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COMMUNITY HEALTH CENTERS FiOR THE MEDICALLY

UNDERSERVED: AN AMERICAN CJ\SE STUDY

llfi:mH · Jl�tt.J I Stephen Verderber Ill� JUll I Translated by Jiang Shan f.l'.l'iji' �IHI)( ff:¥ I Proofed by Xiao Yanwen & Jiang Yu

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Abstract An American case study in evidence-based research and design is discussed. Two recent outpatient clinics are presented. These examples express the outcome of a program that has been in operation for twenty years and has influenced the facility planning and building design of sixty-five capital improvement projects in the state of Louisiana. Keywords Community health, Outpatient healthcare, Residential image and ambiance, Evidence-based research and design. Medically underserved

Introduction

Outpatient community-based care is critical to the overall success of the United States'

healthcare system. A network of local, state, and federal health agencies endeavor to

serve the Nation's diverse population. At present more than 48 million Americans do

not have health insurance. Historically, most of these persons reside in medically under­

served communities. These persons and places tend to suffer from insufficient access

to nearby clinics or hospitals. 1 The lack of access to adequate primary care and disease

prevention care forces these persons, who are often poor, to travel far distances to re­

ceive far more expensive diagnosis and treatment. More intensive healthcare is sought

out elsewhere when prevention-centered local options are few. Hospital care is far mone

costly and is the usually the result of the condition not being treated earlier. 1 Later­

stage illness diagnosis and treatment often requires emergency room care. Even worse!,

many patients and families. lacking the means of transport such as a private family car,

or good rail transport by default, may fall entirely out of the healthcare equation and

opt to not seek out any sort of care at all. 3

In the United States, more than two-thirds of all outpatient clinics for the medically un­

derserved are located in rural communities. Most are located far from urban centers.

The physical environment of this national network is uneven in quality, architecturally. 4

The core dilemma facing care providers at this time-especially in the public, not-for­

profit governmental sector of the American healthcare industry-is the prevalence of

too many poor quality facilities. � The lack of high quality facilities is reaching a crisis

point. This is particularly true for clinics that provide c.are for the medic.ally underserved. 6

A physician or nurse might be forced to work in a poorly planned and poorly main­

tained freestanding outpatient clinic for decades. '

The federal Medicaid program was created in 1965 by the U.S. Congress, for Americans

without private health insurance.8 ln 2010, the administration of President Barack

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Obama approved new national healthcare-access legislation. This new legislation, the

federal Affordable Care Act of 2010, will provide healthcare coverage, beginning in

2014, to more than 31 million Americans (of the 48 million total) who at present remain

uninsured. With the ACA's full implementation coming in 2014, concerns are growing

over the fact that these previously uninsured patients will quickly overwhelm the

nation's existing medical centers, stand-alone hospitals, and community-based out­

patient clinics. 9

With these millions of previously uninsured patients about to enter the nation's health­

care system, the burden placed on the nation's network of outpatient community clin­

ics in particular will be grater than ever before. The worst of the poorest quality facilities

will experience complete breakdown. Many merely limp along, particularly those locat­

ed in the heart of economically disadvantaged communities. Without adequate fund­

ing, these clinics will only fall into further decay and decline. A situation persists where,

sadly, no national database on this physical inventory exists as of yet. The need for such

an inventory and knowledge repository is great and will only increase when the ACA is

fully implemented in 2014. 10 The goal of the following discussion is to present a strat­

egy on how to improve the architectural and functional quality of this national network

of freestanding outpatient primary care and public health clinics.

Evid1ence-based Facility Planning and Design

The /:\CA will provide $11 billion to bolster and expand the U.S. inventory of outpatient

community health centers, beginning on January 1, 2014,: $9.5 billion will be earmarked

to construct new health center facilities specifically in medically underserved areas, and

to specifically expand preventive and primary health care services in these communities.

