIMARY CARE FACIL 12PM

6AM

Range of Services

Monday - Friday

12AM

Saturday-Sunday SPA

6PM

COMMUNITY HEALTH CENTER

NOT AVAILABLE ON WEEKENDS

LIMITED HOURS ON WEEKENDS

12PM

NON-TRADITIONAL MEDICINE

6AM

Wellness

Acupuncture

026 | Health Care Delivery Models

Nutrition

Hours of the Day

12AM

EMERGENCY ROOM RETAIL MEDICAL CLINIC

URGENT CARE CENTER OPERATING SUITES

LITY

SPECIALIST

RETAIL MEDICAL CLINIC

URGENT CARE CENTER OPERATING SUITES NOT AVAILABLE ON WEEKENDS

Allergies

Splinters

Minor Broken Bones

Orthopedics

Brain Surgery Organization of Services/Facilities | 027

Walk-in Availibility vs. Price

EMERGENCY ROOM

Insured Patient EMERGENCY ROOM

Uninsured Patient

Specialist Co-Pay

URGENT CARE

RETAIL MEDICAL CLINIC

Walk-in Availibility URGENT CARE

Standard Co-Pay RETAIL MEDICAL CLINIC

Free Service Unpaid EMERGENCY ROOM Walk-in: Seen Immediately 028 | Health Care Delivery Models

Walk-in: Wait 1 hour

Price

OPERATING SUITE

SAME PRICE FOR INSURED AND UNINSURED SPA

NON-TRADITIONAL MEDICINE

SPECIALIST

OPERATING SUITE

PRIMARY CARE COMMUNITY HEALTH CENTER

COMMUNITY HEALTH CENTER OPERATING SUITE Appointment: Same Day

Appointment: Same Week

Appointment: Same Month Organization of Services/Facilities | 029

Facility Flow Chart User Sequence

Each healthcare facility has its own user flow sequence. These flow charts can be mapped against each other to reveal key differences and similarities in each facility. Every facility begins with the patient entering the facility and immediately after that they begin to differ. All except for the pharmacy have the patient entering some sort of exam room and meeting with an initial staff member such as a nurse. Some facilities involve a second meeting with a more specialized staff member, such as a physician or a surgeon. The sequence ends when the patient exits the facility. This type of diagram is useful for finding gaps in the healthcare market and opportunities for new business models. Each flow chart is shown in more detail under the Interior Environments section.

030 | Health Care Delivery Models

Entrance

Reception

Wait

Exam Room

See Initial Medical Staff

Further Analysis

Check Out & Make Purchases

Exit

Operating Room Emergency Department

Urgent Care Center

Community Health Center

Retail Medical Clinic

Primary Care Office

Mobile Clinic

Pharmacy

Organization of Services/Facilities | 031

032 | Health Care Delivery Models

Interior Environments/Types Operating Room Emergency Room Urgent Care Center Primary Care Facility Community Health Center Retail Medical Clinic Mobile Clinic Pharmacy

Interior Environments/Types | 033

Operating Room Suites Introduction

The Operating Room Suite takes on different forms depending on location. In a hospital setting, the Operating Room Suite contains multiple operating rooms which utilize the support spaces and increase the efficiency. They are also capable of performing more intensive surgeries because of the ability to keep patients overnight. The Operating Room Suite in an Outpatient Surgical Center performs less severe surgeries in which the patient can recover from anesthesia in a short period of time and be discharged.

034 | Health Care Delivery Models

IN 2011:

AGE OF SURGICAL PATIENTS

46,000,000

0-14 years

53,000,000

INPATIENT PROCEDURES PERFORMED

65 plus

15-44 years

OUTPATIENT PROCEDURES PERFORMED

growth of outpatient procedures is “ The fueled by medical advances, including minimally invasive procedures, better anes-

45-64 years

”

pain at home.

Top 5 outpatient surgeries

Top 5 inpatient surgeries

Lens and cataract procedures

7 million

Arteriography and angiocardiography

1.7 million

Endoscopy (examination) of large intestine

5.7 million

Caesarean section

1.3 million

Endoscopy of small intestine

3.4 million

Cardiac catheterizations

1.1 million

Therapeutic or prophylactic injections and infusions

1.4 million

Endoscopy of small intestine

1 million

Removal of skin lesion or tissue

1.1 million

Diagnostic ultrasound

888,000

Interior Environments/Types | 035

History

The concept of the Operating Room began in the military as a tent specifically use to perform rudimentary surgeries on injured soldiers. It evolved as Operating Theaters were developed in the late 18th century as a spectacle. People gathered to watch surgeries be performed, the excitement increasing as the danger increased. Over time surgery became incorporated into hospitals and then finally adopted the standard of sterilization.

036 | Health Care Delivery Models

In the late 18th century, Operating Theaters were utilized to perform live surgeries as a form of entertainment.

The concept of Operating Room began as the Roman military tent and hospital system.

1770

1700

1880

Surgery became a specialized portion of the hospital in the late 19th century. This change began at Johns Hopkins Hospital.

The earliest operating rooms were used in the 18th century as an alternative to at home surgeries.

65 AD

In 1884 Gustav Neuber, a German surgeon, created restrictions to enforce sterilization. In 1990 gloves became a standard requirement.

1884

Timeline

Interior Environments/Types | 037

Program Analysis

038 | Health Care Delivery Models

Typical Operating Room Suite

Semi-Restricted Spaces

Program

Area

General Equipment and Supplies

100 sf

2.2%

Wheelchair Storage

65 sf

1.4%

Handwashing Station

60 sf

1.3%

Medical Gas Storage Anesthesia Equipment

35 sf

.8%

35 sf

.8%

Sterilization Facilities

100 sf

2.2%

Environmental Services

75 sf

1.6%

Soiled Workroom

70 sf

1.5%

Operating Room

850 sf

18.5%

Staff Changing Room - Men’s

120 sf

2.6%

Staff Changing Room - Women’s

160 sf

3.5%

Staff Breakroom

85 sf

1.8%

Nurses Station

165 sf

3.6%

Pre-operative and Post-operative Observation

460 sf

10%

Multipurpose Room

75 sf

1.6%

Patient Changing Room - Men’s

120 sf

2.6%

Patient Changing Room - Women’s

160 sf`

3.5%

Exam/Interview Room

65 sf

1.4%

Reception

180 sf

3.9%

Waiting Room

380 sf

8.3%

Total

4600 sf

Emergency Resuscitation Equipment

Interior Environments/Types | 039

Thresholds of Public Space

Semi-Restricted

Restricted

Restricted Areas Unrestricted

040 | Health Care Delivery Models

Restricted zones can only be entered from Semi-restricted zones.

Patient v. Employee

Operating Room v. Support Space

Unrestricted Areas Street clothes are allowed and traffic is not limited.

Semi-Restricted Areas Scrubs and head coverings are required and traffic is limited. Spaces included: Storage areas for clean and sterile supplies. Work areas for storage and processing of instruments Corridors leading to the restricted areas for the surgical suite Scrub sink areas

60.9% Patient Space

18.5% Operating Space

Restricted Areas Masks, scrubs and head coverings are required in the sterile area.

Interior Environments/Types | 041

User Experience

WAIT

Enter

See Receptionist

WAIT

Escorted to Observation Area

Meet with Doctors and Nurses

The patient journey to the operating room varies greatly depending on the severity of injury, but for this exercise a typical outpatient procedure will be explored. Beginning after the entry, the patient visits the receptionist to check-in. Then they may be taken into the interview room to answer questions regarding both ailments and insurance. After waiting in the waiting room, the patient needs to change out of street clothes into surgical attire. They then wait

042 | Health Care Delivery Models

WAIT

Back to Observation Area

Exit

in the pre and post operative observation area where they will meet with the doctors, nurses and other staff involved in their surgery. This area is also where presurgical preparations will take place before the patient is moved to the operating room. After the surgery, they are moved back into the observation area, under the direct supervision of a nurse, until the anesthesia wears off and the patient is ready to be discharged.

Patient

Doctor

Nurse, Physicianâ&#x20AC;&#x2122;s Assistant or Medical Assistant

* Dot size relative to wait time Interior Environments/Types | 043

User Experience

Upon entry into the Operating Suite at an Outpatient Surgical Center, the patient would need to check in with the receptionist.

044 | Health Care Delivery Models

From the nursing station, the nurses can monitor all the pre and post operative patients.

From the patient bed, the curtains provide privacy while still allowing the nurses and staff to monitor patients.

The operating room is equipped with equipment on movable carts to be flexible for multiple types of procedures.

Interior Environments/Types | 045

Code Adjustments

046 | Health Care Delivery Models

SCRUB FACILITIES Hands free scrub station shall be provided directly adjacent to the entrance to operating room.

PRE-OPERATIVE AND POST-OPERATIVE HOLDING AREA Area of monitoring patients before and after surgical procedure. Minimum 80 sq ft clear floor area for each patient. 5ft clear between patient stretchers. Cubicle curtains required for patient privacy. Required to be directly accessible from semi-restricted zone.

NURSING STATION Area required for storage and documentation with visual control of clinical area. Located to permit visual surveillance of traffic entering semi-restricted area. Medication distribution station shall be provided in addition to a refrigerator for pharmaceuticals.

EMERGENCY EQUIPMENT Convenient access is required to use of emergency resuscitation equipment and supplies in both surgical and recovery areas.

STAFF AND PATIENT CHANGE AREAS Space required to change out of street clothes. Must include: lockers, toilets, clothing change area, and space for administering medications for patients.

Interior Environments/Types | 047

Types of Operating Rooms

Class A Operating Room

“

The size and location of the operating room shall depend on the level of care and equipment

”

program.

048 | Health Care Delivery Models

These operating rooms are for surgery and other procedures that require ‘minimal’ sedation. Minimum clear floor area of 150 sf. Minimum clear dimension of 12 ft. Minimum clear distance of 3’-6” at each side, the head and the foot of the operating table. May be accessed from the semi-restricted corridors of the surgical suite or from an unrestricted corridor adjacent to the surgical suite.

Class B Operating Room

Class C Operating Room

These operating rooms are for surgery and other procedures that require ‘moderate’ sedation.

These operating rooms are for surgery and other procedures that require ‘deep’ sedation.

Minimum clear floor area of 250 sf.

Minimum clear floor area of 400 sf.

Minimum clear dimension of 15 ft.

Minimum clear dimension of 18 ft.

Minimum clear distance of 3’-6” at each side, the head and the foot of the operating table.

Minimum clear distance of 4’-0” at each side, the head and the foot of the operating table.

May be accessed from the semi-restricted corridors of the surgical suite.

Interior Environments/Types | 049

Emergency Department Introduction

Throughout the last twenty years, the use of Emergency Departments (ED) in the United States has increased over 25%.With the advancement of the Affordable Care Act, EDs have become Americaâ&#x20AC;&#x2122;s most convenient place to go with an ailment. Within the United States alone, 48.2 of every 100 people will visit an ED at least once in their life.

050 | Health Care Delivery Models

ED visits a year in US

4.8

Average ED wait time in minutes:

days

48%

Of people in the US who vist an ED

17.2 mil.

46 58 2002

tay fS

129.8 mil.

ge Length a r o ve

2012

Number of ED visits resulting in hospital admission

Emergency departments are a medical treatment facility specializing in acute care of patients who present without prior appointment, either by their own means or by ambulance. The emergency department is easily accessible to the public and usually found in a hospital. Due to the unplanned nature of patient attendance, these departments must provide initial treatment for a broad spectrum of illnesses and injuries, some of which may be life-threatening and require immediate attention. In some countries, emergency departments have become important entry points for those without other means of access to medical care. The emergency departments of most hospitals operate 24 hours a day, although staffing levels may be varied in an attempt to mirror patient volume. Interior Environments/Types | 051

History As hospitals progressed throughout the 1940â&#x20AC;&#x2122;s, Emergency Departments were established to receive patients for admission to their hospitals. However, due to the decline in physicians as a result of attrition in the number of general practitioners entering practice, medical care in these new departments was initially subjugated to medical students and local volunteers.

1 2 3 4 5 6

Initially, some departments were run under the supervision of RNs who triaged patients for care by calling physicians to ask if they could come to the emergency department to treat specific patients or symptoms. Other emergency departments were staffed by foreign physicians or other physicians who were uncredentialed or unqualified to treat patients due to their own incompetence, criminal records, or addictions. But, by the 1970â&#x20AC;&#x2122;s, the traditional emergency departments that we now see in a typical hospital had emerged.

052 | Health Care Delivery Models

“

established in the 1970’s per the desires of EMS teams.

With the outbreak of WWI, the US Army was well prepared and was the first organization to use a fleet of specialty designed motorized ambulances for EMTs and combat medics. The world's first “emergency department” was established specifically to treat injured rather than ill patients, opened at the Birmingham Accident Hospital. The center had three trauma teams, each including two surgeons and an anesthesiologist, and also a burns team with three surgeons,

1940

1915

The first specialized trauma care center was opened in 1911 in the United States at the University of Louisville Hospital in Louisville, Kentucky.

1900

After the “EMS Systems ACT of 1973” is passed, the EMS was firmly established as apart of the medical infrastructure of the United States as its own discipline and science. Because of this, Emergency Departments became transfixed and prevalent in hospitals.

1970

During the Civil War, the Union Medical Department implemented the use of committed, customized horse drawn wagons as ambulances.

1860

“

Interior Environments/Types | 053

Typical Emergency Department Layout

25’

102’ 3’ 6’

054 | Health Care Delivery Models

12’

24’

Program

Area

Ambulance Drop Off & Check in

Utility & Storage

290

10%

Exam Rooms

305

11%

Consultation Rooms

265

Storage

100

Main Entrance

120

325

10%

1200

34%

480

15%

Reception

Waiting Room wc Restrooms N

Nurse Control Center

Staff Circulation & Resuscitation Exam Rooms

Total Area :3170 sq. ft.

Interior Environments/Types | 055

Public & Private Space

Public Private

16%

Public vs. Private 38% Semi-Public

056 | Health Care Delivery Models

38%

Spaces dedicated to patient examination:

EXAM ROOM : 785 sf TOTAL : 3170 sf

= 25%

Casework and room area used for storage:

STORAGE :

240 sf

TOTAL :

3170 sf

= 8%

Spaces not used for circulation, storage or utilities:

UNUSABLE :

1100 sf

Total : 3170 sf

= 34%

Interior Environments/Types | 057

User Experience Patient Experience

Size determines time spent at location Patient Circulation

Enter ED

058 | Health Care Delivery Models

Check In

Wait

Enter Exam Room

See Medical Professional

Exit

Size determines time spent at location Staff Circulation

â&#x20AC;&#x153;

The average registered nurse to patient ratio in Emergency Departments is 1:2. Interior Environments/Types | 059

Ambulatory vs. Walk-In Arrival

060 | Health Care Delivery Models

“

8.9”% of ED patients are admitted via an ambulance.

Physician conducts a full diagnostic Greeter Nurse Least sick assessed by triage nurse

Sickest walk-in admitted for immediate care

Patient sent to: 1. Post screening follow up 2. Further treatment 3. Hosptial bed 4. Home

Children sent to Pediatric Emergency Department Stretcher triage

Patients Treated

Interior Environments/Types | 061

Average ED Wait Times

â&#x20AC;&#x153;

Patients admitted to the hospital from the ED during periods of high crowding died more often than similar patients admitted to the same hospital when the ED was less crowded.

â&#x20AC;&#x153;

Least Minutes

Most Minutes 062 | Health Care Delivery Models

Average Waiting Room Times in Boston

Beth Isreal Deaconess Medical Center Boston Medical Center Brigham & Womenâ&#x20AC;&#x2122;s Faulkner Mass General Hospital Tufts Medical Center Massachusetts ED Average National ED Average

Minutes Interior Environments/Types | 063

User Experience

When patients first arrive at an Emergency Department, they will enter the waiting room and check in. Here, they are assessed and either designated to wait for an available time slot or transfered to an immediate care room.

064 | Health Care Delivery Models

After patients leave the waiting room or enter via an ambulance, they are brought to an exam room to see a medical specialist. During this transfer they pass through the main circulation area where a 24 hour nurse call station is located.

While in an exam room, a patient will be visited by a nurse to check the patientâ&#x20AC;&#x2122;s vitals and then will be seen by a medical specialist. These rooms are either single or double bed spaces and are usually equpit with a crash cart, storage facility and overnight bed.

For certain circumstances that do not require immediate attention, a patient will speak to a medical specialist in a consultation room. This allows for exam rooms to open up more quickly for the use of other patients.

Interior Environments/Types | 065

Code Adjustments

066 | Health Care Delivery Models

Single-bed exam/treatment room with a min. clear floor area of 120 sf Double-bed exam/treatment room with a min. clear floor area of 80 sf

This allows for the staff to use surfaces quickly and efficiently without the interference of additives. The base for these surfaces must have floor self-coving of a height of 6 in.

