"Designing for Health" is a monthly, web-exclusive series from the healthcare interior design leaders at Perkins+Will that focuses on the issues, trends, challenges, and research involved in crafting today's healing environments.
Why is getting a doctor’s appointment so difficult? I recently moved to a new city and needed a new primary care physician: What I thought was a simple task became pure frustration. The first three I called said appointments for first-time patients were a six- to nine-month wait. The fourth said they only schedule annuals in the fall, and the last took my number and never called back. I take little solace that I am not the only person experiencing frustration over an apparent shortage of physicians. 1
The primary care shortage is not new. For years, student enrollment has dropped because of a disparity in compensation between general internal medicine and the specialties. Unfortunately, many expect this shortage will be exacerbated by other factors. The single largest factor is population growth, for which the U.S. Census Bureau projects a growth of about 50 million between 2006 and 2025. The second main factor is population aging. We now have 10,000 baby-boomers turning 65 each day, and as we continue to age we require more frequent access to primary care services. The most recent factor expected to play into this shortage is increased healthcare coverage for an estimated 32 million Americans through the Affordable Care Act. In total, the Association of American Medical Colleges (AAMC) estimates a deficit of 45,000 primary care physicians by 2020, and 124,000 to 159,000 physician across all specialties by 2025.2
At the same time, the healthcare design and construction industry is seeing a shift in focus from large, acute hospital projects to ambulatory care centers, community health clinics, and medical office buildings. There are a number of reasons for this shift, but it can partially be related to efforts to address the problem of the shrinking supply of primary care providers.
Primary care providers and practices across the country are beginning to realign under two models of organized care delivery: medical homes and accountable care organizations. Medical homes are a big shift from traditional, physician-centered care to team-based, patient-centered care. In this model, the physician becomes the point-of-contact and coordinator of care, but holistic care is provided by the team. Teams may include nurse practitioners, dieticians, mental health providers, and social workers. This integrated care approach sees patients through all stages of life and disease, and also integrates healthcare information technology for improved coordination between providers.
The medical home model has real space implications. The traditional medical office building approach of individual physician offices does not typically support a team-based model; so many providers are working with designers to create spaces that facilitate a new way of working. Community of Hope, a community clinic in Washington D.C., is an established medical home. In order to support this model of care in the growth and consolidation of their services, Perkins+Will designed a provider workspace that includes team-work rooms within a clinical module of six exam rooms. The team-work rooms are designed to encourage collaboration in the holistic care of patients. Kelly Sweeney McShane, executive director at Community of Hope, says “The strategy is for our new clinic is to support team based care— care that is centered around the entire person, considering not only medical and dental care but mental health and social well being.” These clinical modules are located with access to natural light and views to nature for staff well being.
Accountable care organizations differ from the medical home model in that they encompass a number of practices and specialties, and could include multiple medical homes. While these organizations can take on many forms, they have a few potential space implications. There is an increased need for buildings with deeper floor plates to support the strategic co-location of multi-specialty clinic practices. Due to the unsuitability of much of the existing medical office stock, this means substantial capital investments at a time when there are multiple competing pressures for capital and increasing scrutiny over the necessity. Because of this, many healthcare providers are partnering with developers in the construction of new ambulatory care centers and community health clinics.
Due to the reduced operational budgets anticipated in the short-term, healthcare clients are looking for ways to improve their efficiency and flexibility. One strategy for achieving this is clinic space planning based on a universal exam module. Each module typically includes four-to-six exam rooms designed large enough to meet the needs of any specialty (typically 120 square feet) with room for family members or additional care providers. This standardization is similar in concept to the standardization of patient rooms, but with efficiency as the key focus. As clinic specialties change, grow or shrink, and as staffing models are refined, these modules also provide flexibility and conserve future capital resources. At the Arlington Free Clinic, a non-profit, community based and volunteer driven clinic, flexibility and efficiency were key design drivers. In addition to universal rooms, Perkins+Will designed a truly multi-purpose room. Through use of an operable partition, sliding doors and reconfigurable furniture the space transforms from a board room, to a community meeting space, to a Pilates and yoga studio for staff and patients.
Besides designing facilities to support a specific model of care, there is a surge in the construction of community health clinics and ambulatory care centers purely to support the new population of insured Americans. The Emergency Department will no longer be the point-of-entry to the healthcare system for this population, as long as there are enough physicians and enough clinics with office space to support the demand.
This is an interesting period in time for the healthcare industry. As it begins to reorganize under the Affordable Care Act and prepares for a new wave of patients, the best paths for success have not been tried and the outcomes are not yet clear. As designers, this presents an exciting opportunity to help our clients find their way and leverage the built environment to support these new models of care delivery.
Bonny Slater is an interior designer at Perkins+Will in Washington, D.C., where she brings a research-based approach to every project. She can be reached at email@example.com.
- Bodenheimer B, Pham HH. Primary care: current problems and proposed solutions. Health Aff (Millwood). 2010;29:799–805.)
- Association of American Medical Colleges. Physician shortages to worsen without increases in residency training. Click here.
Accessed on March 8, 2011.
Past installment of "Designing for Health" include (click on the title to access the full article):
Designing for an International Standard of Care in Transforming Global Cultures
There Is An App for That
Healing the Hospital
Exploring Collaboration in the Consolidated Interventional Platform
The Differences between U.S. and U.K. Clinical Planning Models