This includes an expansion of dental and behavioral health services. u Evidence-based

research and design. or EBR&D, can and should guide any current and future invest­

ments in this system. Few individual states or local towns, however, have established

perfom,ance-based, i.e. evidence-based, facility planning or architectural minimum poli­

cies or standards for outpatient community health centers that reach beyond the most

basic national building code-requirements. Evidence-based research and design (EBR&O)

for health extends beyond building codes per se, and is defined as the systematic

documentation and analysis of empirical data that then is translated into facility plan­

ning and design. The post occupancy evaluation. or POE, in this regard, is capable of

empowering care providers in helping them learn what works and what does not work

in a �Jiven healthcare facility. 12 The post occupancy evaluation can yield many positive

outcomes of great value to healthcare providers. This information is compliant with but

yet extends beyond codes to include issues of patient and staff flow. user needs and

references, and strategies to reduce occupants' environmental stress. 13 The POE can be

of great help to architects and to medical planners. 14 The emerging field of EBR&D in

healthcare architecture is just beginning to blossom as it gains momentum, acceptance,

funding. and increased sponsorship by the federal government and by private philan­

thropic foundations. 15 Scant EBR&D in the U.S. has been completed that is centered on

outpatient freestanding primary care settings. 26

The State of Louisiana has achieved success over the past two decades in its quest to

repla,ce the majority of its publicly-operated freestanding community-based outpatient

clinic:,. This has occurred over a twenty-one year period, and this program has been

centered on EBR&D. It has been paid for and supported by Louisiana's statewide health

and hospitals agency. In the fall of 1990. the State of Louisiana Department of Health

and Hospitals' Office of Public Health (DHH-OPH) embarked upon (under the first au­

thor's direction in the role of consultant) a strategic. evidence-based healthcare facility

improvement program. This effort, the Strategic Facility Improvement Initiative, or SF!,

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FEATURE THEME I 1:■9�

was created to assess, redefine, and redevelop Louisiana's network of then-132 free­

standing program sites across Louisiana's sixty-four parishes (counties). 17 This net\vork

consisted of nine regional offices, seven regional laboratories, seventeen specialty

clinics, i.e. STD/TB clinics, and nine Children's Special Health Services (CSHS) clinics, and

seventy-four parish health centers. 13 This SR program now stands as the longest run­

ning health agency-sponsored EBR&D effort of its kind anywhere in North America. 19

Prior to 1990, Louisiana's network of public health facilities was highly uneven in qual­

ity. Each parish operated autonomously when it came to its clinic facility, without scant

coordination or knowledge sharing between jurisdictions. However, every parish is

mandated by the 1974 Louisiana State Constitution to pay for, build, and operatEi its

own Parish Health Unit, and DHH-OPH is mandated to staff and operate every pro­

gram site throughout the State. Suffice to say, the sitL1ation across parishes was any­

thing but equitable in terms of the architecture of this network. New facilities some­

times did not meet Americans With Disabilities Act (ADA) minimum standards for

handicap access; some even lacked sinks in exam rooms, and little concern was paid to

patient privacy or confidentiality needs. As of November 1990, 66% of all DHH-OPH

facilities had been housed in the same quarters for thirty years or longer. Nearly all of

the program sites suffered from a chronic case of deferred maintenance. The system

was broken.

The SR process, beginning in the fall of 1991, first yielded an evidence-based compen­

dium of 140 facility site planning and architectural design guidelines. These, each one

page in length, augmented with graphic diagrams, were based on twenty-five on-site

post occupancy evaluations. These twenty-five POEs consisted of photos, interviews,

focus groups, and detailed walk-throughs. In addition, an 11-page statewide facility

survey was administered statewide in 1991, 2003 and again in 2012. 20 The survey's

contents centered on external conditions such as on-site parking, nearby public trans­

port, site lighting and the general aesthetic appearance of the exterior of the clinics.

Interior issues studied covered the main waiting room and subwaiting room, sign-in

station, patient intake/admissions, medical records storage and retrieval spaces, of­

fices, storage spaces, examination rooms, laboratories, nutritional education rooms,

workspaces for physicians and nurses, and staff break rooms. Lighting levels, priva,cy

amenities for patients, and the overall appearance and condition of the interior of the

facility were also examined. The facility survey was completed by staff persons in every

clinic and support facility in the statewide DHH-OPH network. The survey results were

analyzed statistically and the results were translated into the 140 planning and desi£1n

guidelines. These findings then became the basis of the design of all future renovated

facilities and replacement facilities. Concepts (as translated from the survey evidence

provided by the building users) included the importance of easy-to-navigate paths

and corridors, effective directional signage, courtyards as spatial orientation device·s,

occupants' preference for nature and natural materials such as wood, natural daylight

where feasible, meaningful views to the outside, sustainable design amenities such as

solar and geothermal systems, and patient privacy.