Designed to ensure that emergency medical staff & hospital security personnel maintain control of access at all times

Smooth, non-porous, non-adsorptive, non-perforated surfaces

Centralized nurse station

These centralized stations must have a nurse call center and convenient monitoring capabilities available. The nurse call center must have a patient accessible area where a nurse can always be reached.

Corridor width for stretcher transport must be min. 8'-0 Safety Glass, Wired Glass or BreakResistant Plastic with bottom-frame height of less than 5 ‘-0” AFF Ceiling Heights are a min. of 7 ‘-10” in all clinical or staff spaces, min. 7 ‘-8” in corridors, and min. 7 ‘-8” in toilet storage rooms

This minimum requirement allows for staff to rotate a standard sized stretcher a full 360 degrees and also allow for two standard sized strechers to pass next to each other.

Interior Environments/Types | 067

Urgent Care Facility Introduction

Urgent Care Facilities have become more popular in the past 10 years as the demand for quick, quality care increases. Urgent Care Facilities have many benefits that make them a exceptional alternative to an Emergency Room. The scope of services provided range from injury or illness more severe than a standard Primary Care Provider, however not critical enough for an Emergency Room visit. Typical visits include, fevers, upper respiratory infections, sprains and strains and lacerations. The hours of operation are typically greater than a Primary Care Provider, including weekends and holidays. However, an insured patient would typically pay no more than a standard co-pay. For uninsured patients, the rates are very reasonable and much less than an Emergency Room visit. Wait times in an Urgent Care Center are typically much less than in an Emergency Room, with 69% of patients waiting less than 20 minutes for walk-in patients.

068 | Health Care Delivery Models

Location Statistics

10%

RURAL

URBAN

15%

IN 2012:

9,000

128

IN THE UNITED STATES

IN MASSACHUSETTS

Average 81.1%

90.6%

Open 8:00 AM or earlier

close 7:00 PM or later

SUBURBAN

357 Weekly Visits per Center

Franchise Physician Group Hospital

More than 40 minutes 21 to 40 minutes

75%

Wait Times Less than 20 minutes

Ownership Non-Physician Corporation

Interior Environments/Types | 069

History

The popularity of the Urgent Care Facility is growing, specifically since the creation of the Urgent Care Association of America in 2004. Previously, Urgent Care Facilities were run by individuals and were known for poor quality care. Currently, many Urgent Care Facilities are being purchased by hospitals to alleviate congestion in their Emergency Departments.

070 | Health Care Delivery Models

Timeline

1985

1982

2004

The Urgent Care Association of America was formed in 2004

NOW Care opened in Minneapolis and St. Paul, MN in 1982.

2012

Hospitals began purchasing Urgent Care Centers to alleviate pressure in Emergency Rooms.

2005

Beginning in 1973, the National Association for Ambulatory Care helps physicians open new facilities, including Urgent Care Facilities.

1973

About 9,000 Urgent Care Centers nationwide in 2012.

In the late 1980â&#x20AC;&#x2122;s the popularity of Urgent Care Centers began to decline because of stigmas of low quality care.

Interior Environments/Types | 071

Typical Urgent Care Facility Layout

072 | Health Care Delivery Models

Typical Urgent Care Facility Program

Area

Multipurpose Room

150 sf

Procedure Room

170 sf

Wheelchair Storage

40 sf

Observation Area

330 sf

Nurses Station

110 sf

Waiting Room

330 sf

Reception

110 sf

Clean Storage

120 sf

Exam Room

120 sf

Treatment Rooms

330 sf

Radiology

140 sf

Soiled Workroom

60 sf

Janitorâ&#x20AC;&#x2122;s Closet

50 sf

Restroom

100 sf

Administrative Offices

200 sf

Patient Record and Xray Storage

120 sf

Total

3590 sf Interior Environments/Types | 073

must be â&#x20AC;&#x153;Patient accompanied or admitted

Spacial Analysis

by an employee to enter this zone.

â&#x20AC;&#x153;

Employees Only Private Public vs. Private Public

074 | Health Care Delivery Models

Exam Room v. Service Space

17.3% Exam Rooms

Patient vs. Employee

User vs. Storage

73.3% Patient Space

82.3% User Space

Interior Environments/Types | 075

User Experience X-Ray

WAIT

Enter Urgent Care

See Receptionist

Escorted to Exam Room

WAIT

Meet with Nurse or Physician’s Assistant

In an Urgent Care Facility, the user experience is fairly standardized and prescribed. Upon entry and check-in the patient is escorted to an exam room to meet with a nurse or physician’s assistant for a preliminary exam. After this, the patient’s journey may vary depending on injury and tests required. Some patients may move on to radiology, some are seen by a doctor for further examination, and others are discharged with a prescription or treatment

076 | Health Care Delivery Models

Doctor

Check Out and Pay

Exit

plan. Urgent Care Facilities are required to have at least one procedure room for performing minor procedures such as setting minor broken bones or sutures. After a procedure the patient may move to the observation area before they are discharged. The doctor would move from one exam room or procedure room to another where they are needed to see multiple patients.

Patient

Doctor

Nurse, Physicianâ&#x20AC;&#x2122;s Assistant or Medical Assistant

* Dot size relative to wait time

Interior Environments/Types | 077

User Experience

Upon entry into the Urgent Care Facility the path to visit the receptionist to check in is clear.

078 | Health Care Delivery Models

The receptionist also has a clear view of the waiting area to monitor waiting patients.

This long hallway lined with private doorways is typical of an office building.

After waiting in the waiting room, the patient also waits in the exam room for the doctor to examine them.

Interior Environments/Types | 079

Code Adjustments

080 | Health Care Delivery Models

RADIOLOGY CAPABILITIES X-ray equipment appropriate to the diagnostic services offered by the clinic in at least one radiographic room of adequate size for the equipment provided. Adequate storage space for files of x-ray films. PROCEDURE ROOM One required with hand washing station for performing minor procedures. 3’-6” required on all sides of patient bed and 80 square feet of clear space. OBSERVATION FACILITY Area of monitoring patients before they are discharged or transferred to a hospital facility. NURSING STATION Area required for storage and documentation with visual control of clinical area. WAITING ROOM Larger waiting room required to handle a variety of illnesses of walk in patients. ADMINISTRATIVE AREA Each clinic shall provide adequate space and equipment for reception and waiting areas, for administrative and staff offices, and for storage of patient records. Entrance shall allow for visual control of arriving vehicles. Interior Environments/Types | 081

average wait time for a “ The patient in an Urgent Care Facility

Urgent Care Facility vs. Emergency Room

is nearly 1/3 of the average wait time of an ‘Urgent’ patient in the Emergency Room.

”

Emergency Room Wait Times based on Acuity

Urgent Care Facilities have emerged an alternative to Emergency Room visits for less severe injuries or illnesses. As seen in the chart to the left, “Urgent” patients, defined as needing to be seen in 15-60 minutes, were on average seen within 63.3 minutes in Emergency Rooms. These patients, along with less severe, “Semi-urgent” and “Non-urgent”, could be seen at a an Urgent Care Facility much more quickly. 69% of patients at Urgent Care Facilities are seen within 20 minutes.

Immediate (2% of visits) Emergent (10% of visits) Urgent (41% of visits) Semiurgent (35% of visits) Nonurgent (7% of visits) No Triage (4% of visits) 0

082 | Health Care Delivery Models

Ane sthe sio log ist

RO OM EMER GEN CY

LEVEL 5 ilization / Surgery / Stab Trau ma N

Crit ic

/ are al C

/ ay -R

ialist Services / Physica Spec l Th era p

Allergies

Physical Exam

Broken Bones Minor Wounds

Initial Evaluation Vaccinations

Minor Eye Injury

Skin Conditions

Strep Throat

Diagnostic ie n

Ca r

72% 79% 73% 82% 72% 82% 79% 77% 83%

24/7 Laboratory

URGENT C AR E

$345 $595 $400 $525 $370 $617 $531 $486 $665

LEVEL 4

rage ove te C dia me

$97 $127 $110 $94 $102 $112 $111 $111 $110

% Saved

LEVEL 3

utre ach Pro gr

Surgery / Radiology opedic / Em Orth erge ncy Me dic ine n o / i t G a t e i n c s e u r s a e l Surg R / eon Care s/ ive 24/ ens 7 Im Int

ry / rge osu r u Ne

Co n

Allergies Bronchitis Earache Sore Throat Pink Eye Sinusitis Strep Throat Upper Respiratory Infections Urinary Tract Infections

Urgent Care

LEVEL 2

Most Common ER Visits

ery urg

e urs

Urgent Care Facility and Emergency Room Cost Comparison

S tic las

Internal Medicine / Ed ucati rgery / on a ac Su i d r nd O / Ca

Cost is also a large factor steering patients away from Emergency Rooms, towards Urgent Care Facilities. As seen in the chart below, the cost of the most common conditions seen in Emergency Rooms are drastically higher than Urgent Care Facilities.

LEVEL 1

a ce / ri m R e d u c e d Co s t / P

This diagram compares the services performed at an Urgent Care Facility to the various Levels of Emergencry Rooms.

Interior Environments/Types | 083

Small Alternative Prototypes These prototypes explore the various layouts possible for an Urgent Care Facility. The typology can be morphed to fit into various urban contexts. These small prototypes could occupy unique lots in an urban setting to optimize real estate potential.

1 8

3 4

5 5 180â&#x20AC;&#x2122;

Waiting Room

Reception

Offices

Nurses Station

Storage

Exam Rooms

Specialty Rooms

Restroom

084 | Health Care Delivery Models

500â&#x20AC;&#x2122;

6 1000’

1000’

7 3

3 5 7 180’

3 5 300’

Interior Environments/Types | 085

Medium Alternative Prototypes These medium sized prototypes are more indicative of the typical Urgent Care Center. They have several exam or procedure rooms to allow for a larger number of walk-in patients, while still remaining self sufficient and malleable to fit into the urban context.

1 3

8 2 4

600â&#x20AC;&#x2122;

Waiting Room

Reception

Offices

Nurses Station

Storage

Exam Rooms

Specialty Rooms

Restroom

086 | Health Care Delivery Models

550â&#x20AC;&#x2122;

4 6

750’ 950’

6 7

600’ 7

600’

Interior Environments/Types | 087

Large Alternative Prototypes The large prototype is typical of an Urgent Care Facility with a hospital. These facilities are larger and capable of catering to a wider range of patientâ&#x20AC;&#x2122;s illnesses or injuries. A patient could be transferred to the Emergency Room or hospital if necessary. Many hospitals in the Boston area have Urgent Care Facilities as part of their hospital to attempt to lessen the congestion in the Emergency Room.

088 | Health Care Delivery Models

Waiting Room

Reception

Offices

Nurses Station

Storage

Exam Rooms

Specialty Rooms

Restroom

720’

1200’ Interior Environments/Types | 089

Primary Care Facility Introduction

Primary Care facilities can range from small mom and pop offices in residential areas with one doctor to a larger consortium of physicians all operating under the same roof. Primary care physicians or PCPs were traditionally the family doctor, making house calls and taking care of the entire family unit. Traditionally primary care was the way most Americans in suburban areas received their care. Now with health care becoming more accessible through retail locations and walk-in clinics primary care facilities may be dying out. As wait times rise to become month before a doctor can see a patient, and some offices no longer even accepting new patients other means of health care are being sought after.

090 | Health Care Delivery Models

History Turn of the 20th Century By the end of the century, the treatments, which had become increasingly complex, were administered either in the doctorâ&#x20AC;&#x2122;s office or in an impersonal hospital setting. During this same period, the profession also witnessed the growth of specialism, the improvement of medical education, and the rise of public health services. Doctors willingly opted for office practice over home practice because they viewed the former as a method of economizing on their time and resources.

2006 Massachusetts statewide health care plan called MassHealth goes into effect. MassHealth pays for health care for certain low- and medium-income people living in Massachusetts, including a program for individuals who are HIV positive.

After 1920 After 1920, physicians no longer needed to ask permission of the church before starting their practice or performing surgery. Finally, reliable prescription drugs, and penicillin began to curb sickness before surgery or other last resorts were necessary.

2009 Primary Care Progress (PCP) is founded on the heels of Harvard Medical School defunding the Primary Care Division. PCP is a non for profit organization of educators and medical proffessionals who seek to aid and support primary care physicians by educating them on the latest practices and to promote the importance of primary care

Interior Environments/Types | 091

About Primary Care Facilities can be staffed by a number of people. There can be Physicians Assistants, Nurse Practitioners, or Registered Nurses under the umbrella of an M.D. or a D.O. The offices can be made up of a mix of Doctors and Nurses or a group of Doctors. Primary Care Facilities will generally accept only a limited number of insurance plans and may not be accessible to all people unless the Doctor is in their plan. The facilities are usually open during normal business hours from 9 to 5 and may have a day open on weekends. Primary Care Facilities can be related to a hub hospital or medical center, where physicians from the respective centers will work during the week when they are not in the hospital. Otherwise Primary Care Facilities will be privately owned by a physician or group of physicians.

092 | Health Care Delivery Models

98% People insured in the State

3495

Primary Care Physicians in the Boston area

US Average Physicians Accepting New Patients in MA

MA Average

86% Accept Medicare

47%

58% Accept MassHealth

1.5 Doctors per 1000 people

1.25 Doctors per 1000 people

Average Wait for a General Practitioner: 44 Days S

Average Wait for a Pediatrician: 24 Days T

Interior Environments/Types | 093

Typical Primary Care Layout

094 | Health Care Delivery Models

Program

Area

Waiting Area

336 sq. ft.

40%

Reception

96 sq. ft.

Exam Rooms

305 sq. ft.

29%

Physicianâ&#x20AC;&#x2122;s Office

73 sq. ft.

Storage

28 sq. ft.

Bathroom

35 sq. ft.

Total Area - 1052 sq. ft

Interior Environments/Types | 095

Spatial Analysis

Usable Space vs. Exam Rooms

220 sq. ft. Net Area Gross Area 1051 sq. ft. =

21%

096 | Health Care Delivery Models

Usable Space vs. Exam Rooms

749 sq. ft. Net Area Gross Area 1051 sq. ft. =

71%

Interior Environments/Types | 097

Code Adjustments

098 | Health Care Delivery Models

Nurses Station with a work counter, communication system, space for supplies, provisions for charting

Min. clear floor area 80 sf

Min. clearance 2‘-8“ at each side of examination table, recliner or chair

Min. continuous clearance 2‘-8“ at foot of examination table, recliner or chair

Counter or shelf space for writing or electronic documentation

Handwashing station

Separate toilet room with Handwashing station that is private for patients

Interior Environments/Types | 099

User Touchpoints

WAIT Enter Primary Care

Check-in

WAIT Escorted to Exam Room

WAIT Meet with Nurse

See Doctor

Check out and Pay

100 | Health Care Delivery Models

EXIT

Patients must be seated and wait until it is their turn to see the Doctor

The Doctor will see patients in the Exam room and try to diagnose what is wrong with them

A receptionist or Nurse will check patients in before they see the Physician Interior Environments/Types | 101

Community Health Center Introduction

Community Health Centers (CHCs) are a form of primary care that caters specifically to Medically Underserved Areas. Also referred to as Federally Qualified Health Centers (FQHCs), these facilities are typically urban and provide primary and preventative care to the community, especially low-income and the unemployed. CHCs are neighborhood based, emphasizing community building and patient-doctor relationships. Even when a patient enters a better financial situation, they tend to remain with the CHC. Run by a board of directors, CHCs are made up of a network of doctors, nurses, dentists and other specialists. All services exist in one convenient location.

are neighborhood â&#x20AC;&#x153; CHCs based, emphasizing

102 | Health Care Delivery Models

â&#x20AC;&#x153;

community building and patient-doctor relationships.

$24 billion

Public Insurance Revenue

35%

Private Insurance Revenue

per medical visit on average

10%

22% 6%

19%

State/Local Grants

Federal Grants

Goal of

per dental visit on average

303

CHC REVENUE SOURCES

Self-Pay Revenue (2.5%)

= $149

6% Other

is saved in the health care system annually through the use of CHCs across the US

= $173

Private/Foundation Grants

CHCs in the City of Boston

CHCs in the greater Boston area

CHCs in the Commonwealth of Massachusetts

615,708

million patients served

different organizations in MA

2015

Total CHC patients in Massachusetts

Interior Environments/Types | 103

CHCs receive subsidies from the federal government in the form of cash grants, cost-based reimbursements for patients with public insurance like Medicaid, and free malpractice coverage. They charge for services based on a â&#x20AC;&#x153;sliding feeâ&#x20AC;? scale that takes into account the patientâ&#x20AC;&#x2122;s family size and income. The Affordable Care Act aims to increase federal funding for community health centers to meet the growing demand of primary care as more people get health coverage. The Act set aside $11 billion dollars for CHCs to be used over the next five years. Modern CHCs have been around for about 47 years. There are now more than 1,200 CHCs nationwide serving around 20 million patients.

