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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
6
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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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7
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
8
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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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1. 18l!t!c �Ml::bofF ;!111J. mif. 7 ia;oJ/61i'JH'l'ffillrl£!\Ji'MJ ( li:111) ll!fl}'FfflEi!<ff 'P'IJ ■JI�§-�5¥ilii ( E Ill)Figure 1: Eighteenth-century map of lower Mississippi river, depicting slave plantation boundaries(left); Annotated
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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iH��&fitla"J�ffi2WifflHfiliWlffit. ffetcp§!i!i 2012
f!o{fffle"J��lllr�ll�ttlffijjll:t;l1Jifilmllit��ffibl iP<�l!Jl:
�Et!Architects Design Studio i2it. SFI��J..miW�iii.Je"Jli;i
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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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i2iiEiti&� (!fl 7c) 3tffl:1J-'L}�f□ loJit'.i:��BJl� 111l 7dl
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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
brell .I 200S�B'-J3Z:§: Jtcp@f1SSFI]jjj§B'-J�liffift. fH±��im
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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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