Public Health Capital Improvements: 1990-2012

The SF! program's continuous operation since 1991 has been a testament to it bein9

a win for the local community as well as a win for the statewide agency. Its longev·­

ity and continued financing has hinged on these five factors: strong grassroots local

support, a demonstrated track record of beautiful new replacement facilities, a belief

in the power of evidence-based healthcare research and design, perseverance on the

part of the SFI team, and a statewide health agency with courage and vision. 21 A total

of sixty-five capital improvement projects have been successfully completed as of the

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end of 2012. Of these, forty-one completely new replacement facilities were constructed,

fift,�en facilities were renovated and/or expanded, and nine existing buildings were

adapted to healthcare uses. The average project planning phase, inception, to ground­

breaking, was 12.8 months; average length of time from groundbreaking to opening day

was 10.9 months. With respect to the distribution of construction activity, the average

size of a new facility was 9,949 total building gross square feet (BGSF). This represented

407,909 total BGSF in new construction. Renovations and adaptive uses of existing build­

ings averaged 4,972 BGSF per project, totaling 119,328 BGSF. The average project cost

$1,020,512 (unadjusted for inflation). Capital improvement expenditures across the nine

administrative regions totaled $66.3 million. This construction activity has been counter­

balanced to some extent by thirty (30) facility closures. The services housed in these clin­

ics were consolidated into nearby existing facilities.

As mentioned, the SF! is the longest running EBR&D healthcare program of its kind. In

Louisiana, most of the program sites in need of capital improvement are now done, al­

though considerable work remains. 11 A number of replacement facility projects remain

in the planning stage at this writing. 23 The SR also responds to any clinic that has been

damaged in recent Hurricanes. The 2012 statewide facility survey results once again re­

flected continued support of staff personnel for the SR program. Staff often reported

that a halo effect occurs whenever a new or renovated facility opens. The number of av­

era,ge monthly patient visits can rise as much as 20% as opposed to when the clinic was

housed in its old quarters. Longtime patients often comment on the new clinic's more

inviting atmosphere and its uplifting aesthetics.

Two Case Studies

1. Clinic Center in Rayville

For thirty years, the health unit in Rayville, Louisiana was housed in the center of a town

of 12,000 residents in a prefab mental structure it shared with a branch of the State

Office of Social Services. In recent years the occupants had been forced to endure the

stench of a broken sewer line running directly beneath the clinic. This, compounded by

the windowless conditions, was too much for occupants, especially during the long hot,

humid summer months. A section of a map that was drawn in the late 18th century,

Norman's Chart of the Lower Mississippi River, by the French cartographer Adrian Persac,

illustrated every slave plantation parcel between New Orleans and Baton Rouge, on both

sides of the Mississippi River. Each plantation was identified by its landowner and by the

family name. Today's pattern of asymmetrical plat boundaries endures as much as a fas­

cinating tapestry of bisecting, interdependent geometries, as a testament to the bygone

era of the c1ntebellum Old American South (Figure 1).

ThE! proposed replc1cement clinic for Rayville, designed by the c1uthor, houses an environ­

mental health program, a clinical realm comprising six trans-programmatic exam rooms,

and a clerical and administrative realm with a set of five combined intake-staff offices.

Square footage totals 10,150, and the building is elevated four feet above the Mississippi

River delta flood plain. The building's "legs" provide structural support in this regard, and

HVAC systems are supplied from beneath the main floor via an 18-inch depth interstitial

two-way truss system (Figures 2-6). The parti' features these planning and architectural

concepts:

De•centralization - the main vehicular and pedestrian access point to the building occurs

near its midsection. This allows for direct access to either an autonomous environmental

health module, to one side or the clinic on the other side of this arrival/patient drop-off

drive.

Flexible Configuration - the parti' is transformable, able to take on any number of alter­

native shapes, from linear to curvilinear, re-configurable on sites elsewhere of varying

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9

FEATURE TI-!EME I �--�

proportions. Its pre-manufactured pods can be deployed in a horizontal accordi­

on-like or variable expansion depending on user needs.

Parking/Site Access - the separation of the environmental health program "build­

ing" apart from the clinic "building" allows for options regarding the placement

of parking areas, access drives, and pedestrian walkways leading to and from the

facility.

Minimum on the Site Impact - the thin, linear footprint of the facility allows for

the retention of the maximum amount of existing natural vegetation on its en­

vironmentally sensitive site. The building possesses 'lightness' in this regard as it

appears to float above the ground plane. Its linearity also affords the direct trans­

mission of natural daylight into interior spaces.