104 | Health Care Delivery Models

History “Neighborhood health centers” were established as a War on Poverty demonstration program

The concept of community health centers was born with infant milk stations in NYC

The first modern CHC, Columbia Point Health Center, was founded in Dorcester, MA

Federally Qualified Health Center program requires “cost-based reimbursement” for Medicare and Medicaid

CHCs begin offering free, rapid HIV testing to all patients

Funding of CHC was transferred from the Office of Economic Opportunity to the Department of Health, Education and Welfare.

First government-funded district health center established in NYC

Affordable Care Act allots $11 billion over 5 years to CHC’s

1901

1965

1971

2010

2006

1989

1970 1971

1965

1960

1914

1901

NACHC founded

2010 Interior Environments/Types | 105

Typical CHC Layout

109’-6”

R E

172’-5” 2’ 4’

8’

16’

32’

106 | Health Care Delivery Models

Program

Area

Administration

682 sq. ft.

4.5%

Exam Rooms

3457 sq. ft.

23.0%

Support/Mechanical

1021 sq. ft.

6.8%

317 sq. ft.

2.1%

Community Spaces

1720 sq. ft.

11.4%

Restrooms

750 sq. ft.

4.9%

5397 sq. ft.

36.0%

1689 sq. ft.

11.2%

R Reception

E Circulation/Egress Waiting Areas

Total Area: 15,033 sq. ft.

Interior Environments/Types | 107

Spatial Analysis

nly

Sta

ff O

nly

Shar

21%

18%

PUBLIC VS PRIVATE

61% 108 | Health Care Delivery Models

ti Pa

O nt

Total area

GROSS NET

Spaces where health care is provided

3,457 sf 15,033 sf

23.0% 77.0%

13.5%

Total area

GROSS NET

Spaces with patient access

13,013 sf 15,033 sf

86.5%

Total area

GROSS NET

86.5%

38.0%

All occupiable program spaces

9,343 sf 15,033 sf

23.0%

62.0%

62.0% Interior Environments/Types | 109

User Experience Visitor Flow Chart

Attend educational programs and events

Enter CHC

See receptionist

Get escorted to exam room

Exit

WAIT

See nurse

Visit pharmacy

See doctor Check out and pay

Visit optical shop

The Community Health Center provides a variety of services in-house and therefore there are many unique paths a visitor might take. Typically, when a visitor enters the facility, they may either see the receptionist to check in for an appointment or go to the community room for an educational program. After attending the program, the visitor would likely leave the facility. When a visitor is there for an appointment, they will 110 | Health Care Delivery Models

then wait to be escorted to an exam room, meet with the nurse, then the doctor, and then check out and pay. After paying, they will likely stop by the in-house pharmacy or optical shop and make a purchase on the way out.

User Circulation Size determines time spent at location Patient Circulation

2’ 4’

8’

16’

32’

Interior Environments/Types | 111

User Experience

The waiting room is immediately visible from the top of the stairs.

112 | Health Care Delivery Models

After checking in with the receptionist, the user waits to be escorted to the exam room. The receptionist is able to observe the entire waiting room.

The user is escorted past the reception desk, down a hallway and to the exam room.

The CHC contains standard primary care exam rooms as well as special purpose rooms such as dental, mental health, optical, etc.

Interior Environments/Types | 113

Code Adjustments

114 | Health Care Delivery Models

At least one exam room is available for each provider on duty Rooms are permitted to serve as both examination and treatment rooms Required support areas for exam rooms include: nurse station, documentation area, medical distribution station, nourishment area

Waiting areas for patients & escorts under staff control. Seating area contains at least two spaces for each exam room. Accessible to wheelchairs.

Toilet rooms for patient use permit access without passing through public areas Adequate space and equipment for reception and waiting areas, for administrative and staff offices and for storage of patient records Design ensures appropriate levels of patient acoustical & visual privacy during care

Reception located to provide visual control of entrance to outpatient unit. Immediately apparent from entrance.

Special purpose exam rooms (ENT, eye) shall have minimum clear floor area of 100 sf and min. 2â&#x20AC;&#x2122;-8â&#x20AC;? clearance around bed, table or chair Public toilets accessed from waiting area, separate from patient care/staff areas Multipurpose room for conferences, meetings & health education The location of the neighborhood center shall permit convenient access to public transportation Interior Environments/Types | 115

Retail Medical Clinic Introduction

Retail Medical Clinics (RMC) often referred to as Convenient Care Clinics (CCC) are an emergent trend in how Health Care is distributed. Retail Medical Clinics aim to aid primary care physicians and emergency rooms by accepting walk-in patients and treating minor illnesses and ailments. The nost popular clinics researched here are the Minute Clinic at CVS, Healthcare Clinic at Walgreens, Target Clinic, and the Clinic at Walmart. Generally Retail Medical Clinics are staffed by Nurse Practitioners (NP), who are registered nurses with a higher level of specialty education, or Physician Assistants (PA), who are health care practitioners that may work under a team of physicians. The Retail Medical Clinics see patients on a walk-in first come forst serve basis They generally accept almost all insurance polices but have their prices clearly posted for those who are uninsured.

116 | Health Care Delivery Models

Retail Medical Clinics in America - July 2013

RMC Users Minute Clinic - CVS - 665 Healthcare Clinic - Walgreens - 371 The Little Clinic - Kroger, Fryâ&#x20AC;&#x2122;s - 93

20% Age 6-17

Target Clinic - Target - 54 RediClinic - H-E-B Stores - 30 FastCare - Walmart, Shopko, Giant Eagle, ShopRite - 25 Baptist Express Care at Walmart - Walmart - 18

44%

DR Walk-in Medical Clinics - Duane Reade - 13 Aurora Quick Care - Walmart - 10

Age 18-44

Lindora Health Clinics - Rite Aid - 7

23% Age 45-64 67% Insured

33% Self Pay

Average Cost per Visit Retail Clinic $100 Urgent Care $175

63% 37% Female Male

61% Did Not Have a PCP

97% Were Not Triaged to an ED 7% Age 65+

Primary Care $150 Emergency Room $575

Interior Environments/Types | 117

In Massachusetts While there are a number of CVS Minute Clinics and Rite Aid Health Clinics in Massachusetts no Retail Medical Clinics of any type exist in Boston. Mayor Menino opposed the establishment of these types of clinics arguing that it would have a negative effect on the areas network of community health centers and emergency rooms.

118 | Health Care Delivery Models

History

With the coming Affordable Care Act Retail Clinics are expected to rapidly grow.

2013+

Massachusetts creates regulations for retail clinic terming them Limited Service Clinics, detailing what services they can provide.

2008

2006

Walgreens partners with Takecare Clinic.

2007

CVS aquires MinuteClinic.

QuickMedX officially changes its name to MinuteClinic.

2002

2000

QuickMedX is the first Retail Medical Clinic. They opened in Minneapolis in 8 supermarkets.

Target Launches the Target Clinic.

Interior Environments/Types | 119

Typical Retail Medical Clinic Layout

120 | Health Care Delivery Models

Program

Area

Exam Rooms

139 sq. ft.

85%

Waiting

17 sq. ft.

10%

Reception/Check-In

8 sq. ft.

Storage

Shared w/ Retail Store

Bathroom

Shared w/ Retail Store Total Area - 164 sq. ft.

Interior Environments/Types | 121

Spatial Analysis

Usable Space vs. Exam Rooms

139 sq. ft. Net Area Gross Area 139 sq. ft. =

100%

Retail Medical Clinic vs. Exam Room

139 sq. ft. Net Area Gross Area 164 sq. ft. =

122 | Health Care Delivery Models

85%

Retail Medical Clinic vs. Retail Location

139 sq. ft. Total Retail Location Area = 8000 sq. ft.

Retail Medical Clinic Area =

2% of total floor area

Retail Medical Clinic vs. Support Rooms 2% of Bathroom Area + 2% of Janitorial Area + Retail Clinic Area =

1 sq. ft.

139 sq. ft.

141 sq. ft.

141 sq. ft. Net Area Gross Area 232 sq. ft. =

61%

Interior Environments/Types | 123

Code Adjustments

124 | Health Care Delivery Models

Min. floor area 56 sf (exclusive of fixed casework) Locked storage for biologicals & drugs Storage for sterile equipment & supplies Safeguards patient dignity & privacy List of Services provided by the clinic to be posted and visible

Services

Hand sanitizer dispenser located outside each exam room Waiting Area with adequate space and provisions for wheel chairs Separate access from clinic to toilet facilities or Toilet facilities shared with host entity Janitorâ&#x20AC;&#x2122;s closet dedicated to clinic or Janitorâ&#x20AC;&#x2122;s space shared with host entity Interior Environments/Types | 125

Work Flow and Efficiency The retail medical clinic model forces the patient to enter through the same entrance used by retail customers. The patient must also usually make his or her way to the back of the store in order to access the clinic area. Since there is no private waiting area the customer is encouraged to shop while they wait to see the health care professional. Finally, in the case of retailers with pharmacies, the patient has access to the convenience of filling their prescription in store before leaving.

126 | Health Care Delivery Models

Retail Medical Clinic exam rooms attempt to achieve a maximum efficiency. They are often as small as they can possibly be usually between 80 and 100 square feet.

Fill Prescription Retail Clinic Enter RMC

WAIT Walk Through Aisles

Enter Info

WAIT Enter Exam Room

See Buy Something Health EXIT Professional

Buy Something Interior Environments/Types | 127

Case Studies - CVS Minute Clinic QuickMedx retail clinics opened in Minnesota in 2000. With the clinics becoming increasingly popular and with the addition of insurance coverage they became Minute Clinic in 2002. After adding corporate office locations Minute Clinic began its partnership with CVS in 2005 and then in 2006 Minute Clinic was officially acquired by CVS. There are now over 650 CVS Minute Clinic locations in 25 states across the United States.

128 | Health Care Delivery Models

Our research into Minute Clinics around Boston brought us to a number of locations. The locations which all have close proximity to Boston and are Medway, Franklin, Medfield, Cambridge, Newton, and Watertown. These six location are all existing suburban CVS Pharmacy retail locations that have all been retrofitted to incorporate either one or two Minute Clinic exam rooms and waiting areas.

Pharmacy

CVS Medway

Receiving

The Medway CVS was fitted for the first Minute Clinic in Massachusetts. The Minute Clinic is located near the pharmacy and is in close proximity to the health, medical, and hygiene items.

Baby

Clinic Room

Medical

Clinic Room

Hygiene Hygiene Make-up

Make-up

Seasonal

Make-up

School

Seasonal

Make-up Toiletries

Cards

Hair

Health

Toiletries

Health

Hygiene

Health

Hygiene

Medical Health

Hygiene - 16% Pharmacy - 12% Cosmetics - 11% Health - 10% Seasonal - 9% Receiving - 8% Checkout - 4% Minute Clinic - 4% Groceries - 3%

Medical

5â&#x20AC;&#x2122;

Hygie ne

Food

Medical

dic al Me

Refrigerated

8â&#x20AC;&#x2122;

Food

Checkout

Interior Environments/Types | 129

Clinic Room

Checkout

CVS Franklin Make-up

Make-up

Hygiene

Hair

Seasonal

Cleaning

Hygiene - 17% Seasonal - 14% Pharmacy - 13% Health - 12% Groceries - 9% Cosmetics - 7% Receiving - 6% Checkout - 6% Minute Clinic - 3%

Make-up

Hygiene

Toiletries

Cards

School

Baby

First Aid

Medical

Food

Health

Food

Refrigerated

The Franklin CVS is an excellent example of a retrofitted Minute Clinic. The clinic room is adjacent to the checkout counter near the entrance to the store and within close proximity to the unrelated food items.

10’

4’ 7’ Office Space

Pharmacy

Receiving

5’

atio

cre

nal od

Check Out

n so

130 | Health Care Delivery Models

Pharmacy

Receiving

CVS Medfield The Medfield CVS had modern Minute Clinic Rooms equipped with exam tables and an independent waiting area from the pharmacy. The clinic rooms are in a somewhat close proximity to related items.

Clinic Clinic Room Room

Baby

Medical

Hygiene

Toiletries

Beverages

Food

Seasonal

Hygiene

Hair

Make-up

efrigerated

School

CardsR

Health - 17% Hygiene - 14% Pharmacy - 12% Seasonal - 10% Groceries - 10% Checkout - 7% Receiving - 6% Cosmetics - 5% Minute Clinic - 4% 8’

9’

9’7”

8’

Card

ool

Sch

icin

Checkout

Interior Environments/Types | 131

Case Studies - Walgreens, Target, and Walmart Walgreens Walgreens acquired Take Care Health System in 2007 and with that acquisition expected to open more than 400 Retail Medical Clinics nation wide. Walgreens also acquired Option Care in 2007, which is a network of more than 100 pharmacies in 34 states that provides specialty pharmacy and home infusion services. The Take Care Clinics would later be re-branded to Walgreens Health Care Clinic. The Health Care Clinic offers a wide range of services at 370 locations across 18 states. There are no locations in Massachusetts possibly due to the presence of CVS Minute Clinics in the area in conjunction with strict regulations on RMCs in Massachusetts. Walgreens location in downtown Boston has a full consultation room currently being used for private patient/pharmacist screenings. This location offers monitoring services for patients on a medication regimen but it does not and cannot operate as a Retail Medical Clinic.

132 | Health Care Delivery Models

Target Clinic The target Clinic was first unveiled in 2006, the same year that Minute Clinic was incorporated into CVS. Target Clinics appear in Super Targets alongside Target Optical and Target Photo in 52 locations across 6 states (Florida, Illinois, Maryland, Minnesota, North Carolina, and Virginia). Target Clinics have a limited range of services and are staffed by Nurse Practitioners and Physician Assistants that are employed by Target.

The Clinic At Walmart The Clinic at Walmart utilizes an different business model than the aforementioned Retail Medical Clinics. Walmart rents the space in its stores to a private retailer who staffs and operates the clinic independently of Walmart. They currently have 101 locations operating in 20 states but again none in Massachusetts.

Interior Environments/Types | 133

Services by Location Vaccinations Flu Shot Flu Shot High Dose Pneumonia (Pneumococcol) Hepatitis A Hepatitis B Chickenpox (Varicella) HPV (Human Papillomavirus) Meningitis (Meningococcal) MMR Shingles (Herpes Zoster) Td (Tetanus booster) Tdap (Whooping Cough) Polio Typhoid

Key CVS Pharmacy Boston CVS Minute Clinic - Massachusetts CVS Minute Clinic Target Clinic Walgreens Healthcare Clinic The Clinic at Walmart

134 | Health Care Delivery Models

Minor Illnesses

Minor Injuries

Allergy symptoms (2 years+) Bladder Infection Cold Bronchitis / cough Earache / ear infection Flu-like symptoms Headaches & migraines Joint pain Laryngitis Lyme disease Mononucleosis (mono) Motion sickness prevention Sinus infection / congestion Pink eye & styes Sore throat / strep throat Upper respiratory infection Swimmerâ&#x20AC;&#x2122;s Ear Urinary tract infection Minor back pain

Blisters Bug bites & stings Deer tick bites Jellyfish stings Minor burns Minor cuts & lacerations Minor wounds & abrasions Splinter removal Sprains / strains Suture & staple removal corneal (eye) abrasions foreign body removal from eye and ear

Wellness & Monitoring Health screening Cholesterol monitoring Diabetes monitoring Physicals Birth control injection Ear wax removal EpiPen refill Medication renewal Pregnancy Evaluation Smoking cessation Tuburcleosis Testing Vitamin B12 Injection Weight loss program High Blood Pressure Asthma Acid Influx and Indigestion Cardiovascular Conditions Chronic Bronchitis Emphysema Minor depression Osteoarthritis Osteoporosis Thyroid Disorders A1c check

Lab Testing Blood sugar test Flu test influenza A & B HbA1c Mononucleosis test Cholesterol (Lipid Panel) Negative quick strep Pregnancy test Quick strep Urine dip stick PPD Tuburculeosis Testing

Interior Environments/Types | 135

Mobile Clinics Introduction

A Mobile Treatment Unit is a mobile vehicle containing medical diagnostic or treatment equipment which is used to provide mobile medical services. Simply stated, it is a clinic on wheels that is primarily devoted to the care of outpatients.

136 | Health Care Delivery Models

$ In v

Mobile Clinics in the US

1:18

11%

ed urn et

2,100

Private

vs. Value ted R s e

53%

Types of Insurance

36%

None

Native Hawaiian

Average Enthnicity of Mobile Clinic Visitors 49%

White 39%

Public

American Indian Asian

3,101

African American

Average Number of Visits Per Year Per Clinic

A Mobile Clinic is unique because it operates on wheels and is primarily devoted to the care of outpatients. Mobile Clinics can be privately operated or publicly managed and funded. They typically cover the primary health care needs of populations in local communities, in contrast to larger hospitals which offer specialized treatments and admit inpatients for overnight stays. Mobile Clinics are different from stationary clinics because they require a “host location” or licensed health care facility where a mobile diagnostic or treatment unit of a clinic providing mobile medical services docks in order to provide its services. Usually these “host locations” take the form of a hospital, or larger clinic that provides the licensing that carries an umbrella license that permits its Mobile Clinics to perform procedures. In addition, Mobile Clinics are also required to adhere to their own unit code requirements. Interior Environments/Types | 137

History Mobile Clinics are a new growing form of health care delivery that only began to emerge at a popular rate in the late 1970â&#x20AC;&#x2122;s. Over the years, these traveling clinics became successful in three distinct categories: military aid for soldiers, emergency aid in developing countries, and efficient urban health care distribution. These areas have been made successful by Mobile Clinics because they can either provide health care to areas that are difficult to access basic health care such as remote countries, or areas like cities 1 that are separated by a lack of public transportation. Mobile Clinics often engage 2 local communities using integrated Mobile 3 Clinic options and not only provide basic 4 procedures and examinations, but also educate the community on healthy living. 5 Interestingly, a majority of mobile clinics are 6 free and do not require any form of health insurance.

138 | Health Care Delivery Models

Cambridge: The Forsyth Institute, Dental Mobile Clinic

Boston: The Family Van, Harvard Medical School # visitors/year = 4848 Blum Family Resource Van # visitors/year = 357 The Blood Mobile Health In Motion Van AHOPE Needle Exchange Van

Randolph: Health Innovations # visitors/year = 1095 El-Shaddai Dental Associates, Dental Mobile Clinic

â&#x20AC;&#x153;

The use of Mobile Clinics are first recorded. Mobile Clinics were originally used for therapy and rehabilitation.

The use of Mobile Clinics are first recorded. They were originally designed to be used for therapy and rehabilitation procedures on those recovering from surgery or illness.

Mobile Clinics begin using telemedince as a primary form of travel care. These clinics not only do routine checkups and simple procedures, but also have the ability to access an MD off site.

2010

1990

The United States Military begins using Mobile clinics as a form of disease prevention as well as for on site emergency medical attention.

1870

1860

â&#x20AC;&#x153;

Mobile Clinics were originally used for therapy and rehabilitation procedures.

Interior Environments/Types | 139

Typical Mobile Clinic Layout

8’

* Square footages do not reflect those of a host location.

36’ 1’

140 | Health Care Delivery Models

2’

4’

8’

Program

Area

Exam Rooms

32%

Storage

15%

Circulation

Utility & Mechanical

32%

Storage

Main Entrance

Total Area : 247 sq. ft.

Interior Environments/Types | 141

Public & Private Space

Truck Utility Private 30%

35%

Public vs. Private 35%

Semi-Public

142 | Health Care Delivery Models

Spaces dedicated to patient examination:

EXAM ROOM :

80 sf

TOTAL : 247 sf

= 32%

32%

68%

Casework space used for storage: 23%

STORAGE :

57 sf

TOTAL :

247 sf

= 23%

77%

Spaces not used for circulation, storage or utilities:

UNUSABLE :

167 sf

Total :

247 sf

32%

= 68%

68%

Interior Environments/Types | 143

User Experience

â&#x20AC;&#x153;

Mobile Clinics typically have 5-7 members registered nurses and 2-4 NPs.

Size determines time spent at location

Staff Circulation Patient Circulation

144 | Health Care Delivery Models

Although Mobile Clinics are limited in size, they offer a variety of storage space; this space is usually centrally located in the clinics primary circulation zone.

Enter Mobile Clinic

Check In

Exam rooms typically flank these primary circulation spaces. Even though they are small they each house an exam bed and casework for storage.

Enter Exam Room

See Medical Professional

Exit

Interior Environments/Types | 145

Who are Using Mobile Clinics?

r 18 de Un

5 er 6 Ov 12%

35% Ages Served

65 40-

32%

21%

-40 18 Native Hawaiian

Average Enthnicity of Mobile Clinic Visitors 49%

White 39%

146 | Health Care Delivery Models

American Indian Asian African American

â&#x20AC;&#x153;

Children under the age of 18 make up for 35% of the average Mobile Clinic age served.

â&#x20AC;&#x153;

Approximately 28% of all Mobile Clinics in the United States are Primary Care Clinics. Types of Services Provided by Mobile Clinics in the US Homelessness Disaster Relief Maternal & Infant Health Mental Health Mammography Specialty Primary Care Prevention Dental

100

150

200

250

300

Interior Environments/Types | 147

Code Adjustments

148 | Health Care Delivery Models

A license “Host Location” is required for all Mobile Clinics and must be license to for each procedure the clinic is performing Road access suitable for trailer turning radius Storage areas for clean gowns & supplies adjacent to gowning areas & access point to mobile unit

< 20’

Min. 20‘-0” separation between mobile unit & any unsprinklered building Air conditioning required in unit

Mobile unit limited in size to accommodate 4 or fewer workers at any one time

Safeguards in place adequate to prevent movement of unit while in use Min. 30‘-0” separation between any building outside air intake & any HVAC or generator exhaust from unit

Interior Environments/Types | 149

The Pharmacy Introduction

A pharmacy is a facility where medicine is prepared and dispensed. An outpatient pharmacy deals directly with patients, while an inpatient pharmacy deals with medical personnel and is typically located within a hospital. The research within this book focuses on outpatient pharmac Outpatient pharmacies are located in a variety of facilities but the most widely used type is the retail pharmacy chain, such as CVS, or Walgreens. With the aging population, the number of prescriptions is also rising and is expected to continue increasing. A licensed pharmacy requires a registered pharmacist on duty at all times. A pharmacy with a licensed immunizing pharmacist may also administer vaccines. Retail pharmacies hours vary, but they are typically open 9:00 am to 6:00 pm on the weekends and 8:00 am to 10:00 pm during the week.

150 | Health Care Delivery Models

38% PHARMACY LOCATIONS

Low loyalty at retail chain pharmacies:

Independent

12%

Retail Chains

23%

Percent of customers that would switch over to mail order pharmacies

Hospitals

WALMART CVS

Other (Government, Academic)

27%

WALGREENS

Number of prescriptions filled annually by age

44% 41% 35%

$10.73 54%

cost of an average prescription co-pay

of prescriptions are filled at a RETAIL PHARMACY

162

age

pharmacies in the city of BOSTON

Interior Environments/Types | 151

History pharmacy is transitioning to a “ the ‘services-centric’ facility

“

Over time, pharmacies and the traditional corner store merged into the modern retail pharmacy. These facilities sell medicine as well as groceries, cosmetics and household items. Pharmacy was recognized as a legitimate profession that required formal education in 1821 with the founding of the Philadelphia College of Pharmacy. In 1852, the American Pharmaceutical Association was organized to provide standards for education and care. A 2003 law requiring pharmacists to offer consultation to patients shifted the environment of the pharmacy. Rather than being a “dispensing-centric function”, the pharmacy is transitioning to a “servicescentric” facility. Pharmacists are now looked at as health care service providers. 152 | Health Care Delivery Models

First college to train pharmacists in the US founded as Philadelphia College of Pharmacy

1729

1821

Durham-Humphrey Amendment states that pharmacists are no longer allowed to prescribe medicine

1963

1994

1963

1951

1930

Medicare Prescription Drug and Modernization Act requires pharmacists to offer counseling when they provide medication

CVS Pharmacy founded in Lowell, MA

American Pharmaceutical Association founded

1821

1752

1729

First hospital pharmacy opens in Philadelphia

1852

First US apothecary shop â&#x20AC;&#x153;The Marshall Apothecaryâ&#x20AC;? opens in Philadelphia

Pharmacists begin training to administer vaccines

2003

Pharmaceutical research became popular in the US

1994 Interior Environments/Types | 153

Typical Pharmacy Layout

24’-4”

Drive-thru

55’-4” 1’ 2’

4’

8’

154 | Health Care Delivery Models

16’

Program

Area

Compounding room

100 sq. ft.

7.6%

Drive-through

18 sq. ft.

1.4%

Office

65 sq. ft.

4.5%

Storage

568 sq. ft.

42.5%

Pharmacist Circulation/Work Space

310 sq. ft.

23.5%

Patient consultation

98 sq. ft.

7.4%

Waiting

12 sq. ft.

0.9%

Patient drop-off

14 sq. ft.

1.0%

Patient pick-up

21 sq. ft.

1.6%

Total Area: 1554 sq. ft.

Interior Environments/Types | 155

Pu b

lic

Spatial Analysis

19.3%

d PUBLIC Share 10.2% VS PRIVATE

70.5%

Pri va

156 | Health Care Delivery Models

55’-4” 24’-4”

Total area

GROSS NET

Space used for storage

171 sf 1,554 sf

11.0%

11.0% 89.0%

Total area

GROSS NET

Spaces with patient access

459 sf 1,554 sf

29.5%

29.5% 70.5%

Total area

GROSS NET

Patient/pharmacist interaction zone

159 sf 1,554 sf

75 sf 84 sf

10.2%

47.2%

52.8%

Private Interaction Zone Public Interaction Zone

Interior Environments/Types | 157

User Experience User Circulation

Patient and pharmacist “circulation is separate except for key moments in the ‘interaction zone’.

“

Size determines time spent at location Patient Circulation Pharmacist Circulation Patient/Pharmacist Interaction Zone

1’ 2’

4’

8’

16’

Visitor Flow Chart

Enter Pharmacy

Drop off prescription/ consultation

158 | Health Care Delivery Models

Wait for prescription to be filled

Pick up prescription

Pay for prescription

Most pharmacies are located within other buildings. The user must navigate through the building using signage to guide them.

The user is able to wait by the pharmacy while their prescription is being filled, with direct visual access to the pharmacist. User is eye-level with products.

Pick up, drop off, and consultation zones are located along the counter with privacy partitions.

Most pharmacies have drive-through windows for more convenient pick-up than entering the store.

Interior Environments/Types | 159

Code Adjustments

160 | Health Care Delivery Models

Floor area not less than 300 square feet to accommodate the appropriate pharmaceutical equipment and to facilitate the proper preparation and compounding of prescribed medications.

Includes a thermometer to maintain an internal temperature of between 36° F and 46° F.

Refridgerator to store pharmaceuticals Minumum ceiling height 7’-10”

Sink within compounding and dispensing area Area suitable for confidential consulting

Provide an unobstructed view of the pharmacist on duty 10 sq. ft. minimum counter space for patient interaction

Barrier separation from unauthorized personnel

Gooseneck faucet with hot and cold running water within the compounding and dispensing area. Immediately accessible to all personnel. Includes soap or detergent. Includes air dryers or single-use towels.

A pharmacy must provide signage stating “Patient Consultation Area”, designed to provide adequate privacy for confidential visual and auditory patient counseling. The private consultation area must be accessible by a patient from the outside of the prescription dispensing area without having to traverse a stockroom or the prescription dispensing area.

Interior Environments/Types | 161

162 | Health Care Delivery Models

Emerging Technologies Telemedicine Types Equipment and Spaces

Emerging Technologies | 163

Telemedicine Description

is not a separate medical “ Telemedicine specialty, rather it is used to enhance a patients experience. ”

Definitions Absentia: Care at a distance. An old practice which was often conducted via post. Telemedicine: The use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status. Telehealth: The distribution of information relating to healthcare rather than medical treatment.

Growth in Market Value

Services Provided via Telemedicine

Remote Patient Monitoring Consumer Medical and Health Information

in millions

Primary Care and Specialist Referral Services

$10

237%

GROWTH IN FIVE YEARS

$6 $4

Medical Education $2 2007 164 | Health Care Delivery Models

2012

Hospitals begin extending care to patients in remote areas.

1970

1770

65 AD

In the early 1900s, people living in remote areas in Australia used twoway radios, powered by a dynamo driven by a set of bicycle pedals, to communicate with the Royal Flying Doctor Service of Australia.

Modern technologies such as computers, wireless internet, and smart phones have allowed telemedicine to evolve to the level it is today.

1996

In its early manifestations, African villagers used smoke signals to warn people to stay away from the village in case of serious disease.

The Federation of State Medical Boards (FSMB) adopted A Model Act to Regulate the Practice of Medicine Across State Lines, calling on state medical boards to adopt a “special purpose license” to authorize limited practice in states other than the physician’s state of practice.

2000

Timeline

Emerging Technologies | 165

Licensure Traditionally, licensure to provide medical care is provided in a specific state. This initially created a challenge for physicians to provide telemedicne in states in which they do not hold a license. Some physicians overcome this obstacle by utilizing the “consultation exception” which allows “occasional, infrequent, or limited practice within a state”. Another alternative is for a physician to be “endorsed” by a state to practice telemedicine, however this process

can be “lengthy, complicated and expensive process” requiring full review and analysis. Massachusetts does not currently have a telemedicine license law and it is up to the prestigious Massachusetts Medical Board’s opinion if the professional may be licensed to practice telemedicine. -Health Resources and Services Administration

166 | Health Care Delivery Models

Benefits Improved Access

Improved Quality

Telemedicine was initially, and is still used today, to provide medical care to patients in remote locations. In addition to remote patients, telemedcine to assist patients with any type of limited access. This can include, patients with limited mobility and patients with limited access to trasportation. “Telemedicine has a unique capacity to increase service to millions of new patients”.

The quality of healthcare can be improved when the experts in certain conditions and procedures can be utilized in infinitely more cases than traditional conditions. Telemedicine works the most effectively in mental health and ICU care, providing superior care to patients based on reduced stress from travel and unfamiliar environments.

Cost Efficiencies

Patient Demand

There are several ways that telemedicine is a cost effective solution to delivering healthcare. The first and most apparent solution is that the patient doesn’t have to travel to an office for an appointment, saving money in travel costs and in staffing and operating costs for an office. Subsequent cost savings occur through the management of chronic conditions allowing for fewer and shorter hospital stays.

“Over the past 15 years study after study has documented patient satisfaction and support for telemedicine services”. Patients are encouraging of the new technologies and relieved to reduce their travel time and expenses. In addition to the time and money benefits, patients are known to have shorter recovery times in less stressful environments. -American Telemedicine Association

Emerging Technologies | 167

Types

Telemedicine Delivery The various types of telemedicine each have their own purpose and can be useful for different scenarios. The most simple form of has been used since the conception of telemedicine is the Store and Forward type. This can be used for general telehealth questions from patient to doctor, or to relay patient information from one physician to other physicians. For a more complete health check, the next level of telemedicine is appropriate, Remote Monitoring and Self-Testing. In this form patients take their own vitals and sends them to a physician, which gives the doctor or nurse a more comprehensive view of the patients health. This can be used for remote monitoring of chronic conditions alleviating the need to travel for these simple tests. Finally, the most sophisticated form of telemedicine is Real Time Interactive. This can be used to accurately diagnose a patients condition, or even direct the performance of procedures from remote locations using video conferencing or image and phone conferencing. This technology is the more current and covers the broadest scope of illnesses or injuries. 168 | Health Care Delivery Models

Store and Forward Gather acquired medical data into a medium that is transmitted to medical professional for convenience. Commonly facilitated by email.

Remote Monitoring/Self-Testing

Real Time Interactive

Usage of informational devices to monitor patients and feed data to remote provider. Typically used for chronic diseases such as heart disease, diabetes, asthma, etc.

Usage of telephone, audio/video communication, online conversing and home visits. May have clinical technician at home site to assist remote provider.

Improvements from the Previous Type

Emerging Technologies | 169

Equipment and Spaces Equipment

Medical Testing Equipment Blood Pressure Monitor Pulse Oximeter Weight Scales Oxygen monitor Glucose Tester Communication Equipment Telephone Video camera Microphone Digital Monitor Speakers

170 | Health Care Delivery Models

Spaces Space

Type

Equipment

Additional Personnel

Home (Remote Location)

Store-and-Forward

Computer

None

Remote Monitoring

Medical Testing Equipment Computer

None

Real-time Interactive

Medical Testing Equipment Computer Audio Visual Equipment

None

Store-and-Forward

Computer

None

Remote Monitoring

Medical Testing Equipment Computer

None

Real-time Interactive

Medical Testing Equipment Computer Audio Visual Equipment

Nurse/Aid

Remote Monitoring

Medical Testing Equipment Computer

Nurse/Aid

Real-time Interactive

Medical Testing Equipment Computer Audio Visual Equipment

Nurse/Aid

Physicianâ&#x20AC;&#x2122;s Office

Real-time Interactive

Medical Testing Equipment Computer Audio Visual Equipment

Nurse/Aid

Operating Room

Real-time Interactive

Medical Testing Equipment Computer Audio Visual Equipment

Surgeon and Nurses

Home (Limited Mobility)

Clinic

Emerging Technologies | 171

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176 | Health Care Delivery Models

“Licensure of Clinics”. 105 CMR 140.000. Massachusetts Department of Public Health. “Registration, Management and Operation of a Pharmacy or Pharmacy Department”. 247 CMR 6.00. Massachusetts Department of Public Health.