Modularization - ten modular pods are structurally autonomous from one an­

other and yet interconnected and stabilized by steel tubular conduits. The legs of

these pods are telescopic. These devices allow for variability in deployment, not

unlike the elevated jet ways passengers use to embark and disembark airliners in

an airport.

Sustainable Environmental Systems - the building parti' minimizes the reliance

on costly mechanical HVAC systems through the use of passive solar design

techniques, including sunscreens, roof overhangs, and a geothermal system. The

building maximizes sustainable 'green' building materials, furnishings, and fixtures

throughout.

Decentralized Seating - the building is intensely human-scaled. Six window seat

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floor plan of Rayville, Louisiana Clinic (proposal)(Right)

10

2.11utm1A�ffcp,i:,,i1§1o.1�lllt Figure 2: Rayville outpatient clinic. view to west

lllillllfl 2013.06 I URBANISM AND ARCHITECTURE Jun 2013

3. U1J;ll�ffcp,(.,ffiffl.!l/,l!t Figure 3: Rayville outpatient clinic, view to southeast

4 1lt!IHFIA f2'ff cp,L..'l-i�f□cp,L..'i�it ):ff Figure 4· Rayville outpatient clinic, check-in/

rnain waiting area

5. '!B!i8'ffl�ffcp,i:,,;ailiti;t;J:1=�A fiimilil"Jllairi!�1t!R

Figure S: Rayv ille outpatient clinic window-seating along corridor

6. llt!1HFUll!i'7'f'•t'.•lt'!lo.l'.¥:1t-ll"JUlff Figure 6: Rayville outpatient clin,c, view

to el!1erior

ba�,s are placed along the clinic's undulating pedestrian spine that allow views to

the surrounding landscape. This precludes having to sit in an institutional ·waiting

room: As for personal space, five or six can sit comfortably here, or perhaps just a

nurse and his/her patient, engaged in private consultation.

Flel<ible Room Spaces - the intake/admit offices and exam rooms provide flexible

spaice for transactions between the patient and the staff person, from private con­

sultation to diagnostic/treatment use to small group meetings. The examination

rooms can be converted in size via mechanically activated panels. Exam rooms are

spa,cious, allowing nurse and physician to also use it for his or her administrative

work.

Communal Spaces - the nutritional education kitchen doubles as subwaiting room

and a staff conference room. A multipurpose community health education room is

housed in the environmental health wing across the arrival/patient drop-off drive.

These spaces feature natural daylight and views to the surrounding landscape.

2. New Campus of Clinic Center in New Iberia

Numerous replacement facilities have opened recently, including the new campus

in !New Iberia, Louisiana (2012). It was designed by the Architects Design Studio

(Fi9ure 7) in consultation with SFI project team (including this author). As with oth­

er replacement facilities, EBR&D directly helped shape the architecture. The main

clinic, its porte' cochere' and an adjoining environmental health building are con­

nected by a covered walkway (7a). The interior of the facility is attractive and pre­

sents a positive, dignified image to its users, with a large main waiting room that

adj:oins a sign-in station, five spacious intake/clerical offices, and a Vital Records

Office for birth certificates and death certificates. Large full height glass doors al­

low the staff to maintain direct visual contact with the main waiting room without

compromising patient confidentiality during intake interviews (7b). The clinic labo­

ratory is linked to an adjoining restroom for use by patients for them to provide

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11

FEATIJAE THEME ;tDfl�

pass through specimens through a l' x l' stainless steel portal (7c). The in­

take/clerical offices are spacious (7d). The examination rooms are equipped

with a gowning alcove, a flex exam table, sink, charting desk, and supply

cabinets. This zone double functions as a nurse/physician workstation (7e).