“Outpatient Pharmacy”. OP20 Compliance Checklist. Massachusetts Department of Public Health. “Primary Care Outpatient Centers”. OP2 Compliance Checklist. Massachusetts Department of Public Health. “Outpatient Radiation Therapy”. OP6 Compliance Checklist. Massachusetts Department of Public Health. “Outpatient Surgical Facilities”. OP9 Compliance Checklist. Massachusetts Department of Public Health. “3.1 Common Elements for Outpatient Facilities”. 2010 Guidelines for Design and Construction of Health Care Facilities. Facilities Guidelines Institute. “3.5 Specific Requirements for Freestanding Urgent Care Facilities”. 2010 Guidelines for Design and Construction of Health Care Facilities. Facilities Guidelines Institute. “3.7 Specific Requirements for Outpatient Surgical Facilities”. 2010 Guidelines for Design and Construction of Health Care Facilities. Facilities Guidelines Institute. “3.3 Specific Requirements for Small Primary Care (Neighborhood) Outpatient Facilities”. 2010 Guidelines for Design and Construction of Health Care Facilities. Facilities Guidelines Institute.

Sources | 177

182 | Health Care Delivery Models

History and Culture

3 The Doctorâ&#x20AC;&#x2122;s Office The Hospital The Pharmacy The Retail Clinic Doctor Patient Relationship Psychology of Interior Space Branding / Marketing

Sources | 183

180

History/Background Timeline Typical Doctor’s Office New Concept Typical Waiting room New Concept New Trends

The Doctor’s Office | 181

History/Background Early 1800’s /1900’s

“

Studies of how bacteria

” 182 | History and Culture

Early Doctor Office The early doctor office was small and simple in design. The Doctorâ&#x20AC;&#x2122;s Office | 183

Timeline

Evolution of the Doctors Office

An optometristâ&#x20AC;&#x2122;s office had no private room or bed to examine the patient. Only a chair next to the doctor was used to take all of the patients information.

184 | History and Culture

The McCook House Museum, has a model of the Doctor Office which takes advantage of natural light in the room.

In western towns, the doctorâ&#x20AC;&#x2122;s office was a big room with more equipment. The introduction to privacy began with closed rooms.

The White House doctorâ&#x20AC;&#x2122;s office has a big shelves that carry a lot of the Medical Records and books. Also it was used as an exam room.

The exam room got smaller, less dense, and has only a few cabinets with no natural light in the room.

The Doctorâ&#x20AC;&#x2122;s Office | 185

Doctor’s Office Typical Floor Plan

“

Everyone hates waiting gotten so bad that one

” 186 | History and Culture

The Doctorâ&#x20AC;&#x2122;s Office | 187

New Concept

Spatial Efficiencies in Doctor’s Office Design

“

188 | History and Culture

They created a new system

”

The Doctorâ&#x20AC;&#x2122;s Office | 189

Typical Waiting Room

The Doctor’s Waiting Room Typical Floor Plan

“

Waiting rooms today are

”

190 | History and Culture

The Doctorâ&#x20AC;&#x2122;s Office | 191

New Concept

The Doctorâ&#x20AC;&#x2122;s Waiting Room

192 | History and Culture

The Doctorâ&#x20AC;&#x2122;s Office | 193

New Trends

Skip the Doctorâ&#x20AC;&#x2122;s Office with iPhone Clip-Ons

No more doctors Otoscope 194 | History and Culture

Introducing the new Home Otoscope/ Dermascope

“ ” The Doctor’s Office | 195

196

The Hospital Histroy/Background Timeline Connection New Concept

The Hospital | 197

History/Background Early 1800-1900

â&#x20AC;&#x153;

The evolution of hospitals from charitable guesthouses to centers of

â&#x20AC;?

198 | History and Culture

The Hospital | 199

Historical Timeline From 1860 to 2005

“

200 | History and Culture

”

The Hospital | 201

Timeline of the Hospital Evolution Building

â&#x20AC;&#x153;

202 | History and Culture

â&#x20AC;?

The Hospital | 203

Evolution of a Building Typology

204 | History and Culture

The Hospital | 205

Connection Partnerâ&#x20AC;&#x2122;s Healthcare

206 | History and Culture

The Hospital | 207

New Concept Future Surgical Room

208 | History and Culture

The Hospital | 209

210

The Pharmacy History Evolution New Concept

The Pharmacy | 211

History

1900 - Present During the early 1900â&#x20AC;&#x2122;s, pharmacists played an important role in diagnosing and treating illnesses. They were respected in the community and often viewed to be equals to doctors. However, many did not have academic training. Rather it was common for pharmacists to be trained through apprenticeships. The number of drugs available for retail was limited. Therefore, it was common that pharmacists would sell additional items to supplement their business. This also allowed them to increase their store profitability.

â&#x20AC;&#x153;

212 | History and Culture

It often took a while for the pharmacist to concoct the various ingredients for medications. As a result, there were seating areas and soda fountain machines that made the customers comfortable as they waited. The nearly half a century, the soda machine was the center of the pharmacy, drawing customers in and promoted conversations. This created a pharmacy with an environment different than today. As time went on, the profession became more standardized. Colleges and universities started to expand there programs and as a result more stringent requirements for pharmacists came into place.

Soda machine was the

drawing customers in and

Pharmacy also sold perfumes, cosmetics, spices, and flavorings.

â&#x20AC;?

Cafe seating area

Bottled drugs located in the back of the store

Stools at Counter

Pharmacist engaging with customers

Soda Fountain

The Pharmacy | 213

Timeline The classic form of the corner drugstore began to emerge. W.B. Morrison & Co. Old Corner Drug Store where Charles Alderton a young pharmacist created Dr Pepper.

Pharmacists fulfilled the role of apothecary, preparing drug products for medicinal use. The soda machine was the center of the pharmacy, drawing customers in and promoted conversations

214 | History and Culture

Large scale manufacturing by pharmaceutical industry, intro to prescription only medicine, limited the role of pharmacists, dispensing and labeling of products.

The Food, Drug, and Cosmetic Act created the perscription drug, which created a new class of drugs that pharmacist could not dispense without a written order from a licensed prescriber.

Pharmacists had evolved toward a more patient oriented practice. Developed the concept of clinical pharmacy. Educational reform became the method to advance in the profession.

Electronic medicine counting machines were created to increase efficiency and accuracy of filling prescription medication.

Large commercial pharmacy allow a one stop shop for customers providing various products for purchase.

The Pharmacy | 215

Evolution

Optimized for Efficiency Today, pharmacies are not very conducive to conversation or relationships as they were in past. They have been optimized for efficiency much like a fast food restaurant. They offset the low margin cost of selling generic drugs with high volume out put. This means that pharmacists often don’t have time or incentive to engage in a personal relationship with customers. Often, you stand on line waiting for your turn to meet with the pharmacist who is usually the pharmacy’s less-professional assistant behind a glass wall, or you roll down your window at the drive thru to received your bag with you medication inside. “My pharmacy in the U.S. is so different and in many ways vastly inferior to that found in many ancient traditional cultures. For one thing, stools in the Chinese medicine shop mean I’m supposed to sit. The entire place is set up with the intention that conversation and consultation are part of the norm.” Yet studies have shown that a “good relationship 216 | History and Culture

with a pharmacist can greatly increase the chances of staying on a drug regimen.” According to PhRMA in 2011, 75% of people in the United States do not take their medication properly in some way or another. As a result, this costs the health care system close to $100 billion annually.

PHARMACY

Pharmacies are not “conducive to conversation

”

WHOLESALER DRUG

DOCTOR

INSURANCE

Industry

PATIENT

Pharmacys deal with a variety of different groups of people in their everyday business. The Pharmacy | 217

1915 The soda fountain becomes the focal point in the pharmacy. Bottled drugs located in the back of the store.

218 | History and Culture

2013 Modern day pharmacy design are not conducive to having conversations or building relationships with customers.

The Pharmacy | 219

Soda Fountain The Fair Oaks Pharmacy promotes their main focal point, the soda fountain, to draw customers to their store.

220 | History and Culture

Drive Thru Walgreens sign displays what they expect will draw customers to their store, the drive thru

The Pharmacy | 221

New Concept

Redefining the Pharmacy In 2010, Walgreens began to work with IDEO, a design firm based out of Palo Alto, CA, to work on redefining the community pharmacy. IDEO is the same firm who helped create the Apple store concept. Instead of the old walled off style and a single customer services window that pharmacy’s today are accustomed to, Walgreens tasked IDEO to create a space that was sleek, had modern finishes, and an open floor plan. IDEO began by helping Walgreens with series of in-depth market research. Through interviews and shopalongs with customers, IDEO was better able to understand what customers hopes, fears, and goals for their personal health were. This helped IDEO to design a pharmacy that would help engage customers and provide health and wellness advice. In the end, IDEO created two prototypes for Walgreens. These two concepts were then launched at two pilot locations in Chicago in November 2010. Like the Apple store, customers who come 222 | History and Culture

“ now customer service and

”

Round desk used as a hub to interact with customers Large display informs customers how long wait time is

Pharmacist desk is more open iPad used to access customer information to better attend to customers needs

Small display to input information for express prescription fill

The Pharmacy | 223

Perscription Bottled drugs New drop off and pick up is more open. Side display machines allow for quick and easy interface to drop off perscription.

in sign up for a consultation ahead of time and a flat screen monitor projects a wait list so you know how many people are ahead of you. Then, customers meet with a so-called health guide, who is a trained professional (pharmacy technician or nurse practitioner), who is there to answer basic questions and can look up their medications using an iPad. Then the customer meets with the pharmacist who now sits at a desk behind 224 | History and Culture

the health guide. No longer is the pharmacist sitting behind a wall. They are now able to better engage with the customer. “The pill is no longer the product,” Mr. Crawford said. “The product is now customer service and relationships.” This new design also has consultation rooms and a Take Care Clinic area. Here, customers

Ask Your Pharmacist Ask your pharmacist promotes interaction and allows the pharmacist to build personal relationships with customers.

can go to learn how to administer self-injected prescriptions or get flu shots. Walgreen aims to have 3,000 of their 7,000 pharmacies converted to this model by 2015. This collaborative project between IDEO and Walgreens allowed the company to redefine the pharmacy.

The Pharmacy | 225

226

The Retail Clinic History Current Demand Expansion of Service

The Retail Clinic | 227

History

Retail Clinics Retail clinics are popping up all across the country. They give customers easy and fast access to treatment for simple conditions. Before the there were retail clinics, if someone needed to consult a doctor for care after hours they would have to either go to an urgent care center or the ER. The idea behind the retail clinic is to be dramatically cheaper and more convenient than the emergency room or the doctor’s office.

In 2000, the first retail clinic appear in Minneapolis operated by QuickMedx, which later became MinuteClinic. They are based on a business model that is focused on low price, high volume, and minimal staff. It is important that retail clinics are located in high traffic retail locations with high visibility and ease of access. They are generally found in “big-box” discount stores such as Wal-

Average Cost of Medical Treatment

228 | History and Culture

$110

$166

$570

Retail Clinic

Doctors Office

Emergency Room

â&#x20AC;&#x153;

Mart or Target, grocery stores, or in retail pharmacies such as CVS or Walgreen. They can operate within as little as one hundred square feet of the retail space.

â&#x20AC;?

The Convenient Care Association (CCA) was created in 2006 due to the increasing popularity of retail clinics. The association works with health care experts to implement uniform treatment and develop policies and regulations.

RETAIL CLINICS IN THE U.S. (2006 - 2015) 4,000

3,000

650

2,000

MinuteClinic 1,000

0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

The Retail Clinic | 229

Current Demand MinuteClinic

There are two factors driving the increase in demand for retail clinics. The first is that there is a shortage of family doctors and the second is that an estimated 30 million people will receive healthcare with the Affordable Care Act. “With a growing shortage of primary care physicians, an increase in obesity and chronic disease, an aging population and an influx of newly insured Americans, MinuteClinc is playing an

“ ” important role in patient care in the United States.” MinuteClinic sees 25 to 30 people per day in a clinic.

Pharmacy Sales and Other Purchases

25-30

People Visit MinuteClinic Per day 230 | History and Culture

70%

Become New Pharmacy Members

38%

Buy an Over the Counter Product

80%

Purchace General Merchandise

21 of 30 people who visit a MinutieClinic will become new pharmacy members

Receiving

Baby Medical Medical

Make-up

School

Seasonal

24 of 30

Food Refrigerated

people who visit a MinutieClinic will purchace general merchandise

Seasonal

Make-up Toiletries

Cards

Hygiene

Health

Toiletries

Health

Hygiene

Health

Hair

Medical

Hygiene

11 of 30 people who visit a MinutieClinic will buy an over the counter product

Hygiene

Food

The Retail Clinic | 231

Expansion of Service Chronic Care

Today, most retail clinics provide patients with simple, acute health conditions. However, that is expected to change as demand for chronic care increase. 25% of the population in America has at least two or more chronic conditions. It is said that this will continue to get worse and is predicted to increase by 38% by 2020. As the Affordable Care Act rolls out, retail clinics are expanding their services to meet this increase in demand. Many question whether or not the expansion of chronic care in retail clinics will result in lower quality, increased cost, and pose a risk to patients long-term health. Dr. Jeffrey Cain, president of the American Academy of Family Physicians said, â&#x20AC;&#x153;Retail clinics may not have some specialty services needed to treat those with complex diseases. In addition, family physicians establish relationships and get to know their patients, which better enables them to help someone with diabetes learn how to eat better, start exercising and stick with their treatment plan.â&#x20AC;? 232 | History and Culture

1 out of 2 Adults in America has at least one chronic illness

7 out of 10 Deaths among Americans each year resulted from chronic diseases

1 out of 3 American will develop diabetes by 2050

â&#x20AC;&#x153; services into non-acute

9.5%

8.2%

U.S. childern have asthma

U.S. adults have asthma

â&#x20AC;?

Walgreen has begun to partner with larger health providers across the country to create patient-care protocols and other programs. Walgreen company objectives are to â&#x20AC;&#x153;help address the need for greater access to care by working corroboratively with physicians to support and complement their care plans for chronic patients.

U.S. childern are obese

13%

27.5%

CVS MinuteClinic is also expanding its scope of services into non-acute areas. This includes monitoring and point of care testing for diabetes, hypertension, high cholesterol and asthma in addition to vaccinations and routine physical examinations. This additional service is projected to account for 25 percent of the MinuteClinic volume within the next five years.

11.5%

25.9%

U.S. adults have heart disease

U.S. adults are obese

U.S. adults have arthritis

The Retail Clinic | 233

MinuteClinic Waiting room consists of a couple of chairs outside of the exam rooms.

234 | History and Culture

Walgreens Large waiting room.

The Retail Clinic | 235

236

Doctor Patient Relationship Length of Stay Acute Conditions Chronic Conditions

Doctor Patient Relationship | 237

Length of Stay Throughput

The doctor patient relationship has become frayed due to several factors. The first is that patients are unhappy with the rising cost of healthcare and doctors are pressured by H.M.O.’s to increase the number of patients they see. As a result, there has been a shift in the attitude of the profession. This shift has mostly to do with the switch from “patient” to “customer.” A “patient” is viewed as someone whom you would treat as though they were a family member. You would treat them to the best of your ability. However, this began to change during the 1980’s and 1990’s when the healthcare dollars became scarce. This resulted in doctors having to account for costs and do things more efficiently. It started operate more like a business. This was when “patient” was replaced by “customer.” A “customer” is treated differently than a “patient” is treated. “Customers” would go to hospitals or to the doctor to purchase 238 | History and Culture

“ Check-In

gR aitin oom W

doctors to an average sevenminute “encounter” with each

minutes

eck-Out Ch

minutes

Inter a

minutes

with Ph ion ct

n icia ys

for Physic i ait

”

minutes

Doctor Patient Relationship | 239

Length of Time Since Last Contact With Doctor Last 6 months 6 months to 1 year 1 year to 2 years 2 years to 5 years More than 5 years Never

healthcare. The business model change to “healthcare for money.” The “customer” comes into your office, they receive the healthcare they came for, then they pay, and then leave. Healthcare as a result become more transactional rather than building a relationship with the “customer.” This new model, changed the way doctors treated and interacted with “patients” or 240 | History and Culture

67% 16% 8% 6% 3% 1% now “customers.” They have to focus on improving the bottom line, which is done by increasing efficiency of what they call “throughput” which is the number of patients they see. No longer is the focus on how well a “patient” is doing. Rather, the focus is on “how long do you plan on keeping sick people in the intensive care unit.”

5 Components of Care Affected by Time In an article in the N.Y. Times, stated that “Publicly traded H.M.O.’s, for example, began restricting doctors to an average sevenminute “encounter” with each customer. This apparently kept shareholders happy. But it reduced the doctor patient relationship to a financial concept in a business school term paper.” M.B.A’s and politicians have tried to change the healthcare system so that it is more economical and efficient. However, this may have come at the cost of the doctor patient relationship. The article goes on to say, “Restoring the doctor patient relationship will not save anyone any money. But I submit that it doesn’t have to. There are other ways to curtail healthcare costs. Some invite high technology; others do not. None of them requires patients to sacrifice their selfrespect.”

Patient Satisfaction Physicians who spent time in health education and the effects of treatment recieved higher patient satisfaction.

Outcomes of Chronic Diseases Communication between patient and doctor is associated to more effective information gathering.

Prescribing Practices Physicians who expressed feeling a lack of time in their medical practices had higher rates of writing prescriptions that physicians who did not.

Physician Satisfaction Physician staisfaction is connected to the amount of time they have to do their work. Affects quality of care and prescription rates.

Risk of Malpractice Claims A physician’s risk of malpractice claims are associated with visit length.

Doctor Patient Relationship | 241

Acute Conditions Retail Clinics

“ ” Retail clinics in a way have redefined the health care industry. One example of that is with how they view patients. “Patients” are to be treated with great care; you talk with them, you comfort them, and help them make life-changing decisions. However, the retail industry has in a way changed the “patient” to a “customer.” Like in any business, “customers” are treated differently. With retail clinics, customers are there to purchase health care. Health care therefore has become more business like. If physicians are faster or spend less time with their customers, the better their bottom line will be. In 2012, the RAND Corporation created a study that looked at the impact of retail medi-

242 | History and Culture

cal clinics on primary care. The study found mixed evidence that supported the idea that retail clinics actually disrupts the use of primary care services or doctor patient relationships. However, the study found that people who visited retail clinics were less likely to return to their primary care physician for future illnesses. “There is concern whether retail clinics may disrupt the relationship between patients and their personal physicians, which may make it difficult to maintain the quality and continuity of medical care.” – Dr. Ateev Mehrotra (Associate Professor at the University of Pittsburgh School of Medicine, Researcher at RAND) Researchers examined a large group of people who used retail clinics to see if their visit

had any impact of the number of times they went to visit their primary care physician. The study found that, “People who visited a retail medical clinic for one of 11 common ailments such as respiratory infection or urinary tract infection were less likely over the next 12 months to visit a primary care physician the next time they needed similar care.” (RAND) They also found that the patients who visited retail clinic also had “less continuity of care, such as seeing the same physician for their medical needs.” Although, the study did not find any evidence

Acute Conditon Diagnose/Treat: Strep Throat Pink Eye Ear Infection Nose Infection Throat Infection

that retail clinics have a negative impact on primary care or doctor patient relationships, you can see that there is an impact. Only time will tell whether this impact is negative or positive to the primary care industry.

Vaccinations: Flu / Pneumonia / Hepatitis Minor Injuries: Burns Suture Removal Staple Removal Poison Ivy

Doctor Patient Relationship | 243

Chronic Conditions Understanding Emotional Pain

Chronic Conditon

Doctors are able to help patients with physical pain, but often are not able to address the patientâ&#x20AC;&#x2122;s needs emotionally. When a patient is diagnosed with a chronic disease, it becomes a life changing moment for them. It changes their day to day lifestyle. As a result, this can put a large amount of emotional stress on them. Today, there are not very many services or products that meet this emotional need for patients who have been diagnosed with a chronic disease within the first six months. If you are diagnosed with a chronic disease, you are 25% more likely to feel depressed. If a patient is depressed, they are twice as likely to miss their medication. As a result, the patient falls into a downward spiral. The patient misses their medication, then they start to feel more physical pain, which then makes them feel more emotional pain. The first six months is critical for helping patients to get adjusted with their conditions and back onto the right track.

244 | History and Culture

Diagnose/Treat: Diabetes Hypertension High Cholesterol Asthma

â&#x20AC;&#x153; â&#x20AC;?

In 2011, MinuteClinic became the first retail clinic to launch an educational program designed to enhance communication between health care providers and patients. By doing so CVS believes that this will improve health outcomes for its patients. Called â&#x20AC;&#x153;Ask Me 3â&#x20AC;? this program encourages patients to ask and to understand three primary questions.

Bottled drugs located in the back of the store

1. What is my main problem? 2. What do I need to do? 3. Why is it important for me to do this? This program evolved out of a partnership with the National Patient Safety Foundation. CVS MinuteClinic practitioners have been trained on the program so that they can introduce the program to their patients and have them understand the three questions.

Doctor Patient Relationship | 245

246

Psychology of Interior Space Attribute Spatial Approach Environmental Approach Research

Psychology of Interior Space | 247

Attribute Visual Arts

“ subject matter and convey a Result

248 | History and Culture

”

Effects of Nature and Abstract Pictures on Heart Surgery Patients

Reduce Anxiety

(Fewer doses of strong pain medicine)

Psychology of Interior Space | 249

Materials

â&#x20AC;&#x153; engagement than others

250 | History and Culture

â&#x20AC;?

Better Performance

Psychology of Interior Space | 251

Color Theory in Healthcare

252 | History and Culture

“ ” Psychology of Interior Space | 253

Functional Color in Design

“

” 254 | History and Culture

Waiting areas Color palette

Reason

Patient rooms Color palette

Goal

Surgical rooms in 1960s and 1970 Today

Color palette

Psychology of Interior Space | 255

Acoustic Elements to Improve Outcomes

“

256 | History and Culture

”

Psychology of Interior Space | 257

Impact of Music Music Therapy Program

“ Research shows that certain ” 258 | History and Culture

Psychology of Interior Space | 259

Spatial Approach Single vs. Multi-Patient Room

260 | History and Culture

Psychology of Interior Space | 261

Environmental Approach View of Nature/Plants, Natural light

Results

â&#x20AC;&#x153; Those who had nature view â&#x20AC;? 262 | History and Culture

Psychology of Interior Space | 263

Staff Walking Efficiency

“design tends to increase might be an increase

”

264 | History and Culture

Psychology of Interior Space | 265

Garden’s Impact

“ indicates that recovery from stress was faster and more Results

266 | History and Culture

”

Responses from 143 garden users at four San Francisco Bay Area hospitals (Cooper Marcus, C. and M. Barnes, 1995).

Psychology of Interior Space | 267

Garden Design in Healthcare

“ ”

268 | History and Culture

Psychology of Interior Space | 269

Research

Evidence Based Design (EBD)

Evidence-based design â&#x20AC;&#x153; strategies have become

â&#x20AC;?

270 | History and Culture

Psychology of Interior Space | 271

Evidence Based Design (EBD) Checklist

â&#x20AC;&#x153; Evidence-based design is a addresses issues from the

â&#x20AC;?

272 | History and Culture

Psychology of Interior Space | 273

LEED 2009 Guideline for Healthcare

“ ”

274 | History and Culture

Psychology of Interior Space | 275

LEED for Healthcare Examples

276 | History and Culture

Psychology of Interior Space | 277

278

Branding/Marketing Branding Types

Branding/Marketing | 279

Branding Types

Brands Values and Personalities

â&#x20AC;&#x153; â&#x20AC;? 280 | History and Culture

Branding/Marketing | 281

Vague

Practical

282 | History and Culture

Emotional

Specific Branding/Marketing | 283

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284 | History and Culture

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http://www.angieslist.com/articles/quick-low-cost-care-attracts-customers-retail-clinics.htm

www.mtic.dk/sites/default/files/ulrich_pdf_hammel_neurocenter_august.13

http://www.pinterest.com/mdgadvertising/healthcare-marketing/ (image)

http://www.usgbc.org/leed/rating-systems/healthcare

http://www.healthcaredesignmagazine.com/article/use-color-healthcaresettings http://www.pva.org/site/c.ajIRK9NJLcJ2E/b.6738073/k.9877/The_Psy-

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http://www.mycentraljersey.com/article/20131022/ NJNEWS/310220016/?nclick_check=1 http://www.1856.org/nshmap1.html http://www.ariehsharon.org/Archive/Hospitals-and-Health-Centers/OldBeilinson-1930s/16558947_XNCMgr#!i=1247059564&k=TbVd7Th http://www.yelp.com/biz_photos/newton-wellesley-hospital-newton?select =CHQBl8PuRrpuiCWkAs5AAQ#CHQBl8PuRrpuiCWkAs5AAQ

http://www.rootsweb.ancestry.com/~asylums/northampton_ma/ http://www.bharchitects.com/en/projects/360 http://www.disability.wa.gov.au/understanding-disability1/understanding-disability/history-of-disability-services/early-1900s--hospitals-for-theinsane/

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286 | History and Culture

http://www.northshoremedical.com/en-US/aboutus/Pages/default.asp

http://continuingeducation.construction.com/article. php?L=222&C=928&P=3 http://music.miami.edu/musictherapy/ress_project.html www.mtic.dk/sites/default/files/ulrich_pdf_hammel_neurocenter_august.13 http://www.hksinc.com/places/ texas-health-presbyterian-hospital-flower-mound/ http://www.healthdesign.org/clinic-design/clinic-examples/carol-milgardbreast-center

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Sources | 287

180 | Health Care Delivery Models

Urban Environment

4 Mapping Demographics Zoning Typologies Street Presence

Sources | 181

Mapping Existing Healthcare Infrastructure Accessibility

Mapping | 291

Existing Healthcare Infrastructure Emergency Rooms

With one of the highest densities of healthcare institutions and other healthcare delivery models, the healthcare infrastructure of Boston, Massachusetts is quite extensive. Emergency Rooms act as the front line of healthcare delivery because of their wide range of services and hours of operation.

â&#x20AC;&#x153;

With one of the highest densities of healthcare institutions and other healthcare delivery models, the healthcare infrastructure of Boston, Massachusetts is quite extensive.

Massachusetts General Hospital 55 Fruit Street

â&#x20AC;&#x153;

Typically attached to supporting hospitals, there are a significant number of emergency rooms throughout Boston and surrounding neighborhoods.

292 | Urban Environment

Beth Israel Deaconess Medical Center 330 Brookline Avenue

2mi

Mapping | 293

Urgent Care Facilities As more and more people begin to use emergency rooms as primary healthcare, wait times are increased exponentially, essentially rendering emergency rooms a last resort option. Urgent care facilities are able to provide a more economical and timely experience than emergency rooms while still providing similar services. Urgent care facilities are typically privately owned, but can be affiliated with or attached to major institutional hospitals. In locations where hospitals and/or emergency rooms are too far away, urgent care facilities play an important role in the fabric of urban healthcare. The two locations situated in East Boston are prime examples of unaffiliated, privately owned urgent care facilities that take advantage of areas lacking in existing healthcare delivery models.

294 | Urban Environment

East Boston Neighborhood Health Center 10 Grove Street

Urgent Care Medical Clinic 581 Boylston Street

2mi

Mapping | 295

Primary Care Offices

â&#x20AC;&#x153;

Larger institutions and hospitals have also realized that primary spread their brand and utilize their staff to the fullest.

â&#x20AC;&#x153;

Primary care offices allow people access to regular, non-emergency healthcare. These offices are typically comprised of a consortium of doctors whom own the facility privately. Larger institutions and hospitals have also realized that primary care offices are a good way to spread their brand and utilize their staff to the fullest. With the decline of available urban space, institutions are able to branch out to more suburban locations in order to expand their clientele while also expanding their infrastructure. Typically centrally located in residential neighborhoods as way to access a large customer base and provide ease of access.

296 | Urban Environment

MGH Chelsea Healthcare Center 100 Everett Avenue

Harvard Vangaurd Medical Associates 133 Brookline Avenue

2mi

Mapping | 297

Community Health Centers Community health centers provide comprehensive healthcare services to large masses in urban environments.

â&#x20AC;&#x153;

Community health centers provide comprehensive healthcare services to large masses in urban environments.

â&#x20AC;&#x153;

South End Community Health Center 1601 Washington Street

With an extensive range of services, community health centers are essentially miniature hospitals with a strong community presence and focus. Because of the nature of the services, i.e. nutritional health, parenting classes, after-school programs and healthcare education, community health centers tend to thrive in multicultural, diverse neighborhoods. Mattapan Community Health Center 1575 Blue Hill Avenue

298 | Urban Environment

2mi

Mapping | 299

University Health Centers Boston is a major hub for both healthcare and education in the United States, therefore it is only fitting for university health centers to have a significant presence in the healthcare urban fabric of Boston. University health centers act as the primary mode of healthcare for students whom comprise a large percentage of the population in Boston. University health centers are almost always located within the campus master plan providing ease of access for all the attending students. These health centers typically do not provide extensive healthcare services but focus on preventative care and education.

Boston University: Student Health Services 881 Commonwealth Avenue

Northeastern University: Health and Counseling Services 74 Forsyth Street

300 | Urban Environment

2mi

Mapping | 301

Retail Medical Clinics Retail medical clinics are a relatively new and innovative model for healthcare delivery. These clinics are considered accessory use to a larger retail use, i.e. CVS’ MinuteClinic and provide a range of minor and preventative healthcare services. As the adjacent map represents there are no retail medical clinics located in Boston and CVS MinuteClinic is the only RMC in Massachusetts. Massachusetts’ public policy poses difficult and stringent requirements which deter other RMCs from expanding to Massachusetts. In order to protect the existing healthcare infrastructure, Boston public policy forbids the use of retail medical clinics.

CVS Minute Clinic 211 Alewife Brook Parkway

“

In order to protect the existing healthcare infrastructure, Boston public policy forbids the use of retail medical clinics.

“

302 | Urban Environment

CVS Minute Clinic 36 White Street

2mi

Mapping | 303

Mobile Health Clinics Mobile health clinics offer a unique and interesting healthcare option for the residents of Boston. These health clinics typically provide a singular service or minimal range of services, i.e. mammograms, blood donations, etc. The mobility of these health clinics allows their services to reach a larger network of patients without needing to have multiple clinic locations. Each mobile clinic follows a strict schedule and route in order to gain recognition and develop a reputation in the particular location. The map represents regular docking locations of mobile health clinics within Boston.

The Family Van

The Blood Mobile

304 | Urban Environment

2mi

Mapping | 305

Immunizing Pharmacies In the past, pharmacies were one of the main healthcare delivery modes where patients could get diagnosed, treated and prescribed medicine all in one location. Over time healthcare has shifted in such a way that pharmacies primarily provide patients with their prescribed pharmaceuticals, ointments and other treatments. Today, with such an emphasis on fastpace lifestyles, pharmacies have begun to recognize a need to provide the busy professional, student and/or parent with quick and easy immunizations and vaccinations. This appealing business model allows immunizing pharmacies to provide important preventive healthcare that may not have otherwise been administered.

CVS Pharmacy I Photo 423 West Broadway Street

Walgreens Pharmacy 585 Washington Street

306 | Urban Environment

2mi

Mapping | 307

Accessibility Subway & Bus Routes

â&#x20AC;&#x153; â&#x20AC;&#x153;

residents travel throughout the city. Accessibility is key when determining the viability of potential sites and locations. In Boston, subway and bus lines play a vital role in the way residents travel throughout the city. The map clearly shows a high concentration of healthcare infrastructure along the designated subway and bus routes. Since healthcare is an essential component of sustainable life, it is beneficial to develop healthcare infrastructure in areas of local convenience and transportation options. This insures a higher level of accessibility and a larger radius of potential patrons which ultimately determines the profitability and success of the particular healthcare delivery modes.

308 | Urban Environment

The pharmacy locations are good examples of the importance of accessibility and access to transportation infrastructure. These pharmacies are primarily owned and operated by large companies (CVS and Walgreens) where profitability is the number one determinant. It is clear that the existing locations are deliberately chosen for their proximity to public transportation and commercial infrastructure. Each one of the individual pharmacy locations is either directly adjacent to a bus route and subway line.

Emergency Room

Urgent Care Facility Primary Care Office Community Health Center University Health Center Mobile Clinic Retail Medical Clinic Immunizing Pharmacy Red Line Green Line Blue Line Orange Line Bus Routes

2mi

Mapping | 309

Pedestrian Walking Radius Urban environments, such as Boston, are inherently pedestrian friendly because of their density and availability of public transportation. In order to properly represent the adjacencies of the citiesâ&#x20AC;&#x2122; existing healthcare infrastructure and public transportation, the adjacent map denotes a half-mile walking radius around each location. A large percentage of the locations are clearly shown within a half-mile walking radius of public transportation. In addition, the map begins to identify areas potentially lacking in healthcare infrastructure. Using this information provided, coupled with additional information from the following section, prime locations can begin to be identified and categorized as to which healthcare delivery modes would thrive best in a particular location. For example, a retail pharmacy may not thrive in an urban environment with little access to pubic transportation but an emergency room, where vehicular transportation might be more likely.

310 | Urban Environment

South Boston This neighborhood has a community health center and immunizing pharmacy centrally located, but seems that there are areas toward the eastern edge that do not have immediate access to a healthcare delivery mode. Is there an opportunity to capitalize on this information? Roslindale This neighborhood does not have any existing healthcare infrastructure. Why? By reviewing the demographic and zoning information in the following chapters particular healthcare opportunities can begin to be determined. Hyde Park Hyde Park is a large, industrial neighborhood with virtually no existing healthcare infrastructure. Are there locations in which some healthcare infrastructure would succeed?

Half Mile Walking Radius

Emergency Room

Urgent Care Facility Primary Care Office Community Health Center University Health Center Mobile Clinic Retail Medical Clinic Immunizing Pharmacy Red Line Green Line Blue Line Orange Line Bus Routes

2mi

Mapping | 311

Demographics Population Households Gender Age Composition Race/Ethnicity Income Level Education Level Chronic Disease Study of Asthma

Population

The Population Distribution, Census 2000 Answering the question of “Who are the residents of Boston?” is fundamental to understand the health experience of our city. Although the study of population can be described in many different ways, it is essentially the examination of the basics like “How many people live in Boston?” “How old are they?” “How many men and women live here?” and “What are their income levels?”

residents.