The environmental health program section in the adjoining building features

a main waiting area, open plan work area, the laboratory for field specimen

storage, and offices for Parish Sanitarians who inspect food establishments,

water quality, and who review all sewerage permits for new construction in

the local community (7f). The nutritional education demonstration kitchen is

configured to simulate the scale and function of a residential kitchen (7g), and

an electronic, modular, Spacesaver system houses the medical charts that are

non-digital (7h),

Summary

In EBR&D, the daily inhabitants are viewed as possessing knowledge and in­

sights of importance. The sponsoring client, medical planner, interior designer,

landscape architect, medical equipment and furnishings specialist, and the

Project Architect can all benefit 24 Too often, unfortunately, the role of the

day-to-day occupant is overlooked, or dismissed entirely as a resource. But

this is not the way it has worked in the SR program. The experience and pref­

erences of the direct occupants - staff and patients - have functioned as the

bedrock foundation of the SFI and its metrics in Louisiana. The core philoso­

phy of the SR program is the belief in the importance of early intervention with

the building's users - with this step being essential to the overall success of any

construction project. 25 Choosing the most suitable location to build a replace­

ment facility has proven in many cases to be painstaking, requiring weeks,

months (even years) of deliberations, and at times, political setbacks. All this,

even before the architect is hired. ls the best strategy renovation, new con-

12

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f□�f�fro-L:.t&lmlil:�•�if!�:§� 1'61 *'fiZ-1oJ��i�AHih1

ciJ�:,(��"i'effif/J (Stephen Verderber) ffi�d1I- IJoseph Kim­

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struction, or a combination of both? The project scope, construction and furnishings

budget. and the construction site must be established. � The reader is referred to Ver­derber and Kimbrell (2005) for a broader discussion of the SFI protocols, its operation­alization at the local community level, and its broader health policy implications. 27

In rnral towns and villages across the U.S., a new healthcare facility is an important addition to the community. A beautiful new freestanding outpatient clinic can rival a new public library - as symbols of civic pride and accomplishment. 28 A new clinic inom? town will ohen spark a competitive spirit, with a neighboring town soon elect­ing to follow suit. This is a positive trend and is to be encouraged. Louisiana is a state that persistently ranks at or near the bottom in national health statistics. It has one of

the highest poverty rates, lowest median income levels, and highest percentages of uninsured. 29 Approximately 947,000 residents lived below the poverty line in 2011, the stalte's poverty rate was 21.1 % (second highest in the nation), and the median fam­

ily income was $40,658 (ranking 46 out of SO states). Worse, 20.8% of its residents, or 938,000 persons, did not have private health insurance of any sort. Only Texas and Ne­vada had higher rates of uninsured citizens. 30

In Louisiana, stubborn rivalries still linger between urban, suburban, and rural communi­ties over the equitable distribution of very limited taxpayer dollars. 31 The SF! and its useof EBR&D transcend political rivalries and turf wars while concurrently embracing local vernacular architecture traditions. 32 As for the Architect, his or her legal responsibility isto serve the best interests of the public's "health, safety, and welfare." H Unfortunately, the promise of EBR&D in the service of the medically underserved remains largely unfulfilled. Many architects in the United States, and globally, are about to be called upon to rethink their position in this regard. 3A Architectural advancement requires a disciplined commitment to move beyond the status quo. is More than 31 million more Americans soon will have healthcare insurance coverage as provided through the Af­fordable Care Act of 2010. For the first time in many decades, a new source of funds will be available for building new and replacement freestanding outpatient care clinics

in medically underserved neighborhoods, towns, and cities. This has not occurred since the demise of the federally funded Hill-Burton capital construction program for national hospital and clinic construction. This program ran from 1946 to 1971. Patient advocacy - for persons with health disparities - has been at the heart of this twenty-one year program. Sadly, many medically underserved, along with their caregiv­ers, continue to coexist in overcrowded, dysfunctional settings. 36 All this, while govern­ment sector health care providers are being called upon to do more yet with fewer fiscal resources due to budget cutbacks. 37 One highly promising means to increasepatient access to care, especially in rural locales, is to bring mobile health clinics into

the healthcare delivery system in places where patient access to care remains limited. The absence of a fixed site, permanent clinic will not suffice. These clinics-on-wheels are redeployable, versus always opting to construct a stationary "permanent" build­ing. Furthermore, a mobile clinic is far less costly to build, operate, is less taxing on the environment, and can help alleviate chronic funding shortfalls on the part of the care provider organization. 38 The alternative is unacceptable - coping with an overcrowdedforty to fihy year-old fixed-site clinic plagued with a leaky roof and a gravel parking lot, with little hope of meeting federal Health Information Privacy and Protection Act (HDPPA) or federal Americans With Disabilities Act (ADA) minimum facility design and construction standards. 39 Innovative fixed-site and transportable architectural solutions are needed. 40 There has perhaps never been a more opportune moment in the U.S.to innovate - reinvent - freestanding outpatient clinic building types for the medically underserved.

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