The answers to these questions represent demographic factors such as gender, age and race/ethnicity that may impact the health experience. These characteristics are often risk factors for disease or are associated with poorer health outcomes. For instance, there is an increased risk for heart disease, as an individual gets older. This section maps these demographic factors Boston. The foundation for understanding the context of health in Boston is built on this description of its

Along with the indication of Boston healthcare facilities in the city -- primary care, emergency rooms, clinics, and community health centers. The relationship between healthcare locations and population density becomes clearer. As we can see, generally these facilities are located in areas and neighborhoods with more population. For example, Back Bay and downtown areas seems to be the most concentrated areas for healthcare facilities.

The following map provides an overview of the distribution of overall residents of Boston across the various neighborhoods. It seems that the densest districts of population are Fenway and Back Bay, as well as some concentrated dense areas such as UMass in Dorchester, Lower Allston, and the intersection of Hyde Park and Roslindale.

Primary Health Care Emergency Room Clinics Community Health Center

2500 or lower 2501-5000 5001-7500 7501-9000 9001 or above

Population Growth, 1900-2000 In 2010, Boston had 617,594 residents, and was the most populous city in Massachusetts. The Decennial Census data illustrates a dramatic variation of the population of Boston over the past 110

years; it reached its peak of 801,444 residents in 1950. In 1980, it significantly dropped down to 562,994.

900,000

801,444

800,000 748,060 700,000

617,594 600,000 562,994

560,892 500,000 1900

1920

1940

1960

1980

2000

Since 1980, Boston’s population started to gradually increase every 10 years. In 2010, it reached 617,594 residents, representing a ten-year growth of 4.8% from 2000.

“

The foundation for understanding the context of health in Boston is built on this description of its residents.

“

Households

Total Number of Households, Census 2000 The U.S. census chart below shows the number of households in Boston, with a total of 115,096 family households and 124,432 non-family households.

The map on the right demonstrates the distribution of households in Boston as well as healthcare facility locations.

150,000

120,000

90,000

60,000

30,000

Ho F u a W seh mily i un th C old de hi r 1 ldr 8 en yr M s ar pl ried e W Fa -cou ith m un C ily de hi r 1 ldr 8 en Si ng yrs l Ho e Fe u W se mal i h e un th C old de hi r 1 ldr 8 en yr s No Ho n-F u a Ho seh mily Li use old vin h Ho g A olde us lon r er e > hol 65 de yr r s

Primary Health Care Emergency Room Clinics Community Health Center

250 or lower 251-500 501-750 751-1000 1001 or above

Gender

Population Division The chart below shows the percentage of male and female that make up the total population of Boston, with slightly more female (51.1%) than males (48.9%) in 2007.

residences, only 5% of the city is male dominated, and the remaining 20% of the city is where the population of male and female are about the same.

The map on the right visually demonstrates the ratios of male to female throughout the city by census tracts. Approximately over 75% of the city is predominantly female

To understand the map, for instance, the ratio of 50-75% represents the percentage of male divided by female. In which, 50% means that if there are 100 males, there will be 200 females; similarly 75% means 150 males compares to 200 females. Therefore, the ratio is smaller when there are more females, and it gets bigger when there are more males. When the ratio is nearly 100%, it is when the numbers of females and males are getting close to each other.

60% 50% 40% 30% 20% 10% 0%

Male

Female

Primary Health Care Emergency Room Clinics Community Health Center

Male:Female Ratio Predominantly 50-75% 75.1-99% Female 99.1-101% Equal 101.1-125% Predominantly 125-150% 150.1-200% Male Non-residential area

Age Composition Age Census, 2000

The three maps on the following pages demonstrate the distribution of Boston population by census tracts in different age groups: children are considered to people under the age of 18; adults are people over 18 but less than 64; seniors are people over the age of 64. Notice that the variation of colors on the map does not represent the density of population, rather a record of population lives within that area, unless its been related with its size. In general, Boston has a lot more adults (1864 yrs) than children (<18) or seniors (>64). Not only because of the larger span of its age group. As shown on the category dividends, the adult’s categories have distinctively higher values under each category. For example, it accounts for “more than 3000” at most, while the children group accounts for “more than 1000”, and the senior group accounts for “more than 300”.

Comparatively, there are more children in South Boston (Dorchester and Mattapan neighborhoods); meanwhile, there is a denser population of adults who live in Fenway, Back Bay and Lower Allston; while many of the seniors lives in downtown Boston and southwest Boston (West Roxbury and Hyde Park). With healthcare facilities indicated on the maps, the location of those facilities seems to be more closely linked with the distribution of adult residents. For example, there are more facilities in Fenway and Back Bay than the other neighborhoods.

Primary Health Care Emergency Room Clinics Community Health Center

Age <18 less than 200 201-400 401-600 601-800 801-1000 more than 1000

Primary Health Care Emergency Room Clinics Community Health Center

Age 18 - 64 less than 500 500 -1000 1001-1500 1501-2000 2001-3000 more than 3000

Primary Health Care Emergency Room Clinics Community Health Center

Age > 64 less than 50 51-100 101-150 151-200 201-300 more than 300

Race/Enthnicity

Population Majority, Census 2000 The population of Boston has been always diverse over time. [2] The following map provides an overview of the distribution of major ethnic groups (>50%) of Boston residents by tracts across various neighborhoods. As the map demonstrates, north Boston has a primarily white population (>50%) while Roxbury and Mattapan are primarily black (>50%), and predominantly Hispanics and Asian populations (>50%) are scattered in central Boston. Along with the indication of Boston healthcare facilities in the city -- primary care, emergency room, and clinics. The relationship between healthcare and race/ ethnicity density becomes clearer. As we have observed from the map, it seems these facilities are located in areas and

neighborhoods with a larger white population rather than other race groups. For example, the North of the city has a higher concentration of healthcare facilities, which coincides with large majority white neighborhoods.

Primary Health Care Emergency Room Clinics Community Health Center

White > 50% Black > 50% Hispanics > 50% Asian > 50% Others Others Non-residential area

Income Level

Income of Boston Households, Census 2000 The following map demonstrates the distribution of the income level of Boston households by tracts across various neighborhoods. As the map indicates, Mid-income households are the major group throughout the city (40-60%), most members in this class (>60%) lives in south Boston. More households with higher incomes (>60%) lives in North End, Back Bay and Jamaica Plain; With more lower income households (>60%) dwells, some of the poorer areas are therefore considered to be downtown Boston, South End Roxbury as well as West Roxbury. Along with the indication of Boston healthcare facilities in the city -- primary care, emergency room, and clinics. The relationship between healthcare location and income level however are less clear than the other maps. First of all, healthcare facilities are likely to be located in more wealthy neighborhoods, such as

Back Bay, North End and Jamaica Plain. However there seems to be an inadequacy in Charlestown, East Boston and Roslindale and Hyde Park where the residents are mostly mid-income.

Primary Health Care Emergency Room Clinics Community Health Center

Low Income (40-60%) Low Income (>60%) Mid Income (40-60%) Mid Income (>60%) High Income (40-60%) High Income (>60%)

Education Level

Highest Education Level Attained , Census 2010 The following chart investigates the highest education level has been attained by individuals over age 25 of Boston in 2010, and compares to that of Massachusetts and United States in the same year. Thereâ&#x20AC;&#x2122;s a higher percentages of Massachusetts residents who have obtained a high school diploma and completed some college or an associate degree compared to Boston residents in 2010. However, more of Boston residents have a Bachelorâ&#x20AC;&#x2122;s (>21%) or Graduate degree (16%) compared to Massachusetts and the U.S. If we relate the figures with the map of the adult population (age 18-64), we can roughly make assumption of where these higheducated populations are located. Reading from the map, it could possibly be Fenway, Lower Allston and the area

around UMass in Dorchester since these areas have more population. Since these areas are close to many universities and colleges, this assumption could be true. Comparatively, these areas also have more healthcare facilities.

2010 Highest Education Level Attained (Populations Age 25+)

Boston Massachusettes United States 30% 25% 20% 15% 10% 5% 0%

Did Not Complete High School High School

Some College

Associate Degree

Bachelors Degree

Graduate Degree

Chronic Disease Maps of Chronic Disease

Asthma, heart disease, diabetes and obesity are common chronic diseases in Boston. Chronic diseases can impact every aspect of an individualâ&#x20AC;&#x2122;s physical health as well as his/ her life including relationships with family and friends, education and employment, level of physical activity, emotional health, and financial well-being. Furthermore, chronic disease can lead to severe disability, reduce quality of life, and even death.

â&#x20AC;&#x153;

Chronic diseases are among the most common and most costly health conditions, but they are also amongst the most preventable.

â&#x20AC;&#x153;

Visiting a healthcare provider for routine screening and early detection of disease

certainly aids in prevention. It is also important that these healthcare providers work with communities to provide health education and increase awareness about prevention and risk factors of the disease; also increase disease screening within the community, providing comprehensive chronic disease care. In order to fight with these chronic diseases, prevention and disease management are very important to success. Therefore, mapping disease demographics can help us to make infer whether certain groups of people have an increased chance of getting the disease. Further, the study of the disease demographics is very useful when relate with the location of healthcare facilities, to help determine if more facilities should be established for the service.

Primary Health Care Emergency Room Clinics Community Health Center

Heart Disease Hospitalizations 2005,2006 and 2007 Combined 15.0 or less 15.1-20.0 20.1-35.0

Primary Health Care Emergency Room Clinics Community Health Center

Diabetes Hospitalizations 2005, 2006 and 2007 Combined 1.0 or less 1.1-2.0 2.1-3.0

Primary Health Care Emergency Room Clinics Community Health Center

Obese Adult Residents 2005 and 2006 Combined Lower than overall Not different from overall Higher than overall

Study of Asthma

Asthma Incidents Among Adults 2009 by Census Tracts and Neighborhoods

“

Asthma is a chronic respiratory disease characterized by episodes of

“

Youth have the risk of developing asthma. A family history of asthma, allergies can increase the risk of individual developing asthma. Studies have shown that among the different races/ethnicities, Puerto Ricans have the highest prevalence rate of asthma, followed by Blacks and American Indians. The map on the right demonstrates asthma incidents among adults of Boston in 2009 by census tracts and neighborhoods. As we can see, there are more incidents in Roxbury, Mattapan, Hyde Park and South Dorchester community; meanwhile, the least incidents are recorded at South Boston, South End, Back Bay and Fenway. In the following maps and charts, we will investigate more into the relation between

asthma disease and Boston demographics, such as gender, race and income; also we will be conclude on if there should be more healthcare facilities in those “more severe” areas.

Primary Health Care Emergency Room Clinics Community Health Center

1-25 (23) 25-50 (40) 50-100 (54) 100-250 (40)

Asthma Hospitalization Rates, 1994-1997 The following maps demonstrate Asthma hospitalization rates of Boston residents and among children under age 5. One of the asthma studies done by HSPH indicates that poorer communities are at higher risk for the disease. Jack Spengler, co-coordinator of the effort and the Akira Yamaguchi professor of environmental health and human habitation at HSPH concluded:

â&#x20AC;&#x153;

neighborhoods, such as Back Bay, Fenway, Charlestown and Allston, asthma hospitalization rates are considerably lower (1.0-2.7%). For combined years 2005-2007, the average asthma hospitalization rate for children under age 5 was highest in Roxbury, Fenway, South End, Dorchester and Mattapan (9.1-16.0); the lowest asthma hospitalization rates are in the north and West Roxbury (6.0-9.0).

Housing has a lot to do with increasing asthma rates because this is

The map on the left shows that Roxbury -one of the poorer community in Boston -- has the highest asthma hospitalization rate (6.37.9%); followed by South End and Dorchester with more mid-income members (4.5-6.2%). Comparatively, in those wealthier

â&#x20AC;&#x153;

Primary Health Care Emergency Room Clinics Community Health Center

1.0-2.7 2.8-4.4 4.5-6.2 6.3-7.9

Primary Health Care Emergency Room Clinics Community Health Center

Asthma Hospitalizations of Children Under Age 5 by Neighborhood, 2005, 2006 and 2007 Combined Asthma Hospitalizations per 1,000 population 6.0 or less 6.1-9.0 9.1-16.0

Asthma Rates, Census 2001-2010 The chart below shows an overview of the growth of average Asthma rates in Boston from 2001 to 2010. It seems that the rate has been controlled in between 2003 to 2005, with a decrease to 9% 2001 and

maintained until 2006â&#x20AC;&#x201D;when it gets back to 11% again. After a little decline of 1% in 2008, it floats back to 11% in 2010.

12% 11%

10%

8% 2001

2003

2005

2006

2008

2010

By Gender, 2006 The Following chart demonstrate Asthma rates in adults of 2006 by gender, in which it shows males with a lower rate of 8%, while females have a significantly higher rate of 14%.

15% 12% 9% 6% 3% 0%

Male

Female

If this information is combined with the map of gender division: with higher asthma rate among women, and predominantly female residents lives in South Boston, i.e. Roxbury and Mattapan neighborhoods. We can therefore infer that Asthma prevalence could be possibly higher in those areas.

Primary Health Care Emergency Room Clinics Community Health Center

Male:Female Ratio Predominantly 50-75% 75.1-99% Female 99.1-101% Equal 101.1-125% Predominantly 125-150% 150.1-200% Male Non-residenctial area

By Income, Census 2007 The chart below shows average asthma rates among Massachusetts’s adults in 2007 by income. Clearly, adults with higher incomes ($50,000-74,999 and $75,000) have lower asthma rate of 8.3%; while adults with lower incomes (<$25,000) have the highest asthma rate at about 13.4%.

Comparing this information with the map of income distribution and the map of asthma hospitalization rates, we can then deduce the relation between asthma incidents or rates and Boston population. For example, Back Bay has lower asthma rates, because it’s considered as a richer community; on the contrary, a poorer community such as Roxbury has higher asthma rates.

15% 12% 9% 6% 3% 0%

<$25,000 $25,000 –34,999

$35,000 –49,999

$50,000 –74,999

$75,000+

Primary Health Care Emergency Room Clinics Community Health Center

Households Income $10,250.00-$24717.00 $24,717.01-$37,274.00 $37,274.01-$52,433.00 $52,433.01-66,250.00 $66,250.01-$87,464.00 $87,464.01-$143,819.00 Non-residenctial area

By Races/Enthnicity, 2007 The following chart indicates asthma rate among Massachusettsâ&#x20AC;&#x2122;s adults in 2007 by races. Among the four major races, Hispanics has the highest asthma rate of 12%; followed by Blacks with a rate of 10% and whites of 9.8%; Asians havev the lowest rate at 6%.

To compare the figures with the map of majority races/ethnicity in Boston and the map of asthma hospitalization rates, we can then make some deduction on the relation between asthma incidents and races. For example, Roxbury with the most reported asthma rates also has the most of black population.

12% 10% 8% 6% 4% 2% 0%

White

black

Hispanic

Asian

Primary Health Care Emergency Room Clinics Community Health Center

White > 50% Black > 50% Hispanics > 50% Asian > 50% Others

Zoning Zone Designations Observations

Zoning | 349

Zone Designations Definitions

The Boston Redevelopment Authority regulates the designation of neighborhood subdistricts and manages the allowed, conditional, or forbidden uses for each subdistrict within the larger neighborhood districts. For the sake of this text, the “clinic” use group will be the focus of the following graphics and information.

The designations awarded to the various subdistricts, for each use group, are the following:

“Clinic”, a place for the medical or similar examination and treatment of persons as outpatients.

Conditional - “The granting of a permit for any use so marked may be authorized conditionally by the Board of Appeal acting under the provisions of Article 6, subject to the requirements set forth in the use item column. The continued right to a conditional use is dependent upon maintaining the character and extent of operations and structures.”

“

Interestingly, the BRA does not distinguish between different types of clinics; a methadone clinic is considered the same as a community health clinic.

350 | Urban Environment

Allowed - “Any use so marked shall be allowed as a matter of right, subject only to the requirements set forth in the use item column.”

Forbidden - “No land or structure in any district shall be erected, used, or arranged or designed to be used, in whole or in part, for any use specified in the use item...”

Subdistricts Residential Subdistricts 1 Family (1F) 2 Family (2F) 3 Family (3F) Multi-Family (MFR)

Business Subdistricts

Local Convenience Neighborhood Shopping Community Commercial

Industrial Subdistricts Local Industrial

Institutional Subdistricts

Neighborhood Institutional

Conservation Protection Subdistricts Conservation Protection

Community Facilities Subdistricts Open Space Subdistricts

While the use regulations differ from neighborhood district to district, it is important to note some trends that emerge when mapping the “allowability” of Boston. “Clinics,” as defined by the BRA, are almost always disallowed in all residential subdistricts. In Roxbury, on the other hand, “clinics” are designated for conditional use in multifamily subdistricts. Business subdistricts, typically located centrally along a major route of transportation, are designated for conditional use in regards to “clinics.” Some neighborhood districts, like Dorchester, are slightly more stringent in their allowability of “clinics” in business subdistricts. Contradictorily, Hyde Park designates “clinics” as allowable in many of the business subdistricts. Industrial subdistricts tend to follow the same trends as the business subdistricts, where as the institutional subdistricts lean to a majority allowed use designation. Zoning | 351

Mapping The zoning map graphically represents each subdistrict of Boston and denotes whether or not a “clinic,” as defined by the BRA is allowed, conditional or forbidden. The map is a tool to locate potential sites for urban healthcare development and help determine trends in the Boston zoning code as it pertains to healthcare uses. As the map clearly represents there are minimal locations where “clinics” are outright allowed. These areas are typically existing healthcare institutional master plan overlays which have, over time, facilitated the need to designate their subdistrict as such.

“

The nature of an ever growing and developing city, like Boston, requires the need for frequent variances and board approvals to keep up with the changing fabric of the city. Subsequently, there is a large percentage of conditional use designations for “clinic” throughout the neighborhood districts. Unlike the scattered zones of allowed use, clusters of conditional use zones become emerge as potential indications of the urban fabric within. While the majority of the zoning subdistricts of Boston are designated as forbidden for “clinics,” due to dense residential and open space zoning, the map provides enlightening information for urban healthcare infrastructure and development.

The zoning map graphically represents each subdistrict of Boston and

“

conditional or forbidden. 352 | Urban Environment

Allowed Use Conditional Use Forbidden Use

2mi

Zoning | 353

Observations

Typical Trends and Atypical Conditions Institutional Ring As evident in the map, a ring of institutional subdistricts, where “clinics” are either allowed or conditional, form around the center of Boston. This can attributed to the high concentration of universities and hospitals, but could provide potential opportunities when developing new healthcare infrastructure. High-Density of Conditional Use Interestingly, Roxbury, unlike the other surrounding neighborhood districts, has a large percentage of subdistricts designated for conditional use in regards to healthcare. This can be attributed to being the neighborhood district where multifamily subdistricts are given this designation. Infrastructure Branches These branches spread from the dense, urban spaces of Downtown Boston out through the more residential neighborhood districts along major routes of transportation, i.e. subway lines and highways. This typical trend in zoning along existing transportation infrastructure could inform decisions about potential location for successful healthcare development. High-Density of Allowed Use Hyde Park clearly has the highest density of subdistricts that allow “clinics” in all of Boston. Subdistricts that are primarily designated as conditional use in other neighborhood districts are designated as allowed use in Hyde Park. The highly industrial nature of this district, especially in the Readville area, could be a determining factor in the zoning structure.

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Allowed Use Conditional Use Forbidden Use

2mi

Zoning | 355

High-Density of Conditional Use Roxbury

The Northern edge of Roxbury, as the adjacent map represents, consists virtually of entirely conditional use subdistricts for healthcare infrastructure. Similar to other neighborhood districts, Residential and Open Space subdistricts are considered forbidden, but Multifamily subdistricts are designated as conditional. Due to the demographics of Roxbury, there is an abundance of housing projects and public housing facilities, ultimately contributing to the density of conditional use subdistricts.

356 | Urban Environment

There is clearly an effort, on behalf of the Boston Redevelopment Authority, to develop Roxbury, one of the lowest income neighborhoods of Boston. The map represents large Economic and Industrial Development Areas, such as the Greater Roxbury and new Market, in order to revitalize the economy and work-force of the neighborhood. It may be beneficial to take advantage of the preferred development incentives when determining potential healthcare development areas.

Neighborhood Institutional

Institutional

Greater Roxbury Economic Development Area

Multifamily & Local Services

Row Houses

Institutional

Community Facilities Multifamily

Open Space Community Facilities

New Market Industrial Development Area Dudley Square Economic Development Area

Neighborhood Shopping Allowed Use Three Family

Conditional Use Forbidden Use

Zoning | 357

Infrastructure Branches Jamaica Plain

Higher concentration of allowable and conditional use subdistricts seem to develop around Infrastructure branches stemming from Downtown Boston. In order to determine the components that make up these typical conditions, the adjacent map depicts an existing case of the phenomenon in Jamaica Plain. Located around both Washington Street and the Orange Line, subdistricts such as the Neighborhood Shopping, Local Industrial, and Local Convenience become abundant. Local Industrial Subdistricts are both the largest and most frequent of possible locations for future clinics where Residential, Open Space, and Conservation Subdistricts remain forbidden. Lastly, located at the heart of the Franklin Park Zoo a Neighborhood Institutional Subdistrict, Lemuel Shattuck Hospital, stands alone.

358 | Urban Environment

Two Family

Open Space

Local Industrial

Neighborhood Shopping

Local Convenience

Local Industrial

Conservation Protection

Neighborhood Institutional

Neighborhood Shopping Open Space

Community Facilities One Family Allowed Use Conditional Use Forbidden Use

Zoning | 359

High-Density of Allowed Use Hyde Park

Hyde Park is unique in the fact that it has a much larger percentage of allowable use subdistricts compared to other neighborhood districts. As the adjacent maps represents, Open Space and Residential Subdistricts are designated as forbidden, but what makes Hyde Park an atypical condition is that Neighborhood Shopping and Local Convenience subdistricts are designated as allowed. The map represents the southern tip of Hyde Park near Readville, a highly industrial area as shown. With Hyde Park Avenue and the commuter rail dissecting the high concentration of allowed use subdistricts, this region of Boston could be a prime location for new healthcare infrastructure, especially an institutional hospital that is looking to branch out from their main campus and expand their patient radius.

360 | Urban Environment

Open Space

Neighborhood Shopping Local Convenience

Two Family

Open Space

Local Industrial

Neighborhood Shopping

Local Industrial One Family

Allowed Use Conditional Use Forbidden Use

Zoning | 361

Typologies Kiosk Insert Box Insert Stand-Alone Minute Clinic

Typologies | 363

Kiosk The Kiosk is the smallest delivery method for basic primary healthcare typically consisting of a chair, a computer kiosk to sign in and sometimes an small enclosure. It is usually located within a section of the program of a larger establishment, typically with in a pharmacy for convenience of prescription filling. Kiosks are generally used for monitoring basic vitals, diagnosis via telehealth devices or telemedicine and consultations with doctors. The more advanced kiosks are booths or small examination rooms that usually have a healthcare attendant to provide assistance if required. This typology provides the least amount of privacy and typically located within the least traffic zone of the building. There is no threshold between the environment and the healthcare unit.

364 | Urban Environment

most basic delivery â&#x20AC;&#x153; The method for healthcare that requires limited or no medical assistance.

â&#x20AC;?

Typologies | 365

CVS Minute Clinic

convenient current model of Healthcare delivery that addresses “ Most many common and chronic symptoms. Located within CVS Pharmacies. The minimum level of healthcare service based on three

”

CVS Caremark’s prototype model for “safe, affordable, convenient” healthcare. Currently provides basic primary healthcare from limited shot types to chronic diseases such as diabetes to ear infections. Services provided are covered by most major healthcare providers. Due to its success, this prototype is slowly expanding its services based on the increasing demands and surveys. The incorporation of telemedicine is a future possibility as the clinic evolves and becomes a more successful model for primary healthcare. The Minute Clinic is located within a CVS Pharmacy adjacent to the pharmacy. As a new prototype for healthcare delivery many of the clinics are retrofitted to existing

366 | Urban Environment

buildings and may not always be ideally located. The clinic typically consists of a sign in computer kiosk, two examination rooms and a couple chairs along the wall for waiting. Privacy is limited to only inside the examination rooms. The clinic is treated similar to retail goods on display. This may give the user a negative experience due to the lack of privacy.

Typologies | 367

Box Insert A medium size clinic with at least two to four examination rooms, a designated waiting area and a front reception desk are common within this typology. It is located within a mixed-use establishment. These medium size clinics provide an intermediate range of healthcare. They provide full services of traditional primary care and may offer non-traumatic services of the hospital emergency room such as x-rays and other larger diagnostic testing. The Box Insert is most flexible providing the ability to fit into various urban environments. As healthcare evolves, the Box Insert typology is becoming the model for retail clinics and urgent care due to the freedom from medical institutions and allowing primary healthcare to distance itself from large medical centers. Many urban urgent care centers are box inserts within hospitals or larger community health centers. The Box Insert often has a presence on the street. Signage and articulation of the entrance from the exterior often provide a less “institutional medical” feeling as these clinics try to promote comfort and local 368 | Urban Environment

accessibility. This typology that attempts to blend in with the existing urban environment.

“ ”

Typologies | 369

Stand-Alone

“ ” The Stand-alone is the largest size typology with at least four examination rooms, a designated waiting area, a front reception desk, and may contain special care rooms (x-rays, MRI,etc) if it is not a pharmacy. These larger size typologies provide the a basic to limited-advanced range of healthcare. Chain Pharmacies may fall into the standalone typology because of their retail component acts as a “box insert” in these particular instances. They are typically situated on its own lot but may be a part of a plaza development. This typology is more common in suburbs but is slowly moving into the city presenting itself as a health center providing more than one 370 | Urban Environment

type of care. In a stand-alone typology, a kiosk insert or box insert may be contained within in order to provide a particular range of healthcare services. Many community health centers are stand-alones that have urgent care centers as box inserts.

Typologies | 371

Street Presence Signage Thresholds

Street Presence | 373

Signage As the concept of health has become more prominent in todayâ&#x20AC;&#x2122;s world signage for identification of medical institutions is generally led by branding of the service provider. Hospitals originally had small placards on the entrance of the campus gates but as expansion and merging of healthcare providers, signs have become a branding billboard at the main entrances. Currently only the Emergency Room signs of hospitals provide a semi-standard universal sign often with directional markers. The current presence of healthcare is isolated due to zoning codes and makes a discussion for the integration. The growing idea of convenience of healthcare provides a platform for thinking of how it is presented within neighborhoods. Some questions brought forth are does it blend in with existing retail stores acting like a traditional corner store or does it declare its presence in a manner to service the community. 374 | Urban Environment

3D Internal Lighted Sign

Awning

Sign w

ith flat

text

Street Presence | 375

20’

18”

30”

18” KIOSK

Window Sign Window Sign

376 | Urban Environment

Street Presence | 377

378 | Urban Environment

Thresholds

The medical appearance has changed its image over the years. Early hospitals were on the periphery of the city to â&#x20AC;&#x153;keep the illnessesâ&#x20AC;? away from the healthy city. As care advances through methods and technology, their facilities slowly begin to express the same level of sophistication. Old institutions were situated on a plinth surrounded by grass and during urbanization new institutions became surrounded by dense residential and commercial buildings. As the hospital moves into the city the less green open space surrounds the building which led to the development of medical campuses. Presently, healthcare facilities, especially hospitals, are trying to provide a more public appeal. In doing so, large atriums, gardens, courtyards and street furniture and

streetscape within the institutionâ&#x20AC;&#x2122;s medical campus provide a public realm where people can walk through without the overwhelming feeling of emotions hospitals generally instill. The emergence of heavy glazing on the facade is an attempt for medical institutions to promote transparency between the public realm and healthcare. Medical institutions presently use glass in innovative ways to promote the advanced technology and premium service. The threshold of entering the healthcare environment has changed dramatically from picturesque gated lawn to direct entry from a public sidewalk.

Street Presence | 379

Meeting the Street

1914

PRESENT The urban hospital maintained its isolation from the rest of the city by defining a campus. During the expansion of hospitals, the realization of limited space forced hospitals to address the street directly. This made the hospital edge overwhelming with opaque walls along sidewalks. These hospitals no longer have the space on their campus for a grand green 380 | Urban Environment

entrance from the street. The new approach to resolve the solid monumental address to the pedestrian city is developed through the use of materials for the ground floor and the incorporation of small sidewalk streetscapes.

Street Presence | 381

Saint Elizabethâ&#x20AC;&#x2122;s Medical Center in Brighton, Massachusetts exemplifies the opacity urban hospitals can have when they meet the sidewalk along Cambridge Street. On Washinton Street, greenery and a less rigid retaining wall with some greenery in an attempt to have a softer street edge.

382 | Urban Environment

Street Presence | 383

Urban Integration

Healthcare is a vital service and is presented in various forms within a city. However, healthcare has an institutional hospital image that historically ostracized the ill. To lessen the institutional appeal of healthcare, an integration with the urban environment was made. As primary care gained additional methods of delivery, the emergence of retail clinics and healthcare centers have moved into existing community buildings. Through this integration a presence of convenience and commonality.

384 | Urban Environment

Street Presence | 385

15’

4’

386 | Urban Environment

12’

Healthcare Residential Retail

As healthcare begins to leave the confines of the hospital campus, integration with other building uses addresses a measure of convenience and commonality.

Street Presence | 387

Sources

Information Mapping Health of Boston, 2009: Demographics http://www.bphc.org/about/research/hob/Forms% 20%20Documents/3.%20 DemographicsPrinted_ HOB09_22Apr09_with%20pics.pdf Health of Boston, 2012 - 2013: Demographics http://www.bphc.org/about/research/Forms%20%20 Documents/HOB12-13Docs/B_HOB12-13_Boston_ Section.pdf Health of Boston, 2009: Chronic Disease http://www.bphc.org/about/research/hob/Forms%20 %20Documents/HOB%20with%20Charts/14. ChronicDiseaseText%20w%20tables_HOB09_ 30Apr09.pdf Public Housing Gets Asthma Treatment http://archives.focus.hms.harvard.edu/2002/May17_ \2002/research_briefs.html Demographics Health of Boston, 2009: Demographics http://www.bphc.org/about/research/hob/Forms%20 %20Documents/3.%20DemographicsPrinted_ HOB09_22Apr09_with%20pics.pdf Health of Boston, 2012 - 2013: Demographics http://www.bphc.org/about/research/Forms%20%20 Documents/HOB12-13Docs/B_HOB12-13_Boston_ Section.pdf Health of Boston, 2009: Chronic Disease http://www.bphc.org/about/research/hob/ Forms%20%20Documents/HOB%20with%20 Charts/14.ChronicDiseaseText%20w%20tables_ HOB09_30Apr09.pdf

388 | Urban Environment

Public Housing Gets Asthma Treatment http://archives.focus.hms.harvard.edu/2002/ May17_2002/research_briefs.html Zoning http://www.bostonredevelopmentauthority.org/zoning/zoningcode-maps http://www.bostonredevelopmentauthority.org/zoning/zoningcode-maps https://plus.google.com/114783487323630378464/about

Images Mapping

Behavioral

Risk Factor

2005-2009 American Community Survey 5-Year Estimates http://www.isgenuity.com/index.asp https://plus.google.com/114783487323630378464/about http://www.boston.com/yourtown/news/mattapan/2012/09/ citizens_ bank_to_cut_ribbon_on.html Demographics http://www.isgenuity.com/index.asp [front_page] http://www.surreylife.co.uk/people/leading_ladies_ of_surrey_ business_1_2322794

Asthma Among Massachusettes Adults, 2007 Surveillance System (BBRFSS), Boston Public Health Commission Zoning http://www.bostonredevelopmentauthority.org/zoning/zoningcode-maps http://www.bostonredevelopmentauthority.org/zoning/zoningcode-maps Typologies Solo Health kiosk http://www.forbes.com/sites/stephenwunker/2013/

MassGIS: OliverMapingTool | http://maps.massgis.state.ma.us/ map_ol/oliver. php U.S. Census 2010, SF1. Decennial Censuses, U.S. Department of Commerce, Bureau of the Census,1900-2000.

next-generation-kiosks-disrupt-medicine-andhealthcare-marketing/ HealthSpot Kiosk http://www.healthmgttech.com/online-only/thedoctor-is-always-in.php

United States Census Bureau, 2007.

Cisco-HealthPresence-Pod_Prototype http://www.ehi.co.uk/news/ehi/3140/healthcarebooths-go-on-trial-in-scotland

U.S. Census Bureau, 2010 American Community Survey

Street Presence

Acute Case Mix Files, Massachusetts Division of Health Care Finance and Policy

Faulkner Hospital http://www.brighamandwomens.org/departments_ and_services/medicine/medical_professionals/ residency/medpeds/facilities.aspx

United States Census Bureau, 2000.

Asthma Incidents Among Adults 2009 by Census Tracts and Neighborhoods Assessment and DataSystems,1994-1997

MGH ER

http://www.wcvb.com/news/local/metro/MGHNurse-tells-of-ER-horrors-after-boming/-/11971628/ 19843068/-/12x3bvs/-/index.html

Boston Behavioral Risk Factor Survey 2005 and 2006, Boston

Street Presence | 389

INNOVATION IN URBAN HEALTHCARE ARCH 7130 GRADUATE RESEARCH STUDIO FALL 2013 The buildings in this volume were designed as prototypical residential types by fifth-year students in the undergraduate architecture program at Northeastern University in Boston. The students innovated by working within the constraints of the building code and prevalent construction technologies rather than by exploring more radical (and unrealistic) approaches.